Non-invasive respiratory support in preterm infants.

Survival of preterm infants has increased steadily over recent decades, primarily due to improved outcomes for those born before 28 weeks of gestation. However, this has not been matched by similar improvements in longer-term morbidity. One of the key long-term sequelae of preterm birth remains bronchopulmonary dysplasia (also called chronic lung disease of prematurity), contributed primarily by the effect of early pulmonary inflammation superimposed on immature lungs. Non-invasive modes of respiratory support have been rapidly introduced providing modest success in reducing the incidence of bronchopulmonary dysplasia when compared with invasive mechanical ventilation, and improved clinical practice has been reported from population-based studies. We present a comprehensive review of the key modes of non-invasive respiratory support currently used in preterm infants, including their mechanisms of action and evidence of benefit from clinical trials.

Lower airway microbiota in children with Down syndrome compared to controls with similar respiratory symptomatology.

BACKGROUND: Children with Down syndrome (DS) often present with chronic or recurrent respiratory symptoms and generally have a more severe and prolonged disease course in case of infection. This can be caused by anatomical and/or immunological predisposition. With this study, we aim to compare microbial composition in the lower airways of patients with DS versus controls, to see if we can explain the difference in disease course. METHODS: All endoscopic procedures under general anesthesia in patients with DS were reviewed retrospectively. We compared the microbiological data from bronchoalveolar lavage fluid (BALF) cultures (when available) to a cohort of children with chronic respiratory symptoms but without any other relevant medical history. RESULTS: Endoscopic data were available for 65 DS patients, BAL cultures for 47 out of 65 patients (72%). The "control" group consisted of 150 children without significant underlying disease, who were matched for age and sex. BAL culture results were available for 135 out of 150 patients (90%). Microorganisms were categorized and compared between both groups, with no statistical differences. Among the microorganisms tested, the most frequently reported were typical bacteria such as Haemophilus influenzae, Moraxella catarrhalis, Streptococci and Staphylococci. CONCLUSIONS: No significant differences in lower airways microbial composition of children with DS and chronic respiratory symptoms were found when compared to controls presenting similar symptomatology. A suggestion for future research may be to investigate possible differences in drug sensitivity.

Temporal trends of care practices, morbidity, and mortality of extremely preterm infants over 10-years in South Wales, UK.

Contemporary outcome data of preterm infants are essential to commission, evaluate and improve healthcare resources and outcomes while also assisting professionals and families in counselling and decision making. We analysed trends in clinical practice, morbidity, and mortality of extremely preterm infants over 10 years in South Wales, UK. This population-based study included live born infants < 28 weeks of gestation in tertiary neonatal units between 01/01/2007 and 31/12/2016. Patient characteristics, clinical practices, mortality, and morbidity were studied until death or discharge home. Temporal trends were examined by adjusted multivariable logistic regression models and expressed as adjusted odds ratios (aOR) with 95% confidence intervals (95% CI). A sensitivity analysis was conducted after excluding infants born at < 24 weeks of gestation. In this population, overall mortality for infants after live birth was 28.2% (267/948). The odds of mortality (aOR 0.93, 95% CI [0.88, 0.99]) and admission to the neonatal unit (0.93 [0.87, 0.98]) significantly decreased over time. Non-invasive ventilation support during stabilisation at birth increased significantly (1.26 [1.15, 1.38]) with corresponding decrease in mechanical ventilation at birth (0.89 [0.81, 0.97]) and following admission (0.80 [0.68-0.96]). Medical treatment for patent ductus arteriosus significantly decreased over the study period (0.90 [0.85, 0.96]). The incidence of major neonatal morbidities remained stable, except for a reduction in late-onset sepsis (0.94 [0.89, 0.99]). Gestation and centre of birth were significant independent factors for several outcomes. The results from our sensitivity analysis were compatible with our main results with the notable exception of death after admission to NICU (0.95 [0.89, 1.01]). There were significant improvements in survival and reduction of late-onset sepsis of extreme preterm infants in South Wales between 2007 and 2016. The sensitivity analysis suggests that some of the temporal changes observed were driven by improved outcomes in the most preterm of infants. Clinical practices related to respiratory support have changed but significant variations in clinical practices and outcomes between centres remain unexplained. The adoption of regional evidence-based clinical guidelines is likely to improve outcomes and reduce variation.

The prevalence of lower airway anomalies in children with Down syndrome compared to controls.

INTRODUCTION: Children with Down syndrome (DS) often present with chronic respiratory symptoms. Congenital airway anomalies have been described but data about prevalence is scarce and a comparison to controls is lacking. We aim to compare the endoscopic and clinical data of children with DS to controls without significant medical history. METHODS: All endoscopic procedures under general anesthesia (broncho- and/or direct laryngoscopy) in patients with DS were reviewed. We compared clinical and endoscopic data to a cohort of children with respiratory symptoms but without any other relevant medical history. RESULTS: Endoscopic data were available for 65 patients with DS. The median age was 2.9 years (range: 0.2-17), 63% were boys. The most common clinical presentation was recurrent respiratory infections (37%). Other major symptoms were chronic cough and/or noisy breathing (23%) and stridor (20%). Endoscopy was normal in 29% of patients. The largest group of patients (44%) had some form of airway malacia. Tracheal bronchus and subglottic stenosis were each isolated findings in 3.1% of patients. Twenty percent presented with combined airway anomalies. The control group consisted of 150 children (matched for age and sex) without significant underlying disease. The most common presentations were chronic cough and/or noisy breathing (29%), persistent radiographic abnormalities (20%), and suspicion of aspiration of a foreign body (15%). In the majority of controls (68%), no airway anomaly was found. Other findings were malacia (22%), tracheal bronchus (1%), and subglottic stenosis (1%). A combined anomaly was found in 5%. CONCLUSION: Congenital airway anomalies were seen in 71% of patients with DS, compared with 32% of controls. Combined anomalies are more frequent in DS. Complete lower airway endoscopy is recommended in patients with DS as it may influence therapeutic decision-making.

Protracted bacterial bronchitis: bronchial aspirate versus bronchoalveolar lavage findings: a single-centre retrospective study.

Retrospective chart review of 133 children who underwent bronchoscopy because of possible protracted bacterial bronchitis to compare the results of bronchial aspirates with those of bronchoalveolar lavage (BAL). When comparing BAL and bronchial aspirate in 70 patients where both samples were available, the result was comparable in 46 cases (65%). If only bronchial aspirates would have been available, seven patients (10%) would have been overtreated, four children (6%) undertreated and three (4%) would have received a different treatment. Although, BAL and bronchial aspirate are comparable in the majority of cases, differences exist with an impact on treatment decision, underlying the uncertainties in the pathophysiology of protracted bacterial bronchitis.

Respiratory morbidity in children with cerebral palsy: an overview.

Respiratory problems have a significant impact on morbidity and mortality in patients with cerebral palsy (CP). In particular, recurrent aspiration, impaired airway clearance, spinal and thoracic deformity, impaired lung function, poor nutritional status, and recurrent respiratory infections negatively affect respiratory status. Bronchopulmonary dysplasia may contribute to pulmonary problems, but asthma is not more common in CP than in the general population. We discuss treatment options for each of these factors. Multiple coexisting and interacting factors that influence the respiratory status of patients with CP should be recognized and effectively addressed to reduce respiratory morbidity and mortality. WHAT THIS PAPER ADDS: Respiratory problems are a significant cause of morbidity in patients with cerebral palsy (CP). Respiratory status in patients with CP is influenced by recurrent aspiration and impaired airway clearance. Spinal and thoracic deformity, impaired lung function, poor nutrition, and respiratory infections also negatively affect respiratory status. These factors should all be addressed to reduce respiratory problems in patients with CP.

MORBILIDAD RESPIRATORIA EN NIÑOS CON PARÁLISIS CEREBRAL: UNA VISIÓN GENERAL: Los problemas respiratorios tienen un impacto significativo sobre la morbilidad y mortalidad en pacientes con parálisis cerebral (PC). En particular, aspiraciones recurrentes, incapacidad para despejar la vía aérea, deformidades de la columna y del tórax, deterioro de la función pulmonar, un pobre estado nutricional e infecciones pulmonares recurrentes, afectan negativamente el estado respiratorio. La displasia broncopulmonar puede contribuir a estos problemas pulmonares, pero el asma no es más común en PC que en la población general. Discutimos las opciones terapéuticas para cada uno de estos factores. La coexistencia e interacción de múltiples factores que influencian el estado respiratorio de las pacientes con PC deben ser reconocidos y tratados efectivamente para reducir la morbilidad respiratoria y la mortalidad.

MORBIDADE RESPIRATÓRIA EM CRIANÇAS COM PARALISIA CEREBRAL: UM PANORAMA: Problemas respiratórios têm impacto significativo na morbidade e mortalidade em pacientes com paralisia cerebral (PC). Em particular, aspiração recorrente, limpeza deficiente das vias aéreas, deformidade espinhal e torácica, função pulmonar deficiente, pobre estado nutricional, e infecções respiratórias recorrentes podem afetar o estado respiratório negativamente. A displasia broncopulmonar pode contribuir para problemas pulmonares, mas a asma não é mais comum em PC do que na população geral. Nós discutimos opções de tratamento para cada um destes fators. Múltiplos fatores coexistentes ou que interagem e que influenciam o estado respiratório de pacientes com PC devem ser reconhecidos e efetivamente abordados para reduzir a morbidade e mortalidade respiratória.