Chronic Suppurative Lung Disease in Children: Definition and Spectrum of Disease.

The most common clinical suppurative lung conditions in children are empyema, lung abscess, and bronchiectasis, and to a less often necrotizing pneumonia. Until recently, bronchiectasis was the most common form of persistent suppurative lung disease in children. Protracted bacterial bronchitis is a newly described chronic suppurative condition in children, which is less persistent but more common than bronchiectasis (1). In addition, the term "chronic suppurative lung disease" has been used recently to describe the clinical features of bronchiectasis when the radiographic features needed to make a diagnosis of bronchiectasis are absent. Webster's New College Dictionary defines suppuration as the process of forming and/or discharging pus. Pus is a body fluid resulting from intense inflammation in response to infection that leads to neutrophil influx and apoptosis, microbial clearance, and often necrosis of nearby tissue. Pus is primarily composed of white blood cell debris.

Mycobacterium abscessus complex lung infection in a toddler with a tracheostomy.

Mycobacterium abscessus complex and other non-tuberculous mycobacteria are infrequently encountered respiratory pathogens in patients with tracheostomies. We report a 4-year-old girl with a tracheostomy, placed during infancy for management of severe bronchopulmonary dysplasia and laryngeal stenosis, who developed a M. abscessus complex lung infection. There was clear evidence of parenchymal involvement and true infection beyond colonization. She demonstrated dramatic clinical, laboratory, and radiographic improvement after prolonged anti-mycobacterial therapy.

Lung function and biomarkers of airway inflammation during and after hospitalization for acute exacerbations of childhood asthma associated with viral respiratory symptoms.

BACKGROUND: There are limited data assessing relationships between biomarkers of inflammation and lung function after hospitalization for asthma exacerbations in children. OBJECTIVE: To assess the associations in asthmatic children among changes in lung function, fraction of exhaled nitric oxide (FENO), and cysteinyl leukotrienes (CysLTs) in exhaled breath condensate (EBC) after hospitalization for acute asthma. METHODS: Spirometry and FENO were measured and EBC collected for CysLT measurement from 40 children during and 1, 2, and 4 weeks after hospitalization for an asthma exacerbation and during a single-study visit for 40 healthy children. RESULTS: Enrollment FENO and EBC CysLT concentrations were higher in the children with asthma than in healthy individuals (mean FENO, 31.6 vs 7 ppb; P < .0001; mean EBC CysLT, 7.9 vs 4.9 ppb; P = .03). Among children with asthma, improvement in lung function reached a plateau within 2 weeks after hospital discharge. The EBC CysLT concentrations were not associated with changes in lung function, use of albuterol, or use of inhaled corticosteroids (ICSs). Among asthmatic children enrollment FENO was not associated with changes in lung function during follow-up. However, among children who had an elevated enrollment FENO (≥25 ppb), patients who did not use ICSs after hospital discharge had lower end-of-study lung function than those who used ICSs. At 2 and 4 weeks after hospital discharge, FENO was higher among patients who reported albuterol use more than twice weekly and among patients who reported no ICS use. CONCLUSION: FENO measured at hospital discharge among children hospitalized with acute asthma may be useful in identifying patients who will respond to ICS therapy.

The management of community-acquired pneumonia in infants and children older than 3 months of age: clinical practice guidelines by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America.

Evidenced-based guidelines for management of infants and children with community-acquired pneumonia (CAP) were prepared by an expert panel comprising clinicians and investigators representing community pediatrics, public health, and the pediatric specialties of critical care, emergency medicine, hospital medicine, infectious diseases, pulmonology, and surgery. These guidelines are intended for use by primary care and subspecialty providers responsible for the management of otherwise healthy infants and children with CAP in both outpatient and inpatient settings. Site-of-care management, diagnosis, antimicrobial and adjunctive surgical therapy, and prevention are discussed. Areas that warrant future investigations are also highlighted.

Executive summary: the management of community-acquired pneumonia in infants and children older than 3 months of age: clinical practice guidelines by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America.

Evidenced-based guidelines for management of infants and children with community-acquired pneumonia (CAP) were prepared by an expert panel comprising clinicians and investigators representing community pediatrics, public health, and the pediatric specialties of critical care, emergency medicine, hospital medicine, infectious diseases, pulmonology, and surgery. These guidelines are intended for use by primary care and subspecialty providers responsible for the management of otherwise healthy infants and children with CAP in both outpatient and inpatient settings. Site-of-care management, diagnosis, antimicrobial and adjunctive surgical therapy, and prevention are discussed. Areas that warrant future investigations are also highlighted.

Use of a lung model to assess mechanical in-exsufflator therapy in infants with tracheostomy.

BACKGROUND: The mechanical in-exsufflator (MIE) is commonly used to augment cough in patients with neuromuscular disease from infancy to adulthood. Little is known about the alveolar pressures, lung volumes, and expiratory flow rates generated by the MIE when used via tracheostomy tube in infants and children. METHODS: A high-fidelity mechanical lung model was programmed to simulate infants with tracheostomy tubes. Generated pressures, volumes, and expiratory flows using the MIE device at variable insufflation/exsufflation pressures and times were recorded. The primary measure of interest was maximal expiratory flow (MEF). RESULTS: Pressure equilibration across the tracheostomy tube did not occur with insufflation time <1 sec. Longer insufflation time significantly increased measured alveolar pressures, lung volume, and MEF until TLC was reached. Longer exsufflation time did not significantly increase MEF. Higher insufflation pressures resulted in greater lung volumes, with >70% vital capacity attained at insufflation pressures as low as 20 cmH2 O. Though higher insufflation pressures resulted in increased expiratory flow rates, more negative exsufflation pressure had a greater absolute impact on MEF. CONCLUSIONS: Using the MIE via tracheostomy tube in an infant lung model, we found that an insufflation time of >1 sec is required for equilibration of insufflation pressure and alveolar pressure. Longer exsufflation time does not significantly alter MEF. Higher insufflation and exsufflation pressures both increased MEF, but greater exsufflation pressure had more substantial impact.

American College of Chest Physicians consensus statement on the management of dyspnea in patients with advanced lung or heart disease.

BACKGROUND: This consensus statement was developed based on the understanding that patients with advanced lung or heart disease are not being treated consistently and effectively for relief of dyspnea. METHODS: A panel of experts was convened. After a literature review, the panel developed 23 statements covering five domains that were considered relevant to the topic condition. Endorsement of these statements was assessed by levels of agreement or disagreement on a five-point Likert scale using two rounds of the Delphi method. RESULTS: The panel defined the topic condition as "dyspnea that persists at rest or with minimal activity and is distressful despite optimal therapy of advanced lung or heart disease." The five domains were: measurement of patient-reported dyspnea, oxygen therapy, other therapies, opioid medications, and ethical issues. In the second round of the Delphi method, 34 of 56 individuals (61%) responded, and agreement of at least 70% was achieved for 20 of the 23 statements. CONCLUSIONS: For patients with advanced lung or heart disease, we suggest that: health-care professionals are ethically obligated to treat dyspnea, patients should be asked to rate the intensity of their breathlessness as part of a comprehensive care plan, opioids should be dosed and titrated for relief of dyspnea in the individual patient, both the patient and clinician should reassess whether specific treatments are serving the goal of palliating dyspnea without causing adverse effects, and it is important for clinicians to communicate about palliative and end-of-life care with their patients.

The conversion to metered-dose inhaler with valved holding chamber to administer inhaled albuterol: a pediatric hospital experience.

BACKGROUND: Metered-dose inhalers with valved holding chambers (MDI-VHCs) have been shown to be equivalent to small-volume nebulizers (SVNs) for the delivery of bronchodilators in children. At Seattle Children's Hospital and Regional Medical Center we sought to implement the conversion from SVN to MDI-delivered albuterol in nonintubated patients receiving intermittent treatments. METHODS: There were 4 distinct interventions used to plan and implement this conversion program: (1) literature review, (2) product selection, (3) policy and operational changes, and (4) staff training. Bronchodilator administration guidelines and clinical pathways for asthma and bronchiolitis were revised to recommend MDI-VHC use in lieu of SVNs. Computerized physician order sets were amended to indicate MDI-VHC as the preferred method of delivering inhaled albuterol in children with asthma and bronchiolitis. Data from administrative case mix files and computerized medication delivery systems were used to assess the impact of our program. RESULTS: MDI-VHC utilization increased from 25% to 77% among all non-intensive-care patients receiving albuterol, and from 10% to 79% among patients with asthma (p < 0.001). Duration of stay among patients with asthma was unchanged after conversion to MDI-VHC (p = 0.53). CONCLUSIONS: Our program was very successful at promoting the use of MDI-VHC for the administration of albuterol in our pediatric hospital. Duration of stay among patients with asthma did not change during or since the implementation of this program.

American College of Chest Physicians consensus statement on the respiratory and related management of patients with Duchenne muscular dystrophy undergoing anesthesia or sedation.

This statement on the management of patients with Duchenne muscular dystrophy (DMD) undergoing procedural sedation or general anesthesia represents the consensus opinion of a multidisciplinary panel convened under the auspices of the American College of Chest Physicians. Expert recommendations on this subject are needed for several reasons. First, patients with DMD have an increased risk of complications when they undergo sedation or general anesthesia. In addition, due to improved cardiopulmonary therapies, patients with DMD are experiencing an unprecedented duration of survival. As a result, it is more common for them to require procedures involving sedation or general anesthesia. The risks related to anesthesia and sedation for DMD patients include potentially fatal reactions to inhaled anesthetics and certain muscle relaxants, upper airway obstruction, hypoventilation, atelectasis, congestive heart failure, cardiac dysrhythmias, respiratory failure, and difficulty weaning from mechanical ventilation. This statement includes advice regarding the highly interrelated areas of respiratory, cardiac, GI, and anesthetic management of patients with DMD undergoing general anesthesia or procedural sedation. The statement is intended to aid clinicians involved in the care of patients with DMD and to be a resource for other stakeholders in this field, including patients and their families. It is an up-to-date summary of medical literature regarding this topic and identifies areas in need of future research.

Chronic productive cough in school children: prevalence and associations with asthma and environmental tobacco smoke exposure.

BACKGROUND: The relationships between chronic productive cough (CPC), environmental tobacco smoke (ETS) exposure, and asthma are not clearly established in children. Therefore, we wished to determine the prevalence of CPC and examine the relationships between CPC, ETS exposure, and asthma in young teenagers. METHODS: We performed a cross sectional survey of 2397 Seattle middle school students, 11-15 years old, using written and video respiratory-symptom questionnaires. We defined CPC as--daily cough productive of phlegm for at least 3 months out of the year; current asthma as--yes to "Have you had wheezing or whistling in your chest in the past 12 months?" and yes in the past year to any of the four video wheezing/asthma video scenarios; and ETS exposure as exposed to tobacco smoke at least several hours each day. We used multilogistic regression to examine relationships between CPC, asthma, and ETS exposure and included in the model the potentially confounding variables race, gender, and allergic rhinitis. RESULTS: The prevalence of CPC was 7.2%. Forty-seven percent (82/173) of children with CPC met criteria for current asthma, while only 10% (214/2224) of those without CPC had current asthma. Current asthma had the strongest associated with CPC, odds ratio (OR) 6.4 [95% CI 4.5-9.0], and ETS was independently associated with both CPC, OR 2.7 [1.8-4.1] and asthma, OR 2.7 [1.5-4.7]. CONCLUSION: In a population of young teenagers, CPC was strongly associated with report of current asthma symptoms and also with ETS exposure. This suggests that asthma and ETS exposure may contribute to CPC in children. However, this study was not designed to determine whether asthma was the actual cause of CPC in this population of children.

Prevalence and impact of gastroesophageal reflux in adolescents with asthma: a population-based study.

We determined the prevalence of gastroesophageal reflux disease (GERD) symptoms and the associations between GERD symptoms and asthma morbidity in a population of adolescents with asthma. Two thousand, three hundred and ninety-seven students attending six middle schools in Seattle completed the International Study of Asthma and Allergy in Children (ISAAC) written and video survey that included additional questions pertaining to GERD symptoms and asthma morbidity. Based on their responses, children were categorized as having undiagnosed current asthma, physician-diagnosed current asthma, or no asthma symptoms. The prevalence of GERD symptoms occurring at least weekly or daily was determined for each group. The asthma morbidity outcomes were emergency department visits, physician visits, missed school days, and use of inhaled medications for respiratory symptoms within the past year. Associations between GERD symptoms and asthma morbidity outcomes were determined using logistic regression. The prevalence of GERD symptoms was significantly higher among students with current asthma (19.3%; 95% confidence interval (CI), 14.9-24.2) than students with no asthma symptoms (2.5%; 95% CI, 1.8-3.4). In children with current asthma (n = 296), symptoms of GERD that occurred at least weekly were strongly associated with emergency department visits (odds ratio (OR), 5.0; 95% CI, 2.6-9.6), physician visits (OR, 2.5; 95% CI, 1.3-4.6), missed school (OR, 2.0; 95% CI, 1.1-3.7), and inhaled medication use (OR, 2.5; 95% CI, 1.3-4.7). The associations between GERD symptoms and emergency department visits, physician visits, and inhaled medication use were stronger among children with asthma who reported daily GERD symptoms (n = 14) than among children reporting weekly GERD symptoms (n = 57). The prevalence of GERD symptoms was greater in adolescents with current asthma than in those without asthma. In addition, the presence of at least weekly GERD symptoms was strongly associated with greater asthma morbidity and the use of asthma medications.

The prevalence of ibuprofen-sensitive asthma in children: a randomized controlled bronchoprovocation challenge study.

OBJECTIVE: To determine the prevalence of ibuprofen-sensitive asthma in school-aged children with mild or moderate persistent asthma. STUDY DESIGN: A randomized, double-blind, placebo-controlled, crossover bronchoprovocation challenge study in children 6 to 18 years of age with mild or moderate persistent asthma. Patients received a single dose of ibuprofen or placebo, per randomization, and then returned 2 to 7 days later to repeat the procedures after taking that study drug not received at the first visit. At each visit, patients performed spirometry before and (1/2), 1, 2, and 4 hours after administration of study drug. We defined bronchospasm as a > or =20% decrease from baseline in the forced expired volume in the first second (FEV1) and ibuprofen sensitivity as bronchospasm following administration of ibuprofen but not placebo. RESULTS: Of the 127 patients screened, 100 (mean age, 11 years) completed the study. Two patients met criteria for ibuprofen-sensitive asthma, resulting in a prevalence of 2% (95% CI: 0.2%-7%). Neither patient was known to have had any exposure to ibuprofen before the study. CONCLUSION: The prevalence of ibuprofen-sensitive asthma was low but non-zero in this group of children with mild or moderate asthma. The possibility of ibuprofen-induced bronchospasm should be considered before administering ibuprofen to children with asthma.

Changes in asthma prevalence and impact on health and function in Seattle middle-school children: 1995 vs 2003.

BACKGROUND: The prevalence of asthma has increased during the past several decades but may have stabilized during the last 5 years. It is not known whether the functional and health impact of asthma has decreased during the past decade. OBJECTIVE: To evaluate changes during a recent 8-year period in the prevalence and health and functional impact of current asthma symptoms in young teenagers. METHODS: In 1995 and 2003, 2,330 and 2,397 middle-school students from Seattle, WA, respectively (median age, 13 years), completed written surveys and answered questions pertaining to 4 wheezing or asthma video scenarios. Children were categorized as having physician-diagnosed current asthma (wheeze in the past year and a physician diagnosis of asthma), undiagnosed current asthma symptoms (wheeze in the past year without a physician diagnosis), or no asthma. Outcome measures were the prevalence of asthma and undiagnosed asthma symptoms and the differences between years in respiratory-associated functional impairment (exercise limitation, missed school, disrupted sleep) and health impact (physician visits, wheeze-limited speech). RESULTS: The prevalence of physician-diagnosed current asthma increased from 1995 to 2003 (3.0% to 6.2%), whereas that for undiagnosed current asthma symptoms decreased (12.0% to 6.2%). The degree of functional and health impairment was similar between the 2 study periods for each subgroup and was highest in the children with physician-diagnosed current asthma. CONCLUSIONS: The prevalence of current asthma symptoms in middle-school children from Seattle decreased slightly between 1995 and 2003, whereas the diagnosis of asthma increased. However, the health and functional impact of asthma did not diminish. Asthma is being diagnosed more often, but many children with asthma are still not achieving good asthma control.

Adherence to montelukast versus inhaled corticosteroids in children with asthma.

Our objective was to compare adherence to montelukast with adherence to inhaled corticosteroids (ICS) in children with persistent asthma. In this retrospective study, we obtained data from a computerized hospital pharmacy database and medical records on 14l patients, 3-18 years of age, who received care for asthma at a military medical center. For each patient, we collected fill/refill data from a consecutive 6-month period and calculated an adherence rate, i.e., (# doses filled/# doses prescribed) x 100. We then determined whether the patient had "good adherence" (adherence rate, > or =70%) or "very poor adherence" (adherence rate, <50%). Eighty-one children were prescribed montelukast, and 104 took ICS; 44 of these children took both. The majority of patients had mild or moderate persistent asthma. There was no significant difference between mean adherence rates: 71% (95% CI, 65-77%) for montelukast vs. 67% (95% CI, 61-73%) for ICS. Fifty-one percent of patients taking montelukast had good adherence, compared to 41% in the ICS group (P = 0.27). Nineteen percent of the montelukast group and 26% of the ICS group had very poor adherence (P = 0.31). Using pharmacy refill data, we found that children with asthma were no more likely to take montelukast than inhaled corticosteroids. Adherence to both medications was suboptimal, even in a system that provides free and easy access to medications.

Interpretation of the tuberculin skin test reaction by pediatric providers.

BACKGROUND: The tuberculin (TB) skin test is widely used, but it is not easy to read. There are few data on how well pediatric care providers interpret the TB skin test or on the success of various methods used to read the skin test reaction. OBJECTIVE: To determine the ability of pediatric care providers to correctly read a positive TB skin test reaction and to identify the most successful method of measuring a TB skin test reaction. METHODS: Twenty nurses, 16 staff pediatricians, 13 residents and 8 medical students who were working in a large pediatrics clinic were asked to read a 15-mm TB skin test reaction of a known converter. The study participants read the skin test using any technique they wished. The primary outcome measure was the percentage of providers who read the TB skin test as > or = 10 mm (considered a correct reading). RESULTS: Seventy-seven percent (44 of 57) of the participants interpreted the TB skin test as > or = 10 mm, but 18% (10 of 57) of them read the skin test as negative (< or = 5 mm). The participants used a variety of interpretation techniques with 18 using the ballpoint pen technique. Participants who used the pen technique were significantly more likely to read the skin test as > or = 10 mm compared with those who used other methods (94% vs. 69%; P = 0.04). Pen technique users were also significantly less likely to measure the reaction as < or = 5 mm (0% vs. 26%; P = 0.02). CONCLUSIONS: Many providers, regardless of professional training and experience, read a 15-mm TB skin test reaction as > or = 10 mm, but a significant minority interpreted it as negative. Use of the pen technique may decrease the number of false negative readings. Specific instruction on use of the pen technique to read TB skin tests should be incorporated into medical training curriculums.