Search

Introduction Cow's milk and egg are the most frequent causes of food allergy in the first years of life. Treatments such as oral immunotherapy (OIT) have been investigated as an alternative to avoidance diets. No clinical practice guides on the management of OIT with milk and egg are currently available. Objectives To develop a clinical guide on OIT based on the available scientific evidence and the opinions of experts. Methods A review was made of studies published in the period between 1984 and June 2016, Doctoral Theses published in Spain, and summaries of communications at congresses (SEAIC, SEICAP, EAACI, AAAAI), with evaluation of the opinion consensus established by a group of experts pertaining to the scientific societies SEICAP and SEAIC. Results Recommendations have been established regarding the indications, requirements and practical aspects of the different phases of OIT, as well as special protocols for patients at high risk of suffering adverse reactions. Conclusions A clinical practice guide is presented for the management of OIT with milk and egg, based on the opinion consensus of Spanish experts.

The diagnosis of IgE-mediated cow's milk allergy (CMA) is often based on clinical history and on specific IgE levels and/or skin-prick tests (SPT), both of which are sensitive but not specific. The gold standard, oral food challenge (OFC), is expensive and time-consuming and involves a risk of severe allergic reactions. This study aimed to determine the value of specific IgEs, ratios of specific IgEs for cow's milk and its components to total IgE, and wheal size on SPT for predicting a positive OFC for CMA.We retrospectively studied 72 patients [median age, four years; age range 0.75-15 years] sensitized to cow's milk who underwent OFCs to milk. predictive variables between patients with positive and negative OFCs were compared. Receiver operator characteristic (ROC) curves were uses to assess variables' discriminatory capacity and Youden's index to determine the best cut-offs for predicting CMA.The OFC was positive in 39 (54%) patients. Wheal size on SPT and all specific IgEs and specific-to-total IgE ratios were significantly different between patients with positive OFCs and those with negative OFCs (p0.001). The variable with the greatest area under the ROC curve was casein-specific IgE (0.98), followed by β-lactoglobulin-specific IgE (0.923), casein-specific-to-total-IgE ratio (0.919), and α-lactalbumin-specific IgE (0.908). Casein-specific IgE ≥0.95kU/L yielded 88.9% sensitivity and 90.9% specificity.In our center, casein-specific IgE0.95kU/L can obviate an OFC to cow's milk for the diagnosis of CMA in patients sensitized to cow's milk with a compatible history.

Allergic respiratory diseases are major health problems in paediatric population due their high level of prevalence and chronicity, and to their relevance in the costs and quality of life. One of the most important risk factors for the development of airway diseases in children and adolescents is atopy. The mainstays for the treatment of these diseases are avoiding allergens, controlling symptoms, and preventing them through sustained desensitization by allergen immunotherapy (AIT). AIT is a treatment option that consists in the administration of increasing amounts of allergens to modify the biological response to them, inducing long-term tolerance even after treatment has ended. This treatment approach has shown to decrease symptoms and improve quality of life, becoming cost effective for a large number of patients. In addition, it is considered the only treatment that can influence the natural course of the disease by targeting the cause of the allergic inflammatory response. The aim of this publication is to reflect the advances of AIT in the diagnosis and treatment of allergic respiratory diseases in children and adolescents reviewing articles published since 2000, establishing evidence categories to support the strength of the recommendations based on evidence. The first part of the article covers the prerequisite issues to understand how AIT is effective, such as the correct etiologic and clinical diagnosis of allergic respiratory diseases. Following this, the article outlines the advancements in understanding the mechanisms by which AIT achieve immune tolerance to allergens. Administration routes, treatment regimens, dose and duration, efficacy, safety, and factors associated with adherence are also reviewed. Finally, the article reviews future advances in the research of AIT.

Introduction Cow's milk and egg are the most frequent causes of food allergy in the first years of life. Treatments such as oral immunotherapy (OIT) have been investigated as an alternative to avoidance diets. No clinical practice guides on the management of OIT with milk and egg are currently available. Objectives To develop a clinical guide on OIT based on the available scientific evidence and the opinions of experts. Methods A review was made of studies published in the period between 1984 and June 2016, Doctoral Theses published in Spain, and summaries of communications at congresses (SEAIC, SEICAP, EAACI, AAAAI), with evaluation of the opinion consensus established by a group of experts pertaining to the scientific societies SEICAP and SEAIC. Results Recommendations have been established regarding the indications, requirements and practical aspects of the different phases of OIT, as well as special protocols for patients at high risk of suffering adverse reactions. Conclusions A clinical practice guide is presented for the management of OIT with milk and egg, based on the opinion consensus of Spanish experts.

Allergic respiratory diseases are major health problems in paediatric population due their high level of prevalence and chronicity, and to their relevance in the costs and quality of life. One of the most important risk factors for the development of airway diseases in children and adolescents is atopy. The mainstays for the treatment of these diseases are avoiding allergens, controlling symptoms, and preventing them through sustained desensitization by allergen immunotherapy (AIT). AIT is a treatment option that consists in the administration of increasing amounts of allergens to modify the biological response to them, inducing long-term tolerance even after treatment has ended. This treatment approach has shown to decrease symptoms and improve quality of life, becoming cost effective for a large number of patients. In addition, it is considered the only treatment that can influence the natural course of the disease by targeting the cause of the allergic inflammatory response. The aim of this publication is to reflect the advances of AIT in the diagnosis and treatment of allergic respiratory diseases in children and adolescents reviewing articles published since 2000, establishing evidence categories to support the strength of the recommendations based on evidence. The first part of the article covers the prerequisite issues to understand how AIT is effective, such as the correct etiologic and clinical diagnosis of allergic respiratory diseases. Following this, the article outlines the advancements in understanding the mechanisms by which AIT achieve immune tolerance to allergens. Administration routes, treatment regimens, dose and duration, efficacy, safety, and factors associated with adherence are also reviewed. Finally, the article reviews future advances in the research of AIT.

Aim: Streptococcus pneumoniae is the most common cause of bacteraemia, pneumonia, sinusitis and acute otitis media. With the advent of conjugate vaccines, there is now the possibility of preventing disease caused by this organism. However, little is known about the epidemiology of invasive pneumococcal disease in children in Spain. The aim of this study was to determine the incidence and the clinical and microbiologic characteristics of invasive pneumococcal disease in Sabadell, an industrial area in the province of Barcelona, Spain. Methods: From January 1990 to December 2000, the case records of children with pneumococcal invasive disease at Sabadell Hospital were retrospectively (1990–1996) reviewed and prospectively (1997–2000) collected. The hospital serves a population of 61 143 children under 15 y of age, 18 073 children under 4y of age and 7300 children under 2 y of age. Results: A total of 112 children (54% under 24 mo of age and 93% under 6 y of age) with invasive pneumococcal disease were diagnosed during a period of 11 y. The incidence of invasive pneumococcal disease was 76 per 100000 for children aged 0 to 24 mo, 45 for children aged 0–48 mo and 16.6 for children aged 0-14 y. Occult bacteraemia was the most common manifestation of invasive pneumococcal disease (66 cases), pneumonia was the second form (34 cases) and meningitis (10 cases) and arthritis (2 cases) were the other clinical manifestations. Of the 105 strains tested, 8.6% were highly penicillin resistant, 37.1% were intermediately penicillin resistant, 16.2% were intermediately cefotaxime resistant and 32.4% were erythromycin resistant. Pneumococci of serogroups 6, 14, 18, 19, 1, 5, 4, 9, 23 and 33 were the most frequently isolated groups (92%) but only 6, 9, 14, 19 and 23 were resistant to penicillin, cefotaxime, or erythromycin. Conclusions. In this study the incidence of invasive pneumococcal disease was found to be greater than that reported elsewhere in Spain and Europe. Penicillin resistance levels are high but the trend towards increasing penicillin resistance may have ended over the past few years. The currently licensed seven-valent (7-V) pneumococcal conjugate vaccine would cover 78% of cases of invasive pneumococcal in children aged 0–14 y, 80% in children aged 0–24 mo and 100% of cases of penicillin- or cefotaxime-resistant invasive pneumococcal disease.

Resumen: La pletismografía corporal completa permite la medición de volúmenes, capacidades y resistencias pulmonares. Es una técnica bien estandarizada y ampliamente utilizada en neumología pediátrica, aunque requiere equipo específico, personal especializado y cierta colaboración por parte del paciente. La pletismografía utiliza la ley de Boyle para determinar el volumen de gas intratorácico o capacidad residual funcional, y una vez determinada esta, se extrapolan el volumen residual y la capacidad pulmonar total. La medición de la capacidad pulmonar total es necesaria para el diagnóstico de patología restrictiva. La resistencia de la vía aérea es una medida de obstrucción, pudiéndose determinar la resistencia total, que incluye la resistencia de la pared torácica, tejido pulmonar y vía aérea, y la resistencia específica, que es un parámetro más estable que corresponde al producto de la resistencia de la vía aérea por la capacidad residual funcional. La complejidad de esta técnica, las ecuaciones de referencia, las diferencias en el equipamiento, la variabilidad de la misma y las condiciones en las que se realiza han hecho necesaria su estandarización. Se analizan a lo largo del artículo los aspectos prácticos de esta técnica, especificando las recomendaciones para su realización, sistemática de calibración y los cálculos que se deben llevar a cabo, así como la interpretación de los resultados obtenidos. El objetivo de esta publicación es favorecer una mejor comprensión de los principios de la pletismografía completa con el fin de optimizar la interpretación de los resultados favoreciendo un mejor manejo del paciente y un consenso en la especialidad. Abstract: Whole body plethysmography is used to measure lung volumes, capacities and resistances. It is a well standardised technique, and although it is widely used in paediatric chest diseases units, it requires specific equipment, specialist staff, and some cooperation by the patient. Plethysmography uses Boyle's law in order to measure the intrathoracic gas volume or functional residual capacity, and once this is determined, the residual volume and total lung capacity is extrapolated. The measurement of total lung capacity is necessary for the diagnosis of restrictive diseases. Airway resistance is a measurement of obstruction, with the total resistance being able to be measured, which includes chest wall, lung tissue and airway resistance, as well as the specific airway resistance, which is a more stable parameter that is determined by multiplying the measured values of airway resistance and functional residual capacity. The complexity of this technique, the reference equations, the differences in the equipment and their variability, and the conditions in which it is performed, has led to the need for its standardisation. Throughout this article, the practical aspects of plethysmography are analysed, specifying recommendations for performing it, its systematic calibration and the calculations that must be made, as well as the interpretation of the results obtained. The aim of this article is to provide a better understanding of the principles of whole body plethysmography with the aim of optimising the interpretation of the results, leading to improved management of the patient, as well as a consensus among the speciality.

The diffusion capacity is the technique that measures the ability of the respiratory system for gas exchange, thus allowing a diagnosis of the malfunction of the alveolar-capillary unit. The most important parameter to assess is the CO diffusion capacity (DLCO). New methods are currently being used to measure the diffusion using nitric oxide (NO). There are other methods for measuring diffusion, although in this article the single breath technique is mainly referred to, as it is the most widely used and best standardised.Its complexity, its reference equations, differences in equipment, inter-patient variability and conditions in which the DLCO is performed, lead to a wide inter-laboratory variability, although its standardisation makes this a more reliable and reproductive method.The practical aspects of the technique are analysed, by specifying the recommendations to carry out a suitable procedure, the calibration routine, calculations and adjustments. Clinical applications are also discussed. An increase in the transfer of CO occurs in diseases in which there is an increased volume of blood in the pulmonary capillaries, such as in polycythemia and pulmonary haemorrhage. There is a decrease in DLCO in patients with alveolar volume reduction or diffusion defects, either by altered alveolar-capillary membrane (interstitial diseases) or decreased volume of blood in the pulmonary capillaries (pulmonary embolism or primary pulmonary hypertension). Other causes of decreased or increased DLCO are also highlighted. Resumen: La capacidad de difusión es la técnica que mide la capacidad del aparato respiratorio para realizar el intercambio gaseoso y así diagnosticar la disfunción de la unidad alvéolo-capilar.El parámetro más importante a evaluar es la capacidad de difusión del CO (DLCO). Actualmente hay nuevos métodos para medir la capacidad de difusión utilizando óxido nítrico (NO). Existen diferentes métodos de medida, aunque en este artículo nos referiremos sobre todo a la técnica de la respiración única, la más utilizada y mejor estandarizada.Su complejidad, sus ecuaciones de referencia, las diferencias en equipamiento, la variabilidad interpacientes y las condiciones en las que se realiza hacen que exista una gran variabilidad interlaboratorio, habiéndose realizado estandarizaciones para hacer este método más fiable y reproducible.Se analizan los aspectos prácticos de la técnica, especificando las recomendaciones para la realización de un procedimiento adecuado, sistemática de calibración y cálculos y ajustes necesarios. También se exponen sus aplicaciones clínicas.Se produce un aumento de la transferencia de CO en las enfermedades en las que existe un aumento del volumen sanguíneo en los capilares pulmonares, en la policitemia y en la hemorragia pulmonar. Existe una disminución de la DLCO en los pacientes con reducción del volumen alveolar o en los defectos de difusión, ya sea por alteración de la membrana alvéolo-capilar (enfermedad intersticial) o por disminución del volumen de sangre en los capilares pulmonares (embolia pulmonar o hipertensión pulmonar primaria). También se exponen otras causas de disminución o aumento de la DLCO.

The clinical and immunological characteristics that suggest diverse forms of primary immunodeficiency are discussed. Data on the hospitals that perform immunological, molecular and genetic tests for the diagnosis of most of the primary immunodeficiencies in Spain are presented.

Resumen Antecedentes Streptococcus pneumoniae es la primera causa de infeccion invasiva adquirida en la comunidad en la infancia. Supone la causa principal de bacteriemia y neumonia bacteriana y la segunda causa de meningitis bacteriana, solo por detras de la meningitis meningococica. Ademas, es el agente causal mas importante de otitis media y sinusitis en el nino. Recientemente, con la comercializacion de la primera vacuna antineumococica conjugada, parece posible la prevencion de esta infeccion tan frecuente. Objetivos Conocer la incidencia de la infeccion invasiva por Streptococcus pneumoniae en el Hospital de Sabadell, que sirve a una poblacion de 371.663 habitantes, y establecer el posible impacto de la aplicacion de las nuevas vacunas antineumococicas conjugadas en los ninos de nuestra area. Metodos Desde enero de 1990 hasta diciembre de 2001 hemos recogido de forma retrospectiva (1990–1996) y posteriormente de forma prospectiva (1997–2001) todos los casos de infeccion invasiva neumococica diagnosticados en nuestro hospital. El Hospital de Sabadell sirve a una poblacion de 61.143 ninos menores de 15 anos de edad, 18.073 menores de 4 anos y 7.300 menores de 2 anos, segun datos de 1997, y hemos calculado las tasas de incidencia segun este censo. Asimismo, se ha determinado el serogrupo del neumococo en la mayoria de los casos, para poder establecer el porcentaje de proteccion que tendrian las vacunas antineumococicas conjugadas. Resultados En estos 12 anos hemos diagnosticado un total de 126 casos de infeccion invasiva neumococica, el 55% en menores de 2 anos de edad, el 79% en menores de 4 anos y el 91% en menores de 6 anos. La incidencia de infeccion invasiva neumococica fue de 79 casos por 100.000 ninos menores de 2 anos, 46 casos para el grupo de 0 a 4 anos y 17 casos para el de 0 a 15 anos de edad. La forma clinica mas frecuente fue la bacteriemia oculta con 74 casos (51/100.000 Conclusiones Actualmente, el neumococo es la primera causa de infeccion invasiva en la infancia en nuestra area, con incidencias que superan en estos momentos a la infeccion meningococica. Nuestra incidencia es mas alta que la publicada en nuestro pais hasta el momento, quiza debido al elevado numero de casos de bacteriemia oculta. La vacuna antineumococica conjugada heptavalente comercializada desde 2001 protegeria el 76% de todos nuestros casos, siendo este porcentaje algo mayor en los menores de 2 anos (81%) y menor en los mayores de 6 anos (42%).

Antecedentes: Streptococcus pneumoniae es el primer agente causal de neumonía bacteriana adquirida en la comunidad en la infancia. Para su diagnóstico el aislamiento en sangre de S. pneumoniae es el único método válido. Con la aparición de las nuevas vacunas conjugadas antineumocócicas se pueden prevenir estas infecciones. Existen estudios sobre la incidencia global de la enfermedad invasiva neumocócica (EIN) y sobre sus formas más graves como la meningitis, pero muy pocos la neumonía neumocócica bacteriémica (NNB) y sus complicaciones en la infancia. Objetivos: Conocer la incidencia, forma de presentación clínica y analítica, porcentaje y días de ingreso, respuesta al tratamiento antibiótico y resistencia a éstos, complicaciones y serogrupos causales de la NNB en nuestros medio para estimar la necesidad de una vacunación sistemática. Material y métodos: Desde enero de 1990 hasta mayo de 2002 se han recogido todos los casos pediátricos de EIN diagnosticados en nuestro hospital. Del total de estos casos se analizaron diversas características en los pacientes con NNB. Se consideraron NNB los casos con radiología torácica compatible con neumonía y hemocultivo o cultivo de líquido pleural positivo para S. pneumoniae. Se calculó la incidencia, tanto de la EIN como de la NNB, según los datos de población censales. Todas las cepas de S. pneumoniae fueron enviadas para serotipificación al Laboratorio de Referencia de Neumococos del Instituto de Salud Carlos III en Majadahonda (Madrid). Se estimó la cobertura vacunal de la nueva vacuna antineumocócica conjugada heptavalente según los serotipos incluidos en ella y la distribución de los serotipos. Resultados: Se diagnosticaron 40 casos de NNB, lo que representa una incidencia de 17, 10 y 5 casos por 105 niños menores de 2, 4 y 15 años, respectivamente. La edad media fue de 50 meses, siendo el 43% menores de 4 años. El mayor número de casos se dio en enero, marzo, abril y mayo. Ingresaron el 77,5 % de los casos y la estancia media fue de 9,2 días. La duración media de la fiebre fue de 2 días y en los pacientes con derrame pleural fue de 4,2 días. Presentaron fiebre todos los casos, siendo su duración media antes del ingreso de 4 días. El 58 % de los pacientes tenían tos. El 39% presentaban afectación de su estado general, vómitos el 47 % y dolor abdominal el 28 %. En la auscultación respiratoria se detectaron estertores en el 30 % de los casos, hipofonesis en el 28 % y polipnea o disnea en el 35 %. En la mayoría de los pacientes se observó un infiltrado alveolar unilateral y el 20 % de los casos tenían un derrame pleural. El 78 % de los casos tenían una leucocitosis superior a 15.000 y el 93 % una neutrofilia mayores de 60 %. La velocidad de sedimentación globular y la proteína C reactiva fueron elevadas en el 77 y 85 % de los casos, respectivamente. El 40 % de las cepas tenían una sensibilidad disminuida a la penicilina y el 5% eran resistentes. El 18 % tenían una sensibilidad disminuida a cefotaxima y el 18% eran resistentes a eritromicina. Se serogruparon 34 cepas y en los menores de 59 meses, el 84 % de los serogrupos eran los incluidos en la vacuna heptavalente. Conclusión: La importante morbilidad de la NNB y la distribución de los serogrupos implicados apoyaría la utilización de la nueva vacuna heptavalente en esta edad. : Background: Streptococcus pneumonia is the most common bacterial cause of community-acquired pneumonia in children. The reference standard for etiological diagnosis is isolation of S. pneumoniae from blood. Since the advent of conjugate vaccines, disease caused by this organism can now be prevented. Many studies have been performed of the global incidence of invasive pneumococcal infections and of pneumococcal meningitis but few studies investigated bacteremic pneumococcal pneumonia and its complications in children. Objectives: To determine the incidence, patient characteristics, clinical signs, laboratory data, percentage and days of hospitalization, response to antibiotic treatment, antibiotic resistance, complications and causal serogroups of bacteremic pneumococcal pneumonia in our environment in order to estimate requirements for systematic vaccination programs. Material and methods: From January 1990 to May 2001, data on all pediatric cases of invasive pneumococcal infections diagnosed in our hospital were collected. Several characteristics of patients with bacteremic pneumococcal pneumonia were analyzed. Bacteremic pneumococcal pneumonia was diagnosed in patients with positive blood or pleural fluid cultures for S. pneumoniae and radiographically evident pulmonary infiltrate. The incidence of both types of pneumonia were determined according to population census data. All S. pneumonia strains were sent to the Pneumococci Reference Laboratory of the Instituto Carlos III in Madrid for serotyping. We estimated the serotype coverage of the pneumococcal 7-valent conjugate vaccine according to the serotypes included in this vaccine and their distribution. Results: Forty cases of bacteremic pneumococcal pneumonia were diagnosed, yielding an incidence of 17, 10 and 5 cases per 105 children aged less than 2, 4 and 15 years old respectively. The mean age was 50 months and 43 % were aged less than 4 years. Peaks occurred in January, March, April and May. A total of 77.5 % of the patients were admitted to hospital and the mean length of stay was 9.2 days. The mean duration of fever was 2 days and was 4.2 days in patients with pleural empyema. All patients presented fever and its mean duration before admission was 4 days. Fifty-eight percent of the patients had cough. Thirty-nine percent appeared generally unwell, vomiting was present in 47 % and abdominal pain in 28%. Respiratory auscultation detected rales in 30 % of the patients, hypophonesis in 28 % and polypnea or dyspnea in 35 %. Most patients showed alveolar bilateral infiltrations and 20 % had pleural empyema. Seventy-eight percent had WBC counts > 15,000 and 93 % showed neutrophilia of > 60%. Erythrocyte sedimentation rate and C-reactive protein were elevated in 77 % and 85 % of the patients, respectively. Overall, 40 % of the isolates showed intermediate susceptibility to penicillin and 5% were resistant. Eighteen percent showed intermediate susceptibility to cefotaxime and 18 % were resistant to erythromycin. Thirty-four strains were serogrouped and in children ≤ 59 months, 34 % of the serogroups were included in the pneumococcal 7-valent pneumococcal conjugate vaccine. Conclusion: The significant morbidity of bacteremic pneumococcal pneumonia and the implicated serogroups support the use of the new heptavalent vaccine in the pediatric age group.

Whole body plethysmography is used to measure lung volumes, capacities and resistances. It is a well standardised technique, and although it is widely used in paediatric chest diseases units, it requires specific equipment, specialist staff, and some cooperation by the patient. Plethysmography uses Boyle's law in order to measure the intrathoracic gas volume or functional residual capacity, and once this is determined, the residual volume and total lung capacity is extrapolated. The measurement of total lung capacity is necessary for the diagnosis of restrictive diseases. Airway resistance is a measurement of obstruction, with the total resistance being able to be measured, which includes chest wall, lung tissue and airway resistance, as well as the specific airway resistance, which is a more stable parameter that is determined by multiplying the measured values of airway resistance and functional residual capacity. The complexity of this technique, the reference equations, the differences in the equipment and their variability, and the conditions in which it is performed, has led to the need for its standardisation. Throughout this article, the practical aspects of plethysmography are analysed, specifying recommendations for performing it, its systematic calibration and the calculations that must be made, as well as the interpretation of the results obtained. The aim of this article is to provide a better understanding of the principles of whole body plethysmography with the aim of optimising the interpretation of the results, leading to improved management of the patient, as well as a consensus among the speciality.

Resumen: Los pacientes con enfermedad neuromuscular constituyen un grupo de riesgo importante para sufrir con frecuencia situaciones de fracaso respiratorio agudo o crónico. Desde que nacen o son diagnosticados requieren un seguimiento por parte del neumopediatra para diagnosticar y tratar las complicaciones respiratorias, que son su principal causa de fallecimiento, dentro de un contexto multidisciplinar.El soporte ventilatorio y la asistencia a la tos han mejorado la calidad de vida y el pronóstico a largo plazo de muchos de estos pacientes.En este artículo los autores repasan la fisiopatología, evaluación de la función respiratoria, trastornos del sueño y complicaciones respiratorias más frecuentes en las enfermedades neuromusculares.En un próximo artículo se analizarán los diversos tratamientos utilizados desde el punto de vista neumológico. Abstract: Patients with neuromuscular disease are an important group at risk of frequently suffering acute or chronic respiratory failure, which is their main cause of death. They require follow-up by a pediatric respiratory medicine specialist from birth or diagnosis in order to confirm the diagnosis and treat any respiratory complications within a multidisciplinary context.The ventilatory support and the cough assistance have improved the quality of life and long-term survival for many of these patients.In this paper, the authors review the pathophysiology, respiratory function evaluation, sleep disorders, and the most frequent respiratory complications in neuromuscular diseases.The various treatments used, from a respiratory medicine point of view, will be analyzed in a next paper.

The diffusion capacity is the technique that measures the ability of the respiratory system for gas exchange, thus allowing a diagnosis of the malfunction of the alveolar-capillary unit. The most important parameter to assess is the CO diffusion capacity (DLCO). New methods are currently being used to measure the diffusion using nitric oxide (NO). There are other methods for measuring diffusion, although in this article the single breath technique is mainly referred to, as it is the most widely used and best standardized. Its complexity, its reference equations, differences in equipment, inter-patient variability and conditions in which the DLCO is performed, lead to a wide inter-laboratory variability, although its standardization makes this a more reliable and reproductive method. The practical aspects of the technique are analyzed, by specifying the recommendations to carry out a suitable procedure, the calibration routine, calculations and adjustments. Clinical applications are also discussed. An increase in the transfer of CO occurs in diseases in which there is an increased volume of blood in the pulmonary capillaries, such as in the polycythemia and pulmonary hemorrhage. There is a decrease in DLCO in patients with alveolar volume reduction or diffusion defects, either by altered alveolar-capillary membrane (interstitial diseases) or decreased volume of blood in the pulmonary capillaries (pulmonary embolism or primary pulmonary hypertension). Other causes of decreased or increased DLCO are also highlighted.

Patients with neuromuscular disease are an important group at risk of frequently suffering acute or chronic respiratory failure, which is their main cause of death. They require follow-up by a pediatric respiratory medicine specialist from birth or diagnosis in order to confirm the diagnosis and treat any respiratory complications within a multidisciplinary context. The ventilatory support and the cough assistance have improved the quality of life and long-term survival for many of these patients. In this paper, the authors review the pathophysiology, respiratory function evaluation, sleep disorders, and the most frequent respiratory complications in neuromuscular diseases. The various treatments used, from a respiratory medicine point of view, will be analyzed in a next paper.

Immunotherapy selectively modulates the allergen-specific immune response. It involves the gradual administration of increasing amounts of allergen for the purpose of inducing protective immunological changes and it is the only curative approach for specific type I allergy.Description of the allergic inflammation.- Comprehension of the early cellular changes after specific immunotherapy has been initiated. Exposure of the mechanisms involved in tolerance induction by regulatory T cells (Treg) with the inhibition of the Th2 responses. Comprehension of IL-10 and transforming growth factor (TGF- ) roles. Explanation of specific IgE, IgG and IgA changes. Description of the suppression of inflammatory responses during immunotherapy.

Resumen: La capacidad de difusión es la técnica que mide la capacidad del aparato respiratorio para realizar el intercambio gaseoso y así diagnosticar la disfunción de la unidad alvéolo-capilar.El parámetro más importante a evaluar es la capacidad de difusión del CO (DLCO). Actualmente hay nuevos métodos para medir la capacidad de difusión utilizando óxido nítrico (NO). Existen diferentes métodos de medida, aunque en este artículo nos referiremos sobre todo a la técnica de la respiración única, la más utilizada y mejor estandarizada.Su complejidad, sus ecuaciones de referencia, las diferencias en equipamiento, la variabilidad interpacientes y las condiciones en las que se realiza hacen que exista una gran variabilidad interlaboratorio, habiéndose realizado estandarizaciones para hacer este método más fiable y reproducible.Se analizan los aspectos prácticos de la técnica, especificando las recomendaciones para la realización de un procedimiento adecuado, sistemática de calibración y cálculos y ajustes necesarios. También se exponen sus aplicaciones clínicas.Se produce un aumento de la transferencia de CO en las enfermedades en las que existe un aumento del volumen sanguíneo en los capilares pulmonares, en la policitemia y en la hemorragia pulmonar. Existe una disminución de la DLCO en los pacientes con reducción del volumen alveolar o en los defectos de difusión, ya sea por alteración de la membrana alvéolo-capilar (enfermedad intersticial) o por disminución del volumen de sangre en los capilares pulmonares (embolia pulmonar o hipertensión pulmonar primaria). También se exponen otras causas de disminución o aumento de la DLCO. Abstract: The diffusion capacity is the technique that measures the ability of the respiratory system for gas exchange, thus allowing a diagnosis of the malfunction of the alveolar-capillary unit. The most important parameter to assess is the CO diffusion capacity (DLCO). New methods are currently being used to measure the diffusion using nitric oxide (NO). There are other methods for measuring diffusion, although in this article the single breath technique is mainly referred to, as it is the most widely used and best standardized.Its complexity, its reference equations, differences in equipment, inter-patient variability and conditions in which the DLCO is performed, lead to a wide inter-laboratory variability, although its standardization makes this a more reliable and reproductive method.The practical aspects of the technique are analyzed, by specifying the recommendations to carry out a suitable procedure, the calibration routine, calculations and adjustments. Clinical applications are also discussed. An increase in the transfer of CO occurs in diseases in which there is an increased volume of blood in the pulmonary capillaries, such as in the polycythemia and pulmonary hemorrhage. There is a decrease in DLCO in patients with alveolar volume reduction or diffusion defects, either by altered alveolar-capillary membrane (interstitial diseases) or decreased volume of blood in the pulmonary capillaries (pulmonary embolism or primary pulmonary hypertension). Other causes of decreased or increased DLCO are also highlighted.

Whole body plethysmography is used to measure lung volumes, capacities and resistances. It is a well standardised technique, and although it is widely used in paediatric chest diseases units, it requires specific equipment, specialist staff, and some cooperation by the patient. Plethysmography uses Boyle's law in order to measure the intrathoracic gas volume or functional residual capacity, and once this is determined, the residual volume and total lung capacity are extrapolated. The measurement of total lung capacity is necessary for the diagnosis of restrictive diseases. Airway resistance is a measurement of obstruction, with the total resistance being able to be measured, which includes chest wall, lung tissue and airway resistance, as well as the specific airway resistance, which is a more stable parameter that is determined by multiplying the measured values of airway resistance and functional residual capacity. The complexity of this technique, the reference equations, the differences in the equipment and their variability, and the conditions in which it is performed, has led to the need for its standardisation. Throughout this article, the practical aspects of plethysmography are analysed, specifying recommendations for performing it, its systematic calibration and the calculations that must be made, as well as the interpretation of the results obtained. The aim of this article is to provide a better understanding of the principles of whole body plethysmography with the aim of optimising the interpretation of the results, leading to improved management of the patient, as well as a consensus among the speciality. Resumen: La pletismografía corporal completa permite la medición de volúmenes, capacidades y resistencias pulmonares. Es una técnica bien estandarizada y ampliamente utilizada en neumología pediátrica, aunque requiere equipo específico, personal especializado y cierta colaboración por parte del paciente. La pletismografía utiliza la ley de Boyle para determinar el volumen de gas intratorácico o capacidad residual funcional, y una vez determinada esta, se extrapolan el volumen residual y la capacidad pulmonar total. La medición de la capacidad pulmonar total es necesaria para el diagnóstico de patología restrictiva. La resistencia de la vía aérea es una medida de obstrucción, pudiéndose determinar la resistencia total, que incluye la resistencia de la pared torácica, tejido pulmonar y vía aérea, y la resistencia específica, que es un parámetro más estable que corresponde al producto de la resistencia de la vía aérea por la capacidad residual funcional. La complejidad de esta técnica, las ecuaciones de referencia, las diferencias en el equipamiento, la variabilidad de la misma y las condiciones en las que se realiza han hecho necesaria su estandarización. Se analizan a lo largo del artículo los aspectos prácticos de esta técnica, especificando las recomendaciones para su realización, sistemática de calibración y los cálculos que se deben llevar a cabo, así como la interpretación de los resultados obtenidos. El objetivo de esta publicación es favorecer una mejor comprensión de los principios de la pletismografía completa con el fin de optimizar la interpretación de los resultados favoreciendo un mejor manejo del paciente y un consenso en la especialidad.

Bronchial hyperreactivity (BHR) is a characteristic of bronchial asthma. Patients with allergic rhinitis who do not report symptoms of bronchial asthma on spirometry show BHR, which could indicate the presence of subclinical inflammation of the lower respiratory airway. The aim of this study was to investigate whether the patients diagnosed with allergic rhinitis in our unit without symptoms of bronchial asthma had bronchial hyperreactivity and to determine which allergens caused these symptoms in our patients.We performed a retrospective, observational study of patients diagnosed with allergic rhinitis in our Allergy Unit between August 2000 and December 2001. The patients' medical records were reviewed and data on the following were gathered: demographic information, age, sex, rhinitis symptoms (perennial or seasonal), conjunctivitis, atopic dermatitis, bronchitis, sensitization (specific IgE, skin tests, nasal challenge tests), total IgE levels, spirometry performed through stress test (positive with a decrease of FEV115 % with stress or an increase of FEV1 of 12 % after bronchodilation) and family history of allergic disease. A total of 135 medical records of patients with allergic rhinitis were reviewed. Of these, 68 did not report symptoms of bronchial asthma (35 men and 33 women aged between 4 and 18 years). Most of our patients (50/68) reported perennial asthma and were sensitized to mites (44/68). In 14/68 spirometry was not performed at diagnosis. Stress test was positive in 13/54 (24 %). All patients who showed bronchial hyperreactivity were sensitized to mites and only one of these reported seasonal rhinitis.According to the latest guidelines on the treatment and control of allergic rhinitis --The Allergic Rhinitis and its Impact on Asthma Workshop Report-- bronchial asthma and allergic rhinitis are distinct manifestations of a single airway and of the same disease. In view of our results, we recommend systematic evaluation of bronchial hyperreactivity in the study protocol of allergic rhinitis in patients who do not report symptoms of bronchial asthma.

Streptococcus pneumoniae is the most common cause of bacteraemia, pneumonia, sinusitis and acute otitis media. With the advent of conjugate vaccines, there is now the possibility of preventing disease caused by this organism. However, little is known about the epidemiology of invasive pneumococcal disease in children in Spain. The aim of this study was to determine the incidence and the clinical and microbiologic characteristics of invasive pneumococcal disease in Sabadell, an industrial area in the province of Barcelona, Spain.From January 1990 to December 2000, the case records of children with pneumococcal invasive disease at Sabadell Hospital were retrospectively (1990-1996) reviewed and prospectively (1997-2000) collected. The hospital serves a population of 61,143 children under 15 y of age, 18,073 children under 4 y of age and 7300 children under 2 y of age.A total of 112 children (54% under 24 mo of age and 93% under 6 y of age) with invasive pneumococcal disease were diagnosed during a period of 11 y. The incidence of invasive pneumococcal disease was 76 per 100,000 for children aged 0 to 24 mo, 45 for children aged 0-48 mo and 16.6 for children aged 0-14 y. Occult bacteraemia was the most common manifestation of invasive pneumococcal disease (66 cases), pneumonia was the second form (34 cases) and meningitis (10 cases) and arthritis (2 cases) were the other clinical manifestations. Of the 105 strains tested, 8.6% were highly penicillin resistant, 37.1% were intermediately penicillin resistant. 16.2% were intermediately cefotaxime resistant and 32.4% were erythromycin resistant. Pneumococci of serogroups 6, 14, 18, 19, 1, 5, 4, 9, 23 and 33 were the most frequently isolated groups (92%) but only 6, 9, 14, 19 and 23 were resistant to penicillin, cefotaxime, or erythromycin.In this study the incidence of invasive pneumococcal disease was found to be greater than that reported elsewhere in Spain and Europe. Penicillin resistance levels are high but the trend towards increasing penicillin resistance may have ended over the past few years. The currently licensed seven-valent (7-V) pneumococcal conjugate vaccine would cover 78% of cases of invasive pneumococcal in children aged 0-14 y, 80% in children aged 0-24 mo and 100% of cases of penicillin- or cefotaxime-resistant invasive pneumococcal disease.

Specific immunotherapy with allergens is the only treatment capacite of modifying the natural course of allergic diseases. Although its effectiveness is higher when started in early stages, WHO guidelines still consider age under 5 years as relative contraindication.A review of a group of 22 children starting immunotherapy before the age of 5 years in a pediatric allergy unit was attempted to assess the effectiveness and safety of this treatment.Clinical charts of 22 children with house dust mite asthma starting conventional immunotherapy before the age of 5 years were reviewed. In all cases, biologically standardized extracts and conventional subcutaneous schedules have been used and administration was performed in a hospital setting. Effectiveness and safety were evaluated by clinical scores. The average treatment period was 16.95 ( 10.12) months. Systemic reactions (moderate) were observed in 7 children and local reactions in 5. Children treated for more than 1 year (15 patients) showed a decrease in the number of yearly acute exacerbations (from 5.13 to 2.57) and in hospital admissions (from 5 to 2 children). In 10 patients, drug requirements for bronchial asthma were reduced.The clinical data if this study suggest that house dust mite specific immunotherapy under hospital control can be begun in young children with good tolerance and clinical improvement.