To the Editor and to the Editorial Staff (Paediatric Respiratory Reviews):
Dear Editor-in-Chief professor D.Fitzgerald!
Dear Colleagues!
Last publications in your journal regarding the problem of acute pneumonia (AP) in children (1,2,3), drew my attention again to the one-sided approach in search of its solution
From my point of view, the main obstacle to finding the solution is the well-rooted and generally accepted evaluation of the disease nature. The modern general conception of children AP was based on the background of phenomenal early results shown by antibiotic therapy. But the same conception still sees the microbial factor as the main and, as a matter of fact, the only cause of all failures and difficulties treating this disease.
That would be logical and understandable, if we were talking about a very specific pathogen. However, the etiology list of AP is long and the top contender changes periodically (please see attached). At the same time, 70% of children with AP are cured without determination of the abovementioned etiology(1). Thus, in order to cure AP, there is no need to find the etiology of the agent, isn’t it? And which radical changes in solving this problem can a call for further “golden rule” perfection of microbiological diagnosis of AP bring (1)? At the same time, the appearance of signs of dehydration in this particular group of patient and the validity of “intravenous infusion” remain obscure and unexplained. Furthermore, patients with indomitable vomiting and diarrhea who require constant rehydration are not mentioned in this article.
From pathophysiology point of view, AP is acute local inflammatory edema of the lung. Particular individual peculiarities of the initial stage of AP depend, first of all, on organism’s reactivity on one hand, and protection-adaptation abilities, on the other. Increasing pressure in pulmonary circulation forces the body to try and balance the pressure between right and left parts of the heart by partial sequestration of the rate of blood and lung vessels unload. Rapidity and adequacy of these processes explain the disease manifestation, including “anecdotic” descriptions of “electrolyte disbalance”(1).
Efficiency of antibiotics in treating children AP continues to decrease. Today, there are more and more cases of complicated forms of APs even in developed countries(1,3,4,5,6). More and more AP patients need additional treatments alongside the antibiotics. These treatments must stop further progression of the inflammatory process and steadily lead to its liquidation. However, in modern medicine, the only widespread additional treatment is intravenous infusions, which, in fact, cause the opposite effect. I provided you earlier with the results of my own research. (http://IgorKlepikov.blogspot.com/2010/10/acute pneumonia-in-children-article.html
I am not willing to indifferently accept the statement that "however sometimes complications may be encountered”(2). Such a way of viewing the problem leads us far away from understanding the problem and leaves no chance to find a solution. Radical review of AP concept and detailed understanding of the chain of its pathogenetic mechanics are the keys to a successful development of a treatment for this group of patients.
Best regards!
Prof.Igor Klepikov,MD,PhD
References.
1.Prayle A.,Atkinson M.,Smyth A."Pneumonia in the developed world".-Paediatric Respiratory Reviews,12(2011),60-69
2.Balfour-Lynn I.M."How to manage complicated pneumonia."-Paediatric Respiratory Reviews,12S1(2011),S44
3.Proesmans M.,Van De Wijdeven P.,Gijsen B.,Vermenlen F.,Van Paemdonck D.,De Boeck C."Incidence of complicated pneumonia in Belgian children and clinical evolution under conservative management."-Paediatric Respiratory Reviews,12S1(2011),S74
4.Roxburgh C.S.,Youngson G.G.,Townend J.A.,Turner S.W."Trends in pneumonia and empyema in Scottish children in the past 25 years."-Arch.Dis.Child.,2008 Apr;93;316-8
5.Strachan R.,Jaffe A."Assessment of the burden of paediatric empyema in Australia ."-J.Paediatr.Child.Health,2009,Jul-Aug;45:431-6
6.Li S.T.,Tancredi D.J."Empyema hospitalizations increased in Us children despite pneumococcal conjugate vaccine."-Pediatrics,2010,Jan;125(1):26-33
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Paediatric Respiratory Reviews
Editor-in-Chief
Dominic Fitzgerald (Australia)
Associate Editors
Ian Balfour-Lyn (UK), Ernst Eber (Austria) Bruce Rubin (USA)
11th November 2011
Dear Professor Klepikov,
Thank you for your “Open letter to the Editorial Staff of Paediatric Respiratory Reviews”. I appreciate your interest in our journal and what we publish. I have forwarded the article on to members of our Editorial Board for their interest. Our Editorial Board includes experts in respiratory and sleep medicine from all over the world and I am sure they will be interested in the points you have raised in your letter. As a group we are committed to providing the best review articles on topics of interest to our colleagues in paediatric respiratory medicine around the world. Pneumonia is such a topic and this is why we recently published on pneumonia in the developed world as well as in the developing world.
Once again, thank you for taking the time to write a letter to the Board.
With kind regards,
Professor Dominic A. Fitzgerald MBBS PhD FRACP
Paediatric Respiratory and Sleep Physician
Editor in Chief, Paediatric Respiratory Reviews.
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