A. Deschildre

Update on the roles of distal airways in COPD

This review is the summary of a workshop on the role of distal airways in chronic obstructive pulmonary disease (COPD), which took place in 2009 in Vence, France. The evidence showing inflammation and remodelling in distal airways and the possible involvement of these in the pathobiology, physiology, clinical manifestations and natural history of COPD were examined. The usefulness and limitations of physiological tests and imaging techniques for assessing distal airways abnormalities were evaluated. Ex vivo studies in isolated lungs and invasive measurements of airway resistance in living individuals have revealed that distal airways represent the main site of airflow limitation in COPD. Structural changes in small conducting airways, including increased wall thickness and obstruction by muco-inflammatory exudates, and emphysema (resulting in premature airway closure), were important determinants of airflow limitation. Infiltration of small conducting airways by phagocytes (macrophages and neutrophils), dendritic cells and T and B lymphocytes increased with airflow limitation. Distal airways abnormalities were associated with patient-related outcomes (e.g. dyspnoea and reduced health-related quality of life) and with the natural history of the disease, as reflected by lung function decline and mortality. These data provide a clear rationale for targeting distal airways in COPD.

Quand et comment modifier la prise en charge de l'asthme de l'enfant asthmatique à partir de quatre ans ?

Resume Le traitement de l’asthme de l’enfant ne doit pas etre fige mais doit etre regulierement adapte en fonction du controle, defini sur des criteres cliniques et fonctionnels. Chez un enfant dont l’asthme est controle, la decroissance therapeutique s’effectue tous les 3 a 6 mois pour obtenir la dose minimale efficace. Chez un enfant dont l’asthme apparait non controle, il est necessaire dans un premier temps d’evaluer l’observance et de rechercher des facteurs aggravants, rhinite allergique, polysensibilisation, tabagisme, facteurs psychologiques, obesite, reflux gastro-œsophagien, infection. La strategie therapeutique repose sur l’augmentation de la dose de corticoides inhales et sur l’association a d’autres traitements anti-asthmatiques, β2 de longue duree d’action et anti-leucotrienes.The treatment of asthma in children should not be fixed but rather must be regularly adapted to keep the condition under control defined according to clinical and functional criteria. In a child whose asthma is controlled, a step down in therapy should be carried out every 3 to 6 months to achieve the minimal effective level of treatment. In a child whose asthma appears not to be controlled, it is necessary initially to evaluate compliance with therapy and to seek aggravating factors which may include allergic rhinitis, multiple sensitisation, tobacco exposure, psychological factors, obesity, gastro- oesophageal reflux and infection. Where control of asthma is poor the main therapeutic strategy rests on an increase in the dose of inhaled corticosteroid and on the addition of other anti-asthmatic treatments--inhaled long--acting beta 2 agonists and oral leukotriene antagonists.

Asthma control assessment in a pediatric population: comparison between GINA/NAEPP guidelines, Childhood Asthma Control Test (C‐ACT), and physician's rating

Guidelines recommend regular assessment of asthma control. The Childhood Asthma Control Test (C‐ACT) is a clinically validated tool.

The lung is involved in juvenile dermatomyositis.

Juvenile dermatomyositis (JDM) is the main cause of chronic idiopathic inflammatory myopathy of autoimmune origin in children. The aim of this multicenter prospective study was to describe respiratory status and treatment of children followed for JDM.

Bronchiolite oblitérante postinfectieuse

Post-infectious bronchiolitis obliterans (BO) is characterized by inflammatory and fibrotic lesions of small airways following a pulmonary infection and leading to some degree of airway obstruction. It represents a rare cause of chronic obstructive pulmonary disease, and is probably underestimated, especially when the lesions affect small areas of the lungs. The clinical features differ between children and adults. In children, adenovirus is the most frequently involved infectious agent, especially the more virulent serotypes 3, 7 and 21. The clinical and radiological signs vary widely and the functional outcome depends on the extent of the lung injury. The diagnosis is based on the medical history, the CT-scan and functional data. The treatment is symptomatic. The most severe forms may result in chronic respiratory insufficiency. In adults, the frequency of obstructive injuries of the small airways in the context of lung infection is unclear. Parenchymal lesions are often present, resulting in BO with organizing pneumonia. These lesions alter the clinical presentation and the radiographic features of the initial infectious disease and often prove difficult to diagnose and manage. Several authors have published clinical cases describing presumed efficacy of systemic corticosteroids but the data are scarce.

Recommandations sur l’utilisation des nouveaux outils diagnostiques étiologiques des infections respiratoires basses de l’enfant de plus de trois mois

Recommendations for the use of diagnostic testing in low respiratory infection in children older than 3 months were produced by the Groupe de Recherche sur les Avancées en Pneumo-Pédiatrie (GRAPP) under the auspices of the French Paediatric Pulmonology and Allergology Society (SP(2)A). The Haute Autorité de santé (HAS) methodology, based on formalized consensus, was used. A first panel of experts analyzed the English and French literature to provide a second panel of experts with recommendations to validate. Only the recommendations are presented here, but the full text is available on the SP(2)A website.

Série « Les voies aériennes distales dans la BPCO »coordonnée par D. Dusser et N. RocheBronchiolite oblitérante postinfectieusePost-infectious bronchiolitis obliterans

Post-infectious bronchiolitis obliterans (BO) is characterized by inflammatory and fibrotic lesions of small airways following a pulmonary infection and leading to some degree of airway obstruction. It represents a rare cause of chronic obstructive pulmonary disease, and is probably underestimated, especially when the lesions affect small areas of the lungs. The clinical features differ between children and adults. In children, adenovirus is the most frequently involved infectious agent, especially the more virulent serotypes 3, 7 and 21. The clinical and radiological signs vary widely and the functional outcome depends on the extent of the lung injury. The diagnosis is based on the medical history, the CT-scan and functional data. The treatment is symptomatic. The most severe forms may result in chronic respiratory insufficiency. In adults, the frequency of obstructive injuries of the small airways in the context of lung infection is unclear. Parenchymal lesions are often present, resulting in BO with organizing pneumonia. These lesions alter the clinical presentation and the radiographic features of the initial infectious disease and often prove difficult to diagnose and manage. Several authors have published clinical cases describing presumed efficacy of systemic corticosteroids but the data are scarce.

Remodelling and inflammation in preschoolers with severe recurrent wheeze and asthma outcome at school age

The influence of airway remodelling and inflammation in preschoolers with severe recurrent wheeze on asthma outcomes is poorly understood.

Asthme : traitement des exacerbations

INTRODUCTION Exacerbations remain, in both adults and children, a common reason for emergency consultation. The management of the asthmatic patient with an acute exacerbation is well defined. BACKGROUND The initial evaluation, based on the background risk factors and the clinical examination, will determine the choice of treatment and management. Treatment is based on bronchodilators and corticosteroids in the majority of cases. VIEWPOINTS An episode of exacerbation may be the opportunity to establish contact with the patient (an educational approach) to improve the adherence to long-term treatment with inhaled corticosteroids, which remain the best way of preventing future exacerbations. CONCLUSION Early and appropriate management of exacerbations of asthma should reduce asthma morbidity and mortality. It could also reduce the socioeconomic costs of these episodes and the number and duration of hospital admissions.

Interactions micro-organismes et voies aériennes distales : spécificités pédiatriques

The spectrum of respiratory viruses is expanding and emerging diseases have been described regularly over the last fifteen years. The origin of these emerging respiratory viruses may be zoonotic (by crossing species barrier, after changes to RNA viruses such as avian influenza virus type A or coronaviruses), or related to the use of new identification techniques (metapneumovirus, bocavirus). The relationship between bronchiolitis and asthma is now better understood thanks to prospective follow up of birth cohorts. The role of rhinovirus has become predominant with respect to respiratory syncytial virus. The identification of predisposing factors immunological, functional, atopic and genetic, for the onset of asthma after rhinovirus infection suggests that viral infection reveals a predisposition rather than itself being a cause of asthma. The role of bacteria in the natural history of asthma is also beginning to be better understood. The results of the COPSAC Danish cohort have shown the frequency of bacterial identification during wheezy episodes before 3 years, and the impact of bacterial colonization at the age of one month on the onset of asthma by age 5 years. The role of bacterial infections in severe asthma in young children is also discussed.