Ibuprofen does not prevent postbronchoscopy fever in children undergoing broncho-alveolar lavage.

BACKGROUND: Fiber-optic bronchoscopy (FOB) of the lower airways is a routine examination performed for investigating varying respiratory complaints in children. A common side effect is a transient high fever on the day of the FOB. Such episodes are usually unrelated to an infectious process but may cause clinical uncertainty and parental anxiety. We have previously shown that a single dose of systemic dexamethasone significantly reduces the rate of fever postbronchoscopy (FPB). RESEARCH QUESTION: To prospectively analyze the effect of a prophylactic dose of ibuprofen upon the FPB. STUDY DESIGN AND METHODS: Children presenting for elective FOB and broncho-alveolar lavage (BAL) were randomized, in a double-blind fashion, to receive a single dose of ibuprofen syrup 10 mg/kg or placebo prior to the procedure. Parents were contacted the next day to record the presence or absence of fever. RESULTS: Sixty-one children were included in the final analysis. Thirty-one children were in the treatment group and 30 in the placebo group. FPB occurred in 40 children (65%). There was no difference in the rate of FPB between placebo (63%) and treatment (67%) groups (P = .717). Fifty (82%) children had a positive BAL culture. Among them, 38 had FPB (76%) compared with only 2 of 11 (18%) of those with negative culture (P = .00026, relative risk 4.18). About 80% of positive cultures grew Haemophilus influenza. There was no significant difference between the number of BALs with a positive culture between the treatment and placebo groups (87% vs 77%, P = .35). CONCLUSION: FPB occurs in around twothirds of children when BAL is performed. Fever occurred significantly more frequently when BAL culture is positive. A single standard dose of the nonsteroidal anti-inflammatory drug ibuprofen administered before a FOB does not prevent FPB.

Sex-linked difference in blood oxygen saturation.

BACKGROUND: It is not known whether SpO2 in healthy volunteers is affected by sex. OBJECTIVE: To evaluate whether there are differences in SpO2 between young healthy adult males and females and to evaluate whether the differences are already present at birth. METHODS: We studied two cohorts of patients. The first one consisted of young adult volunteers (105 males and 102 females). In these patients, SpO2 was measured as well as selected anthropometric variables (height, weight), vital signs (respiratory rate, pulse rate and body temperature) and obtained data on menstrual cycle phase of the female participants. For the second cohort, we reanalyzed data from a previous prospective study that was performed to compare SpO2 of newborns infants born at different altitudes (sea level or 760 m above sea level). MEASUREMENTS AND MAIN RESULTS: In young male adults, mean SpO2 was 97.1% ± 1.2% versus 98.6% ± 1.0% in females (P < .001). This difference remained significant (P = .002) after correction for BMI, BSA and age, variables that were significantly different between sexes in univariate analysis. The SpO2 in females was unaffected by menstrual phase. In contrast to findings in adults, there were no significant differences in SpO2 measurements in newborn infants attributable to sex. CONCLUSIONS: Healthy young female adults have a higher (1.5%) SpO2 than their male counterparts. This difference is not yet present at birth. Further studies are needed to determine the timing of sex-differences, and to better define the mechanism(s) behind this observation.

Is obstructive sleep apnea syndrome in children season dependent?

INTRODUCTION: The most common cause of obstructive sleep apnea (OSA) in children is an enlargement of tonsils and/or adenoids. Previous studies have shown that the size of adenoids and tonsils is influenced by upper respiratory tract infections and exposure to allergens. The rate of exposure to bacteria, viruses, and allergens fluctuates from season to season. Therefore, we hypothesized that the rate of polysomnograms positive for OSA may vary according to season. OBJECTIVE: The objective of this study is to determine whether the prevalence of OSA in children, as determined by polysomnography, is affected by the season during which the study was performed. METHODS: We retrospectively reviewed polysomnography tests of 296 children, ages 0-12 years, referred for suspected OSA. We compared the Obstructive Apnea Hypopnea Index (OAHI) between the seasons and the rates of abnormal tests in each season according to the degree of severity. RESULTS: The mean OAHI did not significantly differ among the seasons (winter, 3.0 ± 5.0; spring, 3.0 ± 4.9; summer, 4.0 ± 6.3; fall, 3.4 ± 5.7, p = 0.183). When dividing the OAHI by levels of severity, no seasonality was found in moderate (winter, 13.8 %; spring, 6.7 %; summer, 11.7 %; fall, 14.1 %, p = NS) and severe OSA (winter, 8.8 %; spring, 11.2 %; summer, 10 %; fall, 7.8 %, p = NS). There was a small increase in the frequency of mild OSA diagnoses in the summer compared to the other seasons. CONCLUSION: In this study, season does not appear to affect the rate of diagnosis of significant OSA in children. Re-evaluation during a different season is unlikely to provide different results and may postpone surgery unnecessarily.

High-Flow Nasal Cannula Therapy for Obstructive Sleep Apnea in Children.

INTRODUCTION: Over the last decade, high-flow nasal cannula (HFNC) therapy has become an increasingly important and popular mode of noninvasive respiratory support. HFNC facilitates delivery of humidified and heated oxygen at a high flow rate and generates positive airway pressure. METHODS: We present five cases of children with OSA without adenotonsillar hypertrophy who were treated with HFNC. RESULTS: We demonstrated a statistically significant improvement in apnea-hypopnea index and nadir oxygen saturation in this small cohort. CONCLUSION: We present our successful experience of treating severe OSA with HFNC in the home setting. Further randomized controlled trials are needed to determine whether HFNC could be considered as an established alternative for CPAP in OSA in children.

[Foreign body aspiration in children].

Foreign body (FB) aspiration occurs mainly in children under 3 years of age and is one of the most frequent causes of accidental death under 12 months of age. The increased risk of FB aspiration in children is due to the different structure of the pharynx and the upper airways compared to adults. In addition, children have an immature swallowing mechanism and they most commonly aspirate food stuffs. FB aspiration is usually a sudden and dramatic event when the child feels that he is suffocating or choking. After the acute event, the clinical presentation widely ranges from severe respiratory distress to the most minimal symptoms. Bronchoscopy is the best diagnostic and therapeutic modality for FB inhalation. Prevention and rapid diagnosis can be lifesaving. In 2010, the American Academy of Pediatrics published a position paper on prevention of FB aspiration. The association calls for more proactive preventative measures to protect children from FB aspiration and to prevent mortality and morbidity. These include: 1. Raising awareness of parents and caregivers to supervise children and create a safe environment for them. 2. Promoting legislation and enforcing regulations that will prevent dangerous products being sold for children. 3. Changing the design of products, especially food products and toys, that will reduce the risks of choking. In this overview we will show the principles of diagnosis of FB aspiration and a flow chart including when flexible or rigid bronchoscopy is required.

Predictive factors of morbidity in childhood parapneumonic effusion-associated pneumonia: a retrospective study.

STUDY OBJECTIVE: To find the clinical and laboratory criteria that best predict a prolonged fever in children with parapneumonic effusion-associated pneumonia treated conservatively. DESIGN: Retrospective, cohort study. PATIENTS: Children admitted to the Shaare Zedek Medical Center between January 1, 1997, and December 31, 2006, and who had been discharged with a diagnosis of empyema and pleurisy. MEASUREMENTS AND RESULTS: One hundred-twenty children were included, all of whom were treated with antibiotics; in 80 patients, a thoracic drain was introduced; in 23, pleural tap was performed; and in 17 patients, no special procedure was performed. In no case was video-assisted thoracic surgery performed. The mean total days of fever was 12.8 +/- 5.9 (2-29 days), and the mean length of stay at the hospital was 11.5 +/- 4.9 (3-25) days. In 44 patients (37%), a bacterial culture was positive either in blood or in pleural fluid or both. A positive blood or a positive pleural fluid culture was significantly associated with a prolonged fever as was a history of an underlying disease. Platelet counts, serum Na, serum protein, pleural lactate dehydrogenase (LDH), pleural glucose, pleural/serum LDH ratio, pleural/serum glucose ratio, and pleural fluid pH were the only factors significantly but weakly correlated with the total duration of fever or duration of fever after admission. A "fever duration" score using platelet count, pleural fluid pH, pleural/serum LDH ratio, and pleural/serum glucose ratio predicted a prolonged course of fever (>7 days) with a sensitivity of 91% (95% confidence interval: 60%-100%) and a specificity of 47% (95% confidence interval: 25%-71%). CONCLUSIONS: In children with parapneumonic effusion-associated pneumonia, a positive bacterial culture and an underlying disease are associated with prolonged fever. A low score based on platelet count, pH pleural fluid and glucose, and LDH pleural/serum ratio is associated with a prolonged fever. We speculate that children with the risk factors mentioned earlier may be the best candidates for an early aggressive approach.

Does sweat volume influence the sweat test result?

OBJECTIVE: Low volume sweat samples are considered unreliable for the diagnosis of cystic fibrosis, based on the assertion that sweat conductivity and chloride are reduced at lower sweating rates. We aimed to re-evaluate the relationship between sweat volume and test results. DESIGN: We reviewed all sweat tests performed in our institution to assess the relationship between sweat volume and conductivity, and between sweat volume and sweat chloride. We also compared results between pairs of sweat tests taken simultaneously from a single patient, one with sweat volume below and the other above the currently accepted minimum volume (15 microl). RESULTS: A weak inverse relationship between sweat volume and sweat conductivity was found (n=1500, R2=0.105, p<0.001). There was no correlation between sweat volume and sweat chloride (n=463, R2=0.002, p>0.05). In discordant pairs (one below and one exceeding the accepted minimum volume), the mean test result in the low volume sample was slightly higher than its counterpart. In 76 such pairs, mean conductivity was 41.1+/-14.6 mmol/l in the lower volume sample, compared with 36.8+/-16.0 mmol/l in the higher volume sample (p<0.001). Similarly, in 33 of the pairs, mean sweat chloride was 28.4+/-15.7 mmol/l in the lower volume sample compared with 25.1+/-15.2 mmol/l in the higher volume sample (p=0.004). CONCLUSION: A normal sweat conductivity and/or chloride value from a sweat volume <15 microl in a patient whose clinical symptoms are not very suggestive of cystic fibrosis, renders this diagnosis unlikely. In contrast, elevated sweat chloride or conductivity measured from a sample whose volume is <15 microl may represent an artefact related to the low volume.

N-terminal pro-B-type natriuretic peptide as a marker of bronchopulmonary dysplasia in premature infants.

We performed an observational pilot study of plasma concentrations of N-terminal pro-B-type natriuretic peptide (BNP) in premature infants with a diagnosis of bronchopulmonary dysplasia (BPD) at 4 weeks of age and after 1 month of conventional therapy. Thirty-four premature infants born before 34 weeks' gestational age without cardiac or infectious diseases were included. Serum NT-pro-BNP was measured in all neonates at 4 weeks of age. In infants with the diagnosis of BPD (n = 11), measurements were repeated at 6 and 8 weeks of age under conventional treatment. Specific clinical characteristics were collected prospectively. Baseline NT-pro-BNP concentrations were high in healthy premature infants compared with previously reported healthy neonates, and significantly higher in those who developed BPD. There was a significant correlation between concentrations of NT-pro-BNP and severity of respiratory distress as assessed by several methods. The concentrations of NT-pro-BNP decreased significantly over time in BPD infants. Premature infants have high concentrations of NT-pro-BNP at 1 month of age. NT-pro-BNP concentrations are significantly higher in BPD infants and decline over time. NT-pro-BNP concentrations correlate with clinical severity of respiratory disease.

Morgagni hernia mimicking pneumonia in Down syndrome.

Down syndrome patients are immunodeficient and commonly suffer from respiratory infections. Two children with Down syndrome were referred for evaluation of recurrent pneumonia accompanied by persistent infiltrate on chest radiographs. In both cases the radiographic abnormalities were actually found to be Morgagni hernia. When a child with Down syndrome has a persistent lower lobe infiltrate on chest radiograph, the possibility of a diaphragmatic defect should be entertained.

A single dose of dexamethasone to prevent postbronchoscopy fever in children: a randomized placebo-controlled trial.

STUDY OBJECTIVE: To assess the effectiveness of one dose of dexamethasone (0.5 mg/kg; maximum, 10 mg) to prevent fever after bronchoscopy with BAL. DESIGN: Randomized, placebo-controlled study. PATIENTS: Immunocompetent nonfebrile children undergoing fiberoptic bronchoscopy with BAL. MEASUREMENTS AND RESULTS: Sixty-nine children were included in the study. Thirty-eight children received saline solution, and 31 children received dexamethasone. The two groups were similar regarding the number of children < 2 years old, the percentage of abnormal bronchoscopic findings, the number of positive BAL culture findings, and the index of lipid-laden macrophages. Twenty-six children (68%) in the saline solution group (SG) had fever, compared to 3 children (9.6%) in the dexamethasone group (DG) [p < 0.001]. Fever after the procedure appeared later (12.3 +/- 5.5 h) in the DG compared to 5.4 +/- 2.7 h in the SG. CONCLUSIONS: One dose of dexamethasone administered prior to performing bronchoscopy with BAL may prevent fever subsequent to the procedure. Further studies are necessary in order to determine the optimal dosing regimen for dexamethasone when used for this purpose.

Endoscopic findings in children with obstructive sleep apnea: effects of age and hypotonia.

Obstructive sleep apnea (OSA) syndrome is a common disorder among children and is often associated with significant morbidity. The causes of OSA are related to either fixed upper airway abnormalities such as adenotonsillar hypertrophy, or dynamic airway abnormalities such as laryngomalacia and pharyngeal wall collapse. The aim of the present study was to determine the prevalence of dynamic upper airway abnormalities, based on endoscopic findings, in normotonic and hypotonic children with polysomnographically documented OSA. The records of 39 consecutive children with OSA who underwent bronchoscopy (22 with normal tone, and 17 with hypotonia) were reviewed. The prevalence of dynamic defects among children with normal tone decreased with age. All 7 patients less than 1 year old had dynamic abnormalities (isolated or combined fixed/dynamic), compared to only 66% (6/9) of patients between 1-2 years old, and 17% (1/6) of children more than 2 years old. In contrast, dynamic abnormalities were very common among hypotonic children, independent of age. Since children with dynamic defects are less likely to respond to surgical treatments, it would be appropriate to identify these children prior to any intervention. Due to the higher frequency of dynamic defects in both infants (< 1 year) and hypotonic children, it may be appropriate to include endoscopy as part of the diagnostic evaluation of OSA in these subgroups.