Routine chest radiographs in pediatric intensive care units.

OBJECTIVES: To determine whether interventions were performed based on portable routine morning chest x-rays (CXRs) in pediatric intensive care unit (PICU) patients and to identify patient subgroups for whom the routine CXR is most useful. DESIGN: Prospective multiinstitutional study. Setting. PICUs of 15 tertiary care hospitals. Patients. PICU patients who received a routine morning CXR were included in the study. OUTCOME MEASURES: Recorded data included: weight, diagnosis, presence of active cardiopulmonary problems, length of stay, and number and type of devices. The number and types of interventions based on the interpretation of the CXR were recorded. RESULTS: Five hundred twelve routine CXRs were evaluated. The majority of the routine chest radiographs were obtained on patients who were admitted for cardiovascular disease (195/512; 38%) or respiratory failure (186/512; 36%), and 465/512 of the routine CXRs (91%) were performed on patients with one or more devices. Two hundred thirty-one of the 512 routine CXRs (45%) resulted in 1 or more interventions. One hundred fifty-five of the 284 routine CXRs (55%) obtained in children /=40 kg, respectively. The frequency of interventions increased from 19% in children with no devices to >50% in children with 2 or more devices. One or more interventions were performed in 27% of routine CXRs when no active cardiopulmonary problems were present, compared with 51% of routine CXRs when active cardiopulmonary problems were present. Diagnosis and length of intensive care unit stay at the time the routine CXR was obtained did not affect the percentage of CXRs that resulted in interventions. CONCLUSIONS: Routine CXRs are more likely to result in interventions in the smaller, critically ill child with one or more devices and if active cardiopulmonary problems are present.

Treatment of childhood lymphangiomas with interferon-alpha.

PURPOSE: Nonsurgical treatment of lymphangiomas has shown limited efficacy and often carries unacceptable toxicities, demonstrating the need for a more effective, less toxic therapy. PATIENTS AND METHODS: We describe two patients with lymphangiomatosis treated for 12 to 40 months with recombinant interferon-alpha. RESULTS: Both patients demonstrated stabilization or marked improvement of disease, based on clinical and radiologic findings, with minimal toxicity. CONCLUSIONS: The favorable responses to interferon-alpha therapy in these two cases suggest that this is an effective and well-tolerated treatment for lymphangiomas in children.

Consequences of hypogammaglobulinemia and steroid therapy in severe bronchopulmonary dysplasia.

We retrospectively studied the relation between corticasteroid therapy, hypogammaglobulinemia (HG), and recurrent infections in 37 infants with moderate to severe bronchopulmonary dysplasia (BPD). Nineteen of the 37 patients had tracheostomies because of chronic respiratory failure. We hypothesized that recurrent infections were most prevalent in infants whose IgG levels remained low at one year of age (persistent HG) and in infants receiving high doses of corticosteroids during the first year of life. We further hypothesized that the duration of HG was strongly correlated with the cumulative first year steroid dose. We also studied the response to intravenous gammaglobulin (IVIG) replacement therapy in this population of BPD infants. Our results showed an association between first year corticosteroid dose, duration of HG (r = 0.49, p < 0.003), and frequency of infections (r = 0.51, p < 0.001). We noted a relatively strong correlation between frequency of infections and duration of HG (r = 0.84, p < 0.0001). Twenty-four of 37 (65%) infants showed persistent HG and 49% had evidence of abnormal specific antibody production. Sixty-four percent of infants studied had reduced lymphocyte responsiveness to mitogen stimulation. Nineteen of 37 (51%) infants required IVIG for an average duration of 17.9 months due to recurrent infections. The average number of infections per year decreased from 10.6 to 2.8 (t = 12.32, p < 0.0001). There were no complications associated with IVIG therapy, but one infant died of bronchiolitis obliterans following heart-lung transplantation. Eight of 37 (22%) infants have persistent immunologic dysfunction requiring ongoing IVIG at four years or more of follow-up. We conclude that a substantial number of ill infants with BPD will have immune dysfunction characterized by persistently low IgG levels and reduced specific antibody responsiveness to protein antigens. We speculate that these findings are related to the cumulative dose of corticosteroids received in the first year of life and to the severity of underlying disease.

Medical examiners' attitudes toward organ procurement from child abuse/homicide victims.

Solid organ transplant provides lifesaving therapy for infants and children with otherwise terminal diseases, but it is severely limited by donor organ supply. Medical examiners perform a pivotal role in the organ procurement process by determining whether a "heartbeating cadaver" on life support is a medicolegally suitable donor. This descriptive questionnaire study assesses medical examiner practice and behavior regarding organ procurement from child abuse/homicide victims. Obtaining forensic evidence for judicial purposes and releasing organs to children awaiting transplantation are not necessarily conflicting values. Greater than 60% of medical examiners sampled would agree to release organs from abuse/homicide victims in the scenarios presented here if provided with requested information. Further confronting the origins of variable medical examiner practice in this area might result in the availability of additional solid organs for pediatric transplantation.

Chronic respiratory failure of infancy and childhood: clinical outcomes based on underlying etiology.

To assess whether underlying diagnosis affects morbidity and mortality outcomes in patients with chronic respiratory failure, we studied 55 patients with chronic respiratory failure of infancy and childhood (CRFIC). Entry criteria included patients with chronic respiratory failure due to static neurologic or neuromuscular conditions or secondary to other disease processes considered likely to improve or resolve over time. Subjects were grouped into those having chronic lung disease (CLD, n = 22), neurologic or neuromuscular diseases (NM, n = 21), or congenital abnormalities affecting the respiratory system (CA, n = 12). The average duration of follow-up was 21.3 months. There were no differences between groups in mortality with only four deaths (7%). Patients with CLD fared better than those with NM or CA in duration of ventilatory support, duration of tracheostomy, percentage of successful weaning from mechanical ventilation, and neurodevelopmental outcomes. Subjects with CLD had a significantly greater frequency of tracheomalacia (86%), feeding disorders (86%), and hypogammaglobulinemia G (77%). There were no differences between groups for respiratory readmissions or family dysfunction. We conclude that almost all patients with CRFIC will survive, but morbidity outcomes will vary based on the underlying diagnosis.

Diaphragmatic excursion after pleural sclerosis.

Chemical sclerosis of the pleural space is used to prevent recurrence of spontaneous pneumothorax. To test whether sclerosis restricts diaphragmatic excursion, we measured diaphragmatic excursion by ultrasonography in subjects with unilateral pleural sclerosis and compared it with diaphragmatic excursions in normal subjects, in subjects with cystic fibrosis (a diffuse bilateral lung disease), and in those who underwent surgical procedures that obliterate the pleural space. In five subjects with unilateral chemical sclerosis, diaphragmatic excursion was significantly less on the sclerosed side than on the contralateral side (10.7 +/- 1.3 vs 17.3 +/- 1.7 mm, mean +/- SEM; p less than .01). Compared with those of normal subjects, the side-to-side differences in excursion were increased by pulmonary disease (p less than .03) and additionally by unilateral sclerosis (p less than .015). There was no significant difference between diaphragmatic excursions on left and right sides of subjects without history of pleural disease. These data suggest that chemical pleural sclerosis causes a measurable reduction in diaphragmatic excursion on the affected side. The physiologic significance of this effect is not known.

Treatment of respiratory viral infection in an immunodeficient infant with ribavirin aerosol.

An infant with severe combined immunodeficiency syndrome (SCIDS) secondary to adenosine deaminase deficiency had pneumonitis and combined infection with respiratory syncytial virus (RSV) and parainfluenza virus type 3 (PIV3). Four separate courses of ribavirin were delivered by small-particle aerosol. The PIV3 disappeared during the first course, and RSV disappeared after the fourth course on the 58th hospital day. Neither virus returned during profound immunosuppression for bone marrow transplantation. Secretory antibody to both viruses was found and may have assisted in recovery. Strains of RSV from the 9th, 15th, 29th, and 55th hospital days showed similar sensitivities to ribavirin in vitro. Ribavirin can be a useful drug in the treatment of respiratory viral infections in patients with SCIDS.