The future in paediatric respirology

Abstract

The authors were given the charge of providing a vision of the future in paediatric respirology. Themes selected for being ripe for this visionary analysis include bronchopulmonary dysplasia (BPD), asthma, cystic fibrosis (CF), lung infections, obstructive sleep disordered breathing (OSDB) and pulmonary diagnostics and monitoring. A profound reduction or elimination of BPD is seen. Given the strong genetic component of this disease, genetic biomarkers will likely be identified that will permit much earlier recognition of BPD susceptibility and potentially the ability to modify disease course by altering gene expression. The ultimate prevention of BPD will be to prevent prematurity, but recognition of both the genetic basis of BPD and the inflammatory background should lead to improved prevention and therapy. A clear understanding and definition of asthma phenotypes will lead to more specific and targeted therapy, earlier detection and prevention, better monitoring of severity and adherence to therapy, lower mortality and decreased inappropriate diagnosis of asthma. The greatest opportunities in asthma care will likely come through tools to improve adherence to effective therapy. Also, areas are identified where better therapies are needed such as in patients with severe mucus hypersecretion (secretory hyperresponsiveness) especially in those with lifethreatening asthma. The future of CF is easier to foresee with early successes seen in clinical trials. After the expected ability to correct the CF transmembrane regulator, care will need to change and additional research will be needed. Additionally, the face of CF is changing with more adults than children presently having the disease. This will necessitate changes to our approach to treating this disease in a fortunately aging population. If we are going to affect the worldwide lung health of children, we will need to address respiratory infections particularly pneumonia, tuberculosis and HIV-associated infections. Preventive, diagnostic and treatment strategies will shape the future face of these problems. The availability of inexpensive, readily available, and rapid molecular techniques to identify true infection (including HIV and tuberculosis) may permit earlier use of effective therapy while preventing the inappropriate use of antibiotics for common viral diseases. Sleep medicine will continue to be an important aspect of paediatric pulmonology. The evaluation of OSDB cannot rely on full-night attended polysomnography due to limited access. Identifying reliable markers of end organ dysfunction in children with OSDB may permit more rapid identification of patients in need of intervention like CPAP and assisted breathing. In addition, management options, as an alternative to adenotonsilectomy, are listed with a call for further research. Pulmonary diagnostics and monitoring will see the development and refinement of tools like the lung clearance index and the analysis of exhaled gasses, volatiles and dissolved biomarkers of inflammation as techniques ...

“New” Bronchopulmonary Dysplasia

“…In addition to the prevention of premature birth, identifying the specific components of genetic contribution holds the most promise to significantly impact on decreasing, or even curing, the new BPD. 76 Recent publications have put forth the intriguing possibility of linking the pathogenesis of BPD to adult chronic obstructive pulmonary disease or emphysema. 77 In addition, ongoing studies are giving further clinical impetus to the propagation of BPD to a chronic obstructive pulmonary disease-like phenotype.…”

Use of Antibiotics within the IMCI Guidelines in Outpatient Settings in Papua New Guinean Children: An Observational and Effectiveness Study

“…C - reactive protein (CRP) can be also another valuable biomarker but results of randomized trials and meta-analysis are more conflicting. [33], [34], [35], [36] Finally, more experimental tools such as analysis of exhaled gases could be also considered [37]. New recommendations that integrate clinical assessment and biomarkers for the identification of cases that require antibiotics need to be seriously considered.…”

Clarithromycin Inhibits Interleukin-13–Induced Goblet Cell Hyperplasia in Human Airway Cells

“…Excessive mucus secretion can cause airway obstruction, impairment of gas exchange, and airway plugging (4,5), which is a contributing factor to death from asthma (57,58). By inhibiting and mucin production and hypersecretion, clarithromycin may benefit some persons with severe asthma or secretory hyperresponsiveness, which contributes to the pathogenesis of diseases like middle lobe syndrome and near-fatal asthma (59,60).…”