Synchronized abdominal compression as a novel treatment of life-threatening preschool asthma.

Introduction: In severe asthma, management of life-threatening air trapping that persists despite initiation of standard asthma treatment is difficult in the absence of extracorporeal membranous oxygenation.Case study: Three children with life-threatening asthma could not be adequately ventilated despite maximum conventional treatment because of severe air trapping. A novel method of active expiration by abdominal compression with a standard ventilator was adopted with immediate effect with significant improvement in ventilation.Conclusion: Synchronized abdominal compression is a novel and simple method that allows an effective treatment of severe air trapping in an intubated paralyzed asthma child.

Orthodontic plate for management of obstructive sleep apnoea in infants with Pierre Robin sequence: experience and protocol in Hong Kong.

OBJECTIVE: To present the application of the pre-epiglottic baton plate (PEBP) in infants with Pierre Robin sequence (PRS) in the Southern Chinese population (Hong Kong) and to present the diagnosis and management protocol of these infants in our centre. DESIGN: Retrospective case series of three patients with PRS. SETTING: Neonatal Intensive Care Unit in Kwong Wah Hospital and Craniofacial Orthodontic Centre in United Christian Hospital, Hong Kong. PARTICIPANTS: Three new-born infants (two girls, one boy) with PRS and upper airway obstruction due to glossoptosis. METHODS: A protocol for the diagnosis and management of these infants in the Southern Chinese population (Hong Kong) was presented. The three patients received nasal high-flow oxygen and/or continuous positive airway pressure (CPAP) as first-line respiratory support, followed by PEBP for 3-5 months. A two-stage approach was undertaken to ensure accurate positioning of the PEBP. RESULTS: All three infants had improvement in clinical signs, symptoms and polysomnography upon discharge. PEBP and other respiratory aids were weaned off at 3-6 months. CONCLUSIONS: The PEBP, combined with other respiratory support, is a useful modality in the treatment of obstructive sleep apnoea in infants with PRS.

Natural history of snoring in Hong Kong adolescents.

AIM: To determine the natural history of snoring in children when they reached adolescence and the underlying risk factors for persistence of habitual snoring. METHODS: A follow-up telephone survey was conducted to determine the natural history of snoring in children who reached adolescence. The targeted interviewees of the follow-up survey were parents of 3047 children. Adolescents who were snoring ≥6 nights a week were defined as habitual snorers. Potential risk factors for persistent and incident habitual snoring were studied, including age, gender, allergic rhinitis, asthma, body mass index (BMI), sleep duration and daytime sleepiness. RESULTS: Of the 3047 subjects, 2005 (65.8%) were successfully interviewed by phone. The prevalence of habitual snorers was 12.7%. Ninety-one adolescents were persistent habitual snorers. Allergic rhinitis, male gender and higher BMI at follow-up were identified as significant risk factors for persistent habitual snoring. A further 163 children were identified as incident habitual snorers. The risk factors for incident habitual snoring included male gender, asthma, higher BMI at follow-up and younger age at the first survey. In the current study, the mean sleep duration was 7.6 ± 1.0 h. Overall, 90% of the current cohort slept less than the lower limit of international recommendations for sleep duration. CONCLUSIONS: Around 40.6% of habitually snoring children continued to snore habitually as adolescents in the current study, while 9.2% of the initial non-habitual snorers became habitual snorers. Male gender and higher BMI were significant risk factors for both persistent and incident habitual snoring.

Insights from Overviewing Selective International Guidelines for Pediatric Asthma.

BACKGROUND: Asthma is a chronic atopic and inflammatory bronchial disease characterized by recurring symptoms and, episodic reversible bronchial obstruction and easily triggered bronchospasms. Asthma often begins in childhood. International guidelines are widely accepted and implemented; however, there are similarities and differences in the management approaches. There is no national guideline in many cities in Asia. This review aims to provide a practical perspective on current recommendations in the management of childhood asthma, specifically in the following aspects: diagnosis, classification of severity, treatment options, and asthma control, and to provide physicians with up-to-date information for the management of asthma. METHODS: We used the PubMed function of Clinical Queries and searched keywords of "Asthma", "Pediatric," AND "Guidelines" as the search engine. "Clinical Prediction Guides", "Etiology", "Diagnosis", "Therapy," "Prognosis," and "Narrow" scope were used as filters. The search was conducted in November 2022. The information retrieved from this search was used in compiling the present article. RESULTS: Diagnosis is clinically based on symptom pattern, response to therapy with bronchodilators and inhaled corticosteroids, and spirometric pulmonary function testing (PFT). Asthma is classified in accordance with symptom frequency, peak expiratory flow rate (PEFR), forced expiratory volume in one second (FEV1), atopic versus nonatopic etiology, where atopy means a predisposition toward a type 1 hypersensitivity reaction. Asthma is also classified as intermittent or persistent (mild to severe). Unfortunately, there is no disease cure for asthma. However, symptoms can be prevented by trigger avoidance and suppressed with inhaled corticosteroids. Antileukotriene agents or long-acting beta-agonists (LABA) may be used together with inhaled corticosteroids if symptoms of asthma are not controlled. Rapidly worsening symptoms are usually treated with an inhaled short-acting beta-2 agonist (SABA, e.g., salbutamol) and oral corticosteroids. Intravenous corticosteroids and hospitalization are required in severe cases of asthma attacks. Some guidelines also provide recommendations on the use of biologics and immunotherapy. CONCLUSION: Asthma is diagnosed clinically, with supporting laboratory testing. Treatment is based on severity classification, from intermittent to persistent. Inhaled bronchodilator and steroid anti-inflammatory form the main stay of management.

Gender difference in snoring and how it changes with age: systematic review and meta-regression.

PURPOSE: The aim of this study was to study the interactions among age, gender, and snoring across all age groups METHODS: All cross-sectional study reporting gender-specific prevalence of snoring in general population published from 1966 through July 2008 were included and were meta-analyzed. The sources of heterogeneity among primary studies were studied by meta-regression. RESULTS: From a total of 1,593 citations reviewed, 63 were included in the analysis of snoring. These 63 studies were comprised 104,337 and 110,474, respectively. A combined odds ratio of 1.89 with a 95% confidence interval of 1.75-2.03 for male versus female was found. The heterogeneity was significant with an estimated between-study variance, τ (2) being 0.065 and 95% confidence interval of 0.0397-0.0941. Multiple meta-regression showed that age were the significant effect modifier of the relationship between snoring and gender. CONCLUSION: This study found a consistent male predominance in snoring among the general population, and the heterogeneity in the risk of snoring between two genders can be partly explained by age.

Risk factors for post-operative complications in Chinese children with tonsillectomy and adenoidectomy for obstructive sleep apnea syndrome.

PURPOSE: Tonsillectomy and adenoidectomy (T&A) is commonly performed in children with obstructive apnea syndrome (OSAS). It was our hospital practice to observe all patients post T&A in the pediatric intensive care unit. We aim to describe the post-operative complications after tonsillectomy and adenoidectomy in children with OSAS and to identify risk factors for these complications. METHOD: Medical records of patients from 1 to 16 years old with OSAS and T&A done in this department were retrieved for analysis from April 1999 to July 2006. Information of the individual patients including the demographic data, polysomnography data, and presence of post-operative complications were recorded and analyzed. RESULTS: A total of 86 patient records were analyzed (M/F = 69:17). The mean BMI z score was 1.13 ± 1.53, and 36% of patients were classified as obese with z > 1.96. The median apnea-hypopnea index (AHI) before T&A was 9.8 episodes/h. Only six patients had post-operative desaturation. No bleeding complications were reported in our cohort. It was found that patients with desaturation after T&A had significantly higher mean BMI z score than children without desaturation (p = 0.014). There was otherwise no significant difference between the age, sex, AHI score, and the history of allergic rhinitis or asthma between the two groups. CONCLUSION: Our results showed that most children with OSAS underwent T&A without complications. The respiratory complication rate was 7%, and desaturation was the most common post-operative complication. Children with higher BMI z score were more likely to have desaturation after T&A (p = 0.014). Hence, careful monitoring with pulse oximeter after T&A should be offered to those who are obese.

Childhood pertussis is still here: An Asian city's perspectives.

INTRODUCTION: Pertussis, or whooping cough, is a highly contagious respiratory infection that is caused by the bacterium Bordetella pertussis. It is one of the most common causes of death in childhood. It is also a frequent cause of chronic cough in children, adolescents, and adults. METHODS: Global and Hong Kong perspectives of childhood pertussis were described. RESULTS: Hong Kong has prided herself in the city's childhood immunization program. There appear to be no major outbreaks of pertussis since the 1960s. Nevertheless, pediatricians may see isolated cases of pertussis or pertussis-like cases from time to time. Occasionally, infants are severely affected with apneas and managed with ventilator supports in the PICU. Outbreaks of the notifiable disease continue to occur despite a reasonable surveillance system and vaccination program in Hong Kong. Vaccination of mothers, adolescents, and adults are efficacious methods to further reduce the risks of pertussis. Macrolides remain efficacious antibiotics especially used early during the infectious phase. Infants with pertussis may require intensive care support and morbidity is high. CONCLUSIONS: Physicians should be reminded from time to time that outbreaks of pertussis still exist in Hong Kong and in many cities globally.

Trends in childhood asthma hospitalisation in three Asia Pacific countries.

AIM: The study aims to examine recent childhood asthma hospitalisation rates in the Asia Pacific countries of Australia, Hong Kong and Singapore. On the background of reported decline in many countries with high asthma prevalence during late 1990s. METHODS: Annual asthma hospitalisation (ICD9-CM: 493 or ICD10-AM: J45-46)* and population data from 1994 to 2008, of children aged 0-14 years old, were obtained from the Australian National Hospital Morbidity Database, from the Hospital Authority in Hong Kong and from the Ministry of Health in Singapore. Data were stratified in two age groups: 0-4 and 5-14 years old, and also in different periods of calendar years. Time-series regression analyses were used to examine temporal trends. Diagnostic transfer was addressed by examining bronchitis hospitalisations. RESULTS: Significant decreases of up to 6.5% per annum in childhood asthma hospitalisation rates were found over the study period. However, the latter half of the study period showed increases in hospitalisation rates in all countries studied. No evidence of diagnostic transfer was found. CONCLUSION: Although there has been a decrease in childhood asthma hospitalisation rates since the 1990s, a modest increase was observed from 2003 to 2008. Ongoing monitoring is required.

Development of the Chinese version of the Paediatric Allergic Disease Quality of Life Questionnaire: reliability and validity.

OBJECTIVE: Paediatric Allergic Disease Quality of Life Questionnaire is a health-related assessment tool designed for children with allergic diseases. This study aimed to translate the original English version of the Questionnaire to Chinese and to provide psychometric evidence on the validity and reliability of the translated version. DESIGN: Cross-sectional study. SETTING: Out-patient clinic of a non-teaching hospital in Hong Kong. PARTICIPANTS: The Paediatric Allergic Disease Quality of Life Questionnaire was translated to Chinese and then completed by a group of 115 Hong Kong Chinese children (66 male and 49 female; mean age, 11 years) with allergic disease(s). All subjects were asked to respond using visual analogue scales dealing with issues related to the perceived morbidity of allergic diseases. To assess test-retest reliability, 2 weeks later a subgroup of 16 individuals was retested with the same Questionnaire. RESULTS: The internal consistency of the Chinese Paediatric Allergic Disease Quality of Life Questionnaire was satisfactory (Cronbach alpha=0.92). The correlation between the total Questionnaire score and the visual analogue scale score was moderately significant (Spearman's rho=0.49; 95% confidence interval, 0.34-0.62). Structural validity as studied by confirmatory factor analysis found that the structure of subscales was remarkably similar to the original English version. The intra-class correlation between the Questionnaire score from the first and the second test in the subgroup of 16 subjects was 0.75, indicating adequate repeatability. CONCLUSION: The validity and reliability of the Chinese version of the Paediatric Allergic Disease Quality of Life Questionnaire was established for clinical use.

Improvement in quality of life after adenotonsillectomy in a child with Prader Willi syndrome.

INTRODUCTION: We report a child with Prader Willi syndrome who developed obstructive sleep apnea (OSA). This patient underwent surgical treatment for OSA. There was improvement not only on her OSA but in her quality of life score as well. This report highlights the need for a comprehensive assessment in the management of patients with Prader Willi syndrome.

Maternally inherited Leigh syndrome: an unusual cause of infantile apnea.

INTRODUCTION: Leigh Syndrome is an uncommon cause of infantile apnea. CASE SUMMARY: We report a 5-month-old girl with sudden respiratory arrest followed by episodic hyper- and hypo-ventilation, encephalopathy, and persistent lactic acidosis. Computed tomography of the brain revealed symmetric low densities over the basal ganglia, internal capsule, thalami, and midbrain. Cardiac echocardiogram was suggestive of hypertrophic cardiomyopathy. DISCUSSION: Diagnosis of Leigh syndrome due to T8993G mutation was confirmed with polymerase chain reaction and direct DNA sequencing of mitochondrial genome. To our knowledge, this is the first report of proven maternally inherited Leigh syndrome in Hong Kong.

Modified Epworth Sleepiness Scale in Chinese children with obstructive sleep apnea: a retrospective study.

BACKGROUND AND OBJECTIVE: The purpose of this study is to assess whether Chinese children with high apnea-hypopnea index (AHI) are sleepier by a modified Epworth Sleepiness Scale (ESS). MATERIALS AND METHODS: Records were retrospectively reviewed. We included children who were between 3 and 12 years old, admitted for overnight polysomnogram because of suspected obstructive sleep apnea syndrome (OSAS). A modified ESS was used to assess excessive daytime sleepiness (EDS) of the children. RESULTS: One hundred ninety-two Chinese children were included. Children with high AHI, defined as AHI > 5.0, were sleepier than children with AHI less than or equal to 5. After adjustment by age, gender, and obesity, children with high AHI remained significantly sleepier. Modified ESS was significantly correlated with AHI (rho = 0.124, 95% CI = 0.004-0.281). Modified ESS score of >8 was the best cutoff point with the sensitivity and specificity of 0.29 and 0.91, respectively. The odds ratio of children with modified ESS > 10 having high AHI was 4.231 (95%CI = 1.248 to 14.338) and children with modified ESS > 8 had the highest odds ratio, 4.295(95%CI = 1.66 to 11.1), of having high AHI. CONCLUSION: Chinese children with high AHI appear to be sleepier than children with low AHI. Children with suspected OSAS and high modified ESS, i.e., ESS > 8, had significantly higher odds ratio of having high AHI. Increased sleepiness is a specific but not a sensitive symptom in snoring children with high AHI. Screening for EDS in snoring children may help us identify those with high AHI and prioritize the management of those children.

Application of videotape in the screening of obstructive sleep apnea in children.

OBJECTIVE: To determine if watching a videotape that shows features of obstructive sleep apnea (OSA) will improve the accuracy of a verbally administered questionnaire in the prediction of OSA in pediatric snorers. PATIENTS AND METHODS: In a prospective single-blinded, randomized, controlled study at a pediatric clinic for sleep-disordered breathing, we studied children aged 0-18 years, who had been referred to a sleep laboratory for overnight polysomnography (PSG), and their parents from November 1999 to November 2000. The parents were randomized to answer a standard verbally administered panel of three questions (SQ) or a verbally administered panel of questions assisted by videotape (VQ). RESULTS: The parents of 52 and 56 pediatric snorers were assigned to answer SQ and VQ, respectively. The areas under the receiver operating characteristic [ROC] curves (AUCs) for screening of OSA in patients were similar at 0.709 (95% confidence interval (CI)=0.561-0.851) for SQ and 0.714 (95% CI=0.571-0.858) for VQ. The two questionnaires had a reasonable negative predictive value to rule out the presence of OSA (VQ=0.816 and 95% CI=0.726-0.885, SQ=0.828, 95% CI=0.714-0.913). CONCLUSION: The addition of a videotape showing important features of OSA achieved no better accuracy than a standard questionnaire.

Cardiovascular changes in children with snoring and obstructive sleep apnoea.

INTRODUCTION: Adults with obstructive sleep apnoea (OSA) are well documented to be at high risk for cardiovascular abnormalities. Growing evidence suggests that OSA is also associated with cardiovascular consequences in children. The purpose of this review is to examine the available data on this association in children. METHODS: Primary studies were extracted from a MEDLINE search limited to those published between 1970 and 2008. The keywords used included child, sleep disordered breathing, sleep apnoea, snoring, blood pressure and hearts. The relevant articles were selected by consensus between 2 authors. RESULTS: The results suggested that OSA was consistently associated with hypertension. Meta-analysis of risk of hypertension in those with high apnoea-hypopnoea index was undertaken. A combined odds ratio equal to 3.15 was found (95% confidence interval, 2.01 to 4.93). There was evidence for increased sympathetic activation, decreased arterial distensibility and ventricular hypertrophy in children with OSA. CONCLUSION: Childhood OSA is associated with blood pressure dysregulation. The association of OSA with other cardiovascular morbidities requires further study in view of the limited data available currently.

Determinants for asthma control, quality of life and use of complementary and alternative medicine in asthmatic pediatric patients in four cities.

BACKGROUND: Asthma is a significant chronic health problem worldwide. Management aims at disease control by reducing functional impairment and exacerbations and improving quality of life (QoL). We report a multi-center study to survey asthma control and QoL in four cities in the Pearl River Delta. METHODS: The conjoint survey involved ten Hong Kong pediatric hospitals/units, two Shenzhen hospitals, two Macau hospitals, and two Guangzhou hospitals on asthma control (using Asthma Control Test) and QoL (Pediatric Allergic Disease Quality of Life Questionnaire, PADQLQ). Acceptability of a treatment is graded as very good/good/fair/poor. RESULTS: Good asthma control was only reported in 80% subjects in Hong Kong, but higher in sister cities (85-94%, P < 0.001). Allergic rhinitis, "incense burning", and "smoker in family" were prevalent among the four cities. Logistic regression showed better control of asthma was associated with better PADQLQ (B = - 0.029, P < 0.001), better acceptability of bronchodilator (B = - 1.488, P = 0.025), negatively with "smoker in family" (B = - 0.83, P = 0.015) and various PADQLQ domains. Conversely, worse PADQLQ was associated with allergic rhinitis severity (B = 4.77, P < 0.001), poor control of asthma (B = 7.56, P < 0.001), increased frequency of traditional Chinese medicine use (B = 1.7, P < 0.05), increased frequency of bronchodilator usage (B = 1.05, P < 0.05), "smoker in family" (B = 4.05, P < 0.05), and incense burning at home (B = 3.9, P < 0.05). CONCLUSIONS: There are some clinical and cultural differences among the four southern Chinese cities within the Guangdong province. This study identifies potentially modifiable environmental and treatment factors associated with poor asthma control and QoL for health-care interventions. Having a smoker in the family is independently associated with poor asthma control and QoL.

Apnea-hypopnea index as the outcome variable in multiple linear regression analysis: statistical issues.

BACKGROUND: It is common for apnea-hypopnea index (AHI) to be used as an outcome variable in ordinary least squares linear regression. However, the distribution of AHI is not tested. The assumption of ordinary least squares linear regression may be violated. METHODS: The distribution of AHI from a pediatric sleep laboratory was assessed by Kolomgorov-Smirnov test. Transformation of AHI was attempted. In addition, we fitted an ordinary linear regression model (OLSM) and negative binomial regression model (NBRM) of the relationship between body mass index and the rate of apnea and hypopnea events. OLSM and NBRM were evaluated by residuals analysis. RESULTS: AHI from the studied population deviated significantly from normal distribution. Commonly used transformation algorithm could not transform AHI to normal distribution. In addition, OLSM violated the underlying statistical assumptions of homogeneity of variance and normality of error. NBRM, on the other hand, was not restricted by these assumptions. CONCLUSION: The current study suggested AHI is not likely to be normally distributed and its distribution cannot be transformed to normal. Negative binomial regression of the total number of apnea and hypopnea with an offset of log TST should be used in data analysis.

The correlation among obesity, apnea-hypopnea index, and tonsil size in children.

BACKGROUND: The correlation between obesity and severity of obstructive sleep apnea (OSA) is well established in adults, but data are inconsistent in children. We hypothesized that there is a significant correlation between the degree of obesity and the severity of OSA in children. METHODS: We retrospectively reviewed records of weight, height, history, and polysomnography of all 1- to 15- year-old children referred to our sleep laboratory. Children with known anomalies and repeated polysomnography were excluded from this study. Obesity was defined as body mass index z score (BMI Z score) > 1.96. The correlation between BMI Z score and apnea-hypopnea index (AHI) was assessed. Possible confounding factors, ie, age, gender, and tonsil size, were adjusted by multiple linear regression. RESULTS: Four hundred eighty-two children were included in this study. Obese children had a significantly higher AHI (median, 1.5; interquartile range [IQR], 0.2 to 7.0) than the AHI of nonobese children (median, 0.7; IQR, 0.0 to 2.5). BMI Z score was significantly correlated with log-transformed AHI (Ln[AHI]) [r = 0.156, p = 0.003]. BMI Z score and tonsil size were still correlated with Ln(AHI) even after adjusted for other confounding factors (p = 0.001). CONCLUSION: Degree of obesity as measured by BMI Z score and tonsil size are significantly related to severity of OSA as reflected by the AHI, although the correlation is mild.

Twenty-four-hour ambulatory BP in snoring children with obstructive sleep apnea syndrome.

INTRODUCTION: Obstructive sleep apnea syndrome (OSAS) is a known risk factor for hypertension in adults. This relationship is less clear in childhood OSAS. OBJECTIVE: This study examined the relationship between OSAS and 24-h ambulatory BP (ABP), a more accurate assessment than casual BP, in children with snoring. METHODS: Snoring children aged 6 to 15 years who underwent polysomnography in the sleep laboratory were recruited. MEASUREMENT: Twenty-four-hour ABP monitoring was initiated a few hours before polysomnography. The children were classified into two groups: a high apnea-hypopnea index (AHI) group (obstructive AHI > 5/h), and a low-AHI group (AHI < or = 5/h). Mean sleep, wake, and 24-h systolic BP (SBP) and diastolic BP (DBP) were recorded. A child was considered a "nondipper" if his or her mean SBP and DBP did not decrease by >/= 10% during sleep. RESULTS: Ninety-six children (mean age +/- SD, 9.4 +/- 2.8 years) were recruited. Forty-one children were obese. When awake, the high-AHI group children had a significantly higher SBP. When asleep, both SBP and DBP were higher in the high-AHI group. Age, body mass index (BMI) z score, and desaturation index (DI) were significant predictors for elevated sleep DBP. BMI z score was the only significant predictor for wake and sleep SBP. Sixteen children (17%) had hypertension, and all were nondippers. Obese children in the high-AHI group had a significantly higher prevalence of hypertension than obese children in the low-AHI group. This relationship was not found in nonobese children. CONCLUSION: The current study shows that increased DI contributed to the elevation of sleep DBP elevation.

Prevalence of otitis media with effusion in children with allergic rhinitis, a cross sectional study.

OBJECTIVES: Otitis media with effusion (OME) may be caused by various factors including Eustachian tube dysfunction, inflammatory response as well as atopy. Allergic rhinitis (AR), a common chronic disorder in children, is associated with swelling of the mucosa and can therefore result in Eustachian tube dysfunction. This study aims to compare the prevalence of OME in subjects with and without AR. METHOD: Children aged 4-12 were recruited from the clinics at Kwong Wah Hospital, Hong Kong. Subjects recruited were interviewed and a questionnaire filled in regarding nasal obstruction, rhinorrhea, sneezing, itching of the nose and/or post nasal discharge (ARIR document). The children were then examined by a doctor using a pneumatic otoscopy and a portable tympanometer. Children found to have OME were offered a follow-up visit 3 months later. RESULTS: 12 out of 159 (7.5%) of the AR group were found to have OME compared with 3 out of 185 (1.6%) in the non-AR group, p=0.016. During the 2nd visit at 3 months, 85.7% of the AR subjects showed resolution of their OME. CONCLUSIONS: Our data showed a significant difference in the prevalence of OME between AR and non-AR subjects. Of the 185 non AR subjects (Control group), 3 was found to have OME, suggesting a point prevalence of OME of 1.6% in the community in Hong Kong. OME is more likely to occur in children with allergic rhinitis and it may be wiser to manage OME in these individuals differently.