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physiopathology&#44; prevalence&#44; prognosis&#44; genotypes&#44; and phenotypes&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">While some COPDC have been the object of many studies&#44; such as asthma&#44; cystic fibrosis &#40;CF&#41;&#44; recurrent wheezing in infants &#40;RWI&#41;&#44; and bronchopulmonary dysplasia &#40;BPD&#41;&#44; others are known as &#8220;orphan diseases&#44;&#8221; such as primary ciliary dyskinesia &#40;PCD&#41;&#44; non-cystic fibrosis bronchiectasis &#40;NCFB&#41;&#44; plastic bronchitis &#40;PB&#41;&#44; and bronchiolitis obliterans &#40;BO&#41;&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">COPDC are characterized by high prevalence of asthma&#44; RWI&#44; and BPD&#44; or low prevalence of BO&#44; CF&#44; PB&#44; PCD&#44; and NCFB&#46; They are noncommunicable diseases&#44; of long duration and slow progression&#44; showing episodes of pulmonary exacerbation &#40;PE&#41;&#44; acute or permanent airflow limitation&#44; and significant quality of life impairment&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> In all&#44; the main pulmonary symptom is chronic cough&#44; reflecting the presence of alterations in the airways&#44; as there are no cough receptors in the alveoli&#46; Another characteristic is the presence of bronchiectasis in many of them&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Most of them&#44; including some of the several clinical forms of asthma&#44; course with neutrophilic airway inflammation&#44; which contributes to progressive worsening of pulmonary damage and function by releasing&#58; &#40;i&#41; elastase&#58; cleaves elastin and causes bronchiectasis&#44; decreases opsonization and phagocytosis&#44; increases secretion&#44; decrease mucociliary clearance&#59; &#40;ii&#41; DNA&#58; increases the viscosity of secretions&#59; &#40;iii&#41; hydrogen peroxide and other oxidants&#58; causes tissue damage and inactivates &#945;-1-antitrypsin&#59; &#40;iv&#41; IL-8 and LTB4&#58; attract more neutrophils&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Two aspects of COPDC have been thoroughly studied&#58; the genetic component and environmental aggressions that initiate or exacerbate the diseases&#46; Most COPDC show different genotypes&#44; phenotypes&#44; endotypes&#44; and degrees of severity&#44; require different types of management&#44; and have no cure&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Pneumonia&#44; BPD&#44; BO&#44; and&#47;or RWI in the first years of life constitute risk groups for COPD in the long term and should receive medical follow-up and interventions to prevent the potential impact on long-term respiratory sequelae&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#8211;9</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">In all COPDC&#44; PE is often triggered by viral and&#47;or bacterial infections&#44; pollution&#44; and aeroallergens&#46; The PE manifests as acute respiratory failure of varying intensity&#44; both in asthma and RWI&#44; and as increased cough and chronic infection in CF&#44; BPD&#44; NCFB&#44; and PCD&#46; The signs and symptoms of PE are more frequent and intense at nighttime&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">While the majority of acute respiratory diseases can be diagnosed easily and efficiently through history and physical examination&#44; those with a chronic nature may require sophisticated laboratory tests&#46; Continuous and scheduled evaluations by interdisciplinary health teams in specialized centers are required for effective management&#44; better prognosis&#44; and improved quality of life in COPDC&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Establishing protocols based on systematic reviews&#44; meta-analyses&#44; and guidelines allows for gaining control of the signs and symptoms of COPDC&#46; Oral and &#40;OC&#41; inhaled corticosteroids &#40;IC&#41;&#44; mucolytics&#44; bronchodilators&#44; inhaled antibiotics&#44; and other drugs should be used according to specific guidelines for each COPDC&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">While some groups of drugs are widely used&#44; with variable degree of scientific evidence&#44; such as bronchodilators and IC&#44; others&#44; such as long-term macrolide use&#44; are more controversial&#46; The use of macrolides in COPDC have been justified by the anti-inflammatory and immunomodulatory effect&#44; the decrease in mucus production&#44; and neutrophil elastase inhibition&#44; in addition to reducing the production of pro-inflammatory mediators &#40;<span class="elsevierStyleItalic">e&#46;g&#46;</span> IL8&#41; and stimulating phagocytosis of apoptotic cells&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#8211;14</span></a> Although macrolides have shown to be effective in patients with CF and other COPDC&#44; 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NCFB&#44; BO&#44; and PB&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">COPDC&#58; an overview</span><p id="par0065" class="elsevierStylePara elsevierViewall">The first important feature of COPDC is that their clinical manifestations and prevalence are more common in certain age groups&#44; as shown in <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#46; The second is that interactions between the genetic component and environmental aggressions initiate or exacerbate them&#44; as shown in <a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#46; The main differences and similarities between the COPDC are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46; The third characteristic of COPDC is that they evolve with PE&#44; predominantly infectious &#40;CF&#41;&#44; inflammatory &#40;asthma&#41;&#44; and mixed &#40;asthma and viruses&#47;bacteria&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">Infectious PE caused by bacteria are different in healthy children when compared with those with COPDC&#46; <span class="elsevierStyleItalic">Streptococcus pneumoniae</span>&#44; <span class="elsevierStyleItalic">Haemophilus influenzae</span> and <span class="elsevierStyleItalic">Staphylococcus aureus</span>&#44; which have high virulence&#44; are common causes of pneumonia in previously healthy individuals without COPDC and require treatment with low-spectrum antibiotics &#40;<span class="elsevierStyleItalic">e&#46;g&#46;</span>&#44; penicillin and amoxicillin&#41;&#44; but cause short-term mortality&#46; In contrast&#44; many patients with COPDC&#44; especially those with CF&#44; PCD&#44; and NCFB&#44; have PE caused by low-virulence bacteria &#40;<span class="elsevierStyleItalic">Pseudomonas aeruginosa</span> &#40;PA&#41;&#44; <span class="elsevierStyleItalic">Burkholderia cepacia</span> complex&#44; <span class="elsevierStyleItalic">Stenotrophomonas maltophilia</span> and&#44; <span class="elsevierStyleItalic">Achromobacter xylosoxidans</span>&#41;&#44; which cause long-term mortality&#59; however&#44; they require broad-spectrum antibiotics such as aminoglycosides&#44; meropenem&#44; and third-generation cephalosporins &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">Due to the characteristics of COPDC&#44; several guidelines and systematic reviews for the diagnosis and management of the disease have been proposed for both periods between crises and PE of most COPDC&#44; aiming to prevent further deterioration of pulmonary function and damage &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;15&#8211;27</span></a></p><elsevierMultimedia ident="fig0020"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Asthma</span><p id="par0080" class="elsevierStylePara elsevierViewall">Asthmatic individuals who manifested the disease early in life persist with symptoms&#44; and evidence suggests that asthma severity in childhood predicts the disease severity in adulthood&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a> Recent guidelines emphasize difficulties for the definitive diagnosis of asthma in children younger than 5 years&#44; where several COPDC phenotypes have been identified&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">For children older than 5 years&#44; asthma diagnosis is based on&#58; &#40;1&#41; a history of acute respiratory failure crises that improve with short-acting bronchodilators &#40;SABA&#41;&#59; &#40;2&#41; increased serum IgE in the absence of parasitic diseases&#44; eosinophilia&#44; and positive immediate hypersensitivity skin tests for airborne allergens&#59; &#40;3&#41; spirometry and measurement of bronchial hyperresponsiveness &#40;BHR&#41; to methacholine challenge&#46; The diagnosis can be made with the isolated presence and&#47;or combination of the above items 1&#59; 1<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>2&#59; 1<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>3&#59; or 1<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>2<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>3&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Numerous factors have been associated with increased risk of developing asthma in adolescence&#44; of which the following should be mentioned&#58; personal or family history of allergy&#44; male gender&#44; obesity&#44; pollution&#44; exposure to cigarette smoke&#44; RWI&#44; severe infection by respiratory syncytial virus &#40;RSV&#41;&#44; pneumonia in the first year of life&#44; RWI severity&#44; altered pulmonary function&#44; and BHR&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;29&#8211;31</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">There is no specific treatment for asthma&#44; and it is preferable to use the term management for the tools used to attain disease control&#46; The main objectives for outpatient management are&#58; &#40;i&#41; make chronic symptoms minimal or nonexistent&#59; &#40;ii&#41; decrease the intensity and the number of PE&#59; &#40;iii&#41; maintain lung function as close as possible to normal levels&#59; &#40;iv&#41; maintain normal levels of daily activities&#44; including physical exercises&#59; &#40;v&#41; prevent the adverse effects of anti-asthmatic drugs&#59; &#40;vi&#41; prevent disease progression to irreversible airflow limitation&#59; &#40;vii&#41; prevent asthma mortality&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;15&#8211;20</span></a> The main medications to control asthma are inhaled corticosteroids &#40;IC&#41;&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">The classification of the clinical pictures and respective treatment steps are listed below&#58;</p><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Steps in the treatment of asthma</span><p id="par0105" class="elsevierStylePara elsevierViewall">&#40;Step 1&#41; Individuals with intermittent asthma&#44; characterized by normal spirometry and periods between crises lasting longer than 1 month without exacerbations in the last year&#44; should receive SABA&#46; &#40;Step 2&#41; Continued use of IC at low doses and rescue SABA during crisis&#46; &#40;Step 3&#41; Continued use of low doses of IC<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>long-acting beta agonists &#40;LABA&#41; with SABA for crises or IC<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>formoterol for both maintenance and control&#46; &#40;Step 4&#41; IC<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>formoterol for maintenance and crises or medium or high doses of IC<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>LABA and SABA&#44; if necessary&#46; &#40;Step 5&#41; Refer patient to a center specialized in asthma treatment for difficult-to-control disease&#58; consider oral steroids and anti-IgE &#40;omalizumab&#41;&#46; Consider oral corticosteroids in severe PE and if the patient had previous severe PE&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;15&#8211;20</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">Medications and steps are modified to the next step or revert to the previous step&#44; depending on whether or not the asthma is controlled&#46; A decrease in management steps must occur if the asthma is well controlled for at least 3 months&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">It is essential to verify at all consultations&#44; whether the asthma is controlled or not&#44; from the clinical and&#47;or functional point of view&#44; based on six parameters&#58; &#40;i&#41; nocturnal signs and symptoms&#59; &#40;ii&#41; daytime signals and symptoms&#59; &#40;iii&#41; signs and symptoms with physical exercise or limitation in daily activities&#59; &#40;iv&#41; PE&#59; &#40;v&#41; need for relief medication &#40;SABA&#41;&#59; &#40;vi&#41; changes in lung function&#46; Hence&#44; asthma is considered controlled when all parameters are normal&#59; it should be classified as partially controlled in the presence of one or two altered parameters&#59; and finally&#44; non-controlled asthma should be considered when three or more parameters are altered&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">The absence of control of signs and symptoms&#44; frequent exacerbations&#44; previous admission to an intensive care unit &#40;ICU&#41;&#44; low values of forced expiratory volume in 1<span class="elsevierStyleHsp" style=""></span>s &#40;FEV1&#41;&#44; exposure to tobacco smoke&#44; and need to use high-dose medications are characteristics associated with increased risk of adverse events in the future&#46; By definition&#44; an exacerbation at any week is indicative of non-controlled asthma and also of the need for review of the maintenance treatment&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16&#44;17</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">In the management of patients with asthma&#44; the following are essential&#58; &#40;i&#41; management supported by evidence-based medicine&#59; &#40;ii&#41; to perform the diagnosis and&#44; if possible&#44; the phenotype &#40;<span class="elsevierStyleItalic">e&#46;g</span>&#46;&#44; allergic and non-allergic&#41;&#59; &#40;iii&#41; to exclude and treat comorbidities&#59; &#40;iv&#41; to assess and recommend the adequate use of prescribed drugs&#59; &#40;v&#41; to assess&#44; advise&#44; and encourage treatment adherence&#59; &#40;vi&#41; to assess and advise about environmental prophylaxis&#59; &#40;vii&#41; to assess and advise on the triggering factors&#59; &#40;viii&#41; to educate patient&#39;s caregivers about asthma and the factors influencing it&#59; &#40;ix&#41; to give instructions on the adequate use of devices for administration of metered-dose and dry powder inhalers&#59; &#40;x&#41; instructions for patients to be able to recognize when asthma control is deteriorating and what medications to use&#44; when it occurs&#59; &#40;xi&#41; to identify non-controlled patients and causes of lack of control&#59; &#40;xii&#41; to advise that inhaled medications should be used with spacers&#59; &#40;xiii&#41; to advise on the hygiene of spacers&#44; which must be washed and left to soak in water with detergent&#59; &#40;xiv&#41; LABA must not be used in children younger than 4 years&#59; &#40;xv&#41; SABA are the agents of choice in PE&#59; &#40;xvi&#41; IC alone or associated with bronchodilators are the basis of asthma treatment&#59; &#40;xvii&#41; children younger than 6 years can use inhaled medication with spacer and those older than 6 years can use dry powder inhalers&#59; &#40;xviii&#41; to assess pulmonary function regularly&#59; &#40;xix&#41; to advise on the need for long-term medical care&#59; &#40;xx&#41; omalizumab should be prescribed in reference centers for the management of patients with difficult-to-control asthma&#46;</p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Recurrent wheezing in infants &#40;RWI&#41;</span><p id="par0130" class="elsevierStylePara elsevierViewall">There are several phenotypes and risk factors &#40;RF&#41; for RWI&#44; creating difficulties for asthma diagnosis and resulting in an excessive assessment for comorbidities&#46;<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">32&#8211;37</span></a> The main RF include&#58; presence of familial and&#47;or personal allergy&#44; early sensitization&#44; severe RSV infection&#44; maternal smoking during pregnancy&#44; and unfavorable airway geometry&#46; Other implicated RF are&#58; genetic variants&#44; excessive hygiene&#44; Western lifestyle&#44; pollution&#44; gastroesophageal reflux disease &#40;GERD&#41;&#44; low socioeconomic status&#44; urban environment&#44; antibiotic use&#44; diet&#44; few siblings&#44; ethnicity&#44; male gender&#44; and attendance of daycare&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">38</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">Exposure to maternal smoking&#44; both intrauterine and in the early years of life&#44; has contributed to increased incidence and severity of childhood and adult asthma&#44; COPD in adults&#44; lung function deficits&#44; lung hypoplasia&#44; respiratory tract infections&#44; and higher predisposition to sudden death syndrome&#46;<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">39&#8211;41</span></a> Respiratory viruses are the main RF for asthma and RWI initiation or exacerbation&#58; &#40;i&#41; some viruses initiate asthma&#59; &#40;ii&#41; the more severe the respiratory infection&#44; the higher the likelihood of developing asthma&#59; &#40;iii&#41; viruses cause PE in children and adults with established asthma&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">42</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall">The diagnosis of asthma in infants is a major challenge for clinicians&#59; to attain a diagnosis with a high degree of suspicion&#44; the presence of allergy should be investigated&#44; as it is a persistent asthma predictor&#46; The investigation of severe COPDC in children younger than 5 years may require many tests&#44; including high-resolution computed tomography &#40;HRCT&#41;&#44; lung function assessment&#44; cellular and humoral immunity evaluation&#44; bronchoscopy&#44; bronchoalveolar lavage&#44; 24-h esophageal pH-metry&#44; endobronchial biopsy&#44; mutation screening&#44; and sodium and chloride sweat measurements&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a> In contrast&#44; no investigation is necessary for most of RWI&#44; because it cannot differentiated with certainty whether the future course of the RWI will be persistent asthma or transient wheezing&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">43</span></a></p><p id="par0145" class="elsevierStylePara elsevierViewall">Some asthma predictive indices &#40;APIs&#41; have been developed to identify children with RWI and at risk for asthma after 6 years of age &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">38&#44;44</span></a> Some authors have mentioned methodological and practical limitations of APIs&#44; suggesting that they have low capacity and poor sensitivity to predict asthma at school age&#44;<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">45&#44;46</span></a> and that although they are simple and easy-to-apply tools&#44; they have not been sufficiently validated&#46; According to these authors&#44; predicting asthma using simple clinical models is virtually impossible&#46;<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">45&#44;46</span></a></p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0150" class="elsevierStylePara elsevierViewall">Although most of the scientific community is favorable to the use of APIs&#44;<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">47&#44;48</span></a> the search for clinical and&#47;or laboratory markers for the diagnosis of asthma in RWI and children younger than 5 years remains a rich area for future studies&#46; Infants and preschoolers with RWI or asthma have less PE&#44; and show symptom and lung function improvement when treated with IC&#46;<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">49&#8211;51</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">The dosages of the main IC used in COPDC are shown in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Bronchiolitis obliterans &#40;BO&#41;</span><p id="par0160" class="elsevierStylePara elsevierViewall">Bronchiolitis obliterans &#40;BO&#41; is a predominantly neutrophilic COPDC with high levels of proinflammatory cytokines&#44; bronchial remodeling&#44; and fibrosis in the small airways&#46; When the etiology is infectious&#44; it is called post-infectious BO &#40;PIBO&#41;&#46; Most often&#44; PIBO is caused by previous infection caused by adenovirus&#44; but influenza&#44; measles&#44; RSV&#44; and <span class="elsevierStyleItalic">Mycoplasma pneumoniae</span> are also observed&#46; Latin American countries have the highest rates of this disease&#46;<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">27&#44;52&#8211;62</span></a></p><p id="par0165" class="elsevierStylePara elsevierViewall">Studies have shown that lung function remains altered with an obstructive pattern and air trapping during childhood&#46; These patients are often hospitalized due to recurrent respiratory infections&#46; Patients show slight improvement over the years&#46;<a class="elsevierStyleCrossRefs" href="#bib0270"><span class="elsevierStyleSup">54&#44;62</span></a></p><p id="par0170" class="elsevierStylePara elsevierViewall">Five criteria are essential for the diagnosis of PIBO&#58; &#40;i&#41; history of acute viral bronchiolitis and viral pneumonia before the age of 3&#59; &#40;ii&#41; evidence of persistent airway obstruction after the acute event&#44; identified by physical examination and&#47;or lung function&#44; which is not responsive to at least 2 weeks of systemic corticosteroids associated with bronchodilator&#59; &#40;iii&#41; radiological findings of obstruction such as hyperinflation&#44; atelectasis&#44; bronchial wall thickening&#44; and bronchiectasis&#59; &#40;iv&#41; mosaic perfusion and air trapping on HRCT&#59; &#40;v&#41; exclusion of other COPDC&#46;<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">27&#44;60</span></a></p><p id="par0175" class="elsevierStylePara elsevierViewall">Among the causes of BO are&#58; drugs&#44; association with Stevens&#8211;Johnson syndrome&#44; collagenoses&#44; irradiation&#44; foreign body or gastric content aspiration&#44; and graft <span class="elsevierStyleItalic">vs&#46;</span> host disease after transplantation&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">The definitive diagnosis of BO is made through anatomopathological examination of fragments obtained from lung biopsy&#46; BO is classified as&#58; &#40;i&#41; proliferative BO&#44; characterized by airway obstruction by polyps and&#47;or granulation tissue in the lumen of bronchioles&#59; or &#40;ii&#41; constrictive BO&#44; characterized by peribronchial inflammation and fibrosis&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">58</span></a> As the lung biopsy is an invasive test&#44; most studies perform the diagnosis based on clinical history and HRCT&#44; spirometry&#44; and perfusion scintigraphy with technetium&#46; Alterations in HRCT include wall thickening and bronchiole obliteration and&#44; with the disease progression&#44; bronchiectasis&#44; bronchial wall thickening&#44; mosaic perfusion&#44; air trapping&#44; reduced lung volume&#44; and decreased diameter of hilar and peripheral vessels are observed&#46;<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">27&#44;59</span></a></p><p id="par0185" class="elsevierStylePara elsevierViewall">There is no specific treatment for BO&#46; Oxygen therapy is essential in some patients&#44; mainly after ICU discharge for severe acute viral bronchiolitis &#40;AVB&#41; and in patients who develop chronic hypoxemia&#46; Contact prophylaxis with intra and extra-domestic pollutants&#44; reduction of exposure to active and passive smoking&#44; and anti-pneumococcal and influenza vaccination are important steps for BO management&#46; In the early phases of the disease&#44; some patients may benefit from systemic corticosteroid therapy&#46; Bronchodilators&#44; antibiotics in infectious exacerbations&#44; surgery for resection of fixed collapsed lung&#44; and lung transplant have also been used&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a></p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Primary ciliary dyskinesia &#40;PCD&#41;</span><p id="par0190" class="elsevierStylePara elsevierViewall">Primary ciliary dyskinesia &#40;PCD&#41; is an autosomal recessive COPDC caused by several alterations in airway cilia anatomical and functional structure&#44; resulting in inflammation and infection&#44; with an incidence of 1&#58;4000&#8211;40&#44;000 live births&#46; Laterality defects in the thoraco-abdominal organs occur in about 50&#37; of patients with PCD&#44; and most have <span class="elsevierStyleItalic">situs inversus totalis</span> &#40;Kartagener syndrome&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">24&#44;63&#8211;66</span></a></p><p id="par0195" class="elsevierStylePara elsevierViewall">PCD should be suspected in children with&#58; &#40;i&#41; <span class="elsevierStyleItalic">situs inversus totalis</span> or other laterality defect in thoraco-abdominal organs&#59; &#40;ii&#41; recurrent upper &#40;otitis&#44; sinusitis&#41; and lower respiratory tract infections &#40;pneumonia&#44; abscesses&#41; and chronic respiratory tract diseases of undefined etiology &#40;bronchiectasis&#44; chronic cough&#44; atelectasis&#44; and middle lobe syndrome&#41;&#59; &#40;iii&#41; neonatal respiratory distress syndrome of undefined causes&#59; &#40;iv&#41; diagnosis of PCD in other family members&#59; &#40;v&#41; congenital heart disease&#44; especially if associated with heterotaxia&#44; and with chronic and repeated infections of the lower and upper airways&#46;<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">24&#44;67</span></a></p><p id="par0200" class="elsevierStylePara elsevierViewall">Clinical manifestations and alterations in PCD vary according to age<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a>&#58; in the prenatal period&#44; ultrasound may reveal mild fetal cerebral ventriculomegaly&#44; heterotaxia and <span class="elsevierStyleItalic">situs inversus totalis</span> &#40;approximately 25&#37; of individuals with <span class="elsevierStyleItalic">situs inversus totalis</span> have PCD&#41;&#46; PCD prevalence in patients with heterotaxia remains unknown&#46; In the neonatal period&#44; 75&#37; of full-term newborns with PCD have respiratory distress&#44; requiring supplemental oxygen for days or weeks&#46; Some have continuous rhinorrhea&#44; heterotaxia&#44; and hydrocephalus&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall">During childhood&#44; chronic productive cough is observed&#44; in association with atelectasis and&#47;or recurrent pneumonia&#44; atypical asthma that does not respond to treatment&#44; bronchiectasis&#44; NCFB&#44; nasal polyps&#44; chronic rhinosinusitis&#44; hearing impairment&#44; and chronic otitis&#46; In adolescence and adulthood&#44; bronchiectasis&#44; chronic mucopurulent sputum&#44; digital clubbing&#44; spirometry with progressive or mixed obstructive ventilatory pattern&#44; nasal polyposis&#44; and halitosis can be observed&#44; as well as infertility in men &#40;50&#37;&#41; and ectopic pregnancy in women&#46;</p><p id="par0210" class="elsevierStylePara elsevierViewall">Diagnosis is based on clinical and radiological alterations&#44; nasal nitric oxide levels&#44; ciliary beat pattern at video microscopy&#44; structural alterations of the cilia by electron microscopy&#44; and detection of mutations&#46; Only 50&#8211;60&#37; of PCD patients have a known mutation&#46;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">25&#44;68&#44;69</span></a></p><p id="par0215" class="elsevierStylePara elsevierViewall">CF evolves with secondary ciliary dyskinesia&#44; whereas in PCD it is primary&#59; the management of pulmonary disease in these two diseases is virtually identical&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Cystic fibrosis &#40;CF&#41;</span><p id="par0220" class="elsevierStylePara elsevierViewall">CF is an autosomal recessive disease caused by mutations in the CFTR &#40;cystic fibrosis transmembrane regulator&#41; gene&#44; 7q31&#46;2 region&#44; which has more than 2000 identified mutations&#44; divided into six classes regarding the production and function of the CFTR protein&#46; The qualitative or quantitative absence or dysfunction of CFTR causes physiopathological changes in several organs&#46; Most of CF morbidity and mortality is caused by manifestations in the respiratory and digestive tracts&#46;<a class="elsevierStyleCrossRefs" href="#bib0350"><span class="elsevierStyleSup">70&#8211;73</span></a></p><p id="par0225" class="elsevierStylePara elsevierViewall">It is currently known that in Class I&#44; II&#44; and III mutations&#44; the disease starts before symptom onset&#44; constituting a major factor for early intervention and more aggressive treatments&#44; showing promising results in reducing lung function damage and deterioration&#44; with consequent increased survival&#46;<a class="elsevierStyleCrossRefs" href="#bib0350"><span class="elsevierStyleSup">70&#8211;73</span></a></p><p id="par0230" class="elsevierStylePara elsevierViewall">Availability of newborn screening&#44; sweat testing&#44; CFTR gene mutation screening&#44; medications&#44; and possible use of correctors&#44; enhancers&#44; and stabilizers &#40;for some mutations&#41; of the CFTR protein are concrete facts in the last decade&#46; The consequence is that the survival of these patients is increasingly higher&#46;<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">73</span></a> Lung damage and decreased lung function are progressive&#44; and depend on the mutation&#44; gender&#44; polymorphisms&#44; treatment availability and adherence&#44; early treatment&#44; comorbidities&#44; and care in reference centers&#46;<a class="elsevierStyleCrossRefs" href="#bib0370"><span class="elsevierStyleSup">74&#8211;76</span></a></p><p id="par0235" class="elsevierStylePara elsevierViewall">The physiopathology of COPD in CF can be understood with the following six events &#40;6D&#41;&#58; &#40;i&#41; defect in the CFTR gene&#59; &#40;ii&#41; impairment or absence of the CFTR protein&#59; &#40;iii&#41; dehydration of the airway surface liquid&#59; &#40;iv&#41; defect in bacterial clearance in the airways&#59; &#40;v&#41; secondary ciliary dyskinesia&#59; &#40;vi&#41; destruction of the airway epithelium&#46;<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">77</span></a></p><p id="par0240" class="elsevierStylePara elsevierViewall">To attain the diagnosis of CF after neonatal screening&#44; alterations in the gene and or CFTR protein should be verified&#46; The CFTR gene is studied through the analysis of mutations and polymorphisms&#46; The CFTR protein function and&#47;or presence can be assessed in the sweat glands &#40;sweat test&#44; evaporimetry&#44; difference of potential&#44; and pH&#41; nasal epithelium&#44; salivary glands&#44; and digestive tract&#46;<a class="elsevierStyleCrossRefs" href="#bib0390"><span class="elsevierStyleSup">78&#44;79</span></a></p><p id="par0245" class="elsevierStylePara elsevierViewall">Diagnosing or ruling out CF is not always easy&#44; even after comprehensive testing&#44; particularly in adolescents and adults with classes IV&#44; V&#44; and VI mutations&#44; which cause non-classical forms and are often associated with rare mutations&#44; threshold levels of chloride in sweat&#44; late-onset clinical manifestations&#44; and atypical symptoms&#46;<a class="elsevierStyleCrossRef" href="#bib0400"><span class="elsevierStyleSup">80</span></a></p><p id="par0250" class="elsevierStylePara elsevierViewall">As CF affects many organs&#44; its management is complex&#46; The service must have interdisciplinary teams with several health care professionals&#44; physical therapy&#44; medical examinations&#44; frequent visits to the hospital&#44; and use of daily&#44; repetitive medications&#44; which are sometimes complicated and costly&#46;<a class="elsevierStyleCrossRef" href="#bib0405"><span class="elsevierStyleSup">81</span></a></p><p id="par0255" class="elsevierStylePara elsevierViewall">Patients with CF are highly susceptible to chronic lung infection by PA&#46; PA acquisition occurs very early and is related to lung function deterioration and worse CF prognosis&#59; hence&#44; intensive treatment against PA is crucial in the management of CF&#46;</p><p id="par0260" class="elsevierStylePara elsevierViewall">Other bacteria frequently found in the airways of CF patients and that determine the lung function damage and deterioration include <span class="elsevierStyleItalic">S&#46; aureus</span>&#44; <span class="elsevierStyleItalic">H&#46; influenzae</span>&#44; PA&#44; <span class="elsevierStyleItalic">B&#46; cepacia</span> complex&#44; <span class="elsevierStyleItalic">S&#46; maltophilia</span>&#44; and <span class="elsevierStyleItalic">Achromobacter species</span>&#46; Non-tuberculous <span class="elsevierStyleItalic">Mycobacteria</span> &#40;NTM&#41; and other anaerobic bacteria and fungi are found less frequently&#44; and tend to appear at the more advanced stages of lung disease&#46;<a class="elsevierStyleCrossRefs" href="#bib0410"><span class="elsevierStyleSup">82&#44;83</span></a></p><p id="par0265" class="elsevierStylePara elsevierViewall">Inhaled antibiotics &#40;IA&#41; are essential for the treatment of chronic lung infections in CF&#46; The increased survival in patients with CF in recent decades can be partly attributed to the use of IA&#46; They have higher deposition at the infection site and less risk of systemic side effects than parenteral therapy&#44; decrease PE&#44; and improve quality of life and spirometry&#46;<a class="elsevierStyleCrossRefs" href="#bib0420"><span class="elsevierStyleSup">84&#44;85</span></a></p><p id="par0270" class="elsevierStylePara elsevierViewall">CF patients with chronic lung infection by PA should receive long-term&#44; nebulized anti-pseudomonal therapy&#44; unless there is contraindication&#46; Among the IA&#44; tobramycin and colistin are currently available&#44; while aztreonam&#44; levofloxacin&#44; and liposomal amikacin will soon be available&#46;<a class="elsevierStyleCrossRef" href="#bib0430"><span class="elsevierStyleSup">86</span></a> The administration of IA is time-consuming and is a heavy burden for patients&#46; Treatment adherence is a significant challenge&#46;<a class="elsevierStyleCrossRef" href="#bib0435"><span class="elsevierStyleSup">87</span></a></p><p id="par0275" class="elsevierStylePara elsevierViewall">The treatment of the first acquisition episode&#44; from infection to chronic infection and PE due to PA&#44; are reasons for debates and controversies in the literature&#46;<a class="elsevierStyleCrossRef" href="#bib0440"><span class="elsevierStyleSup">88</span></a></p><p id="par0280" class="elsevierStylePara elsevierViewall">PA eradication protocols have demonstrated antibiotic efficacy in the first bacterial isolation&#59; intensive treatment with intravenous antibiotics in PE and IA in the periods between crises&#46;<a class="elsevierStyleCrossRefs" href="#bib0445"><span class="elsevierStyleSup">89&#8211;91</span></a></p><p id="par0285" class="elsevierStylePara elsevierViewall">It is advisable to perform lung damage assessment by HRCT at least every 2 years&#44; and pulmonary function assessment by spirometry at least twice a year&#46;</p><p id="par0290" class="elsevierStylePara elsevierViewall">IA&#44; anti-inflammatory drugs&#44; corticosteroids&#44; bronchodilators&#44; and mucolytics may be necessary for the management of lung disease in CF&#46; Auxiliary measures have shown benefits with respiratory physical therapy&#44; regular exercise&#44; avoiding indoor and outdoor pollution&#44; and active and passive smoking&#46; It is crucial to include treatment adherence measures and continuity of care for life&#46; Visits to the reference center must be monthly during the first year and at least four times a year until adulthood&#46;</p><p id="par0295" class="elsevierStylePara elsevierViewall">Adherence to CF management varies between 35 and 75&#37; and is lower in adolescence&#46; Poor adherence to medication worsens lung function&#44; increases the frequency of PE&#44; and results in a larger number of consultations&#44; hospitalizations&#44; and costs&#46; Therefore&#44; interventions are necessary to improve medication adherence&#46;<a class="elsevierStyleCrossRef" href="#bib0405"><span class="elsevierStyleSup">81</span></a></p><p id="par0300" class="elsevierStylePara elsevierViewall">Many international organizations have proposed that the management of lung disease in CF should be directed by guidelines based on scientific evidence&#46; Thus&#44; recent publications on the management of COPD in CF can be found&#44; and represent the &#8220;state-of-the-art&#8221; for CF reference centers&#46;<a class="elsevierStyleCrossRefs" href="#bib0410"><span class="elsevierStyleSup">82&#44;83&#44;91&#44;92</span></a></p><p id="par0305" class="elsevierStylePara elsevierViewall">Recently&#44; advances in the treatment of CF have gained prominence&#46; Mutations in the CFTR gene have been widely identified&#44; and the highest prevalence of the F508del mutation has been emphasized&#46; Treatment for the specific mutation and&#47;or class of mutations has focused on the study of new drugs&#46; Two drugs have been used in studies considering the F508del mutation in homozygous form&#44; and results of the association of ivacaftor &#40;increases opening of the chloride channel &#8211; potentiator&#41; and lumacaftor &#40;increases protein number in the epithelium &#8211; potentiator&#41; have shown increased chloride transport when compared with the values of the individual drugs&#46;<a class="elsevierStyleCrossRef" href="#bib0465"><span class="elsevierStyleSup">93</span></a></p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Bronchopulmonary dysplasia &#40;BPD&#41;</span><p id="par0310" class="elsevierStylePara elsevierViewall">BPD is a secondary COPDC&#44; and is associated with prematurity and risk factors &#40;RF&#41; related to it&#46; Low birth weight&#44; high fraction of inspired oxygen&#44; patent ductus arteriosus&#44; high intravenous fluid volume values&#44; mechanical ventilation with high pressures&#44; genetic susceptibility&#44; and infection in the neonatal period contribute to the prevalence and severity of BPD&#46; This disease affects approximately 30&#37; of newborns with birth weight less than 1500<span class="elsevierStyleHsp" style=""></span>g&#46;<a class="elsevierStyleCrossRefs" href="#bib0470"><span class="elsevierStyleSup">94&#44;95</span></a></p><p id="par0315" class="elsevierStylePara elsevierViewall">Several studies have shown that most infants who develop BPD evolve with lung function alterations throughout life&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#44;96&#8211;101</span></a></p><p id="par0320" class="elsevierStylePara elsevierViewall">Similar to all COPDC&#44; BPD has no specific treatment&#46; Regarding the advances to reduce mortality in the neonatal period&#44; in recent decades&#44; three factors have clearly proven to be effective&#58; &#40;i&#41; corticosteroid administration to pregnant women with high-risk pregnancies&#59; &#40;ii&#41; administration of surfactants to premature infants&#59; &#40;iii&#41; less aggressive ventilation strategies&#46;<a class="elsevierStyleCrossRefs" href="#bib0510"><span class="elsevierStyleSup">102&#44;103</span></a></p><p id="par0325" class="elsevierStylePara elsevierViewall">The following have also been used&#58; diuretics &#40;furosemide&#41;&#59; bronchodilators&#59; systemic corticosteroids and IC&#59; vitamin A&#59; methylxanthines &#40;pentoxifylline&#44; caffeine&#41;&#59; pulmonary vasodilators &#40;sildenafil&#44; inhaled nitric oxide&#41;&#59; late surfactant administration&#59; and antioxidants &#40;superoxide dismutase&#41;&#44; with varying degrees of efficacy in the management of acute and&#47;or chronic BPD&#46; However&#44; there is little evidence of the beneficial actions of most of these agents when used in short- or long-term management of BPD&#46;<a class="elsevierStyleCrossRefs" href="#bib0510"><span class="elsevierStyleSup">102&#44;103</span></a></p><p id="par0330" class="elsevierStylePara elsevierViewall">BPD is associated with a high incidence of pulmonary arterial hypertension &#40;PAH&#41;&#46; Treatment with sildenafil has been associated with significant improvement in echocardiographic markers of PAH and reduced need for oxygen&#46; The drug is well tolerated&#46;<a class="elsevierStyleCrossRef" href="#bib0520"><span class="elsevierStyleSup">104</span></a></p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Bronchiectasis related to diseases other than CF &#40;NCFB&#41;</span><p id="par0335" class="elsevierStylePara elsevierViewall">Bronchiectasis is an alteration that accompanies many COPDC&#46; It may be associated with and complicate asthma&#44; PCD&#44; CF&#44; BO&#44; and NCFB&#44; and be consequent to measles&#44; pertussis&#44; immunodeficiency&#44; allergic bronchopulmonary aspergillosis&#44; inflammatory bowel disease&#44; rheumatoid arthritis&#44; foreign body inhalation&#44; PCD&#44; BO&#44; respiratory tract malformation &#40;<span class="elsevierStyleItalic">e&#46;g&#46;</span>&#58; tracheoesophageal fistula&#44; congenital cystic adenomatoid malformation&#41; and result from inflammatory and infectious diseases to the airways&#46; NCFB encompasses several etiologies and degrees of severity&#59; a clear cause cannot be established in many patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0525"><span class="elsevierStyleSup">105&#44;106</span></a></p><p id="par0340" class="elsevierStylePara elsevierViewall">Pulmonary disease in NCFB is very similar to CF&#44; BO&#44; and PCD&#46; The challenge a child with NCFB faces is the pursuit of a diagnosis&#46; The management is very similar to that of most COPDC and should be considered on a case-by-case basis&#44; aiming at patient comfort and clinical response&#46;<a class="elsevierStyleCrossRef" href="#bib0535"><span class="elsevierStyleSup">107</span></a></p><p id="par0345" class="elsevierStylePara elsevierViewall">Although some randomized&#44; controlled&#44; double-blind trials have shown that prolonged use of macrolides in patients with NCFB improves quality of life and reduces PE rates&#44; the role of macrolides in NCFB management remains unclear and they cannot be recommended for routine use&#46; Until very recently&#44; these drugs were investigated in small trials of short duration&#44; which did not evaluate relevant clinical outcomes&#44; such as PE and quality of life&#46;</p><p id="par0350" class="elsevierStylePara elsevierViewall">Long-term oral antibiotics should not be routinely prescribed&#46; Macrolides &#40;or other antibiotics&#41; can be considered for a limited period of 12&#8211;24 months&#44; especially in patients with frequent exacerbations&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;108&#44;109</span></a></p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Plastic bronchitis &#40;PB&#41;</span><p id="par0355" class="elsevierStylePara elsevierViewall">PB is a rare COPDC with unknown prevalence and etiology&#44; with formation of bronchial molds of gelatinous or solid appearance in the large airways&#44; whose composition varies&#44; consisting of mucins&#44; fibrin&#44; DNA&#44; or eosinophils&#44; depending on the PB etiology&#46; The diseases most often associated with PB are congenital heart disease and asthma&#46; It has also been described in infection by influenza virus&#44; H1N1&#44; lymphatic diseases&#44; allergic bronchopulmonary aspergillosis&#44; and sickle-cell disease&#46;<a class="elsevierStyleCrossRef" href="#bib0545"><span class="elsevierStyleSup">109</span></a> Although bronchodilators&#44; corticosteroids&#44; antibiotics&#44; mucolytics&#44; physical therapy&#44; antifibrinolytic therapy with heparin&#44; and urokinase have been used&#44; single or repeat bronchoscopy is essential for diagnosis and treatment&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Final considerations</span><p id="par0360" class="elsevierStylePara elsevierViewall">The pediatrician&#39;s actions are vital for the management of COPDC&#46; The clinician should suspect the disease in the presence of signs and symptoms in order to attain an early and accurate diagnosis&#44; know the risk factors and associated comorbidities&#44; and assess treatment adherence&#44; the correct use of prescribed drugs&#44; and their side effects based on well-defined management protocols&#44; preferably based on specific guidelines&#46;</p><p id="par0365" class="elsevierStylePara elsevierViewall">Management benefits should be assessed through the reduction in acute pulmonary exacerbations&#44; increased quality of life&#44; and decreased evolution of lung function loss &#40;spirometry&#44; measurement of oxygen saturation&#44; lung clearance index&#41; and lung damage &#40;HRCT every 2 years&#44; if necessary&#41;&#46; Therefore&#44; the sequential evaluation of lung function and damage should be standardized and continuous&#44; throughout life&#46; For most COPDC&#44; monitoring in specialized reference centers by interdisciplinary teams leads to better outcomes&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Conflicts of interest</span><p id="par0370" class="elsevierStylePara elsevierViewall">The authors declare no conflicts of interest&#46;</p></span></span>"
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          "titulo" => "Recurrent wheezing in infants &#40;RWI&#41;"
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          "titulo" => "Bronchiolitis obliterans &#40;BO&#41;"
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          "titulo" => "Primary ciliary dyskinesia &#40;PCD&#41;"
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          "titulo" => "Cystic fibrosis &#40;CF&#41;"
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          "titulo" => "Bronchopulmonary dysplasia &#40;BPD&#41;"
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          "titulo" => "Bronchiectasis related to diseases other than CF &#40;NCFB&#41;"
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          "titulo" => "Plastic bronchitis &#40;PB&#41;"
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            0 => "Crian&#231;a"
            1 => "Doen&#231;a pulmonar obstrutiva cr&#244;nica"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objectives</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To verify and describe the main events related to the diagnosis and management of chronic obstructive pulmonary diseases in children &#40;COPDC&#41; and adolescents&#44; considering the interrelated physiopathology&#44; genetic&#44; and environmental characteristics&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Sources</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Relevant literature from PubMed was selected and reviewed&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Summary of the findings</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">COPDC have an environmental and&#47;or genetic origin and its manifestation has manifold genotypes&#44; phenotypes&#44; and endotypes&#46; Although COPDC has no cure&#44; it can be clinically controlled&#46; Chronic cough is the main symptom and bronchiectasis can be present in several COPDC patients&#46; The management of COPDC is more effective if based on guidelines and when treatment regimen adherence is promoted&#46; Oral and inhaled corticosteroids&#44; bronchodilators&#44; inhaled antibiotics&#44; and treatment of pulmonary exacerbation &#40;PE&#41; are the bases of COPDC management&#44; and should be individualized for each patient&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Correct diagnosis and knowledge of risk factors and comorbidities are essential in COPDC management&#46; Procedures and drugs used should be based on specific guidelines for each COPDC case&#46; Treatment adherence is critical to obtain the benefits of management&#46; COPDC clinical control must be evaluated by the decrease in PEs&#44; improved quality of life&#44; reduction of pulmonary function loss&#44; and lung structural damage&#46; For most cases of COPDC&#44; monitoring by interdisciplinary teams in specialized reference centers with surveillance strategies and continuous care leads to better outcomes&#44; which must be evaluated by decreasing pulmonary function damage and deterioration&#44; better prognosis&#44; better quality life&#44; and increased life expectancy&#46;</p></span>"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Verificar e descrever os principais eventos relacionados ao diagn&#243;stico e manejo das doen&#231;as pulmonares obstrutivas cr&#244;nicas em crian&#231;as &#40;DPOCC&#41; e adolescentes&#44; tendo em vista a fisiopatologia&#44; caracter&#237;sticas gen&#233;ticas e ambientais inter-relacionadas&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Fonte dos dados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Revis&#227;o na base de dado PUBMED com sele&#231;&#227;o de refer&#234;ncias relevantes&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">S&#237;ntese dos dados</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">As DPOCC t&#234;m origem ambiental e&#47;ou gen&#233;tica e se manifestam com diversos gen&#243;tipos&#44; fen&#243;tipos e end&#243;tipos e&#44; embora possam ser controladas&#44; n&#227;o t&#234;m cura&#46; O principal sintoma &#233; a tosse cr&#244;nica e muitas cursam com bronquiectasia&#46; O manejo tem maior efic&#225;cia se baseado em <span class="elsevierStyleItalic">guidelines</span> e se a ades&#227;o ao regime terap&#234;utico for estimulada e comprovada&#46; Cortic&#243;ides orais e inalat&#243;rios&#44; broncodilatadores&#44; antibi&#243;ticos inalados e tratamento das exacerba&#231;&#245;es pulmonares &#40;EP&#41; s&#227;o vigas mestras do manejo e devem ser individualizados para cada DPOCC&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclus&#245;es</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Nas DPOCC &#233; fundamental o diagn&#243;stico correto&#44; conhecer os fatores de risco e comorbidades&#46; Os procedimentos e os medicamentos devem ser baseados em <span class="elsevierStyleItalic">guidelines</span> espec&#237;ficos para cada DPOCC&#46; Ades&#227;o ao tratamento &#233; fundamental para obter os benef&#237;cios do manejo&#46; O controle deve ser avaliado pela diminui&#231;&#227;o das EP&#44; melhora na qualidade de vida e redu&#231;&#227;o da evolu&#231;&#227;o da perda da fun&#231;&#227;o e dano estrutural pulmonar&#46; Para a maioria das DPOCC&#44; o acompanhamento por equipes interdisciplinares em centros de refer&#234;ncia especializados&#44; com estrat&#233;gias de vigil&#226;ncia e acolhimento cont&#237;nuos&#44; conduz a melhores desfechos que devem ser avaliados pela diminui&#231;&#227;o da deteriora&#231;&#227;o do dano e da fun&#231;&#227;o pulmonar&#44; melhor progn&#243;stico&#44; melhor qualidade de vida e aumento da expectativa de vida&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Ribeiro JD&#44; Fischer GB&#46; Chronic obstructive pulmonary diseases in children&#46; J Pediatr &#40;Rio J&#41;&#46; 2015&#59;91&#58;S11&#8211;25&#46;</p>"
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          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Age of onset and higher prevalence of major chronic obstructive pulmonary disease in children &#40;COPDC&#41; compared with chronic obstructive pulmonary disease &#40;COPD&#41; in adults&#46; CF&#44; cystic fibrosis&#59; RWIs&#44; recurrent wheezing in infants&#59; BPD&#44; bronchopulmonary dysplasia&#59; PCD&#44; primary ciliary dyskinesia&#59; NCFB&#44; non-cystic fibrosis bronchiectasis&#59; PB&#44; plastic bronchitis&#59; BO&#44; bronchiolitis obliterans&#59; m&#44; month&#59; y&#44; year&#46;</p>"
        ]
      ]
      1 => array:7 [
        "identificador" => "fig0010"
        "etiqueta" => "Figure 2"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr2.jpeg"
            "Alto" => 1591
            "Ancho" => 2500
            "Tamanyo" => 258212
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        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Interactions of causes&#44; effects&#44; and clinical outcomes of chronic obstructive pulmonary disease in children &#40;COPDC&#41;&#46;</p>"
        ]
      ]
      2 => array:7 [
        "identificador" => "fig0015"
        "etiqueta" => "Figure 3"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr3.jpeg"
            "Alto" => 1694
            "Ancho" => 2500
            "Tamanyo" => 305400
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        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Bacterial acute pulmonary exacerbations in chronic obstructive pulmonary disease in children &#40;COPDC&#41; and pneumonia in previously healthy children&#46;</p>"
        ]
      ]
      3 => array:7 [
        "identificador" => "fig0020"
        "etiqueta" => "Figure 4"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr4.jpeg"
            "Alto" => 1927
            "Ancho" => 2500
            "Tamanyo" => 323447
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        "descripcion" => array:1 [
          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Control or non-control of chronic obstructive pulmonary disease in children &#40;COPDC&#41; based on diagnosis&#46;</p>"
        ]
      ]
      4 => array:7 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">&#63;&#44; unknown&#59; ABPA&#44; allergic bronchopulmonary aspergillosis&#59; IA&#44; inhaled antibiotics&#59; BD&#44; bronchodilator&#59; NCFB&#44; non-cystic fibrosis bronchiectasis&#59; BO&#44; bronchiolitis obliterans&#59; PIBO&#44; post-infectious bronchiolitis obliterans&#59; PB&#44; plastic bronchitis&#59; CHD&#44; congenital heart disease&#59; IC&#44; inhaled corticosteroids&#59; CD4&#44; CD4 molecule&#59; CD8&#44; CD8 molecule&#59; CFTR&#44; cystic fibrosis transmembrane regulator&#59; BPD&#44; bronchopulmonary dysplasia&#59; PCD&#44; primary ciliary dyskinesia&#59; COPD&#44; chronic obstructive pulmonary disease&#59; COPDC&#44; chronic obstructive pulmonary disease in childhood&#59; GERD&#44; gastroesophageal reflux disease&#59; PE&#44; pulmonary exacerbation&#59; CF&#44; cystic fibrosis&#59; GM-CSF&#44; granulocyte macrophage-colony stimulating factor&#59; PH&#44; pulmonary hypertension&#59; IgE immunoglobulin E&#59; IL&#44; interleukin&#59; API&#44; asthma predictor index&#59; URTI&#44; upper respiratory tract infection&#59; LABA&#44; long-acting beta-agonists&#59; BAL&#44; bronchoalveolar lavage&#59; LTB4 leukotriene B4&#59; M&#44; mild&#59; Mo&#44; moderate&#59; S&#44; severe&#59; MMP&#44; matrix metallopeptidase&#59; NF-kB&#44; NF-kappaB&#59; VLBW&#44; very low birth weight&#59; RSV&#44; respiratory syncytial virus&#59; RV&#44; rhinovirus&#59; SABA&#44; short-acting beta agonists&#59; RWI&#44; recurrent wheezing in infants&#59; HRCT&#44; high-resolution computed tomography&#59; SPT&#44; skin prick test&#59; TGF&#44; transforming growth factor&#59; IRT&#44; immunoreactive trypsinogen&#59; NBS&#44; newborn screening test&#59; TNF&#44; tumor necrosis factor&#59; RSV&#44; respiratory syncytial virus&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">COPDC characteristics&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">ASTHMA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">RWIs&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">BPD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">BO and PIBO&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">CF&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">BP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">PCD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">NCFB&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Classic adult COPD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Symptom onset&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Before 5 years of life&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#60;2 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Newborn&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#60;3 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#60;2 years in classical forms&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CHD&#58; &#60;5 yearsAsthma&#58; &#62;5 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">First year of life&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">After the second year of life&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Adults &#62;40 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Age of higher prevalence&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Childhood&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#8211;2 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">First year of life&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Childhood and adolescence&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Up to 30 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CHD&#58; &#60;5 yearsAsthma&#58; &#62;5 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Childhood and adolescence&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Childhood and adolescence&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">After 40 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Main clinical marker&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Family history of asthma&#44; personal atopy and positive response to BD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Infection by respiratory viruses&#40;RSV and RV&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">PrematurityOxygen use&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Virus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Chronic colonization of the airways by Pseudomonas aeruginosa and pancreatic failure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Elimination of bronchial casts with sputum&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Suppurative infections of the upper and lower airways&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Recurrent infections and chronic cough&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Smoking&#44; emphysema&#44; and biomass smoke&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Prevalence&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">High&#40;5&#8211;30&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">High&#40;15&#8211;60&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">High&#59; 26&#37; in VLBW infants&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Low&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Low&#46; Classified as rare disease&#46; 1&#58;2500&#8211;1&#58;10&#44;000 live births&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Low&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Low&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Low&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">6&#8211;15&#46;8&#37; of the population older &#62;40 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Bases for diagnosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Spirometry&#44; positive response to BD&#44; IgE&#44; and skin prick test&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#62;3 episodes of wheezing in infancy and positive API&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Prematurity and oxygen therapy for more than 28 days in early life&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Lung biopsy&#44; HRCT and lung perfusion scintigraphy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NBS with a positive IRT&#44; chloride &#62;60<span class="elsevierStyleHsp" style=""></span>mEq&#47;L in sweat&#44; two mutations in the CFTR gene&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Airway cast expectoration and bronchoscopy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Dextrocardia&#44; chronic sinusitis&#44; pneumonia and recurrent URTIs&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">HRCT&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Smoking&#44; emphysema and alpha1 antitrypsin deficiency&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Genotype&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Many chromosomes and polymorphisms&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Many chromosomes and polymorphisms&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Little known&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Little known&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Autosomal recessive with alterations in CFTR gene located on chromosome 7&#46;6 classes of mutations&#46; Many polymorphisms&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Unknown&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Autosomal recessive&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Depends on the etiology&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Phenotype&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Several&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Several&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&#44; Mo&#44; S&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Constrictive proliferative&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Many&#46; With and without pancreatic failure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Depending on the etiology&#44; the bronchial mold has a different composition&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">With and without dextrocardia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Depends on the etiology&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">With and without asthma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">BAL&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Eosinophils&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Neutrophils and&#47;or eosinophils&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Neutrophils&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Neutrophils&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Neutrophils&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Mucin and fibrin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Neutrophils&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Neutrophils&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Neutrophils and macrophages&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Markers in lymphocytes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">High CD4&#47;CD8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Varies whether the BAL is eosinophilic or neutrophilic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Depends on the etiology&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">High CD8&#47;CD4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Inflammatory mediators&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">IL4&#44; IL5&#44; IL9&#44; IL13&#44; TNF-&#945;&#44; GM-CSF&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Varies whether the BAL is eosinophilic or neutrophilic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">TNF-&#945;&#44; IL-1&#44; IL-6&#44; IL-10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">IL1&#946;&#44; IL6&#44; IL8&#44; TNF-&#945;&#44; and NFk&#946;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">IL8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Depends on the etiology&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">IL8&#44; LTB4&#44; proteases&#44; MMP9&#44; TNF-&#945;&#44; TGF-&#946;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Main causes of PE&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Viruses and aero-allergens&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Viruses&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Viruses&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Viruses&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Gram-negative bacteria&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">InfluenzaH1N1&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Viruses and bacteria&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Bacteria and viruses&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Viruses and bacteria&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Response to BD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Little known&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Unknown&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Rare&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Rare&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Low&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Obstruction&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Intermittent in the mild cases and fixed in severe cases&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Intermittent&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Fixed&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Fixed&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Fixed&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Intermittent&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Fixed&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Fixed&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Fixed&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Survival&#47;Mortality&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Long&#47;low&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Long&#47;low&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Depends on the severity and gestational age&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Depends on severity&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#60;40 years &#8211; class I&#8211;III mutations&#46;&#62;40 years &#8211; class IV&#8211;VI mutations&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Low&#47;high&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#60;40 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Depends on the age of onset and etiology&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Depends on the severity&#46;High mortality in the elderly&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Evolution to restrictive lung diseases&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Rare&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Rare&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Rare&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Frequent&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Frequent&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Rare&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Frequent&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Frequent&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Frequent&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Evolution to lung transplantation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Rare&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Comorbidities&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Allergic rhinitis&#44; atopic dermatitis and GERD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">GERD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">GERD and prematurity&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Severe adenovirus infection&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Pancreatic failure&#44; depression&#44; diabetes&#44; and osteoporosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CHD&#44; asthma&#44; lymphatic disease&#44; ABPA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Azoospermia and chronic rhinosinusitis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Asthma and GERD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Treatment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">IC&#59; SABA&#59; LABA&#59; Montelukast&#59; omalizumab&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">IC&#59; SABA&#59; Montelukast&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">IC&#59; SABA&#59;Sildenafil and PHDiuretics&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">IC&#59; SABA&#59; LABA&#59; corticoids&#59; oxygen&#59; tiotropium bromide&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Mucolytics&#59; IA&#59; digestive enzymes&#44; IC&#59; SABA&#59; LABA&#59; corticosteroids&#59;tiotropium&#59; Oxygen&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">bronchoscopy&#59; mucolytics and antifibrinolytics&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Mucolytics&#44; IA&#59; IC&#59; SABA&#59; LABA&#59; corticosteroids and oxygen&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Mucolytics&#59; IA IC&#59; SABA&#59; LABA&#59; corticosteroids&#59; oxygen&#59; macrolides&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">IC&#59; SABA&#59; LABA&#59; corticosteroids&#59; Tiotropium and oxygen&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Perspectives&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Early intervention <span class="elsevierStyleItalic">in utero</span> and early in life at risk populations&#46; Prophylaxis against RSV and RV&#46;Immunomodulation with prebiotics&#44; probiotics and bacterial lysates&#46;Prevention of allergic sensitization&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Permissive hypercapnia and improved care to VLBW infants&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Palivizumab&#59; genes and polymorphisms&#59; respiratory virus vaccines&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Corrections by potentiators and carriers of CFTR protein and new tests for the diagnosis of atypical forms&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Multicenter studies&#44; national registries&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Genetic studies and early diagnosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Prophylaxis against viruses&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Avoid smokingAsthma control&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Main clinical and pathophysiological characteristics of COPDC <span class="elsevierStyleItalic">versus</span> COPD in adults&#46;</p>"
        ]
      ]
      5 => array:7 [
        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">API&#44; asthma predictive index&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">API criteria&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Original API<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Modified API<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">38</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " rowspan="2" align="left" valign="middle">General</td><td class="td" title="table-entry  " align="left" valign="top">Convincing API&#58; more than three episodes of wheezing&#47;year during the first 3 years of life with a major criterion or two minor&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " rowspan="2" align="left" valign="middle">The child must have a history of four or more episodes of wheezing&#46; At least one episode verified and confirmed by a physician&#46;</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Less convincing API&#58; less than three episodes of wheezing&#47;year during the first 3 years of life with a major criterion or two minor&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Major&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">History of parental asthmaAtopic dermatitis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">History of parental asthmaAtopic dermatitis diagnosed by physicianAllergic sensitization to one or more aeroallergens&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Minor&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Allergic rhinitis diagnosed by physicianWheezing unrelated to coldsEosinophilia<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>4&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Sensitization to cow&#39;s milk&#44; egg&#44; or peanutWheezing unrelated to coldsEosinophilia<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>4&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Asthma Predictive Index &#40;API&#41; by Castro-Rodriguez et al&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">44</span></a> and Guilbert et al&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">38</span></a></p>"
        ]
      ]
      6 => array:7 [
        "identificador" => "tbl0015"
        "etiqueta" => "Table 3"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td-with-role" title="table-head ; entry_with_role_rowhead " align="left" valign="top" scope="col">Inhaled corticosteroids&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " colspan="3" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Daily doses in children younger than 5 years</th><th class="td" title="table-head  " colspan="3" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Daily doses &#40;6&#8211;11 years&#41;</th></tr><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Low&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Medium&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">High&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Low&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Medium&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">High&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Beclomethasone Dipropionate HFA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">100&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">50&#8211;100&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#62;100&#8211;200&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#62;200&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Budesonide spray&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">200&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">100&#8211;200&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#62;200&#8211;400&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#62;400&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Nebulized budesonide&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">250&#8211;500&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#62;500&#8211;1000&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#62;1000&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">250&#8211;500&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#62;500&#8211;1000&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#62;1000&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">100&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">100&#8211;200&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#62;250&#8211;500&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#62;500&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Fluticasone propionate dry powder&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">100&#8211;200&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#62;250&#8211;400&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#62;400&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">80&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#62;80&#8211;160&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#62;160&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Mometasone&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">There are no studies&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">110&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">220<span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>440&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">440 or more&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">There are no studies&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">400&#8211;800&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#62;800&#8211;1200&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#62;1200&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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        "titulo" => "Acknowledgements"
        "texto" => "<p id="par0375" class="elsevierStylePara elsevierViewall">To Professor Dr&#46; Paulo Augusto Moreira Camargos for his encouragement&#44; suggestions&#44; and manuscript review&#46; To Professor Dr&#46; Fernando Augusto de Lima Marson&#44; for the excellent chart contributions&#44; text reading&#44; suggestions&#44; and appraisals&#46; To the Pediatric Pneumology Team of Universidade Estadual de Campinas &#40;Unicamp&#41;&#44; for their constant help in the management of COPDC for many years&#58; Adyleia Aparecida Dalbo Contrera Toro&#44; Maria Angela Gon&#231;alves de Oliveira Ribeiro&#44; Andressa Peixoto&#44; Milena Baptistela Grotta&#44; Emilia Gon&#231;alves&#44; and Maria Cristina Sim&#245;es Ferreira&#46;</p>"
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Review article
Chronic obstructive pulmonary diseases in children
Doenças pulmonares obstrutivas crônicas na criança
Jose Dirceu Ribeiroa,
Corresponding author
, Gilberto Bueno Fischerb
a Department of Pediatrics, Faculdade de Ciências Médicas (FCM), Universidade Estadual de Campinas (Unicamp), Campinas, SP, Brazil
b Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre, RS, Brazil
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physiopathology&#44; prevalence&#44; prognosis&#44; genotypes&#44; and phenotypes&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">While some COPDC have been the object of many studies&#44; such as asthma&#44; cystic fibrosis &#40;CF&#41;&#44; recurrent wheezing in infants &#40;RWI&#41;&#44; and bronchopulmonary dysplasia &#40;BPD&#41;&#44; others are known as &#8220;orphan diseases&#44;&#8221; such as primary ciliary dyskinesia &#40;PCD&#41;&#44; non-cystic fibrosis bronchiectasis &#40;NCFB&#41;&#44; plastic bronchitis &#40;PB&#41;&#44; and bronchiolitis obliterans &#40;BO&#41;&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">COPDC are characterized by high prevalence of asthma&#44; RWI&#44; and BPD&#44; or low prevalence of BO&#44; CF&#44; PB&#44; PCD&#44; and NCFB&#46; They are noncommunicable diseases&#44; of long duration and slow progression&#44; showing episodes of pulmonary exacerbation &#40;PE&#41;&#44; acute or permanent airflow limitation&#44; and significant quality of life impairment&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> In all&#44; the main pulmonary symptom is chronic cough&#44; reflecting the presence of alterations in the airways&#44; as there are no cough receptors in the alveoli&#46; Another characteristic is the presence of bronchiectasis in many of them&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Most of them&#44; including some of the several clinical forms of asthma&#44; course with neutrophilic airway inflammation&#44; which contributes to progressive worsening of pulmonary damage and function by releasing&#58; &#40;i&#41; elastase&#58; cleaves elastin and causes bronchiectasis&#44; decreases opsonization and phagocytosis&#44; increases secretion&#44; decrease mucociliary clearance&#59; &#40;ii&#41; DNA&#58; increases the viscosity of secretions&#59; &#40;iii&#41; hydrogen peroxide and other oxidants&#58; causes tissue damage and inactivates &#945;-1-antitrypsin&#59; &#40;iv&#41; IL-8 and LTB4&#58; attract more neutrophils&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Two aspects of COPDC have been thoroughly studied&#58; the genetic component and environmental aggressions that initiate or exacerbate the diseases&#46; Most COPDC show different genotypes&#44; phenotypes&#44; endotypes&#44; and degrees of severity&#44; require different types of management&#44; and have no cure&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Pneumonia&#44; BPD&#44; BO&#44; and&#47;or RWI in the first years of life constitute risk groups for COPD in the long term and should receive medical follow-up and interventions to prevent the potential impact on long-term respiratory sequelae&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#8211;9</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">In all COPDC&#44; PE is often triggered by viral and&#47;or bacterial infections&#44; pollution&#44; and aeroallergens&#46; The PE manifests as acute respiratory failure of varying intensity&#44; both in asthma and RWI&#44; and as increased cough and chronic infection in CF&#44; BPD&#44; NCFB&#44; and PCD&#46; The signs and symptoms of PE are more frequent and intense at nighttime&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">While the majority of acute respiratory diseases can be diagnosed easily and efficiently through history and physical examination&#44; those with a chronic nature may require sophisticated laboratory tests&#46; Continuous and scheduled evaluations by interdisciplinary health teams in specialized centers are required for effective management&#44; better prognosis&#44; and improved quality of life in COPDC&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Establishing protocols based on systematic reviews&#44; meta-analyses&#44; and guidelines allows for gaining control of the signs and symptoms of COPDC&#46; Oral and &#40;OC&#41; inhaled corticosteroids &#40;IC&#41;&#44; mucolytics&#44; bronchodilators&#44; inhaled antibiotics&#44; and other drugs should be used according to specific guidelines for each COPDC&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">While some groups of drugs are widely used&#44; with variable degree of scientific evidence&#44; such as bronchodilators and IC&#44; others&#44; such as long-term macrolide use&#44; are more controversial&#46; The use of macrolides in COPDC have been justified by the anti-inflammatory and immunomodulatory effect&#44; the decrease in mucus production&#44; and neutrophil elastase inhibition&#44; in addition to reducing the production of pro-inflammatory mediators &#40;<span class="elsevierStyleItalic">e&#46;g&#46;</span> IL8&#41; and stimulating phagocytosis of apoptotic cells&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#8211;14</span></a> Although macrolides have shown to be effective in patients with CF and other COPDC&#44; and have shown encouraging <span class="elsevierStyleItalic">in vitro</span> effects&#44; their use in other COPDC has shown to be less effective and requires further studies&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">The objective of this review was to assess and describe the main events related to the diagnosis and management of COPDC&#44; considering the physiopathology and interrelated genetic and environmental characteristics&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Data sources</span><p id="par0060" class="elsevierStylePara elsevierViewall">Review of the PubMed databases with selection of relevant references&#46; The following descriptors were used &#40;according to the MeSH criteria&#41; related to each COPD included in the study&#58; asthma&#44; CF&#44; RWI&#44; BPD&#44; PCD&#44; NCFB&#44; BO&#44; and PB&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">COPDC&#58; an overview</span><p id="par0065" class="elsevierStylePara elsevierViewall">The first important feature of COPDC is that their clinical manifestations and prevalence are more common in certain age groups&#44; as shown in <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#46; The second is that interactions between the genetic component and environmental aggressions initiate or exacerbate them&#44; as shown in <a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#46; The main differences and similarities between the COPDC are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46; The third characteristic of COPDC is that they evolve with PE&#44; predominantly infectious &#40;CF&#41;&#44; inflammatory &#40;asthma&#41;&#44; and mixed &#40;asthma and viruses&#47;bacteria&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">Infectious PE caused by bacteria are different in healthy children when compared with those with COPDC&#46; <span class="elsevierStyleItalic">Streptococcus pneumoniae</span>&#44; <span class="elsevierStyleItalic">Haemophilus influenzae</span> and <span class="elsevierStyleItalic">Staphylococcus aureus</span>&#44; which have high virulence&#44; are common causes of pneumonia in previously healthy individuals without COPDC and require treatment with low-spectrum antibiotics &#40;<span class="elsevierStyleItalic">e&#46;g&#46;</span>&#44; penicillin and amoxicillin&#41;&#44; but cause short-term mortality&#46; In contrast&#44; many patients with COPDC&#44; especially those with CF&#44; PCD&#44; and NCFB&#44; have PE caused by low-virulence bacteria &#40;<span class="elsevierStyleItalic">Pseudomonas aeruginosa</span> &#40;PA&#41;&#44; <span class="elsevierStyleItalic">Burkholderia cepacia</span> complex&#44; <span class="elsevierStyleItalic">Stenotrophomonas maltophilia</span> and&#44; <span class="elsevierStyleItalic">Achromobacter xylosoxidans</span>&#41;&#44; which cause long-term mortality&#59; however&#44; they require broad-spectrum antibiotics such as aminoglycosides&#44; meropenem&#44; and third-generation cephalosporins &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">Due to the characteristics of COPDC&#44; several guidelines and systematic reviews for the diagnosis and management of the disease have been proposed for both periods between crises and PE of most COPDC&#44; aiming to prevent further deterioration of pulmonary function and damage &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;15&#8211;27</span></a></p><elsevierMultimedia ident="fig0020"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Asthma</span><p id="par0080" class="elsevierStylePara elsevierViewall">Asthmatic individuals who manifested the disease early in life persist with symptoms&#44; and evidence suggests that asthma severity in childhood predicts the disease severity in adulthood&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a> Recent guidelines emphasize difficulties for the definitive diagnosis of asthma in children younger than 5 years&#44; where several COPDC phenotypes have been identified&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">For children older than 5 years&#44; asthma diagnosis is based on&#58; &#40;1&#41; a history of acute respiratory failure crises that improve with short-acting bronchodilators &#40;SABA&#41;&#59; &#40;2&#41; increased serum IgE in the absence of parasitic diseases&#44; eosinophilia&#44; and positive immediate hypersensitivity skin tests for airborne allergens&#59; &#40;3&#41; spirometry and measurement of bronchial hyperresponsiveness &#40;BHR&#41; to methacholine challenge&#46; The diagnosis can be made with the isolated presence and&#47;or combination of the above items 1&#59; 1<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>2&#59; 1<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>3&#59; or 1<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>2<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>3&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Numerous factors have been associated with increased risk of developing asthma in adolescence&#44; of which the following should be mentioned&#58; personal or family history of allergy&#44; male gender&#44; obesity&#44; pollution&#44; exposure to cigarette smoke&#44; RWI&#44; severe infection by respiratory syncytial virus &#40;RSV&#41;&#44; pneumonia in the first year of life&#44; RWI severity&#44; altered pulmonary function&#44; and BHR&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;29&#8211;31</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">There is no specific treatment for asthma&#44; and it is preferable to use the term management for the tools used to attain disease control&#46; The main objectives for outpatient management are&#58; &#40;i&#41; make chronic symptoms minimal or nonexistent&#59; &#40;ii&#41; decrease the intensity and the number of PE&#59; &#40;iii&#41; maintain lung function as close as possible to normal levels&#59; &#40;iv&#41; maintain normal levels of daily activities&#44; including physical exercises&#59; &#40;v&#41; prevent the adverse effects of anti-asthmatic drugs&#59; &#40;vi&#41; prevent disease progression to irreversible airflow limitation&#59; &#40;vii&#41; prevent asthma mortality&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;15&#8211;20</span></a> The main medications to control asthma are inhaled corticosteroids &#40;IC&#41;&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">The classification of the clinical pictures and respective treatment steps are listed below&#58;</p><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Steps in the treatment of asthma</span><p id="par0105" class="elsevierStylePara elsevierViewall">&#40;Step 1&#41; Individuals with intermittent asthma&#44; characterized by normal spirometry and periods between crises lasting longer than 1 month without exacerbations in the last year&#44; should receive SABA&#46; &#40;Step 2&#41; Continued use of IC at low doses and rescue SABA during crisis&#46; &#40;Step 3&#41; Continued use of low doses of IC<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>long-acting beta agonists &#40;LABA&#41; with SABA for crises or IC<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>formoterol for both maintenance and control&#46; &#40;Step 4&#41; IC<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>formoterol for maintenance and crises or medium or high doses of IC<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>LABA and SABA&#44; if necessary&#46; &#40;Step 5&#41; Refer patient to a center specialized in asthma treatment for difficult-to-control disease&#58; consider oral steroids and anti-IgE &#40;omalizumab&#41;&#46; Consider oral corticosteroids in severe PE and if the patient had previous severe PE&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;15&#8211;20</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">Medications and steps are modified to the next step or revert to the previous step&#44; depending on whether or not the asthma is controlled&#46; A decrease in management steps must occur if the asthma is well controlled for at least 3 months&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">It is essential to verify at all consultations&#44; whether the asthma is controlled or not&#44; from the clinical and&#47;or functional point of view&#44; based on six parameters&#58; &#40;i&#41; nocturnal signs and symptoms&#59; &#40;ii&#41; daytime signals and symptoms&#59; &#40;iii&#41; signs and symptoms with physical exercise or limitation in daily activities&#59; &#40;iv&#41; PE&#59; &#40;v&#41; need for relief medication &#40;SABA&#41;&#59; &#40;vi&#41; changes in lung function&#46; Hence&#44; asthma is considered controlled when all parameters are normal&#59; it should be classified as partially controlled in the presence of one or two altered parameters&#59; and finally&#44; non-controlled asthma should be considered when three or more parameters are altered&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">The absence of control of signs and symptoms&#44; frequent exacerbations&#44; previous admission to an intensive care unit &#40;ICU&#41;&#44; low values of forced expiratory volume in 1<span class="elsevierStyleHsp" style=""></span>s &#40;FEV1&#41;&#44; exposure to tobacco smoke&#44; and need to use high-dose medications are characteristics associated with increased risk of adverse events in the future&#46; By definition&#44; an exacerbation at any week is indicative of non-controlled asthma and also of the need for review of the maintenance treatment&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16&#44;17</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">In the management of patients with asthma&#44; the following are essential&#58; &#40;i&#41; management supported by evidence-based medicine&#59; &#40;ii&#41; to perform the diagnosis and&#44; if possible&#44; the phenotype &#40;<span class="elsevierStyleItalic">e&#46;g</span>&#46;&#44; allergic and non-allergic&#41;&#59; &#40;iii&#41; to exclude and treat comorbidities&#59; &#40;iv&#41; to assess and recommend the adequate use of prescribed drugs&#59; &#40;v&#41; to assess&#44; advise&#44; and encourage treatment adherence&#59; &#40;vi&#41; to assess and advise about environmental prophylaxis&#59; &#40;vii&#41; to assess and advise on the triggering factors&#59; &#40;viii&#41; to educate patient&#39;s caregivers about asthma and the factors influencing it&#59; &#40;ix&#41; to give instructions on the adequate use of devices for administration of metered-dose and dry powder inhalers&#59; &#40;x&#41; instructions for patients to be able to recognize when asthma control is deteriorating and what medications to use&#44; when it occurs&#59; &#40;xi&#41; to identify non-controlled patients and causes of lack of control&#59; &#40;xii&#41; to advise that inhaled medications should be used with spacers&#59; &#40;xiii&#41; to advise on the hygiene of spacers&#44; which must be washed and left to soak in water with detergent&#59; &#40;xiv&#41; LABA must not be used in children younger than 4 years&#59; &#40;xv&#41; SABA are the agents of choice in PE&#59; &#40;xvi&#41; IC alone or associated with bronchodilators are the basis of asthma treatment&#59; &#40;xvii&#41; children younger than 6 years can use inhaled medication with spacer and those older than 6 years can use dry powder inhalers&#59; &#40;xviii&#41; to assess pulmonary function regularly&#59; &#40;xix&#41; to advise on the need for long-term medical care&#59; &#40;xx&#41; omalizumab should be prescribed in reference centers for the management of patients with difficult-to-control asthma&#46;</p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Recurrent wheezing in infants &#40;RWI&#41;</span><p id="par0130" class="elsevierStylePara elsevierViewall">There are several phenotypes and risk factors &#40;RF&#41; for RWI&#44; creating difficulties for asthma diagnosis and resulting in an excessive assessment for comorbidities&#46;<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">32&#8211;37</span></a> The main RF include&#58; presence of familial and&#47;or personal allergy&#44; early sensitization&#44; severe RSV infection&#44; maternal smoking during pregnancy&#44; and unfavorable airway geometry&#46; Other implicated RF are&#58; genetic variants&#44; excessive hygiene&#44; Western lifestyle&#44; pollution&#44; gastroesophageal reflux disease &#40;GERD&#41;&#44; low socioeconomic status&#44; urban environment&#44; antibiotic use&#44; diet&#44; few siblings&#44; ethnicity&#44; male gender&#44; and attendance of daycare&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">38</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">Exposure to maternal smoking&#44; both intrauterine and in the early years of life&#44; has contributed to increased incidence and severity of childhood and adult asthma&#44; COPD in adults&#44; lung function deficits&#44; lung hypoplasia&#44; respiratory tract infections&#44; and higher predisposition to sudden death syndrome&#46;<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">39&#8211;41</span></a> Respiratory viruses are the main RF for asthma and RWI initiation or exacerbation&#58; &#40;i&#41; some viruses initiate asthma&#59; &#40;ii&#41; the more severe the respiratory infection&#44; the higher the likelihood of developing asthma&#59; &#40;iii&#41; viruses cause PE in children and adults with established asthma&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">42</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall">The diagnosis of asthma in infants is a major challenge for clinicians&#59; to attain a diagnosis with a high degree of suspicion&#44; the presence of allergy should be investigated&#44; as it is a persistent asthma predictor&#46; The investigation of severe COPDC in children younger than 5 years may require many tests&#44; including high-resolution computed tomography &#40;HRCT&#41;&#44; lung function assessment&#44; cellular and humoral immunity evaluation&#44; bronchoscopy&#44; bronchoalveolar lavage&#44; 24-h esophageal pH-metry&#44; endobronchial biopsy&#44; mutation screening&#44; and sodium and chloride sweat measurements&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a> In contrast&#44; no investigation is necessary for most of RWI&#44; because it cannot differentiated with certainty whether the future course of the RWI will be persistent asthma or transient wheezing&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">43</span></a></p><p id="par0145" class="elsevierStylePara elsevierViewall">Some asthma predictive indices &#40;APIs&#41; have been developed to identify children with RWI and at risk for asthma after 6 years of age &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">38&#44;44</span></a> Some authors have mentioned methodological and practical limitations of APIs&#44; suggesting that they have low capacity and poor sensitivity to predict asthma at school age&#44;<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">45&#44;46</span></a> and that although they are simple and easy-to-apply tools&#44; they have not been sufficiently validated&#46; According to these authors&#44; predicting asthma using simple clinical models is virtually impossible&#46;<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">45&#44;46</span></a></p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0150" class="elsevierStylePara elsevierViewall">Although most of the scientific community is favorable to the use of APIs&#44;<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">47&#44;48</span></a> the search for clinical and&#47;or laboratory markers for the diagnosis of asthma in RWI and children younger than 5 years remains a rich area for future studies&#46; Infants and preschoolers with RWI or asthma have less PE&#44; and show symptom and lung function improvement when treated with IC&#46;<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">49&#8211;51</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">The dosages of the main IC used in COPDC are shown in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Bronchiolitis obliterans &#40;BO&#41;</span><p id="par0160" class="elsevierStylePara elsevierViewall">Bronchiolitis obliterans &#40;BO&#41; is a predominantly neutrophilic COPDC with high levels of proinflammatory cytokines&#44; bronchial remodeling&#44; and fibrosis in the small airways&#46; When the etiology is infectious&#44; it is called post-infectious BO &#40;PIBO&#41;&#46; Most often&#44; PIBO is caused by previous infection caused by adenovirus&#44; but influenza&#44; measles&#44; RSV&#44; and <span class="elsevierStyleItalic">Mycoplasma pneumoniae</span> are also observed&#46; Latin American countries have the highest rates of this disease&#46;<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">27&#44;52&#8211;62</span></a></p><p id="par0165" class="elsevierStylePara elsevierViewall">Studies have shown that lung function remains altered with an obstructive pattern and air trapping during childhood&#46; These patients are often hospitalized due to recurrent respiratory infections&#46; Patients show slight improvement over the years&#46;<a class="elsevierStyleCrossRefs" href="#bib0270"><span class="elsevierStyleSup">54&#44;62</span></a></p><p id="par0170" class="elsevierStylePara elsevierViewall">Five criteria are essential for the diagnosis of PIBO&#58; &#40;i&#41; history of acute viral bronchiolitis and viral pneumonia before the age of 3&#59; &#40;ii&#41; evidence of persistent airway obstruction after the acute event&#44; identified by physical examination and&#47;or lung function&#44; which is not responsive to at least 2 weeks of systemic corticosteroids associated with bronchodilator&#59; &#40;iii&#41; radiological findings of obstruction such as hyperinflation&#44; atelectasis&#44; bronchial wall thickening&#44; and bronchiectasis&#59; &#40;iv&#41; mosaic perfusion and air trapping on HRCT&#59; &#40;v&#41; exclusion of other COPDC&#46;<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">27&#44;60</span></a></p><p id="par0175" class="elsevierStylePara elsevierViewall">Among the causes of BO are&#58; drugs&#44; association with Stevens&#8211;Johnson syndrome&#44; collagenoses&#44; irradiation&#44; foreign body or gastric content aspiration&#44; and graft <span class="elsevierStyleItalic">vs&#46;</span> host disease after transplantation&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">The definitive diagnosis of BO is made through anatomopathological examination of fragments obtained from lung biopsy&#46; BO is classified as&#58; &#40;i&#41; proliferative BO&#44; characterized by airway obstruction by polyps and&#47;or granulation tissue in the lumen of bronchioles&#59; or &#40;ii&#41; constrictive BO&#44; characterized by peribronchial inflammation and fibrosis&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">58</span></a> As the lung biopsy is an invasive test&#44; most studies perform the diagnosis based on clinical history and HRCT&#44; spirometry&#44; and perfusion scintigraphy with technetium&#46; Alterations in HRCT include wall thickening and bronchiole obliteration and&#44; with the disease progression&#44; bronchiectasis&#44; bronchial wall thickening&#44; mosaic perfusion&#44; air trapping&#44; reduced lung volume&#44; and decreased diameter of hilar and peripheral vessels are observed&#46;<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">27&#44;59</span></a></p><p id="par0185" class="elsevierStylePara elsevierViewall">There is no specific treatment for BO&#46; Oxygen therapy is essential in some patients&#44; mainly after ICU discharge for severe acute viral bronchiolitis &#40;AVB&#41; and in patients who develop chronic hypoxemia&#46; Contact prophylaxis with intra and extra-domestic pollutants&#44; reduction of exposure to active and passive smoking&#44; and anti-pneumococcal and influenza vaccination are important steps for BO management&#46; In the early phases of the disease&#44; some patients may benefit from systemic corticosteroid therapy&#46; Bronchodilators&#44; antibiotics in infectious exacerbations&#44; surgery for resection of fixed collapsed lung&#44; and lung transplant have also been used&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a></p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Primary ciliary dyskinesia &#40;PCD&#41;</span><p id="par0190" class="elsevierStylePara elsevierViewall">Primary ciliary dyskinesia &#40;PCD&#41; is an autosomal recessive COPDC caused by several alterations in airway cilia anatomical and functional structure&#44; resulting in inflammation and infection&#44; with an incidence of 1&#58;4000&#8211;40&#44;000 live births&#46; Laterality defects in the thoraco-abdominal organs occur in about 50&#37; of patients with PCD&#44; and most have <span class="elsevierStyleItalic">situs inversus totalis</span> &#40;Kartagener syndrome&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">24&#44;63&#8211;66</span></a></p><p id="par0195" class="elsevierStylePara elsevierViewall">PCD should be suspected in children with&#58; &#40;i&#41; <span class="elsevierStyleItalic">situs inversus totalis</span> or other laterality defect in thoraco-abdominal organs&#59; &#40;ii&#41; recurrent upper &#40;otitis&#44; sinusitis&#41; and lower respiratory tract infections &#40;pneumonia&#44; abscesses&#41; and chronic respiratory tract diseases of undefined etiology &#40;bronchiectasis&#44; chronic cough&#44; atelectasis&#44; and middle lobe syndrome&#41;&#59; &#40;iii&#41; neonatal respiratory distress syndrome of undefined causes&#59; &#40;iv&#41; diagnosis of PCD in other family members&#59; &#40;v&#41; congenital heart disease&#44; especially if associated with heterotaxia&#44; and with chronic and repeated infections of the lower and upper airways&#46;<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">24&#44;67</span></a></p><p id="par0200" class="elsevierStylePara elsevierViewall">Clinical manifestations and alterations in PCD vary according to age<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a>&#58; in the prenatal period&#44; ultrasound may reveal mild fetal cerebral ventriculomegaly&#44; heterotaxia and <span class="elsevierStyleItalic">situs inversus totalis</span> &#40;approximately 25&#37; of individuals with <span class="elsevierStyleItalic">situs inversus totalis</span> have PCD&#41;&#46; PCD prevalence in patients with heterotaxia remains unknown&#46; In the neonatal period&#44; 75&#37; of full-term newborns with PCD have respiratory distress&#44; requiring supplemental oxygen for days or weeks&#46; Some have continuous rhinorrhea&#44; heterotaxia&#44; and hydrocephalus&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall">During childhood&#44; chronic productive cough is observed&#44; in association with atelectasis and&#47;or recurrent pneumonia&#44; atypical asthma that does not respond to treatment&#44; bronchiectasis&#44; NCFB&#44; nasal polyps&#44; chronic rhinosinusitis&#44; hearing impairment&#44; and chronic otitis&#46; In adolescence and adulthood&#44; bronchiectasis&#44; chronic mucopurulent sputum&#44; digital clubbing&#44; spirometry with progressive or mixed obstructive ventilatory pattern&#44; nasal polyposis&#44; and halitosis can be observed&#44; as well as infertility in men &#40;50&#37;&#41; and ectopic pregnancy in women&#46;</p><p id="par0210" class="elsevierStylePara elsevierViewall">Diagnosis is based on clinical and radiological alterations&#44; nasal nitric oxide levels&#44; ciliary beat pattern at video microscopy&#44; structural alterations of the cilia by electron microscopy&#44; and detection of mutations&#46; Only 50&#8211;60&#37; of PCD patients have a known mutation&#46;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">25&#44;68&#44;69</span></a></p><p id="par0215" class="elsevierStylePara elsevierViewall">CF evolves with secondary ciliary dyskinesia&#44; whereas in PCD it is primary&#59; the management of pulmonary disease in these two diseases is virtually identical&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Cystic fibrosis &#40;CF&#41;</span><p id="par0220" class="elsevierStylePara elsevierViewall">CF is an autosomal recessive disease caused by mutations in the CFTR &#40;cystic fibrosis transmembrane regulator&#41; gene&#44; 7q31&#46;2 region&#44; which has more than 2000 identified mutations&#44; divided into six classes regarding the production and function of the CFTR protein&#46; The qualitative or quantitative absence or dysfunction of CFTR causes physiopathological changes in several organs&#46; Most of CF morbidity and mortality is caused by manifestations in the respiratory and digestive tracts&#46;<a class="elsevierStyleCrossRefs" href="#bib0350"><span class="elsevierStyleSup">70&#8211;73</span></a></p><p id="par0225" class="elsevierStylePara elsevierViewall">It is currently known that in Class I&#44; II&#44; and III mutations&#44; the disease starts before symptom onset&#44; constituting a major factor for early intervention and more aggressive treatments&#44; showing promising results in reducing lung function damage and deterioration&#44; with consequent increased survival&#46;<a class="elsevierStyleCrossRefs" href="#bib0350"><span class="elsevierStyleSup">70&#8211;73</span></a></p><p id="par0230" class="elsevierStylePara elsevierViewall">Availability of newborn screening&#44; sweat testing&#44; CFTR gene mutation screening&#44; medications&#44; and possible use of correctors&#44; enhancers&#44; and stabilizers &#40;for some mutations&#41; of the CFTR protein are concrete facts in the last decade&#46; The consequence is that the survival of these patients is increasingly higher&#46;<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">73</span></a> Lung damage and decreased lung function are progressive&#44; and depend on the mutation&#44; gender&#44; polymorphisms&#44; treatment availability and adherence&#44; early treatment&#44; comorbidities&#44; and care in reference centers&#46;<a class="elsevierStyleCrossRefs" href="#bib0370"><span class="elsevierStyleSup">74&#8211;76</span></a></p><p id="par0235" class="elsevierStylePara elsevierViewall">The physiopathology of COPD in CF can be understood with the following six events &#40;6D&#41;&#58; &#40;i&#41; defect in the CFTR gene&#59; &#40;ii&#41; impairment or absence of the CFTR protein&#59; &#40;iii&#41; dehydration of the airway surface liquid&#59; &#40;iv&#41; defect in bacterial clearance in the airways&#59; &#40;v&#41; secondary ciliary dyskinesia&#59; &#40;vi&#41; destruction of the airway epithelium&#46;<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">77</span></a></p><p id="par0240" class="elsevierStylePara elsevierViewall">To attain the diagnosis of CF after neonatal screening&#44; alterations in the gene and or CFTR protein should be verified&#46; The CFTR gene is studied through the analysis of mutations and polymorphisms&#46; The CFTR protein function and&#47;or presence can be assessed in the sweat glands &#40;sweat test&#44; evaporimetry&#44; difference of potential&#44; and pH&#41; nasal epithelium&#44; salivary glands&#44; and digestive tract&#46;<a class="elsevierStyleCrossRefs" href="#bib0390"><span class="elsevierStyleSup">78&#44;79</span></a></p><p id="par0245" class="elsevierStylePara elsevierViewall">Diagnosing or ruling out CF is not always easy&#44; even after comprehensive testing&#44; particularly in adolescents and adults with classes IV&#44; V&#44; and VI mutations&#44; which cause non-classical forms and are often associated with rare mutations&#44; threshold levels of chloride in sweat&#44; late-onset clinical manifestations&#44; and atypical symptoms&#46;<a class="elsevierStyleCrossRef" href="#bib0400"><span class="elsevierStyleSup">80</span></a></p><p id="par0250" class="elsevierStylePara elsevierViewall">As CF affects many organs&#44; its management is complex&#46; The service must have interdisciplinary teams with several health care professionals&#44; physical therapy&#44; medical examinations&#44; frequent visits to the hospital&#44; and use of daily&#44; repetitive medications&#44; which are sometimes complicated and costly&#46;<a class="elsevierStyleCrossRef" href="#bib0405"><span class="elsevierStyleSup">81</span></a></p><p id="par0255" class="elsevierStylePara elsevierViewall">Patients with CF are highly susceptible to chronic lung infection by PA&#46; PA acquisition occurs very early and is related to lung function deterioration and worse CF prognosis&#59; hence&#44; intensive treatment against PA is crucial in the management of CF&#46;</p><p id="par0260" class="elsevierStylePara elsevierViewall">Other bacteria frequently found in the airways of CF patients and that determine the lung function damage and deterioration include <span class="elsevierStyleItalic">S&#46; aureus</span>&#44; <span class="elsevierStyleItalic">H&#46; influenzae</span>&#44; PA&#44; <span class="elsevierStyleItalic">B&#46; cepacia</span> complex&#44; <span class="elsevierStyleItalic">S&#46; maltophilia</span>&#44; and <span class="elsevierStyleItalic">Achromobacter species</span>&#46; Non-tuberculous <span class="elsevierStyleItalic">Mycobacteria</span> &#40;NTM&#41; and other anaerobic bacteria and fungi are found less frequently&#44; and tend to appear at the more advanced stages of lung disease&#46;<a class="elsevierStyleCrossRefs" href="#bib0410"><span class="elsevierStyleSup">82&#44;83</span></a></p><p id="par0265" class="elsevierStylePara elsevierViewall">Inhaled antibiotics &#40;IA&#41; are essential for the treatment of chronic lung infections in CF&#46; The increased survival in patients with CF in recent decades can be partly attributed to the use of IA&#46; They have higher deposition at the infection site and less risk of systemic side effects than parenteral therapy&#44; decrease PE&#44; and improve quality of life and spirometry&#46;<a class="elsevierStyleCrossRefs" href="#bib0420"><span class="elsevierStyleSup">84&#44;85</span></a></p><p id="par0270" class="elsevierStylePara elsevierViewall">CF patients with chronic lung infection by PA should receive long-term&#44; nebulized anti-pseudomonal therapy&#44; unless there is contraindication&#46; Among the IA&#44; tobramycin and colistin are currently available&#44; while aztreonam&#44; levofloxacin&#44; and liposomal amikacin will soon be available&#46;<a class="elsevierStyleCrossRef" href="#bib0430"><span class="elsevierStyleSup">86</span></a> The administration of IA is time-consuming and is a heavy burden for patients&#46; Treatment adherence is a significant challenge&#46;<a class="elsevierStyleCrossRef" href="#bib0435"><span class="elsevierStyleSup">87</span></a></p><p id="par0275" class="elsevierStylePara elsevierViewall">The treatment of the first acquisition episode&#44; from infection to chronic infection and PE due to PA&#44; are reasons for debates and controversies in the literature&#46;<a class="elsevierStyleCrossRef" href="#bib0440"><span class="elsevierStyleSup">88</span></a></p><p id="par0280" class="elsevierStylePara elsevierViewall">PA eradication protocols have demonstrated antibiotic efficacy in the first bacterial isolation&#59; intensive treatment with intravenous antibiotics in PE and IA in the periods between crises&#46;<a class="elsevierStyleCrossRefs" href="#bib0445"><span class="elsevierStyleSup">89&#8211;91</span></a></p><p id="par0285" class="elsevierStylePara elsevierViewall">It is advisable to perform lung damage assessment by HRCT at least every 2 years&#44; and pulmonary function assessment by spirometry at least twice a year&#46;</p><p id="par0290" class="elsevierStylePara elsevierViewall">IA&#44; anti-inflammatory drugs&#44; corticosteroids&#44; bronchodilators&#44; and mucolytics may be necessary for the management of lung disease in CF&#46; Auxiliary measures have shown benefits with respiratory physical therapy&#44; regular exercise&#44; avoiding indoor and outdoor pollution&#44; and active and passive smoking&#46; It is crucial to include treatment adherence measures and continuity of care for life&#46; Visits to the reference center must be monthly during the first year and at least four times a year until adulthood&#46;</p><p id="par0295" class="elsevierStylePara elsevierViewall">Adherence to CF management varies between 35 and 75&#37; and is lower in adolescence&#46; Poor adherence to medication worsens lung function&#44; increases the frequency of PE&#44; and results in a larger number of consultations&#44; hospitalizations&#44; and costs&#46; Therefore&#44; interventions are necessary to improve medication adherence&#46;<a class="elsevierStyleCrossRef" href="#bib0405"><span class="elsevierStyleSup">81</span></a></p><p id="par0300" class="elsevierStylePara elsevierViewall">Many international organizations have proposed that the management of lung disease in CF should be directed by guidelines based on scientific evidence&#46; Thus&#44; recent publications on the management of COPD in CF can be found&#44; and represent the &#8220;state-of-the-art&#8221; for CF reference centers&#46;<a class="elsevierStyleCrossRefs" href="#bib0410"><span class="elsevierStyleSup">82&#44;83&#44;91&#44;92</span></a></p><p id="par0305" class="elsevierStylePara elsevierViewall">Recently&#44; advances in the treatment of CF have gained prominence&#46; Mutations in the CFTR gene have been widely identified&#44; and the highest prevalence of the F508del mutation has been emphasized&#46; Treatment for the specific mutation and&#47;or class of mutations has focused on the study of new drugs&#46; Two drugs have been used in studies considering the F508del mutation in homozygous form&#44; and results of the association of ivacaftor &#40;increases opening of the chloride channel &#8211; potentiator&#41; and lumacaftor &#40;increases protein number in the epithelium &#8211; potentiator&#41; have shown increased chloride transport when compared with the values of the individual drugs&#46;<a class="elsevierStyleCrossRef" href="#bib0465"><span class="elsevierStyleSup">93</span></a></p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Bronchopulmonary dysplasia &#40;BPD&#41;</span><p id="par0310" class="elsevierStylePara elsevierViewall">BPD is a secondary COPDC&#44; and is associated with prematurity and risk factors &#40;RF&#41; related to it&#46; Low birth weight&#44; high fraction of inspired oxygen&#44; patent ductus arteriosus&#44; high intravenous fluid volume values&#44; mechanical ventilation with high pressures&#44; genetic susceptibility&#44; and infection in the neonatal period contribute to the prevalence and severity of BPD&#46; This disease affects approximately 30&#37; of newborns with birth weight less than 1500<span class="elsevierStyleHsp" style=""></span>g&#46;<a class="elsevierStyleCrossRefs" href="#bib0470"><span class="elsevierStyleSup">94&#44;95</span></a></p><p id="par0315" class="elsevierStylePara elsevierViewall">Several studies have shown that most infants who develop BPD evolve with lung function alterations throughout life&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#44;96&#8211;101</span></a></p><p id="par0320" class="elsevierStylePara elsevierViewall">Similar to all COPDC&#44; BPD has no specific treatment&#46; Regarding the advances to reduce mortality in the neonatal period&#44; in recent decades&#44; three factors have clearly proven to be effective&#58; &#40;i&#41; corticosteroid administration to pregnant women with high-risk pregnancies&#59; &#40;ii&#41; administration of surfactants to premature infants&#59; &#40;iii&#41; less aggressive ventilation strategies&#46;<a class="elsevierStyleCrossRefs" href="#bib0510"><span class="elsevierStyleSup">102&#44;103</span></a></p><p id="par0325" class="elsevierStylePara elsevierViewall">The following have also been used&#58; diuretics &#40;furosemide&#41;&#59; bronchodilators&#59; systemic corticosteroids and IC&#59; vitamin A&#59; methylxanthines &#40;pentoxifylline&#44; caffeine&#41;&#59; pulmonary vasodilators &#40;sildenafil&#44; inhaled nitric oxide&#41;&#59; late surfactant administration&#59; and antioxidants &#40;superoxide dismutase&#41;&#44; with varying degrees of efficacy in the management of acute and&#47;or chronic BPD&#46; However&#44; there is little evidence of the beneficial actions of most of these agents when used in short- or long-term management of BPD&#46;<a class="elsevierStyleCrossRefs" href="#bib0510"><span class="elsevierStyleSup">102&#44;103</span></a></p><p id="par0330" class="elsevierStylePara elsevierViewall">BPD is associated with a high incidence of pulmonary arterial hypertension &#40;PAH&#41;&#46; Treatment with sildenafil has been associated with significant improvement in echocardiographic markers of PAH and reduced need for oxygen&#46; The drug is well tolerated&#46;<a class="elsevierStyleCrossRef" href="#bib0520"><span class="elsevierStyleSup">104</span></a></p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Bronchiectasis related to diseases other than CF &#40;NCFB&#41;</span><p id="par0335" class="elsevierStylePara elsevierViewall">Bronchiectasis is an alteration that accompanies many COPDC&#46; It may be associated with and complicate asthma&#44; PCD&#44; CF&#44; BO&#44; and NCFB&#44; and be consequent to measles&#44; pertussis&#44; immunodeficiency&#44; allergic bronchopulmonary aspergillosis&#44; inflammatory bowel disease&#44; rheumatoid arthritis&#44; foreign body inhalation&#44; PCD&#44; BO&#44; respiratory tract malformation &#40;<span class="elsevierStyleItalic">e&#46;g&#46;</span>&#58; tracheoesophageal fistula&#44; congenital cystic adenomatoid malformation&#41; and result from inflammatory and infectious diseases to the airways&#46; NCFB encompasses several etiologies and degrees of severity&#59; a clear cause cannot be established in many patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0525"><span class="elsevierStyleSup">105&#44;106</span></a></p><p id="par0340" class="elsevierStylePara elsevierViewall">Pulmonary disease in NCFB is very similar to CF&#44; BO&#44; and PCD&#46; The challenge a child with NCFB faces is the pursuit of a diagnosis&#46; The management is very similar to that of most COPDC and should be considered on a case-by-case basis&#44; aiming at patient comfort and clinical response&#46;<a class="elsevierStyleCrossRef" href="#bib0535"><span class="elsevierStyleSup">107</span></a></p><p id="par0345" class="elsevierStylePara elsevierViewall">Although some randomized&#44; controlled&#44; double-blind trials have shown that prolonged use of macrolides in patients with NCFB improves quality of life and reduces PE rates&#44; the role of macrolides in NCFB management remains unclear and they cannot be recommended for routine use&#46; Until very recently&#44; these drugs were investigated in small trials of short duration&#44; which did not evaluate relevant clinical outcomes&#44; such as PE and quality of life&#46;</p><p id="par0350" class="elsevierStylePara elsevierViewall">Long-term oral antibiotics should not be routinely prescribed&#46; Macrolides &#40;or other antibiotics&#41; can be considered for a limited period of 12&#8211;24 months&#44; especially in patients with frequent exacerbations&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;108&#44;109</span></a></p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Plastic bronchitis &#40;PB&#41;</span><p id="par0355" class="elsevierStylePara elsevierViewall">PB is a rare COPDC with unknown prevalence and etiology&#44; with formation of bronchial molds of gelatinous or solid appearance in the large airways&#44; whose composition varies&#44; consisting of mucins&#44; fibrin&#44; DNA&#44; or eosinophils&#44; depending on the PB etiology&#46; The diseases most often associated with PB are congenital heart disease and asthma&#46; It has also been described in infection by influenza virus&#44; H1N1&#44; lymphatic diseases&#44; allergic bronchopulmonary aspergillosis&#44; and sickle-cell disease&#46;<a class="elsevierStyleCrossRef" href="#bib0545"><span class="elsevierStyleSup">109</span></a> Although bronchodilators&#44; corticosteroids&#44; antibiotics&#44; mucolytics&#44; physical therapy&#44; antifibrinolytic therapy with heparin&#44; and urokinase have been used&#44; single or repeat bronchoscopy is essential for diagnosis and treatment&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Final considerations</span><p id="par0360" class="elsevierStylePara elsevierViewall">The pediatrician&#39;s actions are vital for the management of COPDC&#46; The clinician should suspect the disease in the presence of signs and symptoms in order to attain an early and accurate diagnosis&#44; know the risk factors and associated comorbidities&#44; and assess treatment adherence&#44; the correct use of prescribed drugs&#44; and their side effects based on well-defined management protocols&#44; preferably based on specific guidelines&#46;</p><p id="par0365" class="elsevierStylePara elsevierViewall">Management benefits should be assessed through the reduction in acute pulmonary exacerbations&#44; increased quality of life&#44; and decreased evolution of lung function loss &#40;spirometry&#44; measurement of oxygen saturation&#44; lung clearance index&#41; and lung damage &#40;HRCT every 2 years&#44; if necessary&#41;&#46; Therefore&#44; the sequential evaluation of lung function and damage should be standardized and continuous&#44; throughout life&#46; For most COPDC&#44; monitoring in specialized reference centers by interdisciplinary teams leads to better outcomes&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Conflicts of interest</span><p id="par0370" class="elsevierStylePara elsevierViewall">The authors declare no conflicts of interest&#46;</p></span></span>"
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          "titulo" => "Recurrent wheezing in infants &#40;RWI&#41;"
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          "titulo" => "Bronchiolitis obliterans &#40;BO&#41;"
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          "titulo" => "Primary ciliary dyskinesia &#40;PCD&#41;"
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          "titulo" => "Cystic fibrosis &#40;CF&#41;"
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          "titulo" => "Bronchopulmonary dysplasia &#40;BPD&#41;"
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          "titulo" => "Bronchiectasis related to diseases other than CF &#40;NCFB&#41;"
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          "titulo" => "Plastic bronchitis &#40;PB&#41;"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objectives</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To verify and describe the main events related to the diagnosis and management of chronic obstructive pulmonary diseases in children &#40;COPDC&#41; and adolescents&#44; considering the interrelated physiopathology&#44; genetic&#44; and environmental characteristics&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Sources</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Relevant literature from PubMed was selected and reviewed&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Summary of the findings</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">COPDC have an environmental and&#47;or genetic origin and its manifestation has manifold genotypes&#44; phenotypes&#44; and endotypes&#46; Although COPDC has no cure&#44; it can be clinically controlled&#46; Chronic cough is the main symptom and bronchiectasis can be present in several COPDC patients&#46; The management of COPDC is more effective if based on guidelines and when treatment regimen adherence is promoted&#46; Oral and inhaled corticosteroids&#44; bronchodilators&#44; inhaled antibiotics&#44; and treatment of pulmonary exacerbation &#40;PE&#41; are the bases of COPDC management&#44; and should be individualized for each patient&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Correct diagnosis and knowledge of risk factors and comorbidities are essential in COPDC management&#46; Procedures and drugs used should be based on specific guidelines for each COPDC case&#46; Treatment adherence is critical to obtain the benefits of management&#46; COPDC clinical control must be evaluated by the decrease in PEs&#44; improved quality of life&#44; reduction of pulmonary function loss&#44; and lung structural damage&#46; For most cases of COPDC&#44; monitoring by interdisciplinary teams in specialized reference centers with surveillance strategies and continuous care leads to better outcomes&#44; which must be evaluated by decreasing pulmonary function damage and deterioration&#44; better prognosis&#44; better quality life&#44; and increased life expectancy&#46;</p></span>"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Verificar e descrever os principais eventos relacionados ao diagn&#243;stico e manejo das doen&#231;as pulmonares obstrutivas cr&#244;nicas em crian&#231;as &#40;DPOCC&#41; e adolescentes&#44; tendo em vista a fisiopatologia&#44; caracter&#237;sticas gen&#233;ticas e ambientais inter-relacionadas&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Fonte dos dados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Revis&#227;o na base de dado PUBMED com sele&#231;&#227;o de refer&#234;ncias relevantes&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">S&#237;ntese dos dados</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">As DPOCC t&#234;m origem ambiental e&#47;ou gen&#233;tica e se manifestam com diversos gen&#243;tipos&#44; fen&#243;tipos e end&#243;tipos e&#44; embora possam ser controladas&#44; n&#227;o t&#234;m cura&#46; O principal sintoma &#233; a tosse cr&#244;nica e muitas cursam com bronquiectasia&#46; O manejo tem maior efic&#225;cia se baseado em <span class="elsevierStyleItalic">guidelines</span> e se a ades&#227;o ao regime terap&#234;utico for estimulada e comprovada&#46; Cortic&#243;ides orais e inalat&#243;rios&#44; broncodilatadores&#44; antibi&#243;ticos inalados e tratamento das exacerba&#231;&#245;es pulmonares &#40;EP&#41; s&#227;o vigas mestras do manejo e devem ser individualizados para cada DPOCC&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclus&#245;es</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Nas DPOCC &#233; fundamental o diagn&#243;stico correto&#44; conhecer os fatores de risco e comorbidades&#46; Os procedimentos e os medicamentos devem ser baseados em <span class="elsevierStyleItalic">guidelines</span> espec&#237;ficos para cada DPOCC&#46; Ades&#227;o ao tratamento &#233; fundamental para obter os benef&#237;cios do manejo&#46; O controle deve ser avaliado pela diminui&#231;&#227;o das EP&#44; melhora na qualidade de vida e redu&#231;&#227;o da evolu&#231;&#227;o da perda da fun&#231;&#227;o e dano estrutural pulmonar&#46; Para a maioria das DPOCC&#44; o acompanhamento por equipes interdisciplinares em centros de refer&#234;ncia especializados&#44; com estrat&#233;gias de vigil&#226;ncia e acolhimento cont&#237;nuos&#44; conduz a melhores desfechos que devem ser avaliados pela diminui&#231;&#227;o da deteriora&#231;&#227;o do dano e da fun&#231;&#227;o pulmonar&#44; melhor progn&#243;stico&#44; melhor qualidade de vida e aumento da expectativa de vida&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0025"
            "titulo" => "Objetivos"
          ]
          1 => array:2 [
            "identificador" => "abst0030"
            "titulo" => "Fonte dos dados"
          ]
          2 => array:2 [
            "identificador" => "abst0035"
            "titulo" => "S&#237;ntese dos dados"
          ]
          3 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "Conclus&#245;es"
          ]
        ]
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Ribeiro JD&#44; Fischer GB&#46; Chronic obstructive pulmonary diseases in children&#46; J Pediatr &#40;Rio J&#41;&#46; 2015&#59;91&#58;S11&#8211;25&#46;</p>"
      ]
    ]
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          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Age of onset and higher prevalence of major chronic obstructive pulmonary disease in children &#40;COPDC&#41; compared with chronic obstructive pulmonary disease &#40;COPD&#41; in adults&#46; CF&#44; cystic fibrosis&#59; RWIs&#44; recurrent wheezing in infants&#59; BPD&#44; bronchopulmonary dysplasia&#59; PCD&#44; primary ciliary dyskinesia&#59; NCFB&#44; non-cystic fibrosis bronchiectasis&#59; PB&#44; plastic bronchitis&#59; BO&#44; bronchiolitis obliterans&#59; m&#44; month&#59; y&#44; year&#46;</p>"
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          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Interactions of causes&#44; effects&#44; and clinical outcomes of chronic obstructive pulmonary disease in children &#40;COPDC&#41;&#46;</p>"
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        "tipo" => "MULTIMEDIAFIGURA"
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          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Bacterial acute pulmonary exacerbations in chronic obstructive pulmonary disease in children &#40;COPDC&#41; and pneumonia in previously healthy children&#46;</p>"
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      3 => array:7 [
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        "etiqueta" => "Figure 4"
        "tipo" => "MULTIMEDIAFIGURA"
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          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Control or non-control of chronic obstructive pulmonary disease in children &#40;COPDC&#41; based on diagnosis&#46;</p>"
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      4 => array:7 [
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        "tipo" => "MULTIMEDIATABLA"
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        "tabla" => array:2 [
          "leyenda" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">&#63;&#44; unknown&#59; ABPA&#44; allergic bronchopulmonary aspergillosis&#59; IA&#44; inhaled antibiotics&#59; BD&#44; bronchodilator&#59; NCFB&#44; non-cystic fibrosis bronchiectasis&#59; BO&#44; bronchiolitis obliterans&#59; PIBO&#44; post-infectious bronchiolitis obliterans&#59; PB&#44; plastic bronchitis&#59; CHD&#44; congenital heart disease&#59; IC&#44; inhaled corticosteroids&#59; CD4&#44; CD4 molecule&#59; CD8&#44; CD8 molecule&#59; CFTR&#44; cystic fibrosis transmembrane regulator&#59; BPD&#44; bronchopulmonary dysplasia&#59; PCD&#44; primary ciliary dyskinesia&#59; COPD&#44; chronic obstructive pulmonary disease&#59; COPDC&#44; chronic obstructive pulmonary disease in childhood&#59; GERD&#44; gastroesophageal reflux disease&#59; PE&#44; pulmonary exacerbation&#59; CF&#44; cystic fibrosis&#59; GM-CSF&#44; granulocyte macrophage-colony stimulating factor&#59; PH&#44; pulmonary hypertension&#59; IgE immunoglobulin E&#59; IL&#44; interleukin&#59; API&#44; asthma predictor index&#59; URTI&#44; upper respiratory tract infection&#59; LABA&#44; long-acting beta-agonists&#59; BAL&#44; bronchoalveolar lavage&#59; LTB4 leukotriene B4&#59; M&#44; mild&#59; Mo&#44; moderate&#59; S&#44; severe&#59; MMP&#44; matrix metallopeptidase&#59; NF-kB&#44; NF-kappaB&#59; VLBW&#44; very low birth weight&#59; RSV&#44; respiratory syncytial virus&#59; RV&#44; rhinovirus&#59; SABA&#44; short-acting beta agonists&#59; RWI&#44; recurrent wheezing in infants&#59; HRCT&#44; high-resolution computed tomography&#59; SPT&#44; skin prick test&#59; TGF&#44; transforming growth factor&#59; IRT&#44; immunoreactive trypsinogen&#59; NBS&#44; newborn screening test&#59; TNF&#44; tumor necrosis factor&#59; RSV&#44; respiratory syncytial virus&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">COPDC characteristics&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">ASTHMA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">RWIs&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">BPD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">BO and PIBO&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">CF&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">BP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">PCD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">NCFB&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Classic adult COPD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Symptom onset&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Before 5 years of life&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#60;2 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Newborn&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#60;3 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#60;2 years in classical forms&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CHD&#58; &#60;5 yearsAsthma&#58; &#62;5 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">First year of life&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">After the second year of life&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Adults &#62;40 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Age of higher prevalence&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Childhood&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#8211;2 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">First year of life&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Childhood and adolescence&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Up to 30 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CHD&#58; &#60;5 yearsAsthma&#58; &#62;5 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Childhood and adolescence&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Childhood and adolescence&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">After 40 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Main clinical marker&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Family history of asthma&#44; personal atopy and positive response to BD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Infection by respiratory viruses&#40;RSV and RV&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">PrematurityOxygen use&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Virus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Chronic colonization of the airways by Pseudomonas aeruginosa and pancreatic failure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Elimination of bronchial casts with sputum&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Suppurative infections of the upper and lower airways&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Recurrent infections and chronic cough&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Smoking&#44; emphysema&#44; and biomass smoke&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Prevalence&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">High&#40;5&#8211;30&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">High&#40;15&#8211;60&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">High&#59; 26&#37; in VLBW infants&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Low&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Low&#46; Classified as rare disease&#46; 1&#58;2500&#8211;1&#58;10&#44;000 live births&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Low&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Low&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Low&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">6&#8211;15&#46;8&#37; of the population older &#62;40 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Bases for diagnosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Spirometry&#44; positive response to BD&#44; IgE&#44; and skin prick test&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#62;3 episodes of wheezing in infancy and positive API&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Prematurity and oxygen therapy for more than 28 days in early life&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Lung biopsy&#44; HRCT and lung perfusion scintigraphy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NBS with a positive IRT&#44; chloride &#62;60<span class="elsevierStyleHsp" style=""></span>mEq&#47;L in sweat&#44; two mutations in the CFTR gene&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Airway cast expectoration and bronchoscopy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Dextrocardia&#44; chronic sinusitis&#44; pneumonia and recurrent URTIs&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">HRCT&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Smoking&#44; emphysema and alpha1 antitrypsin deficiency&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Genotype&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Many chromosomes and polymorphisms&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Many chromosomes and polymorphisms&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Little known&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Little known&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Autosomal recessive with alterations in CFTR gene located on chromosome 7&#46;6 classes of mutations&#46; Many polymorphisms&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Unknown&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Autosomal recessive&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Depends on the etiology&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Phenotype&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Several&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Several&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&#44; Mo&#44; S&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Constrictive proliferative&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Many&#46; With and without pancreatic failure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Depending on the etiology&#44; the bronchial mold has a different composition&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">With and without dextrocardia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Depends on the etiology&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">With and without asthma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">BAL&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Eosinophils&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Neutrophils and&#47;or eosinophils&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Neutrophils&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Neutrophils&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Neutrophils&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Mucin and fibrin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Neutrophils&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Neutrophils&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Neutrophils and macrophages&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Markers in lymphocytes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">High CD4&#47;CD8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Varies whether the BAL is eosinophilic or neutrophilic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Depends on the etiology&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">High CD8&#47;CD4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Inflammatory mediators&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">IL4&#44; IL5&#44; IL9&#44; IL13&#44; TNF-&#945;&#44; GM-CSF&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Varies whether the BAL is eosinophilic or neutrophilic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">TNF-&#945;&#44; IL-1&#44; IL-6&#44; IL-10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">IL1&#946;&#44; IL6&#44; IL8&#44; TNF-&#945;&#44; and NFk&#946;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">IL8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Depends on the etiology&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">IL8&#44; LTB4&#44; proteases&#44; MMP9&#44; TNF-&#945;&#44; TGF-&#946;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Main causes of PE&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Viruses and aero-allergens&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Viruses&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Viruses&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Viruses&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Gram-negative bacteria&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">InfluenzaH1N1&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Viruses and bacteria&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Bacteria and viruses&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Viruses and bacteria&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Response to BD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Little known&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Unknown&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Rare&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Rare&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Low&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Obstruction&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Intermittent in the mild cases and fixed in severe cases&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Intermittent&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Fixed&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Fixed&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Fixed&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Intermittent&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Fixed&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Fixed&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Fixed&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Survival&#47;Mortality&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Long&#47;low&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Long&#47;low&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Depends on the severity and gestational age&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Depends on severity&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#60;40 years &#8211; class I&#8211;III mutations&#46;&#62;40 years &#8211; class IV&#8211;VI mutations&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Low&#47;high&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#60;40 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Depends on the age of onset and etiology&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Depends on the severity&#46;High mortality in the elderly&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Evolution to restrictive lung diseases&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Rare&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Rare&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Rare&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Frequent&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Frequent&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Rare&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Frequent&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Frequent&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Frequent&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Evolution to lung transplantation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Rare&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Comorbidities&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Allergic rhinitis&#44; atopic dermatitis and GERD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">GERD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">GERD and prematurity&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Severe adenovirus infection&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Pancreatic failure&#44; depression&#44; diabetes&#44; and osteoporosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CHD&#44; asthma&#44; lymphatic disease&#44; ABPA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Azoospermia and chronic rhinosinusitis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Asthma and GERD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Treatment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">IC&#59; SABA&#59; LABA&#59; Montelukast&#59; omalizumab&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">IC&#59; SABA&#59; Montelukast&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">IC&#59; SABA&#59;Sildenafil and PHDiuretics&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">IC&#59; SABA&#59; LABA&#59; corticoids&#59; oxygen&#59; tiotropium bromide&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Mucolytics&#59; IA&#59; digestive enzymes&#44; IC&#59; SABA&#59; LABA&#59; corticosteroids&#59;tiotropium&#59; Oxygen&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">bronchoscopy&#59; mucolytics and antifibrinolytics&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Mucolytics&#44; IA&#59; IC&#59; SABA&#59; LABA&#59; corticosteroids and oxygen&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Mucolytics&#59; IA IC&#59; SABA&#59; LABA&#59; corticosteroids&#59; oxygen&#59; macrolides&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">IC&#59; SABA&#59; LABA&#59; corticosteroids&#59; Tiotropium and oxygen&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Perspectives&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Early intervention <span class="elsevierStyleItalic">in utero</span> and early in life at risk populations&#46; Prophylaxis against RSV and RV&#46;Immunomodulation with prebiotics&#44; probiotics and bacterial lysates&#46;Prevention of allergic sensitization&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Permissive hypercapnia and improved care to VLBW infants&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Palivizumab&#59; genes and polymorphisms&#59; respiratory virus vaccines&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Corrections by potentiators and carriers of CFTR protein and new tests for the diagnosis of atypical forms&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Multicenter studies&#44; national registries&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Genetic studies and early diagnosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Prophylaxis against viruses&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Avoid smokingAsthma control&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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          "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Main clinical and pathophysiological characteristics of COPDC <span class="elsevierStyleItalic">versus</span> COPD in adults&#46;</p>"
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          "leyenda" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">API&#44; asthma predictive index&#46;</p>"
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">API criteria&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Original API<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Modified API<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">38</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " rowspan="2" align="left" valign="middle">General</td><td class="td" title="table-entry  " align="left" valign="top">Convincing API&#58; more than three episodes of wheezing&#47;year during the first 3 years of life with a major criterion or two minor&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " rowspan="2" align="left" valign="middle">The child must have a history of four or more episodes of wheezing&#46; At least one episode verified and confirmed by a physician&#46;</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Less convincing API&#58; less than three episodes of wheezing&#47;year during the first 3 years of life with a major criterion or two minor&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Major&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">History of parental asthmaAtopic dermatitis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">History of parental asthmaAtopic dermatitis diagnosed by physicianAllergic sensitization to one or more aeroallergens&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Minor&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Allergic rhinitis diagnosed by physicianWheezing unrelated to coldsEosinophilia<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>4&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Sensitization to cow&#39;s milk&#44; egg&#44; or peanutWheezing unrelated to coldsEosinophilia<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>4&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Asthma Predictive Index &#40;API&#41; by Castro-Rodriguez et al&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">44</span></a> and Guilbert et al&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">38</span></a></p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td-with-role" title="table-head ; entry_with_role_rowhead " align="left" valign="top" scope="col">Inhaled corticosteroids&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " colspan="3" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Daily doses in children younger than 5 years</th><th class="td" title="table-head  " colspan="3" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Daily doses &#40;6&#8211;11 years&#41;</th></tr><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Low&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Medium&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">High&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Low&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Medium&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">High&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Beclomethasone Dipropionate HFA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">100&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">50&#8211;100&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#62;100&#8211;200&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#62;200&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Budesonide spray&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">200&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">100&#8211;200&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#62;200&#8211;400&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#62;400&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Nebulized budesonide&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">250&#8211;500&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#62;500&#8211;1000&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#62;1000&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">250&#8211;500&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#62;500&#8211;1000&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#62;1000&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Fluticasone propionate HFA spray&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">100&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">100&#8211;200&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#62;250&#8211;500&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#62;500&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Fluticasone propionate dry powder&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">100&#8211;200&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#62;250&#8211;400&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#62;400&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Ciclesonide&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">160&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">80&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#62;80&#8211;160&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#62;160&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Mometasone&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">There are no studies&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">110&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">220<span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>440&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">440 or more&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Triamcinolone&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">There are no studies&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">400&#8211;800&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#62;800&#8211;1200&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#62;1200&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">Low&#44; medium&#44; and high daily doses of inhaled corticosteroids &#40;IC&#41; in asthma &#40;Global Initiative for Asthma &#8211; GINA&#41; and in chronic obstructive pulmonary disease in childhood&#46;</p>"
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                  "contribucion" => array:1 [
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              "etiqueta" => "2"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
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              "referencia" => array:1 [
                0 => array:2 [
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              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
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            4 => array:3 [
              "identificador" => "bib0025"
              "etiqueta" => "5"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
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                  "contribucion" => array:1 [
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            6 => array:3 [
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                  "contribucion" => array:1 [
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              "identificador" => "bib0040"
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            10 => array:3 [
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              "etiqueta" => "11"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
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                      "titulo" => "Azithromycin&#58; mechanisms of action and their relevance for clinical applications"
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                  "host" => array:1 [
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        "texto" => "<p id="par0375" class="elsevierStylePara elsevierViewall">To Professor Dr&#46; Paulo Augusto Moreira Camargos for his encouragement&#44; suggestions&#44; and manuscript review&#46; To Professor Dr&#46; Fernando Augusto de Lima Marson&#44; for the excellent chart contributions&#44; text reading&#44; suggestions&#44; and appraisals&#46; To the Pediatric Pneumology Team of Universidade Estadual de Campinas &#40;Unicamp&#41;&#44; for their constant help in the management of COPDC for many years&#58; Adyleia Aparecida Dalbo Contrera Toro&#44; Maria Angela Gon&#231;alves de Oliveira Ribeiro&#44; Andressa Peixoto&#44; Milena Baptistela Grotta&#44; Emilia Gon&#231;alves&#44; and Maria Cristina Sim&#245;es Ferreira&#46;</p>"
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Jornal de Pediatria (English Edition)
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