Lung Volume, Breathing Pattern and Ventilation Inhomogeneity in Preterm and Term Infants

BACKGROUND: Morphological changes in preterm infants with bronchopulmonary dysplasia (BPD) have functional consequences on lung volume, ventilation inhomogeneity and respiratory mechanics. Although some studies have shown lower lung volumes and increased ventilation inhomogeneity in BPD infants, conflicting results exist possibly due to differences in sedation and measurement techniques. METHODOLOGY/PRINCIPAL FINDINGS: We studied 127 infants with BPD, 58 preterm infants without BPD and 239 healthy term-born infants, at a matched post-conceptional age of 44 weeks during quiet natural sleep according to ATS/ERS standards. Lung function parameters measured were functional residual capacity (FRC) and ventilation inhomogeneity by multiple breath washout as well as tidal breathing parameters. Preterm infants with BPD had only marginally lower FRC (21.4 mL/kg) than preterm infants without BPD (23.4 mL/kg) and term-born infants (22.6 mL/kg), though there was no trend with disease severity. They also showed higher respiratory rates and lower ratios of time to peak expiratory flow and expiratory time (t(PTEF)/t(E)) than healthy preterm and term controls. These changes were related to disease severity. No differences were found for ventilation inhomogeneity. CONCLUSIONS: Our results suggest that preterm infants with BPD have a high capacity to maintain functional lung volume during natural sleep. The alterations in breathing pattern with disease severity may reflect presence of adaptive mechanisms to cope with the disease process

Experiences with a Knowledge - Based Tutoring System for Student Education in Rheumatology

A knowledge--based tutorial computer system in rheumatologyhad been integrated in a standard course of internal medicine for students in their fourth year of medical curriculum. The tutoring software is based on the expert--system shell--toolkit D3 and its tutorial component D3Trainer. Based on the knowledge base "Rheuma", which is also used for consultation, the "Rheumatrainer" is generated with the D3Trainer. The students visit the course two weeks in groups of two or three twice a week. After taking the medical history from patients, students turn to the tutorial programm "Rheumatrainer" for other parts of the diagnostic process for training of the ensuing diagnostic work up. Using the software, students learn recognition and interpretation of symptoms and findings, indication of further tests and deduction of diagnoses in a trial--and--error environment while the system is able to criticize all decisions of the student

Asthma management

The current article presents the concept of asthma control introduced in national and international guidelines, which envisages treatment according to a step-wise plan depending on the degree of asthma control. To assess the latter, short and simple questionnaires, such as the Asthma Control Test, are available and also validated for use in children. Inhaled corticosteroids (ICS) are still considered the basis of antiinflammatory therapy. Children with poorly controlled asthma under monotherapy with safely dosed ICS may be treated concurrently with a long-acting inhaled beta 2-agonist. In this context, fixed combinations of active substances should be preferred for reasons of compliance, while type and quantity should be adjusted to asthma control regularly in order to avoid long-term overtreatment

Age dependency of GLI reference values compared with paediatric lung function data in two German studies (GINIplus and LUNOKID).

A hallmark of the newly published GLI (Global Lungs Initiative) spirometric reference values is their "all-age" (3-95yr) predictive power, accomplished by incorporating non-linear age dependencies into modelling parameters. This modelling strategy is especially promising for the age range of puberty; however, the performance of GLI-values for adolescents is currently unknown. We calculated GLI-based z-scores for children/adolescents without apparent respiratory diseases from two different German studies, LUNOKID (N = 1943, 4-19 years) and GINIplus (N = 1042, 15 years) and determined the goodness of fit for specific age groups. We defined fit sufficient if the absolute mean of z-scores was <0.5. For children (<10yr) the mean GLI-based z-scores for FEV1 and FVC reached a good fit with mean z-scores for FEV1 between -0.11 and 0.01 and mean z-scores for FVC between 0.01 and 0.16, but larger deviations were observed in adolescents, especially boys (mean z-score -0.58 for FEV1 and -0.57 for FVC in GINIplus). The fit for FEV1/FVC was sufficient. GLI reference values provided reasonable estimates for the individuals enrolled in our studies, which span the age range of lung growth and development. However, we found that GLI-predictions overestimated lung volumes, especially those for German adolescent boys, which may, left unrecognised, lead to erroneous diagnosis of lung disease. Caution should be taken when applying these reference values to epidemiologic studies

Biologicals in childhood severe asthma: the European PERMEABLE survey on the status quo

Introduction: Severe asthma is a rare disease in children, for which three biologicals, anti-immunoglobulin E, anti-interleukin-5 and anti-IL4RA antibodies, are available in European countries. While global guidelines exist on who should receive biologicals, knowledge is lacking on how those guidelines are implemented in real life and which unmet needs exist in the field. In this survey, we aimed to investigate the status quo and identify open questions in biological therapy of childhood asthma across Europe. Methods: Structured interviews regarding experience with biologicals, regulations on access to the different treatment options, drug selection, therapy success and discontinuation of therapy were performed. Content analysis was used to analyse data. Results: We interviewed 37 experts from 25 European countries and Turkey and found a considerable range in the number of children treated with biologicals per centre. All participating countries provide public access to at least one biological. Most countries allow different medical disciplines to prescribe biologicals to children with asthma, and only a few restrict therapy to specialised centres. We observed significant variation in the time point at which treatment success is assessed, in therapy duration and in the success rate of discontinuation. Most participating centres intend to apply a personalised medicine approach in the future to match patients a priori to available biologicals. Conclusion: Substantial differences exist in the management of childhood severe asthma across Europe, and the need for further studies on biomarkers supporting selection of biologicals, on criteria to assess therapy response and on how/when to end therapy in stable patients is evident