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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="para0002" class="elsevierStylePara elsevierViewall">Obstructive sleep apnea &#40;OSA&#41; and asthma are two common respiratory disorders in children and adults&#44; and as such&#44; they can be concurrently present in the same patients&#46; Both OSA and asthma share many common risk factors including obesity&#44; prematurity&#44; environmental exposures&#44; a history of early-life lower respiratory tract infections&#44; gastroesophageal reflux disease&#44; and allergic rhinitis&#46;<a class="elsevierStyleCrossRef" href="#bib0001"><span class="elsevierStyleSup">1</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0002"><span class="elsevierStyleSup">2</span></a> Both asthma and OSA share pathogenic mechanisms which include systemic and localized activation and propagation of inflammatory pathways&#46;<a class="elsevierStyleCrossRef" href="#bib0003"><span class="elsevierStyleSup">3</span></a> Consequently&#44; it is anticipated that there will be a bidirectional link between asthma and OSA&#46; Under the driving assumption of the united airway hypothesis&#44;<a class="elsevierStyleCrossRef" href="#bib0004"><span class="elsevierStyleSup">4</span></a> emerging evidence further suggests that the two diseases may complicate the clinical course of each other&#46; On the one hand&#44; OSA could modify the extent and severity of asthmatic airway inflammation and thereby facilitate the emergence of poorer asthma control&#46; On the other hand&#44; asthma increases the collapsibility of the upper airway and increases vagal tone&#44; contributing to the development and worsening of OSA&#44; along with inflammatory mediators in the lower airways promoting the proliferation of upper airway lymphoid tissues&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">5</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0006"><span class="elsevierStyleSup">6</span></a> One of the corollaries of such interactions is that adenotonsillectomy&#44; the first line of treatment of OSA in children&#44; results in improved asthma control in patients suffering from both diseases&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">5</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0007"><span class="elsevierStyleSup">7</span></a> However&#44; when the converse approach is examined&#44; there is limited evidence on how anti-asthma medications affect OSA severity in the same patients&#46;</p><p id="para0003" class="elsevierStylePara elsevierViewall">With this information as a background&#44; Fumo-dos-Santos and colleagues<a class="elsevierStyleCrossRef" href="#bib0008"><span class="elsevierStyleSup">8</span></a> performed a cross-sectional study in a tertiary Pediatric Pulmonary Clinic in Brazil to investigate the prevalence of OSA in asthmatic children and explore whether sex&#44; puberty status&#44; and asthma severity and control &#40;based on GINA criteria and a questionnaire display any predictive capacity regarding the presence of OSA&#46; The investigators evaluated 80 asthmatic children &#40;age 7&#8211;18 years&#44; 51&#46;3&#37; female&#41; and included a home polygraphy type III study in 76 subjects&#46; The presence of OSA was detected in 61&#46;2&#37;&#44; but no significant associations emerged&#46; Such absence of any meaningful relationships between OSA severity and asthma severity &#40;assessed by either pulmonary function or disease activity&#41; should not be surprising&#46; In the largest study to date involving thousands of children&#44; Bhattacharjee and colleagues showed that adenotonsillectomy led to a reduction in the use of breakthrough medication and hospital admission among asthmatic children whose clinical characteristics essentially became similar to those of asthmatic children who did not have OSA&#46;<a class="elsevierStyleCrossRef" href="#bib0007"><span class="elsevierStyleSup">7</span></a> Thus&#44; considering the high lability&#44; i&#46;e&#46;&#44; day-to-day&#44; or night-to-night variability of each of two diseases in any given patient in addition to the wide spectrum of disease severity for each affected child&#44; it is predictable that the interactions between the two conditions may not necessarily display significant associations in a cross-sectional study that included relatively few subjects&#46; A point of interest was the socioeconomic distribution of the participants&#46; Socioeconomic status was based on the Criterio Brasil Classification&#46; Most of the subjects enrolled belonged to the middle class&#44; with scant representation by both the upper and lowerclass&#46; In light of the social determinants of both asthma and OSA&#44;<a class="elsevierStyleCrossRef" href="#bib0009"><span class="elsevierStyleSup">9</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">10</span></a> expansion of the socioeconomic spectrum to include a more balanced cohort representation would have been of great interest&#46;</p><p id="para0004" class="elsevierStylePara elsevierViewall">What can we learn after reading this paper&#63; First&#44; and most importantly&#44; OSA is frequently present among asthmatic children&#46; Varying prevalence has been reported in other studies based on different criteria used to assess asthma or to define OSA severity &#40;questionnaires&#44; spirometry&#44; polysomnography&#44; portable polygraphy&#41;&#44; but the findings have been quite consistent&#46; Second&#44; sex was not a risk factor for OSA in contrast with many other studies in which both OSA and asthma tend to occur more frequently in boys than in girls&#44; particularly in younger age groups&#44; probably because of their relatively reduced airway size until reaching maturity&#46;<a class="elsevierStyleCrossRef" href="#bib0002"><span class="elsevierStyleSup">2</span></a> Conversely&#44; asthma prevalence increases in females during puberty&#46; Third&#44; usually asthma is associated with more severe OSA&#44; and the presence of OSA is associated with severe asthma&#46; The cross-sectional nature of this study precludes any inferences as to the clinical outcomes&#46;</p><p id="para0005" class="elsevierStylePara elsevierViewall">Thus&#46; Fumo dos Santos and colleagues<a class="elsevierStyleCrossRef" href="#bib0008"><span class="elsevierStyleSup">8</span></a> are to be commended for this study&#44; obviously carried out in a limited resource setting while aiming to concurrently obtain quantitative and objective measures of lung function and respiration during sleep&#46; Notwithstanding such efforts&#44; the jury is still out as to whether two diseases of the airway are to be viewed as worse than each in isolation&#46;</p></span>"
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Editorial
Exploring the bidirectional relationship between asthma and obstructive sleep apnea in Brazilian pediatric patients: one more piece to the Puzzle
Luana Nosettia, David Gozalb,
Corresponding author
gozald@health.missouri.edu

Corresponding author.
a Insubria University, F. Del Ponte Hospital, Department of Pediatrics, Pediatric Sleep Disorders Center, Varese, Italy
b University of Missouri School of Medicine, Department of Child Health, Child Health Research Institute, Columbia, MO, USA
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="para0002" class="elsevierStylePara elsevierViewall">Obstructive sleep apnea &#40;OSA&#41; and asthma are two common respiratory disorders in children and adults&#44; and as such&#44; they can be concurrently present in the same patients&#46; Both OSA and asthma share many common risk factors including obesity&#44; prematurity&#44; environmental exposures&#44; a history of early-life lower respiratory tract infections&#44; gastroesophageal reflux disease&#44; and allergic rhinitis&#46;<a class="elsevierStyleCrossRef" href="#bib0001"><span class="elsevierStyleSup">1</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0002"><span class="elsevierStyleSup">2</span></a> Both asthma and OSA share pathogenic mechanisms which include systemic and localized activation and propagation of inflammatory pathways&#46;<a class="elsevierStyleCrossRef" href="#bib0003"><span class="elsevierStyleSup">3</span></a> Consequently&#44; it is anticipated that there will be a bidirectional link between asthma and OSA&#46; Under the driving assumption of the united airway hypothesis&#44;<a class="elsevierStyleCrossRef" href="#bib0004"><span class="elsevierStyleSup">4</span></a> emerging evidence further suggests that the two diseases may complicate the clinical course of each other&#46; On the one hand&#44; OSA could modify the extent and severity of asthmatic airway inflammation and thereby facilitate the emergence of poorer asthma control&#46; On the other hand&#44; asthma increases the collapsibility of the upper airway and increases vagal tone&#44; contributing to the development and worsening of OSA&#44; along with inflammatory mediators in the lower airways promoting the proliferation of upper airway lymphoid tissues&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">5</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0006"><span class="elsevierStyleSup">6</span></a> One of the corollaries of such interactions is that adenotonsillectomy&#44; the first line of treatment of OSA in children&#44; results in improved asthma control in patients suffering from both diseases&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">5</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0007"><span class="elsevierStyleSup">7</span></a> However&#44; when the converse approach is examined&#44; there is limited evidence on how anti-asthma medications affect OSA severity in the same patients&#46;</p><p id="para0003" class="elsevierStylePara elsevierViewall">With this information as a background&#44; Fumo-dos-Santos and colleagues<a class="elsevierStyleCrossRef" href="#bib0008"><span class="elsevierStyleSup">8</span></a> performed a cross-sectional study in a tertiary Pediatric Pulmonary Clinic in Brazil to investigate the prevalence of OSA in asthmatic children and explore whether sex&#44; puberty status&#44; and asthma severity and control &#40;based on GINA criteria and a questionnaire display any predictive capacity regarding the presence of OSA&#46; The investigators evaluated 80 asthmatic children &#40;age 7&#8211;18 years&#44; 51&#46;3&#37; female&#41; and included a home polygraphy type III study in 76 subjects&#46; The presence of OSA was detected in 61&#46;2&#37;&#44; but no significant associations emerged&#46; Such absence of any meaningful relationships between OSA severity and asthma severity &#40;assessed by either pulmonary function or disease activity&#41; should not be surprising&#46; In the largest study to date involving thousands of children&#44; Bhattacharjee and colleagues showed that adenotonsillectomy led to a reduction in the use of breakthrough medication and hospital admission among asthmatic children whose clinical characteristics essentially became similar to those of asthmatic children who did not have OSA&#46;<a class="elsevierStyleCrossRef" href="#bib0007"><span class="elsevierStyleSup">7</span></a> Thus&#44; considering the high lability&#44; i&#46;e&#46;&#44; day-to-day&#44; or night-to-night variability of each of two diseases in any given patient in addition to the wide spectrum of disease severity for each affected child&#44; it is predictable that the interactions between the two conditions may not necessarily display significant associations in a cross-sectional study that included relatively few subjects&#46; A point of interest was the socioeconomic distribution of the participants&#46; Socioeconomic status was based on the Criterio Brasil Classification&#46; Most of the subjects enrolled belonged to the middle class&#44; with scant representation by both the upper and lowerclass&#46; In light of the social determinants of both asthma and OSA&#44;<a class="elsevierStyleCrossRef" href="#bib0009"><span class="elsevierStyleSup">9</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">10</span></a> expansion of the socioeconomic spectrum to include a more balanced cohort representation would have been of great interest&#46;</p><p id="para0004" class="elsevierStylePara elsevierViewall">What can we learn after reading this paper&#63; First&#44; and most importantly&#44; OSA is frequently present among asthmatic children&#46; Varying prevalence has been reported in other studies based on different criteria used to assess asthma or to define OSA severity &#40;questionnaires&#44; spirometry&#44; polysomnography&#44; portable polygraphy&#41;&#44; but the findings have been quite consistent&#46; Second&#44; sex was not a risk factor for OSA in contrast with many other studies in which both OSA and asthma tend to occur more frequently in boys than in girls&#44; particularly in younger age groups&#44; probably because of their relatively reduced airway size until reaching maturity&#46;<a class="elsevierStyleCrossRef" href="#bib0002"><span class="elsevierStyleSup">2</span></a> Conversely&#44; asthma prevalence increases in females during puberty&#46; Third&#44; usually asthma is associated with more severe OSA&#44; and the presence of OSA is associated with severe asthma&#46; The cross-sectional nature of this study precludes any inferences as to the clinical outcomes&#46;</p><p id="para0005" class="elsevierStylePara elsevierViewall">Thus&#46; Fumo dos Santos and colleagues<a class="elsevierStyleCrossRef" href="#bib0008"><span class="elsevierStyleSup">8</span></a> are to be commended for this study&#44; obviously carried out in a limited resource setting while aiming to concurrently obtain quantitative and objective measures of lung function and respiration during sleep&#46; Notwithstanding such efforts&#44; the jury is still out as to whether two diseases of the airway are to be viewed as worse than each in isolation&#46;</p></span>"
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Article information
ISSN: 00217557
Original language: English
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