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Objective: To assess whether knowledge of asthmatic disease may be a protective factor against the risk of community-acquired pneumonia (CAP) in people with asthma over the age of 18 who receive inhaled treatment., Method: observational study of cases and controls in a population with asthma. One hundred and twenty-three people with asthma diagnosed with pneumonia were recruited according to clinical and radiological criteria (cases), and 246 people with asthma not diagnosed with pneumonia during the past year (controls), matched by age. The main study factor was the assessment of knowledge about asthmatic disease through an ad hoc questionnaire, with seven questions and two possible answers (known, unknown)., Results: the bivariate analysis shows that knowledge of asthmatic disease has a statistically significant association as a protective factor of CAP. In the multivariate analysis, it shows an association of knowledge of asthmatic disease as a protective factor of CAP (OR=.24), regardless of age, level of studies, functionality, and severity of asthma., Conclusions: A good knowledge of asthmatic disease reduces the risk of CAP in asthmatic patients using inhaled treatment., (Copyright © 2018 Elsevier España, S.L.U. All rights reserved.)

Background: The level of asthma control in Latin American countries is still poor and it does not reach the objectives that have been established by international guidelines. The reasons why this occurs are still unknown., Objective: To explore the frequency of anxiety and depression in patients with asthma and its possible associations with the control of this disease., Methods: A cross-sectional study in asthmatic patients from Guayaquil-Ecuador. A chi-squared test was applied in order to assess the associations between the presence of anxiety and depression and the demographic variables. The correlation between the Asthma Control Test (ACT) and the Hospital Anxiety and Depression Scale (HADS) was assessed by applying Kendall´s Tau-b test., Results: Of all 73 patients, 55 (80.9%) were women and 50 (69.4%) had a low educational level; 49 (67.1%) patients had uncontrolled asthma (p=.005). Few patients presented anxiety (2.7%) and depression (1.4%) symptoms (p=.000). The factors that were associated with the highest rate of anxiety and depression were: the age of 60 and younger, female sex, and uncontrolled asthma. There wasn't any significant correlation between asthma control and anxiety or depression scores., Conclusion: Numerous asthmatic patients don't have proper control of their disease, and anxiety or depression disorders seem to have only minor effects on the control of the illness.

Background: Decreased levels of vitamin D influence on the control and severity of asthma., Objective: To evaluate the relationship between vitamin D serum levels and asthma control, as well as nutritional status, quality of life and patient comorbidities., Methods: Cross-sectional, observational, descriptive study of 43 asthmatic patients older than 18 years of age. Multiple logistic and multiple linear regression multivariate analyses of variance were performed; a p-value ≤ 0.05 was considered to be statistically significant., Results: Insufficient vitamin D levels were determined in 83.7 % of patients; 93 % had at least one asthma exacerbation in the previous year. There was no relationship between vitamin D serum levels and asthma control as measured by ACT and FEV1. There was a significant association between body mass index and vitamin D levels (p = 0.013). With a quality of life questionnaire for asthmatic adults, 76.7 % were recorded to have a poor quality of life., Conclusions: No relationship was observed between vitamin D serum levels and asthma control in the patients. Most patients had insufficient vitamin D serum levels, uncontrolled asthma, and poor quality of life. Overweight and grade I obesity were associated with vitamin D insufficient levels.

Objective: To assess prevalence of non controlled (ACT- Asthma Control Test<20) asthma in real world clinical practice in Spain., Design: Observational, cross-sectional study., Location: 58 primary care centers from 13 Autonomous Communities., Participants: Asthma patients attending physicians office to collect repeat prescriptions for continuous treatment (Group A), or due to symptoms worsening (Group B)., Main Measurements: Socio-demographic characteristics (age, gender, education, smoking history), physician's assessment of asthma severity, current treatment for asthma, co-morbidities, healthcare-related resources utilization (primary care or emergency visits, hospitalizations), labour or school absenteeism, ACT score and treatment adherence., Results: 376 patients from group A and 262 from group B were included, 59% female, mean age 45 years, 21% smokers and time since asthma diagnosis 8.9 years. 87% were on short acting beta-2 agonists, 62% long acting beta-2 agonists with inhaled corticosteroids and 13.8% regular inhaled corticosteroids. Poor asthma control was observed in 75.6% from group B and 23.8% from group A; only 5.3% from group A showed total asthma control (ACT=25). Poorer asthma control was significantly associated with longer disease duration and higher use of resources., Conclusions: Prevalence of poor asthma control among patients attending due to symptoms worsening continues to be very high even in patients who come to renew their prescription. Poor asthma control is associated to high use of resources and high impact on burden of disease., (Copyright © 2017 Elsevier España, S.L.U. All rights reserved.)

Objective To verify the association between the self-efficacy of parents/caregivers and control parameters of childhood asthma. Method Cross-sectional study with parents/caregivers of asthmatic children. Data were collected through a sociodemographic questionnaire and the Self-efficacy and their child's level of asthma control scale: Brazilian version. Results Participation of 216 parents/caregivers in the study. There was a statistically significant association between self-efficacy scores and the following variables: unscheduled physician visit (p=0.001), visit to emergency department (p<0.001), hospital stays in the previous 12 months (p=0.005), physical activity limitation (p=0.003), school days missed (p<0.001), impaired sleep (p<0.001), ability to differentiate crisis medication from control medication (p=0.024), use of spacer (p=0.001), performing oral hygiene after use of inhaled corticosteroids (p=0.003), and knowledge of medication gratuity (p=0.004). Conclusion A significant relationship of the self-efficacy of parents/caregivers of asthmatic children with control parameters and training on the necessary skills to reach this control was demonstrated in the study.

The objectives of this work were to investigate the frequency of severe asthma (SA) according to WHO definition and to compare SA patients' characteristics with those of non-severe asthma (NSA); secondly, to investigate the level of control reached throughout a period of regular treatment. Between 1-1-2005 and 12-31-2014, 471 medical records from patients with bronchial asthma assisted in Buenos Aires City were analyzed. SA frequency was 40.1% (189/471), being significantly higher among patients from the public health system (47.7%, 108/226 vs. 33%, 81/245, p = 0.001). SA patients were older than NSA ones (51.3 ± 17.4 vs. 42.6 ± 17.1 years, p = 0.000), presented longer time since onset of the disease (median 30 vs. 20 years, p = 0.000), lower educational levels (secondary level or higher 41.7% vs. 58.1%, p = 0.000), lower frequency of rhinitis (47% vs. 60.6%, p = 0.004), more severe levels of airway obstruction (FEV% 50.2 ± 13.7 vs. 77.7 ± 12.4, p = 0.000), more frequent antecedents of Near Fatal Asthma (11.1% vs. 2.8%, p = 0.000), higher levels of serum IgE (median of 410 vs. 279 UI/l, p = 0.01) and higher demand of systemic steroids requirements and hospitalizations (68.7% vs. 50.7%, p = 0.000 and 37.5% vs. 15.9%, p = 0.000, respectively). A 30.6% of SA patients (58/189) reached a follow-up period of 12 months, 13 (22.5%) of whom reached the controlled asthma level. The frequency of SA found seems to be considerable. Multicenter studies to investigate the levels of control reached by SA patients with access to proper treatment are recommended.

Objective: The Childhood Asthma Control Test (c-ACT) is a validated tool for determining pediatric asthma control. However, it is not validated in the Spanish language in Spain. We evaluated the psychometric properties of the Spanish version of the Childhood Asthma Control Test (Sc-ACT) for assessing asthma control in children ages 4 to11., Methods: This national, multicentre, prospective study was conducted in Spain with asthmatic children and their caregivers. Patients were assessed at 3 visits (Baseline, 2 Weeks, and 4 Months). Clinical variables included: symptoms, exacerbations, FEV1, asthma classification, PAQLQ and PACQLQ questionnaire scores, and asthma control as perceived by physicians, patients and caregivers. The Sc-ACT feasibility, validity, reliability, and sensitivity to change were assessed., Results: A total of 394 children were included; mean (SD) time to complete the Sc-ACT was 5.3 (4.4) minutes. Sc-ACT score was correlated with asthma control as perceived by physician (-0.52), patient (-0.53), and caregiver (-0.51) and with the PAQLQ (0.56) and PACQLQ (0.55) scores. Sc-ACT was found to be significantly related to intensity and frequency of asthma symptoms. Cronbach alpha coefficient α was 0.81 and intraclass correlation coefficient was ≥0.85 for all of the items. The global effect size of Sc-ACT was 0.55. The cutoff point scores of 21 or higher indicated a good asthma control and their MCID was 4 points., Conclusion: The Spanish version of the c-ACT was found to be a reliable and valid questionnaire for evaluating asthma control in Spanish-speaking children ages 4 to 11 in Spain., (Copyright © 2014 Asociación Española de Pediatría. Published by Elsevier España, S.L.U. All rights reserved.)

Baker's asthma, though having been recognized and studied since long time, still stays one of the most common causes of occupational asthma. Moreover, our understanding of the causative agents, the pathophysiological mnechanisms, the usefulness of medical surveillance, the proper treatment and prevention of the disease is still scanty. This is due to either to its complex pathogenesis or to possible confoundings, besides the still inadequate quality and standardization of the tools available as far as the allergologic diagnosis is concerned. Proper medical surveillance, validated causal therapies, efficient primary prevention are still uncertain. Change of employment or relocation is often impossible, particularly among artisan workers. Various evidences have been critically revised and summarized.

Allergic rhinitis and asthma represent global problems of public health affecting all age groups; asthma and allergic rhinitis frequently coexist in the same patients. In Latin American prevalence of allergic rhinitis, although variable, is very high. Allergic rhinitis and its Impact on Asthma (ARIA) started during a workshop of the World Health Organization performed in 1999 and was published in 2001. ARIA proposed a new classification of allergic rhinitis in intermittent or persistent and mild or moderate-severe. This approach of classification reflects more nearly the impact of allergic rhinitis in patients. In its review of 2010 ARIA developed guidelines for diagnosis and treatment of allergic rhinitis and of clinical practices for management of comorbidities of allergic rhinitis and asthma based on GRADE (Grading of Recommendations, Development and Evaluation). ARIA has been spread and implemented in more than 50 countries. In Latin American an intense activity has been developed to spread these recommendations in almost all the countries of the region and it is important to record the obtained goals in the diffusion and implementation of ARIA, as well as to identify the unsatisfied needs from the clinical, research and implementation points of view. Final objective is to reinforce the priority that allergy and asthma should have, especially in children, in the programs of public health, as they have been prioritized in European Union in 2011.

Asthma prevalence has increased over the last few decades, especially in developed countries, and possibly due to different reasons. An association between paracetamol use or exposure at different periods of life, including gestation and childhood, and asthma prevalence has been observed in the last few years. Causality can not be established from observational reports, due to the arguable presence of many confounding factors and biases. Randomised trials are needed to elucidate the nature of this association. The Spanish Paediatric societies subscribing to this paper consider that current evidence is insufficient to discourage the use of paracetamol during gestation or in children with or at risk of asthma., (Copyright © 2012 Asociación Española de Pediatría. Published by Elsevier Espana. All rights reserved.)

Background: Asthma guidelines recommend the adoption of allergen avoidance measures (AAM). To do so, patients need to know their own allergies. However, this degree of knowledge has not yet been assessed. The aims of this study were to determine, in allergic asthma patients: i)the degree of knowledge of their own allergic sensitizations; ii)the percentage of those who knew all their allergies and, in addition, adopted AAM against all of them, and iii)the possible impact of this degree of knowledge on the level of asthma control., Patients and Methods: Descriptive, prospective and multicentre study, including 147patients from 9 Respiratory Medicine outpatient clinics. After confirming the previous allergic asthma diagnosis, a questionnaire was completed. It included asthma control and severity levels, results of previous allergy tests, and the description and number of allergic sensitizations known by the patients and AAM followed., Results: Only 72 (49%) patients knew all their allergic sensitizations and only 48 (33%) were also following AAM against all the allergens to which they were allergic. No relationship was established between the degree of knowledge of their own allergies and the level of asthma control (P=.544)., Conclusions: Overall knowledge about the allergic nature of their disease among asthmatic patients attending Spanish Respiratory Medicine Departments is inadequate. Furthermore, a higher degree of knowledge of their allergies does not seem to lead, by itself, to better asthma control. Both findings seem to question the effectiveness of current educational strategies in this field and consequently, they should be revised., (Copyright © 2012 SEPAR. Published by Elsevier Espana. All rights reserved.)

Objectives: This study aimed to assess the level of asthma control in children aged 6 to 14 years old in a Primary Care Centre., Methodology: A cross-sectional descriptive study was conducted on asthmatic children aged 6 to 14 years old followed up in a Primary Health Care Centre in a metropolitan area of Barcelona. The Asthma Control Test (ACT) was the tool used to measure asthma control. Asthma was considered to be well controlled with an ACT score >20. Demographic and disease specific data were also collected., Results: A total of 46 patients (45% girls, 55% boys) completed the ACT. Their mean age was 8,9 years (SD 2.8). The prevalence of poorly controlled asthma was 41.3%. A family history of asthma was found in 36% of the children, and 43% of them declared to have activity limitations., Conclusions: The high percentage of poorly controlled asthma in children raises the need for reviewing the effectiveness in the processes to improve asthma control in these patients., (Copyright © 2011 Elsevier España, S.L. All rights reserved.)

Objectives: Allergen emissions during soybean unloading operations in the Barcelona harbor have caused asthma epidemics. The present article aimed to describe the surveillance and control measures carried out by the public health services., Methods: Data were extracted from control systems from 1999 to 2009, with description of the surveillance schemes for allergen emissions, environmental concentrations (with defined reference levels) and for health., Results: Of 95 studies of plant emission, four were above the reference levels, and filters were found to be the most likely cause. Mean environmental concentrations were low but were above the reference levels on 13 days; these levels were related to adverse meteorological conditions and incidents in the plants. No health effects were detected in the panel of patients nor epidemic asthma days., Conclusions: The system detects incidents and has shown its usefulness in protecting public health., (Copyright © 2011 SESPAS. Published by Elsevier Espana. All rights reserved.)

Introduction: The coexistence of potentially aggravating processes is common in asthmatics, particularly in patients with difficult control. The primary aim of this study is to ascertain whether comorbidity id more common in uncontrolled patients. As a secondary aim, we propose to evaluate the correlation between the asthma control test (ACT) and the fraction of exhaled nitric oxide (FENO)., Patient and Methods: A prospective, observational study comparing the function and clinical picture of two groups of asthmatics: controlled (ACT≥20) and uncontrolled (ACT<20). They were all assessed for, smoking, rhinosinusitis, obesity, anxiety, depression, vocal cord dysfunction, gastro-oesophageal reflux (GORD), allergic bronchopulmonary aspergillosis (ABPA), COPD and nasal polyps., Results: A total of 50 patients with controlled asthma and 102 with suboptimal control were included. The patients with an ACT≥20 had better lung function, less variation in PEF, less bronchial hyper-reactivity and lower FENO values. Comorbidities were found in 95% of the controlled asthmatics and in 97% of the uncontrolled. Only the presence of nasal polyps, GORD and ABPA was more frequent in the uncontrolled group. However, the simultaneous presence of 3 or more comorbidity factors was significantly more frequent in patients with sub-optimal control (P=0.01). There was no significant correlation between the FENO and the ACT values (rho=-0.08; P=0.32)., Conclusions: Aggravating comorbidities are more common in patients with sub-optimal control. There was no correlation between the FENO and the ACT values., (Copyright © 2009 SEPAR. Published by Elsevier Espana. All rights reserved.)

Background and Objectives: Recent systematic reviews and meta-analyses examining long-acting #b(2)-adrenergic agonists (LABA) as maintenance treatment for asthma have shown surprisingly conflicting results. The aim of the present study was to determine the impact, in terms of efficacy and safety, of previous maintenance treatment on severe asthma exacerbations., Patients and Methods: We retrospectively evaluated the clinical characteristics of exacerbations experienced by 1543 patients with moderate persistent and severe persistent asthma. Drug therapy was as follows: a combination of inhaled LABAs and corticosteroids (493 patients), an inhaled corticosteroid only (456 patients), and no maintenance treatment (594 patients)., Results: Asthmatic patients taking LABAs did not show higher mortality, longer stay in the intensive care unit, longer hospital stay, lower pH, or worse airflow obstruction than the other 2 groups. On the contrary, they had a higher mean (SD) forced expiratory volume in 1 second at discharge (54% [16%]) than patients taking inhaled corticosteroids (48% [19%]) and patients taking no maintenance treatment (48% [20%]) (P=.009). Patients taking no maintenance treatment also had lower mean (SD) pH values (7.37 [0.11]) than patients taking LABAs (7.39 [0.09]) and patients taking inhaled corticosteroids (7.39 [0.08]) (P=.002), and more admissions to the intensive care unit (11.1% vs 6.5% and 7.7%; P=.002 and P=.018, respectively)., Conclusions: This study did not reveal higher morbidity or mortality in severe asthma exacerbations in patients with moderate persistent or severe persistent asthma who had received inhaled LABAs combined with inhaled corticosteroids. On the contrary, asthma patients who did not use maintenance treatment experienced more severe asthma exacerbations.

Background and Objectives: To evaluate anti-IgE (ie, omalizumab) efficacy on severe allergic asthma in order to achieve the efficacy of this treatment on severe allergic asthma progress by means of asthma control questionnaire (ACQ), asthma quality of life questionnaire (AQLQ) as well as pulmonary function (FEV1) and physician overall assessment., Patients and Methods: Fourteen patients were studied who suffered from severe allergic asthma for several years; average 20.7yr. A positive skin prick test or specific IgE antibodies to a common aeroallergen were observed in all patients who were under treatment with high doses of inhaled corticosteroids (eight of them also with oral corticosteroids). Omalizumab 150-600 mg were administrated once or twice monthly and each patient was monthly evaluated until sixteen weeks, deciding at this time which patient was or not responder in order to follow up or not omalizumab treatment., Results: Physician overall assessment improved in 11 out of every 14 patients. A marked improvement was observed at two months in ACQ and AQLQ (p<0.05) and at 3 and 4 moths only in AQLQ and AQLQ-symptoms respectively (p<0.05). The FEV1 improved by 9.4% average (p=0.24). Oral corticosteroids were reduced in 4 of 8 patients and in another one there was a definitive suspension. Two patients suffered adverse reactions which suspension of treatment despite the fact that they presented improvement in questionnaires of quality of life and control of asthma., Conclusions: Omalizumab showed a marked global efficacy in more than 3 out of 4 patients suffering severe allergic asthma as revealed by physician overall assessment. Moreover significant improvements were observed in ACQ; AQLQ; AQLQ-symptoms at 2, 3 and 4 months of treatment, without significant changes in FEV1 probably due to chronic irreversible changes in airways.

Treatment of asthma begins with primary prevention in high risk populations. The proper management of asthma in secondary prevention (to avoid exposure to allergens and aggravating factors such as cigarette smoke, diet rich in fruits and vegetables, oils and timely vaccination against influenza and pneumococcal), patient education, pharmacotherapy and, in allergic patients can be considered immunotherapy. The drugs were divided into rescue treatment for episodes of symptoms and maintenance treatment to maintain control. In patients with asthma and mild intermittent symptoms no more than twice a week, no nocturnal awakenings and no asthma attack last year, will only rescue treatment. In all other patients will install a maintenance treatment with inhaled anti-inflammatory and possibly other drugs that increase the control. To choose the right treatment takes into account the severity of chronic symptoms and at the time of consultation, following five levels of the algorithm that will lead the physician to maintain control of asthma. Level 1. RESCUE: bronchodilators. 1st option inhaled beta2 agonist, applied for exacerbations at any level below. Level 2. Maintenance: inhaled corticosteroid (CElnhal) at low or intermediate doses. Alternative anti-leukotrienes, theophylline extended release, oral beta2 agonists. Level 3. Maintenance: intermediate dose CEinhal combination with long acting beta2 agonist. Alternative: CEInhal with anti-leukotrienes, theophylline extended release, oral beta2 agonists. Level 4. Increase at high doses--very high inhaled steroid plus combined treatment. Level 5. Immunosuppression and Anti-lgE.

Background: The clinical assessment of asthma control is fundamental to evaluate the results of treatment. The Asthma Control Test (ACT) is a questionnaire with five scored items, that differentiates between a well controlled or uncontrolled asthma. It has a Spanish version and has been applied in different countries., Aim: To assess asthma control using the ACT and compare it with the clinical assessment of specialists in a group of pediatric patients., Material and Methods: The ACT was applied to 220 adolescents aged 12 to 17 years, 54% males, with persistent asthma, attended at a respiratory disease unit of a pediatric hospital. The concordance between ACT results and the assessment of specialists was also evaluated., Results: According to ACT and specialists, asthma was controlled in 54% and 63% of patients, respectively. There was a weak concordance between ACT and specialists assessment (Kappa index: 0.27; 95% confidence intervals: 0.14-0.4). The degree of asthma control decreased along with increasing severity of the disease (chi2 = 10.128, p =0.001)., Conclusions: Half of the evaluated asthmatic adolescents do not have an adequate control of their disease. Severity of the disease is inversely related to the degree of control.

Viral respiratory infections are the factor most frequently associated with asthma (independently of phenotype, age, and phase of the natural history of asthma during which the infection occurs) and there is a strong temporal association between viral respiratory infections and acute obstructive/asthmatic episodes. Nevertheless, the role of viral infections in the pathogenesis of asthma remains poorly characterized. The factors that could explain this association are heterogeneous and sometimes contradictory. The four main causative mechanisms implicated in the association between viral respiratory infections and the subsequent development of asthma or wheezing in children are alterations in airway function and size, dysregulation (congenital and acquired) of airway tone, alterations in the immune response to infections, and the genetic variants involved in immune response. These mechanisms should be taken into account in future preventive and therapeutic strategies.

Objective: Interventions to increase asthma knowledge enable children and/or their parents to acquire skills needed for the prevention and/or appropriate management of crises. Periods of illness caused by the disease can thereby be reduced. However, no validated instrument for quantifying knowledge of asthma is available in Spanish. The aim of the present study was to develop and validate an asthma knowledge questionnaire that could be self-administered by parents and/or persons charged with caring for asthmatic children., Material and Methods: The 17 items that make up the questionnaire were obtained on the basis of a review of the literature, focus group discussions, the professional experience of the researchers, and pilot studies. We evaluated the instrument's face, content, and concurrent validity and analyzed its factorial structure. The test-retest reliability of the questionnaire and its sensitivity to change were also assessed., Results: A total of 120 pediatric patients with a mean (SD) age of 4.5 (3.7) years participated. Factor analysis demonstrated a probable structure of 3 factors that together explained 85% of the total variance in results. The opinion of an interdisciplinary group of experts on asthma confirmed the face validity of the instrument. The questionnaire's ability to distinguish between parents with high and low asthma knowledge demonstrated its concurrent validity. Test-retest reliability was demonstrated, as was sensitivity to change between 2 different testing moments., Conclusions: The asthma knowledge questionnaire developed is useful and reliable for quantifying the baseline level of asthma knowledge of parents of asthmatic children as well as to assess the efficacy of an educational intervention aiming to increase knowledge and understanding of the disease.

Occupational bronchial asthma is a diagnostic, therapeutic and public health problem. The central clue for a proper diagnosis is to consider the problem when evaluating every patient with adult onset asthma. An objective confirmation is mandatory because clinical history often gives rise to many false positive cases. Avoidance of contact with the causative agent usually requires the change of work activity which results in an income decrease or unemployment. Despite many efforts in industrial hygiene, recent data shows asthma as the most prevalent cause in the Western world of occupational respiratory disease during working life. The challenge, from an occupational public health standpoint is to create the appropriate industrial hygiene conditions to reduce the burden of worker's exposure to allergens.

Background: The objective of the International Guide on Diagnosis and Treatment of Asthma is to reduce prevalence, mortality and morbidity of asthma., Objective: To demonstrate that implementation of educational workshop increases the knowledge of first contact physicians on the International Guide for Diagnosis and Treatment of Asthma., Material and Methods: Fifty-nine first contact physicians participated. A validated questionnaire was applied before and after the workshop on the International Guide on Diagnosis and Treatment of Asthma. The Student's t test of the program SPSS was used for a statistical analysis., Results: The grades obtained were 36% of correct answers before the workshop and 59% of correct answers after the workshop with a significant p < 0.05 specially in the general area of knowledge., Conclusion: As an educational technique this workshop improves the level of knowledge on the International Guide on Diagnosis and Treatment of Asthma of first contact physicians.

Allergic rhinitis is the commonest chronic respiratory disorder in children and young adults having an important impact for those suffering this condition, as well as for the public health. Allergic rhinitis is frequently associated to other co-morbidities, particularly asthma and conjunctivitis but, also, sinusitis and otitis media. Most of patients suffering rhinitis are cared by GPs and pediatricians and there are evidences that allergic rhinitis is undertreated, particularly the moderate/severe persistent forms. Clinical guidelines have become an important tool providing recommendations for diagnosis and treatment of different medical conditions. They help the process of decision making for GPs and pediatricians, and many of them, contain an update on basic science and epidemiology. In respiratory medicine, guidelines on asthma and rhinitis are available; however, they do not look at the patients globally and focus the disorder on an organ-specific basis without recommendations on co-morbidities. ARIA, Allergic rhinitis and its impact on asthma, has not been developed only to update specialists in allergy/immunology, otorhinolaryngology and neumology on rhinitis and its comorbidities but, also, to provide recommendations for non-specialists. A new classification and severity of allergic rhinitis is proposed replacing the classic perennial and seasonal forms for persistent and intermittent, mild to moderate/severe. ARIA is an initiative in collaboration with the World Health Organization and the master document has been endorsed by many national and international scientific societies and organizations. ARIA is an evidence-based document also stressing on pediatric aspects and providing recommendations for low-income countries.

Rhinovirus infections are the main cause of wheezing in children and adults. Studies carried out with experimental infections report that at least in certain conditions, this infection may spread to the lower respiratory tract as the virus acts on the respiratory epithelium. In vitro experiments with cells from the immune system and lower respiratory tract suggest that the mechanisms of action are directly linked to the production of pro-inflammatory cytokines. Both in vivo and in vitro evidence shows that rhinoviruses may stimulate bronchial epithelial cells to produce cytokines and pro-inflammatory chemokines. They may also stimulate the cholinergic and non-cholinergic nervous system, increasing the production of ICAM-1 and may give rise to a T-lymphocyte non-specific response or to T-lymphocyte replication in direct relation with viral infection. In addition, greater production of cysteinyl leukotrienes has been observed in the secretions of patients with bronchospasm. Experimental infection with Rhinovirus increases clinical symptomatology and bronchial hyperreactivity. The latter is associated with increased eosinophils and cationic proteins in sputum. The above findings suggest that multiple cellular pathways are involved in the induction of exacerbations of asthma induced by the virus. In addition, the possible stimulating role of exposure to allergens in sensitized patients would also increase allergic inflammation. Because of the limited therapeutic efficacy of steroids in reducing exacerbations, new treatment strategies based on greater insight into the physiopathology of the role of viruses in asthma are needed.

Among the different factor (allergens, pollutants, infections) related to the genesis of asthma, only the allergens are capable of generating the type of inflammation that is characteristic to the illness, thus being able to take into account the etiological factors of the said illness. The role of the aerial allergens in the development and seriousness of asthma has been shown, the patients improvement if he is separated from the allergen (high altitudes for people allergic to mites). Even with important methodological difficulties, in controlled clinical tests we have been able to establish the effectiveness of the antiallergenic measures in the handling of asthma, if they are effective in the reduction of the allergenic charge. Avoiding allergens for primary and secondary prevention has a logical and clinical basis but tests on a longer term are necessary and using a larger number of patients before making final conclusions. With respect to the tertiary prevention, several controlled clinical tests have demonstrated the efficiency in the reduction of the allergenic charge and the effectiveness in handling asthma. In addition to eliminating or reducing the contact with pets and pollen when indicated, we should also try to reduce the charge of the mites (an etiological factor in more than 80% of asthma in almost all the patients). It is recommended to use impermeable or semi-permeable covers on mattresses and pillows, to avoid upholstered furniture (at least in the patients bedroom), carpets and rugs and to wash bed linen with hot water, to air the room daily and to avoid exposure to tobacco smoke. There are doubts regarding the efficiency and the safety, on a long term basis, of insecticides, and their use is not recommended according to the latest advice on the handling of asthma.

Allergen specific immunotherapy has been shown to be effective in rigorous double-blind placebo-controlled clinical trials in both children and adults A recent WHO position paper stated that immunotherapy is an effective treatment for patients with allergic rhinitis/conjunctivitis, allergic asthma and allergic reactions from stinging insects and is thought to be more effective in children than in adults. When speaking about children there are several questions that are important regarding the natural course of the disease. One of the most important is whether immunotherapy can prevent asthma, either by preventing sensitisation to allergens related to the development of asthma or by preventing the inflammation in the lungs caused by allergen exposure. Another point could be to establish the differences in the long term outcome of those patients treated with immunotherapy and medication during childhood, compared to the long term outcome of those with comparable asthma features who received only antiasthmatic medication The PAT study is a European multi-center study. The end-point is to show in what capacity allergen specific subcutaneous immunotherapy can prevent the development of asthma in children who only have rhinoconjunctivitis secondary to grass or birch pollen sensitisation. Two hundred and ten children aged from 5 to 13 years were included in the study. Children were randomised to the active treatment group receiving allergen specific immunotherapy with birch and/or timothy pollen allergen extract or to the control group receiving only pharmacotherapy. It is important to highlight that the main criteria to be included was that the children should never have had any asthmatic symptom. Immunotherapy has been effective in terms of decreasing significantly the amount of symptoms in the active group compared to the control one. It was safe with no serious adverse reactions and reduced the risk of the onset of asthma. After two years of treatment more children in the control group developed clinical asthma than in the active group: p = 0.004. Des Roches et al reported the results of a prospective non randomised trial of immunotherapy with Dermatophagoides pteronyssinus in 44 asthmatic children younger than six years of age who were sensitive only to dust mites. The purpose of the study was to assess whether immunotherapy could reduce the development of new sensitisation during a period of three years of follow up. Specific immunotherapy was given with only D. Pteronyssinus extract. All 22 children in the control group developed new sensitivities as determined by skin testing and in vitro tests, while 10 (45%) of 22 children who received mite immunotherapy did not develop additional sensitivities. The findings of this study suggests that immunotherapy may alter the natural course of the allergic sensitisation reducing the risk of developing new sensitisation in mono sensitive children. A limited number of studies have examined the long terms effects of immunotherapy on the clinical presentation of asthma and rhinoconjunctivitis, and have shown a long lasting efficacy decreasing the amount of symptoms 6-10 years after termination. In a retrospective study of children treated with immunotherapy during childhood for at least three years, that were re-evaluated in early adulthood, the control patients who were treated with medication and no immunotherapy suffered almost 3.5 times more symptoms than the active group treated with immunotherapy. The current findings suggest that immunotherapy should be considered earlier in the course of allergic disease to prevent progression or to prevent the development of new sensitisation. Further studies with long term follow up particularly in children could address this possibility.

The past decade of research has led to a greater understanding of the pathogenesis of asthma and, in particular, the pivotal role of the underlying inflammatory process. Along with inheritance in atopic patients, the presence of inhaled triggering allergens are considered the predominant predisposing factors in the development of the disease. We have conducted a longitudinal clinical therapeutic study, which included 45 pediatrics patients with asthma, in order to evaluate whether the removal of any potential inhaled triggering factor, could decrease the requirement of drug based anti-inflammatory therapy. Patients admitted in this study presented at least, two monthly asthma attacks during the last four months. A single treatment with theophylline (group A), beclomethasone (group B) or salbutamol (group C), was prescribed during the first 2 weeks, along with specific instructions to avoid inhaled allergens. Regardless of the drug used, patients showed impressive and prolonged clinical improvement during 6 months, reduction of total IgE serum levels in the three groups (p < 0.02; 0.005 and 0.02 respectively) and favorable modification of force expiratory volume at the first second, forced vital capacity and flow expiratory peak. During the observation period a constant monitoring of mites allergens concentrations was performed, showing a decrease of these antigens, associated with clinical improvement, and only in those patients who remained symptomatic (group A 31%, group B 29% and group C 9%), failures performing the measures designed to reduce their exposure to environmental allergens, was demonstrated. These results suggest that reduction of inhaled triggering factors may decrease the requirement of anti-inflammatory drug therapy to control the symptoms in patients with asthma.

Most of the clinical trials with new drugs on the treatment of asthma are carried out in well selected patients who are not representative of a very clinically heterogeneous disease, with periodic controls differing from those normally undertake in the general practice and specialist consultations. The clinical trials are usually performed over very short periods of time while the normal pharmacologic treatment of asthma requires prolonged treatment. The external validity of these studies is unknown but it is probably not comparable to internal validity. To improve the quality of the clinical trials on asthma, studies should be carried out on patients representing the global population in conditions which are closer to those of the real world and during prolonged periods of time.

1. Evaluation of individual propensity to severe asthma using risk factors. 2. Regular follow-up at intervals of 3-4 months, regardless of the patient's stability in a given moment. 3. Measurements of pulmonary function at each visit and at home daily (PEF). 4. Monitoring evolution in relation to the need for specialist consultations and psychological care. 5. Factors influencing propensity to death should be treated specifically. 6. Designation of a person outside the family responsible for the patient's care. 7. Use of community resources. 8. Monitoring personal/family compliance with treatment programs. 9. Informing the patient and family about the patient's tendency to severe asthma. 10. Developing an emergency plan for facilitating communication when asthma becomes unstable. The plan should emphasize eliminating any delay in obtaining care during an attack. The plan should include: a) A list of preventive medications with dosing guidelines. The simplest possible regimens should be established. b) Criteria for using rescue medication and emergency care in each specific case. c) When the physician should be called in and what to do when the physician cannot be contacted. d) An exact description of the signs and symptoms that indicate that the patient should visit the emergency room without delay. Advance designation of the emergency service to be used. e) Suitable vacation planning. 11. Mechanisms guaranteeing fluid and effective communication between the unit and patients with severe asthma. a) Programs for physicians, nurses and receptionists who take calls to establish measures for recognizing, identifying risk factors, and preventing complications in patients with severe asthma. b) Compilation of a list of patients with severe asthma. c) Patients with severe asthma should be identified by a medical alert card. d) Calls from patients with severe asthma should be taken immediately.

Unlabelled: Prevalence of asthma in children is calculated around 5-10%. In spite of this, severe asthma is not frequent in children (about 1% of asthmatic children), but its prognosis is very worrying as 90% of children with severe asthma continue with asthma in adulthood. The key question is if doctors dedicated to treatment of asthmatic children are able or not able to do something in order to modify this prognosis., Objectives: to evaluate the role of prevention measures in the evolution of severe asthma in children., Methods: in 1995 a prospective study was begun with the aim of evaluating the evolution of a group of children who had been diagnosed as moderate or severe persistent asthma (group A; 18 patients) and comparing it with a control group of children with infrequent episodic asthma (group B, 25 patients). On the first visit we carried out anamnesis, physical exploration, skin tests, a lung function study and we trained the patient in the use of the daily diary card documenting peak expiratory flow (PEF) and asthma symptoms. Three (G-A) or six (G-B) month controls were programmed adjusting the medication dosage. Individual immunotherapy was administered, when indicated., Results: both groups have evolved favourably. All of the patients with severe or moderate asthma, who had done the correct prevention measures and/or immunotherapy, have been able to stop the initial treatment with inhaled glucocorticosteroids (CGS) without lung function or clinical state deterioration. On the other hand the patients with poor compliance of prevention measures continued needing inhaled CGS., Conclusions: adequate prevention measures and/or immunotherapy can influence prognosis of asthmatic children. All of this, in the long run, could avoid or delay the remodelling process and the negative factors of an intensive pharmacotherapy.

Objective: Asthma is a chronic disease of great prevalence among children and with complex treatment. Health education is considered a very important therapeutic tool, but it has been poorly assessed in our environment. The main objectives of this work were to assess the utility of the education in groups of asthmatic children and parents in order to improve the knowledge about the disease, to raise the profile of the self-management concept and to improve the clinical evolution., Patients and Methods: Sixty-one asthmatic children and their parents were distributed into groups according to the age of the patients (less than 2 years, between 2 and 5 years and more than 5 years) and each group attended 6 theoretical and practical sessions on asthma. Theoretical knowledge about the disease and its management was evaluated by using questionnaires before and after the sessions. The clinical evolution of the children was assessed for a period of two years, from the year before the training started until 1 year after it ended., Results: Theoretical knowledge about the disease clearly improved both in children (p = 0.2) and their tutors (p < 0.00001). The yearly number of crises and hospitalizations were not reduced by the training; however, the number of visits to the outpatient clinic significantly decreased (p < 0.001). Patients started using the flow-meter (p < 0.001) and started proper treatment (p < 0.00001) more frequently after attending the group session., Conclusions: Group health education for asthmatic children improves both the knowledge and the self-management of the disease by the patients and their parents, but does not modify the clinical evolution.

The prevalence of atopic dermatitis and other allergic diseases is increasing in industrialized countries. Today we know that atopy is conditioned genetically, but the development of the atopic phenotype requires environmental factors. It is believed that the genetic factors have not changed and that the increased prevalence is due to the increase in exposure to allergenic and non-specific environmental factors. The potential for sensitization is greater in the early years of life, so it is necessary to reduce harmful environmental exposure at these ages. Atopic clinical manifestations develop sequentially, in many cases beginning with atopic dermatitis in the early months of life. We know that children with atopic dermatitis present non-specific bronchial hyperreactivity (58 to 82%), which is a risk factor for the later development of asthma. The presence of specific bronchial hyperreactivity for mites in atopic dermatitis with mite sensitization also has been described, and it has been demonstrated that signs of eczema can develop or become exacerbated by airway exposure during bronchial challenge tests. The evolution from atopic dermatitis to asthma is a possibility that must be kept in mind. Patients should be followed-up and study of hyperreactivity and sensitization to allergens should be carried out in order to prevent the development of clinical symptoms. Prevention should include pneumoallergens, food allergens, and non-specific environmental risk factors, such as parental smoking (particularly mothers), pollution inside and outside the home, etc. Prevention is particularly important in children at risk of allergy, as determined by a family history among first-degree relatives, as well as the presence of atopic dermatitis, particularly of early onset, because these patient are most at risk of developing bronchial asthma in later years. At present, pharmacological prevention is being studied, without overlooking environmental prevention, in children at high risk of atopic disease for the purpose of preventing chronic inflammations that will condition their future as adults. In our daily clinical experience, atopic dermatitis is responsible for 8% of visits to a pediatric allergology unit. We emphasize that 62.5% of our patients with dermatitis are referred when they already have bronchial asthma, which represents an important delay in diagnosis with respect to the onset of symptoms.

Objective: In order to explore the association between poorly controllable asthma and gastroesophageal reflux (GER), a prospective clinical trial is presented., Material and Method: This trial included 28 patients with negative atopic indicators who presented difficulty in the management of their disease. All patients underwent a complete medical history as well as skin tests for common airborne allergens, total serum IgE, peripheral blood eosinophils, spirometry, chest X-ray and esophageal barium films. Additionally, esophageal endoscopy was performed on 9 patients, and esophageal manometry in 1 patient. All were submitted to antireflux therapy and received omeprazole and cisapride for 8 weeks., Results: Complete improvement was observed in 24 patients (85.7%), moderate improvement in 3 patients (10.7%), and no improvement in 1 patient (3.6%). Three patients required antireflux surgery., Conclusions: Symptoms reappeared 2-3 weeks after suspending treatment, which led to the recommendation that antireflux measures become a way of life for these patients.

It is frequent the lack of family adherence toward the therapeutic measures of the allergic diseases. The incidence in the therapeutic non compliance of the asthmatic patients vary from 20 to 80%. In the last decades, the symptomatic expression of the atopic diseases (AD) in the infancy, and in the adolescence of Venezuelans has been transformed into a health care problem, with an inaccessible therapeutic cost for the state and the family. The setup of the first allergic prevention program improved attitudes and perceptions toward bronchial asthma, allergic rhinitis, and atopic dermatitis, by the education of the risk family group, based on the results from previous investigations and adapted to the procedures and customs that govern our current society. A research project, through a multi-disciplinary group included an educational program model for the prevention of allergic diseases in a population from Caracas, Venezuelan allergic pregnant mothers, and their respective couples of a high and middle socioeconomic levels with no helminthic infections (n = 482), group A. Two subgroups were randomly selected for prospective evaluation: A1 (n = 20) without participation in the preventive program or control group, and A2 (n = 15) with participation in the program or intervened group, including strategies to be applied by the family, application of measures and reached goals; immunologic, pediatric, and nutritional sequential control; group B (n = 66), to validate the laboratory tests, and group C (n = 364) to validate immunoclinical diagnoses, in vivo immunodiagnostic tests to the parents and children (clinical history, skin prick tests for cow's milk, egg white, wheat, soybean, cladosporium and Dermatophagoides pteronnysinus), and in vitro tests (total serum IgE, Phadiatop, and Rast to the allergens previously selected). In conclusion, the program permits the identification of atopic risk children, sponsors the systematical application of intervention measures, economic, viable and projected toward the family affected, indicating a positive change through a self-family-management training and new conduct plans, facilitating the participation among the family, the community and the health team, that certifies, an optimistic therapy in the reduction of the clinical manifestations of the atopic diseases in young infants from this tropical population studied.

The role of viral infections as a part of the environmental factors that triggered asthma in atopic subjects, their age specific pattern, as well as many risk factors for the development of subsequent wheezing are described. Some pathogenic mechanisms and their importance in the induction of airway inflammation are mentioned and early identification by laboratory tests in outlined for preventive approach and early antiinflammatory treatment.