High-Flow Nasal Cannula versus Conventional Oxygen Therapy in Children with Respiratory Distress.

PURPOSE: The aim of this study is to determine the clinical efficacy of high-flow nasal cannula (HFNC) therapy compared with conventional oxygen therapy in children presented with respiratory distress. STUDY DESIGN: This was a randomized controlled study. MATERIALS AND METHODS: Infants and children aged between 1 month to 5 years who were admitted to our tertiary referral center for respiratory distress (July 1, 2014 to March 31, 2015) and met the inclusion criteria were recruited. INTERVENTIONS: Infants and children hospitalized with respiratory distress were randomized into two groups of interventions. All clinical data, for example, respiratory score, pulse rate, and respiratory rate were recorded. The results were subsequently analyzed. RESULTS: A total of 98 respiratory distress children were enrolled during the study period. Only 4 children (8.2%) failed in HFNC therapy, compared with 10 children (20.4%) in conventional oxygen therapy group (P = 0.09). After adjusted for body weight, underlying diseases, and respiratory distress score, there was an 85% reduction in the odds of treatment failure in HFNC therapy group (adjusted odds ratio 0.15, 95% confidence interval 0.03-0.66, P = 0.01). Most children in HFNC therapy group had significant improvement in clinical respiratory score, heart rate, and respiratory rate at 240, 360, and 120 min compared with conventional oxygen therapy (P = 0.03, 0.04, and 0.03). CONCLUSION: HFNC therapy revealed a potential clinical advantage in management children hospitalized with respiratory distress compared with conventional respiratory therapy. The early use of HFNC in children with moderate-to-severe respiratory distress may prevent endotracheal tube intubation. TRIAL REGISTER: TCTR 20170222007.

Urinary cysteinyl leukotriene E4 level and therapeutic response to montelukast in children with mild obstructive sleep apnea.

BACKGROUND: Antileukotriene has been used for alleviating disease severity in children with adenotonsillar hypertrophy (ATH) and mild obstructive sleep apnea (OSA). Previous study showed the relationship between urinary cysteinyl leukotriene E4 (uLTE4) level and therapeutic response to montelukast in asthmatic adults. However, this relationship has never been investigated in pediatric OSA. OBJECTIVES: To determine the relationship between uLTE4 level and therapeutic response to montelukast in children with ATH and mild OSA. METHODS: Children aged 3-15 yrs who had ATH and mild OSA were enrolled. All had quality of life (assessed by Thai version OSA-18 QoL questionnaire) and uLTE4 levels measured prior to start a 6-week course of montelukast treatment. Overnight polysomnography (PSG) and QoL reassessment were performed after completing the treatment. Those who demonstrated a large improvement of mean total QoL score or ≥ 50% decrease of obstructive apnea-hypopnea index (OAHI) after the treatment were defined as responders. RESULTS: Twenty-six children were enrolled (mean age 7.5 ± 2.9 yrs, 38.5% male). After 6-week course of montelukast, nine (34.6%) children showed significant improvement. The mean uLTE4 level from the responders was higher comparing to the non-responders (2,952.56 ± 966.9 vs. 978.6 ± 460.8 pg/mg creatinine; p < 0.001). uLTE4 level of ≥ 1,457 pg/mg creatinine had 100% sensitivity and 88.2% specificity in identifying the responders. CONCLUSIONS: We found the association between ULTE4 and therapeutic response to monteleukast. The uLTE4 level of ≥ 1,457 pg/mg creatinine could predict the therapeutic response to montelukast in children who had ATH and mild OSA.

School-Based Educational Interventions Can Significantly Improve Health Outcomes in Children with Asthma.

BACKGROUND: Lack of asthma knowledge among the pediatric patients and their caregivers contribute to poor asthma control in children. There is no data from Thailand on the health outcomes of school-based educational interventions for asthmatic children. OBJECTIVE: To assess the effectiveness of school-based asthma educational interventions on health outcomes, asthma control, and management in asthmatic children. MATERIAL AND METHOD: Forty-seven asthmatic students (6-15 years old), 14 caregivers, and five teachers from the Homkred School participated in the study. Asthma knowledge, workshops on pMDI (pressurized metered dose inhaler) techniques, use of asthma diaries, and self-management plans were provided Pre- and post-tests were administered to assess the asthma knowledge of the asthmatic students, their caregivers, and teachers. Pulmonary function tests (PFT) were used to assess the health outcomes. The controls of asthma and self-management behaviors were assessed at three and six months post-intervention. RESULTS: There were significant improvements of asthma knowledge in all groups (p < 0.01) immediately post-intervention and six months later. At pre-intervention phase, there were 18 children who had FEV1 less than 80% of the predicted value. Their PFT significantly improved for all parameters at post-intervention, but in children who had normal FEV1 at baseline, there were no significant changes. Control of asthma was significantly better three and six months post-intervention. The rate of regular use of ICS (inhaled corticosteroid) significantly increased to 40% at three months and 30% at six months (p < 0.001) post-intervention. In addition, the self-management behaviors in the asthmatic children improved. The teachers' management of asthmatic attacks during the classes also improved. As a result of this, there were fewer emergency room (ER) visits. CONCLUSION: School-based educational interventions can significantly improve asthma outcomes in children with asthma. Therefore, the authors highly recommend the use of this intervention.

A comparison of clinical efficacy between high frequency oscillatory ventilation and conventional ventilation with lung volume recruitment in pediatric acute respiratory distress syndrome: A randomized controlled trial.

PURPOSE: To determine the efficacy of lung volume recruitment maneuver (LVRM) with high frequency oscillatory ventilation (HFOV) on oxygenation, hemodynamic alteration, and clinical outcomes when compared to conventional mechanical ventilation (CV) in children with severe acute respiratory distress syndrome (ARDS). MATERIALS: We performed a randomized controlled trial and enrolled pediatric patients who were diagnosed to have severe ARDS upon pediatric intensive care unit (PICU) admission. LVRM protocol combined with HFOV or conventional mechanical ventilation was used. Baseline characteristic data, oxygenation, hemodynamic parameters, and clinical outcomes were recorded. RESULTS: Eighteen children with severe ARDS were enrolled in our study. The primary cause of ARDS was pneumonia (91.7%). Their mean age was 47.7 ± 61.2 (m) and body weight was 25.3 ± 27.1 (kg). Their initial pediatric risk of mortality score 3 and pediatric logistic organ dysfunction were 12 ± 9.2 and 15.9 ± 12.8, respectively. The initial mean oxygen index was 24.5 ± 10.4, and mean PaO2/FiO2 was 80.6 ± 25. There was no difference in oxygen parameters at baseline the between two groups. There was a significant increase in PaO2/FiO2 (119.2 ± 41.1, 49.6 ± 30.6, P = 0.01*) response after 1 h of LVRM with HFOV compare to CV. Hemodynamic and serious complications were not significantly affected after LVRM. The overall PICU mortality of our severe ARDS at 28 days was 16.7%. Three patients in CV with LVRM group failed to wean oxygen requirement and were cross-over to HFOV group. CONCLUSIONS: HFOV combined with LVRM in severe pediatric ARDS had superior oxygenation and tended to have better clinical effect over CV. There is no significant effect on hemodynamic parameters. Moreover, no serious complication was noted.

Clinical outcomes after utilizing surviving sepsis campaign in children with septic shock and prognostic value of initial plasma NT-proBNP.

BACKGROUND AND OBJECTIVE: The surviving sepsis campaign treatment guideline (SSC) implementation is associated with improved outcome in adults with severe sepsis. The effect on outcome of pediatric sepsis is less clear. PURPOSE: To determine the clinical outcomes of SSC implementation and to investigate the prognostic value of initial plasma NT-proBNP and procalcitonin in children. MATERIALS AND METHODS: Infants and children (aged 1month/0-15 years with severe sepsis or septic shock) were prospectively enrolled and treated according to the guidelines. Initial blood drawn was saved for NT-pro-BNP, procalcitonin measurements and clinical data were also recorded. RESULTS: A total of 47 subjects were recruited. Since the application of the SSC, our mortality rate had significantly decreased from 42-19% (P = 0.003) as compared to the data in the previous 3 years. Clinical factors that significantly increased the mortality rate were: Initial central venous oxygen saturation < 7 0% after fluid resuscitation [odds ratio (OR) = 23.3; 95% confidence interval (CI) 3.7-143; P = 0.001], and initial albumin level (≤ 3 g/dl, OR = 6.7; 95% CI 1.2-37.5, P = 0.03). There was asignificant difference between the initial NT-proBNP levels between survivors and non survivors, (6280.3 ± 9597 ng/L, P < 0.001), but not for procalcitonin (12.7 ± 24.8, 29.3 ± 46 µg/L, P = 0.1), respectively. An initial NT-proBNP level of more than 11,200 pg/ml predicted Pediatric Intensive Care Unit (PICU) mortality with a sensitivity of 85.7% and a specificity of 90%. CONCLUSIONS: A modified SSC for severe sepsis and septic shock significantly reduced the mortality rate in our PICU. High initial NT-ProBNP level was associated with mortality.

Incidence of recurrent wheezing in under 5-year-old human bocavirus infection during one year follow-up.

BACKGROUND: Human bocavirus (HBoV) is a newly identified virus that can cause acute wheezing in young children. The present study aimed to evaluate the incidence and factors associated with recurrent wheezing during 1 year after HBoV lower respiratory tract infection (LRI). MATERIAL AND METHOD: Children younger than 5 years old who were admitted to King Chulalongkorn Memorial Hospital between February 1, 2006 and September 30, 2008 due to LRI were recruited. Their nasopharyngeal aspirates were evaluated for respiratory virus by polymerase chain reaction (PCR) assays. Those who had positive PCR for HBoV and had no underlying diseases were studied. Their clinical presentations were evaluated and their clinical data about recurrent wheezing as well as pulmonary function tests were followed-up for 1 year. RESULTS: Fifteen patients with HBoV-LRI were regularly followed-up. Seven patients (47%) had co-infection with other respiratory viruses. Generalized wheezing was the most common lung sign detected in 73% of cases (11 cases) and 36% (4 cases) of them responded well to bronchodilators. During one year follow-up, serial pulmonary function tests were normal in all cases and most patients were doing well. However 27% of HBoV infected patients (4 cases) developed recurrent wheezing associated with respiratory tract infections. Two of them had to be re-hospitalized. Compared to patients without recurrent wheezing, eosinophil count tended to be higher in those with recurrent wheezing and isolated HBoV infected patients tended to develop recurrent wheezing more than those with co-infection. CONCLUSION: Acute wheezing is a common presenting lung sign in HBo V-LRI. Although the pulmonary function tests of all patients were normal, more than a quarter of patients suffered from recurrent wheezing during one-year follow-up.

Pulmonary function and exercise capacity in children following lung resection surgery.

PURPOSE: To study lung function and exercise capacity in children following lung resection surgery. METHODS: Children aged 6-18 years who had lung resection surgery were studied and compared to normal children (age and sex matched). All had spirometry/body plethysmography and exercise stress test (performed by treadmill and modified Balke protocol). RESULTS: 13 Patients and 13 controls were studied (age 13.2 ± 3.3 years; 46.2 % male). The age at the time of lung resection surgery was 6.5 ± 4.7 years. The time interval between post-surgery and the tests was 6.8 ± 4.4 years. The most common indication for lung resection surgery was congenital lung malformations (61.5 %). 76.9 % of the patients had abnormal lung function. Exercise intolerance due to pulmonary limitations was found in 23.1 % of the patients. At the anaerobic threshold, the V(O2) was not different between the patients and the controls. However, at the end of the exercise, the patients demonstrated lower peak V(O2) than the controls (33.6 ± 6.0 vs. 39.3 ± 8.7 ml/min/kg; p < 0.01). CONCLUSIONS: Abnormal lung functions and exercise intolerance were found in children following lung resection surgery. Children who had lung resection surgery had lower exercise capacity than normal children if the exercise was beyond the anaerobic threshold.

Obstructive sleep apnea among children with severe beta-thalassemia.

The aim of this study was to determine the prevalence and associated factors for obstructive sleep apnea (OSA) among children with severe beta-thalassemia. Children with severe beta-thalassemia without a history of bone marrow transplantation were studied. Polysomnography (PSG) was performed in those who habitually snored to identify OSA. One hundred twenty children (aged 9.3 +/- 3.7 years; 42% male) were studied. Nineteen patients (15.8%) habitually snored. Sixteen had PSG performed. OSA was demonstrated in 10 patients. Six had moderate-to-severe OSA. The estimated prevalence of OSA was 8.3%. All OSA patients had adenoid hypertrophy and 80% had associated tonsil enlargement. The OSA group had a higher serum ferritin level compared to the non-OSA group (3,785 +/- 1,780 vs 1,885 +/- 677 ng/ml; p = 0.03). Six of 10 patients who had OSA underwent adenotonsillectomy. Reactive lymphoid hyperplasia was demonstrated in all cases. The estimated prevalence of OSA in children with severe beta-thalassemia was high (8.3%) and some had severe OSA. Adenotonsillar lymphoid hyperplasia was common among those who had OSA. A high serum ferritin level was associated with the occurrence of OSA. A history of snoring and OSA symptoms should be periodically assessed in children with severe beta-thalassemia.

Potent inflammatory cytokine response following lung volume recruitment maneuvers with HFOV in pediatric acute respiratory distress syndrome.

OBJECTIVE: Lung volume recruitment maneuver (LVRM) may improve gas exchange but inflating the lungs to nearly vital capacity may cause further lung injuries. Our aim was to determine the potent inflammatory cytokine response following lung volume recruitment (LVRM) with high frequency oscillator ventilation (HFOV) in pediatric acute respiratory distress syndrome (ARDS). METHODS: We prospectively recruited pediatric patients (age >1 month - <15 year old) with a diagnosis of ARDS within 72 hrs of PICU admission. They underwent the LVRM protocol combined with HFOV. Any enrolled subject who had a 20% improvement in PaO2/FiO2 (PF ratio) 1 hr after the LVRM we classified as a responder. Baseline clinical data were recorded. Blood was also drawn at baseline, 1 & 24 hrs after LVRM and kept for further sICAM-1, IL-6 & IL-8 analysis. RESULTS: Eighteen children with ARDS were enrolled. Their mean age was at 6.8 +/- 6.1 years (mean +/- SD). The initial oxygen index (iOI) was at 26.8 +/- 17.8 (11.5-84.9). There was no significant differences in sICAM-1, IL-6 and IL-8 levels at baseline; (34 +/- 17.5, 121.7 +/- 115.15, 601.5 +/- 675 pg/ml); 1 hr (39.6 +/- 28.7, 99.8 +/- 75.5, 617.4 +/- 692.5 pg/ml) and at 24 hrs (44.23 +/- 34.4, 109.4 +/- 63.9, 737.6 +/- 922.3 pg/ml) following LVRMs, respectively. However, there was significant difference in the elevation of sICAM-1 levels (%change) from baseline in responders (-1.8 +/- 12.2%) vs. non-responders (47.65 +/- 43.5%) at 1 hr. Additionally, sICAM-1 levels were also significantly higher at baseline, 1 hr and 24 hrs in non-survivors as compared with survivors. CONCLUSION: There was no significant elevation of potent inflammatory cytokines that may indicate further lung injuries in the majority of our patients. However, there was significant elevation of sICAM-1 levels in non-responders and in those who did not survive that may indicate more lung injuries in these individuals.

Gas exchange abnormality during sleep in non-snoring severe thalassemia children.

OBJECTIVE: To study the prevalence and associated factors of gas exchange abnormality during sleep in non-snoring severe thalassemia children. MATERIAL AND METHOD: Non-snoring severe thalassemia children aged 6 to 15 years who had been followed up at King Chulalongkorn Memorial Hospital between June 2009 and March 2010 were studied. Overnight pulse oximetry and end-tidal carbon dioxide tension (P(ET)CO2) monitoring as well as pulmonary function tests were evaluated. RESULTS: Fifty-eight non-snoring severe thalassemia children (aged 10.5 +/- 2.6 years, 43% male) were studied. 67.2% showed abnormal gas exchange during sleep. All of them had nocturnal desaturation (nadir SpO2 87 +/- 6.9%; range 65 to 94%). 33.3% of those who had nocturnal desaturation had associated lung function abnormality. Abnormal lung function was found in 32.8% of the present study patients. Of these, 68.4% had associated nocturnal desaturation. Age, gender nutritional status, size of liver and spleen, history of splenectomy, hemoglobin and serum ferritin level, and lung function were not associated with abnormal gas exchange during sleep. CONCLUSION: Nocturnal desaturation was demonstrated in more than a half of non-snoring severe thalassemia children. Normal lung function did not guarantee normal gas exchange during sleep. However, more than a half of those who had lung function abnormality had associated nocturnal desaturation. Evaluation of gas exchange during sleep would be merited in this group of patients.

Incidence and risk factors of upper gastrointestinal bleeding in mechanically ventilated children.

OBJECTIVE: To identify the incidence and factors related to upper gastrointestinal (UGI) bleeding in children requiring mechanical ventilation for longer than 48 hrs. DESIGN: Prospective analytic study. SETTING: Ten-bed-pediatric intensive care unit of a tertiary care University Hospital. PATIENTS: A total of 110 patients requiring mechanical ventilation for longer than 48 hrs from January 1, 2005 to December 31, 2005. MEASUREMENTS AND RESULTS: UGI bleeding was defined by evidence of blood in nasogastric aspirates, hematemesis, or melena within 5 days of pediatric intensive care unit admission. We prospectively collected data on patient demographics, admission diagnosis, operative status, and pediatric risk of mortality score. UGI bleeding and the potential risk factors including organ failure, coagulopathy, maximum ventilator setting, enteral feeding, stress ulcer prophylaxis as well as sedation were daily monitored. Of the 110 patients who required mechanical ventilation for >48 hrs, the incidence of UGI bleeding was 51.8%, in which 3.6% of the cases presented with clinically significant bleeding (shock, requiring blood transfusion and/or surgery). Significant risk factors were thrombocytopenia, prolonged partial thromboplastin time, organ failure, high pressure ventilator setting >/=25 cm H2O, and pediatric risk of mortality score >/= 10 using univariate analysis. However, the independent factors of UGI bleeding in the multivariate analysis were organ failure (relative risk = 2.85, 95% confidence interval 1.18-6.92) and high pressure ventilator setting >/=25 cm H2O (relative risk = 3.73, 95% confidence interval 1.59-8.72). CONCLUSION: The incidence of UGI bleeding is high in children requiring mechanical ventilation. Organ failure and high pressure ventilator setting are significant risk factors for UGI bleeding.

Evaluation of metered-dose inhaler administration technique among asthmatic children and their caregivers in Thailand.

Ninety-three asthmatic children and their caregivers were studied on their techniques of inhaler administration. Factors associated with the correct use of the device were also evaluated. Only 55.9% of the studied children demonstrated the correct technique in using their inhalation devices. In children using MDI (n = 42), the most common incorrect performance was the step of breathing in slowly at the same time with actuation (n = 17, 40.5%). Among those who used MDI-spacer (n = 51), all medication was given by their caregivers. The most common error was the step of waiting for 30 seconds prior to the next MDI actuation (n = 13, 25.5%). Factors related to the correct performance included duration of use for more than 1 year (p = 0.02), instruction of inhalation technique by trained technicians (p = 0.04) and the education level of the caregivers (p = 0.01). Our study demonstrates that incorrect technique during inhalation is common among Thai children with asthma and emphasizes an essential role of health professionals in regular evaluation of their patients and caregivers to ensure their correct application.

Optimal level of physical activity in children with chronic lung diseases.

AIM: To determine the optimal level of physical activity and its relationship with disease severity in children with chronic lung diseases (CLD). METHODS: Pulmonary function and exercise tests were compared between 18 CLD children (aged 13.5 +/- 2.4 years, 33% male) and 18 healthy controls without any history of lung diseases (age and sex matched). RESULTS: CLD children had lower forced vital capacity (FVC), forced expiratory volume in 1 sec (FEV)(1), forced expiratory flow rate between 25% and 75% of vital capacity (FEF)(25-75%) and total lung capacity (TLC) and higher residual volume (RV)/TLC ratio than controls (77.3 +/- 22.6 vs. 97.9 +/- 12.5%pred; p = 0.002, 74.3 +/- 17.6 vs. 104.0 +/- 12.6%pred; p < 0.001, 49.9 +/- 23.1 vs. 75.6 +/- 18.6%pred; p < 0.001, 82.8 +/- 18.6 vs. 95.6 +/- 9.8%pred; p = 0.04, 30.8 +/- 10.2 vs. 24.4 +/- 5.9%; p = 0.04, respectively). Oxygen consumption at anaerobic threshold (AT) and optimal level of physical activity (metabolic equivalents [METs] at AT) were not different between the two groups and between mild and moderate to severe CLD. However, when the exercise was continued beyond the AT, CLD children demonstrated poorer exercise performance than normal controls. CONCLUSION: Children with CLD demonstrated the same level of optimal physical activity as normal children despite their lower lung function. The optimal level of physical activity was not related to disease severity. The exercise test and exercise should not be performed beyond the AT by the CLD children. Proper exercise test should be done to determine their optimal exercise activity.

Prevalence of Mycoplasma and Chlamydia pneumonia in severe community-acquired pneumonia among hospitalized children in Thailand.

Pneumonia is the leading cause of pediatric morbidity and mortality worldwide, and Mycoplasma pneumoniae and Chlamydia pneumoniae are the two most common atypical pathogens. This study was designed to determine the prevalence and clinical impact of mycoplasma and chlamydia pneumonia in children hospitalized with severe pneumonia. Children 1 month-15 years old with a diagnosis of severe pneumonia (WHO criteria) were recruited between March 2005 and March 2006. Serologic studies were performed for anti-M. pneumoniae and anti-C. pneumoniae IgG/M on admission and 2-4 weeks afterward using ELISA. Of 52 patients, 13 (25%) were positive for Mycoplasma, 8 (15%) were positive for Chlamydia, 4 (7.6%) were positive for a mixed infection and 27 (52%) were negative. The subjects' mean age was 23.8+/-4.1 months. The mean of initial oxygen saturation on admission was 87.5+/-1.2%. Fever and prolonged cough were the leading symptoms. The mean of hospitalization was 18.8+/-2.6 days, chlamydia pneumonia had the longest duration, 30+/-10.2 days and 13/52 (25%) study subjects developed respiratory failure. Only 10% were treated with adequate antibiotic prior to serologic results. There was one mortality (1/52, 2%). Our study suggests that mycoplasma and chlamydia infections are commonly found among children hospitalized with severe pneumonia. Coverage with an appropriate antibiotic should be considered to hasten recovery.

Does nebulized hypertonic saline shorten hospitalization in young children with acute viral wheezing?

BACKGROUND: Although previous studies have shown benefits of nebulized hypertonic saline (HS) for improving airway clearance and shortening hospitalization in infants with bronchiolitis, prospective blinded studies in preschool children with acute viral wheezing are limited. OBJECTIVES: To determine nebulized 3% HS efficacy in young children admitted with acute viral wheezing. METHODS: This double-blind, randomized controlled trial was conducted in children aged 6 months to 5 years admitted with acute viral wheezing from July 1st to December 31st 2016. Patients were randomized to receive inhalation of 2.5 mg salbutamol dissolved in either 3% HS or normal saline (NS). Clinical data, asthma clinical severity score, and length of hospital stay (LOS) were recorded. RESULTS: A total of 47 patients were enrolled (22 in HS and 25 in NS) without significant differences in demographic data and baseline clinical scores. Median LOS and median time of oxygen therapy were significantly shorter in HS than NS group: 48 versus 72 h, P = 0.021 and 36 versus 72 h, P = 0.025, respectively. HS patients had significantly improved asthma clinical severity scores, respiratory rates and oxygen saturation at 12 h compared to NS group (P-value 0.042, 0.032, and 0.043). There were no adverse events. CONCLUSION: In children under 5 years admitted with acute viral wheezing, nebulized hypertonic saline/salbutamol significantly shortened hospital stay length, time of oxygen therapy, and improved asthma clinical severity score faster than normal saline/salbutamol.

Levels of protein C activity and clinical factors in early phase of pediatric septic shock may be associated with the risk of death.

Severe sepsis and septic shock are major causes of morbidity and mortality among children in pediatric intensive care units (PICUs) worldwide. Activated protein C (PC) is a critical endogenous regulator of coagulation and inflammation in patients with sepsis. However, the role of PC in pediatric sepsis is still obscure. We prospectively recruited infants and children aged between 1 month and 15 years old who were admitted to PICU with a clinical diagnosis of systemic inflammatory response syndrome, sepsis, or septic shock. Clinical data were recorded and blood samples kept for further analysis. We then measured the levels of PC activity. Of the approximately 1,100 pediatric patients admitted to PICU from January 1, 2004 to December 31, 2005, 75 were diagnosed with septic shock (6.8%), and 67 samples were available for analysis. Out of these, 41 (61%) were survivors, and 26 (39%) were nonsurvivors. The average plasma PC activity (%) was at 37.8 +/- 4.4. Plasma PC activity (%) was significantly lower in the nonsurvivors compared with the survivors at 23.6 +/- 4.3 and 46.8 +/- 6.3 (P = 0.002), respectively. D-Dimer levels were not significantly different between the survivors (1,461 +/- 266 ng/mL) and the nonsurvivors (1,989 +/- 489 ng/mL) (P = 0.68). Also, there was no correlation between plasma PC activity and D-dimer levels (r = -0.07; P = 0.6). Importantly, the odds of dying were significantly higher in patients whose level of PC activity was less than 25% (odds ratio = 5.6; P = 0.02). Pediatric patients with septic shock demonstrate very low levels of PC activity, and this may be associated with an increased risk of death.

Knowledge of asthma among caregivers of asthmatic children: outcomes of preliminary education.

OBJECTIVES: To assess the knowledge of asthma among the caregivers of asthmatic children and to evaluate the outcomes of preliminary education. MATERIAL AND METHOD: The caregivers of asthmatic patients aged 2-15 years who attended the pediatric chest clinic of King Chulalongkorn Memorial Hospital from January to December 2003 were randomly recruited to answer the questionnaire about asthma prior to the educational discussion with the investigators or nurses. The questionnaire was done again 6 months later. The significant factors associated with adequate knowledge and change of knowledge of the caregivers were identified. RESULTS: Among the 79 study caregivers, forty-two (53.2%) had sufficient knowledge of asthma (score > or = 34 out of 44). The average pre-test score was 33 +/- 3.6 (24-42). The duration of caring for their asthmatic child was the only significant factor associated with adequate knowledge (p < 0. 05). After the educational session, the post-test score was significantly improved (36.0 +/- 2.6; p < 0.001). CONCLUSION: Half of the caregivers of the asthmatic children had insufficient knowledge of asthma. Education about asthma is still needed to improve their knowledge.

Environmental tobacco smoke exposure and respiratory syncytial virus infection in young children hospitalized with acute lower respiratory tract infection.

OBJECTIVE: The present study was performed to determine the relationship between environmental tobacco smoke (ETS) exposure and acute lower respiratory tract infection (LRI) caused by respiratory syncytial virus (RSV) in children. MATERIAL AND METHOD: The authors did the study in 71 children (median age 12 months; 60% male) who were admitted to King Chulalongkorn Memorial Hospital with acute LRI between June and September 2004. 27% had RSV infection. RESULTS: RSV-LRI required longer duration of oxygen therapy than non RSV-LRI (4.5 +/- 1.7 vs 2.8 +/- 1.3 days; p < 0.001). Desaturation in room air was more common in the former group compared to the latter group (37 vs 11%; p = 0.01). There was no difference in urinary cotinine level between the two groups (median 0.5 vs 0.6 mcg/mg Cr; ns). Among RSV-LRI, those with desaturation had higher urinary cotinine level than those without desaturation (median 0.8 vs 0.0 mcg/mg Cr; p = 0.04). CONCLUSION: ETS exposure was not associated with RSV-LRI but increased the risk of desaturation in these patients.

Prevalence and clinical features of mycoplasma pneumoniae in Thai children.

OBJECTIVE: To determine the prevalence and clinical features of mycoplasma pneumoniae in Thai children with community acquired pneumonia (CAP). MATERIAL AND METHOD: Diagnosis of current infection was based on > or = 4 fold rise in antibody sera or persistently high antibody titers together with the presence of mycoplasma DNA in respiratory secretion. The clinical features were compared between children who tested positive for M pneumoniae, and those whose results were negative. RESULTS: Current infection due to M. pneumoniae was diagnosed in 36 (15%) of 245 children with paired sera. The sensitivity and specificity of polymerase chain reaction (PCR) in diagnosing current infection in the present study were 78% and 98% respectively. The mean age of children with mycoplasma pneumoniae was higher than CAP with unspecified etiology. The presenting manifestations and initial laboratory finding were insufficient to predict mycoplasma pneumoniae precisely, the presence of chest pain and lobar consolidation on chest X-ray, however, were significant findings in children with mycoplasma pneumoniae. CONCLUSION: The present study confirms that M. pneumoniae plays a significant role in CAP in children of all ages. Children with this infection should be identified in order to administer the appropriate antibiotic treatment.

Prevalence and clinical presentations of atypical pathogens infection in community acquired pneumonia in Thailand.

OBJECTIVES: To determine the prevalence of atypical pneumonia and clinical presentations in patients with community acquired pneumonia (CAP). MATERIAL AND METHOD: A prospective multi-centered study was performed in patients aged > or = 2 years with the diagnosis of CAP who were treated at seven governmental hospitals in Bangkok from December 2001 to November 2002. The diagnosis of current infection was based on > or = 4 fold rise in antibody sera or persistently high antibody titers together with the presence of DNA of M. pneumoniae or C. pneumoniae in respiratory secretion or antigen of L. pneumophila in the urine. Clinical presentations were compared between patients with atypical pneumonia and unspecified pneumonia. RESULTS: Of 292 patients, 18.8% had current infection with atypical respiratory pathogens (M. pneumoniae 14.0%, C. pneumoniae 3.4%, L. pneumophila 0.4% and mixed infection 1.0%). Only age at presentation was significantly associated with atypical pneumonia in adults, while absence of dyspnea, lobar consolidation, and age > or = 5 years were significant findings for atypical pneumonia in children. CONCLUSION: The present study confirms the significance of atypical pathogens in adults and children. Moreover lobar consolidation is likely to predict atypical pneumonia in childhood CAP.