Implementation of a high fidelity simulation based training program for physicians of children requiring long term invasive home ventilation: a study by ISPAT team.

Introduction: The number of children requiring long-term invasive home ventilation (LTIHV) has increased worldwide in recent decades. The training of physicians caring for these children is crucial since they are at high risk for complications and adverse events. This study aimed to assess the efficacy of a comprehensive high-fidelity simulation-based training program for physicians caring for children on LTIHV. Methods: A multimodal training program for tracheostomy and ventilator management was prepared by ISPAT (IStanbul PAediatric Tracheostomy) team. Participants were subjected to theoretical and practical pre-tests which evaluated their knowledge levels and skills for care, follow-up, and treatment of children on LTIHV. Following the theoretical education and hands-on training session with a simulation model, theoretical and practical post-tests were performed. Results: Forty-three physicians from 7 tertiary pediatric clinics in Istanbul were enrolled in the training program. Seventy percent of them had never received standardized training programs about patients on home ventilation previously. The total number of correct answers from the participants significantly improved after the theoretical training (p < 0.001). The number of participants who performed the steps correctly also significantly increased following the hands-on training session (p < 0.001). All of the 43 participants who responded rated the course overall as good or excellent. Conclusion: The knowledge and skills of clinicians caring for children on LTIHV can be enhanced through a comprehensive training program consisting of theoretical training combined with hands-on training in a simulation laboratory.

Childhood interstitial lung disease in Turkey: first data from the national registry.

The childhood interstitial lung diseases (chILD) Turkey registry (chILD-TR) was established in November 2021 to increase awareness of disease, and in collaboration with the centers to improve the diagnostic and treatment standards. Here, the first results of the chILD registry system were presented. In this prospective cohort study, data were collected using a data-entry software system. The demographic characteristics, clinical, laboratory, radiologic findings, diagnoses, and treatment characteristics of the patients were evaluated. Clinical characteristics were compared between two main chILD groups ((A) diffuse parenchymal lung diseases (DPLD) disorders manifesting primarily in infancy [group1] and (B) DPLD disorders occurring at all ages [group 2]). There were 416 patients registered from 19 centers. Forty-six patients were excluded due to missing information. The median age of diagnosis of the patients was 6.05 (1.3-11.6) years. Across the study population (n = 370), 81 (21.8%) were in group 1, and 289 (78.1%) were in group 2. The median weight z-score was significantly lower in group 1 (- 2.0 [- 3.36 to - 0.81]) than in group 2 (- 0.80 [- 1.7 to 0.20]) (p < 0.001). When we compared the groups according to chest CT findings, ground-glass opacities were significantly more common in group 1, and nodular opacities, bronchiectasis, mosaic perfusion, and mediastinal lymphadenopathy were significantly more common in group 2. Out of the overall study population, 67.8% were undergoing some form of treatment. The use of oral steroids was significantly higher in group 2 than in group 1 (40.6% vs. 23.3%, respectively; p = 0.040).   Conclusion: This study showed that national registry allowed to obtain information about the frequency, types, and treatment methods of chILD in Turkey and helped to see the difficulties in the diagnosis and management of these patients. What is Known: • Childhood interstitial lung diseases comprise many diverse entities which are challenging to diagnose and manage. What is New: • This study showed that national registry allowed to obtain information about the frequency, types and treatment methods of chILD in Turkey and helped to see the difficulties in the diagnosis and management of these patients. Also, our findings reveal that nutrition should be considered in all patients with chILD, especially in A-DPLD disorders manifesting primarily in infancy.

Long-term outcomes of standardized training for caregivers of children with tracheostomies: The IStanbul PAediatric Tracheostomy (ISPAT) project.

BACKGROUND AND OBJECTIVES: Children with tracheostomies are at increased risk of tracheostomy-related complications and require extra care. Standardized training programs for caregivers can improve tracheostomy care and reduce complications. In this study, we compared caregiver knowledge and skill scores after a standardized theoretical and practical training program on tracheostomy care (IStanbul PAediatric Tracheostomy (ISPAT) project) immediately and 1 year post-training and evaluated how this training affected the children's clinical outcomes. MATERIALS AND METHODS: We included 32 caregivers (31 children) who had received standardized training a year ago and administered the same theoretical and practical tests 1 year after training completion. We recorded tracheostomy-related complications and the number and reasons for admission to the healthcare centers. All data just before the training and 1 year after training completion were compared. RESULTS: After 1 year of training completion, the median number of correct answers on the theoretical test increased to 16.5 from 12 at pretest (p < 0.001). Compared with pretest, at 1-year post-training practical skills assessment scores, including cannula exchange and aspiration, were significantly higher (both p < 0.001) and mucus plug, bleeding, and stoma infection reduced significantly (p = 0.002, 0.022, and 0.004, respectively). Hands-on-training scores were better than pretest but declined slightly at 1 year compared to testing immediately after training. Emergency admission decreased from 64.5% to 32.3% (p = 0.013). Hospitalization decreased from 61.3% to 35.5% (p = 0.039). CONCLUSION: Our findings indicate that caregiver training can lead to a persistent increase in knowledge and skill for as long as 1 year, as well as improvements in several measurable outcomes, although a slight decrease in scores warrants annual repetitions of the training program.

The ISPAT project: Implementation of a standardized training program for caregivers of children with tracheostomy.

BACKGROUND: Tracheostomy-related morbidity and mortality mainly occur due to decannulation, misplacement, or obstruction of the tube. A standardized training can improve the skills and confidence of the caregivers in tracheostomy care (TC). OBJECTIVE: Our primary aim was to evaluate the efficiency of standardized training program on the knowledge and skills (changing-suctioning the tracheostomy tube) of the participants regarding TC. MATERIALS AND METHODS: Sixty-five caregivers of children with tracheostomy were included. First, participants were evaluated with written test about TC and participated in the practical tests. Then, they were asked to participate in a standardized training session, including theoretical and practical parts. Baseline and postintervention assessments were compared through written and practical tests conducted on the same day. RESULTS: A significant improvement was observed in the written test score after the training. The median number of correct answers of the written test including 23 questions increased 26%, from 12 to 18 (p < .001). The median number of correct steps in tracheostomy tube change (from 9 to 16 correct steps out of 16 steps, 44% increase) and suctioning the tracheostomy tube (from 9 to 17 correct steps out of 18 steps, 44% increase) also improved significantly after the training (p < .001, for both). CONCLUSION: Theoretical courses and practical hands-on-training (HOT) courses are highly effective in improving the practices in TC. A standardized training program including HOT should be implemented before discharge from the hospital. Still there is a need to assess the impact of the program on tracheostomy-related complications, morbidity, and mortality in the long term.

Pediatric flexible bronchoscopy in the intensive care unit: A multicenter study.

INTRODUCTION: Flexible bronchoscopy (FB) is frequently used for assessment and treatment of patients with respiratory diseases. Our aim was to investigate the contribution of FB to diagnosis and therapy in children admitted to the intensive care units (ICU) and to evaluate the safety of FB in this vulnerable population. METHODS: Children less than 18 years of age who underwent FB in the five neonatal and pediatric ICUs in Istanbul between July 1st, 2015 and July 1st, 2020 were included to the study. Demographic and clinical data including bronchoscopy indications, findings, complications, and the contribution of bronchoscopy to the management were retrospectively reviewed. RESULTS: One hundred and ninety-six patients were included to the study. The median age was 5 months (range 0.3-205 months). The most common indication of FB was extubation failure (38.3%), followed by suspected airway disease. Bronchoscopic assessments revealed at least one abnormality in 90.8% patients. The most common findings were airway malacia and the presence of excessive airway secretions (47.4% and 35.7%, respectively). Positive contribution of FB was identified in 87.2% of the patients. FB had greater than 1 positive contribution in 138 patients and 80.6% of the patients received a new diagnosis. Medical therapy was modified after the procedure in 39.8% and surgical interventions were pursued in 40% of the patients. Therapeutic lavage was achieved in 18.9%. There were no major complications. CONCLUSION: Flexible bronchoscopy is a valuable diagnostic and therapeutic tool in neonatal and pediatric ICUs and is not associated with major complications.

Platypnea-orthodeoxia syndrome in a child: relief of symptoms after transcatheter closure of patent foramen ovale.

Platypnea-orthodeoxia syndrome is a rare clinical entity characterised by positional dyspnoea and arterial desaturation while in the upright position, the symptoms generally occurring in adults. We describe a 12-year-old girl diagnosed with platypnea-orthodeoxia syndrome associated with patent foramen ovale. The symptoms resolved following percutaneous patent foramen ovale closure.

Impulse oscillometry reference values and correlation with predictors in Turkish preschool children.

Er I, Günlemez A, Baydemir C, Kiliçbay F, Ersu R, Uyan ZS. Impulse oscillometry reference values and correlation with predictors in Turkish preschool children. Turk J Pediatr 2019; 61: 560-567. Impulse oscillometry (IOS) is a noninvasive, rapid technique requiring passive cooperation that allows for evaluation of lung function through the measurement of airway resistance and reactance. There are no available reference values for Turkish children. This study is aimed to determine the reference values of IOS parameters and to study their correlation with height, weight, body mass index, and age as predictors in healthy Turkish preschool children. Healthy children between 3-7 years of age who were selected according to ERS/ATS criteria and followed at Kocaeli University outpatient clinic performed IOS. The correlation between the anthropometric predictor variables and resistance and reactance at 5-20 hertz (R5-R20 and X5-X20), the respiratory impedance at 5 hertz (Z5), resistance area (AX) and resonance frequency (Fres) were assessed by regression analysis and stepwise method. 151 children (93 female) with the mean age of 67.9±16.2 months participated in the study. Multilinear regression analysis for IOS values of all children revealed that resistance was significantly correlated with height and reactance was significantly correlated with age (p < 0.05). For girls, height had a negative effect on R5-20, Z5, AX values, while age had a positive effect on X5-20 and a negative effect on Fres (p < 0.05). For boys, weight had a negative effect on R5- 20, Z5 values, while age had a positive effect on X15-20 and a negative effect on AX, Fres (p < 0,05). This study provided reference values of IOS in healthy Turkish children that would be a useful guide for diagnosing and following respiratory diseases in preschool children.

Effect of inhaled steroids on clinical and inflammatoryparameters in children with cystic fibrosis

Background/aim: The effectiveness of inhaled corticosteroids (ICSs) in cystic fibrosis (CF) is controversial. The aim of this study was to investigate the effect of an ICS on bronchial hyperreactivity (BHR), oxidative status, and clinical and inflammatory parameters in CF patients. Materials and methods: CF patients were randomized to receive either 2 mg/day nebulized budesonide or 0.9% normal saline as placebo for 8 weeks. Results: Twenty-nine CF patients (mean age: 10.5 ± 2.9 years) were enrolled in the study. There was no statistically significant difference between the two groups at the end of 8 weeks in terms of symptoms, pulmonary function, BHR, oxidative burst, hs-CRP, or ESR. Although there was a significant decrease in malondialdehyde levels in both groups, there was no difference between the two groups. Percentage of neutrophils in the sputum of patients decreased in the budesonide group (P = 0.006). Although sputum IL-8 levels significantly increased in both groups, there was no statistically significant difference between the two groups. Conclusion: Although there was a significant decrease in the percentage of neutrophils in sputum with budesonide, 8 weeks of 2 mg/day nebulized budesonide was not effective in terms of BHR, oxidative status, or clinical and other inflammatory parameters in children with CF.

Evaluation of pulmonary functions in preschool children born late-preterm.

AIM: The aim of this study was to evaluate the pulmonary functions of preschool children born late-preterm. MATERIAL AND METHODS: Children aged between 3-7 years who were born at 340/7-366/7 weeks' gestation represented the target sample. Patients with a diagnosis of congenital cardiac, pulmonary and/or muscle diseases were excluded. Respiratory symptoms were evaluated using the modified asthma predictive index and International Study of Asthma and Allergies in Childhood criteria for children aged under and over 6 years, respectively. Skin prick tests were performed. Age-matched healthy controls were chosen according to the criteria proposed by the American Thoracic Society. Lung functions were evaluated using impulse oscillometry study in both groups. Data were recorded in the SPSS program. RESULTS: A total of 139 late-preterms and 75 healthy controls participated in the study. The mean gestational week of the late-preterms was 35.3±0.9 weeks. The main admission diagnosis to neonatal intensive care unit was respiratory distress. In the postdischarge period, 54.1% were hospitalized for pulmonary infections at least once, and 57.8% were passive smoking currently. Aeroallergen sensitivity was detected as 25.8% in the late-preterm group; 34.5% and 15.1% were diagnosed as having asthma and non-asthmatic atopy, respectively. Impulse oscillometry study parameters of R5, R10, and Z5 were higher and X10 and X15 were lower in late-preterms than in controls (p<0.05). Late-preterms with and without respiratory distress in the postnatal period revealed no statistical differences for any parameters. CONCLUSIONS: Our findings suggest that presence of increased peripheral airway resistance in late-preterms as compared to term-born controls.

Cathelicidin (LL-37) and human ß2-defensin levels of children with post-infectious bronchiolitis obliterans.

INTRODUCTION: The antimicrobial peptides (AMPs) human ß-defensins and cathelicidin (LL-37) are key factors in innate and adaptive immune responses of the respiratory tract and play an important role in many respiratory diseases. No data are available in the literature about the levels of these AMPs in paediatric patients with post-infectious bronchiolitis obliterans (BO). This study aimed to determine human ß-defensin 2 (hBD2) and LL-37 levels and compare between post-infectious BO patients and the control group. METHOD: The patients diagnosed with post-infectious BO between September 2012 and 2013 and age- and-gender matched healthy controls were enrolled in this multi-center study. Serum hBD2 and LL37 levels were determined with the enzyme-linked immunosorbent assay method. RESULTS: Sixty-three post-infectious BO patients and 65 healthy children (median age 73 ± 55 and 78.74 ± 36.32 months, respectively) were enrolled in the study. The mean of hBD2 levels in patients and the control group were 1.06 ± 0.24 and 0.67 ± 0.72 ng/mL, respectively (P < 0.001). The mean of LL-37 levels in patients and the control group were 72.13 ± 29.06 and 50.10 ± 21.98 ng/mL, respectively (P < 0.001). No correlation was found between these AMPs levels and chronological age, age at the time of diagnosis, gender, Z-scores of weight and length, hospitalization numbers, the disease history before diagnosis and 25-OH D vitamin levels. CONCLUSION: This is the first study to demonstrate the higher levels of serum hBD2 and LL-37 levels in paediatric post-infectious BO patients. These AMPs may have important roles in the immune systems and pathogenesis of these patients.

Evaluation of lung function on impulse oscillometry in preschool children born late preterm.

BACKGROUND: There is a paucity of data on lung physiology in late-preterm children, who may be exposed to a risk of decline in lung function during childhood. In this study, we evaluated lung function in preschool children born late preterm using impulse oscillometry (IOS), and compared the results with those obtained in healthy term-born children. METHODS: Children between 3 and 7 years of age who were born late preterm and who were being followed up at the outpatient clinic were included as the late-preterm group. Age-matched healthy term-born children served as controls. A total of 90 late-preterm and 75 healthy children were included in the study. At 5-20 Hz, resistance (R5-R20), reactance (X5-X20), impedans (Z5) and resonant frequency were measured on IOS. RESULTS: Mean IOS R5 and R10 were significantly higher in the late-preterm group than in the control group (P < 0.05). Mean R5, R10 and Z5 were statistically higher in late-preterm children who had been hospitalized for pulmonary infection compared with the control group (P < 0.05). Mean R5, R10, R15, R20 and Z5 were significantly higher, and mean X10 and X15 significantly lower in late-preterm children with passive smoking compared with late-preterm children without passive smoking and controls (P < 0.05). CONCLUSION: Children born late preterm had signs of peripheral airway obstruction on IOS-based comparison with healthy term-born controls. Besides the inherent disadvantages of premature birth, hospitalization for pulmonary infection and passive smoking also seemed to adversely affect lung function in children born late preterm.

An unusual case of foreign body aspiration mimicking cavitary tuberculosis in adolescent patient: thread aspiration.

Foreign body aspiration continues to be a serious problem in childhood and adolescent period with significant rate of morbidity and rarely mortality. Half of the foreign body aspiration cases have no history of aspiration. The main foreign bodies inhaled are food fragments and different kinds of metallic objects. A 12-year-old girl was referred to the pediatric pulmonology department for chronic cough and hemoptysis. She had persistent infiltration and cavitary lesion mimicking cavitary tuberculosis. There was no contact history with tuberculosis in her family and acid resistant bacillus was not found in the sputum examination. Flexible bronchoscopy was performed for persistent infiltration and hemoptysis and inflamed thread was found in right lower lobe bronchus. This is the first case of thread inhalation mimicking cavitary tuberculosis in an adolescent patient.

The prevalence and risk factors of asthma and allergic diseases among working adolescents.

Certain occupational groups are known to be at particularly high risk of developing allergic diseases. The objective of the present study was to evaluate the prevalence of allergic diseases among working adolescents. The International Study of Asthma and Allergies in Childhood questionnaire was used. Four hundred and thirty six adolescents working in motor, lathe-finish, coiffure and textile and 366 high school students as control group were enrolled to the study. Mean age was 16.8 +/- 1.2 years and 82.9% of them were male. There was no significant difference among groups for ever and current wheezing while doctor diagnosed asthma was higher in lathe- finish group (p = 0.036). Family history of allergy, history of allergic rhinitis, and active smoking were found to be risk factors for asthma and related symptoms. Working in coiffure (p = 0.054), and textile (p = 0.003) were significant risk factors for ever allergic rhinitis. Working in lathe finish (p = 0.023), coiffure (p = .002), and textile (p < 0.001) were associated with a higher risk for current allergic rhinitis. Working in coiffure was a risk factor for ever eczema (p = 0.008) and doctor diagnosed eczema (p = 0.014). It was concluded that working in lathe-finish was associated with doctor diagnosed asthma and active smoking was a risk factor for asthma and related symptoms. Working in coiffure, textile and lathe- finish were risk factors for rhinitis, and working in coiffure was a risk factor for eczema. Preventive measures should be taken at the onset of employment in order to prevent or reduce the detrimental effects of exposures in these occupational groups.

Invasive respiratory aspergillosis is a treatable disease with early diagnosis and aggressive therapy.

This study aimed to document outcome of invasive respiratory aspergillosis (IRA) in pediatric malignancy patients. Patients with febrile neutropenia episodes followed between January 2003 and May 2007 were enrolled. Antifungal therapy was added to those who were still febrile on the 5th day of febrile neutropenia treatment. Patients were screened with computerized tomographies. IRA was identified in 22 of 98 patients. There were 13 males and the mean age was 97 months. Proven infection was established in 3, probable in 7, and possible in 12 patients. Liposomal amphotericin B was administered to all patients and was successful in 10 patients. Modifications with caspofungin or voriconazole were done in liposomal amphotericin B failures. The median duration of antifungal therapy was 5.5 months. The median follow-up time was 29 months. There was no evidence of IRA in 12 patients after completion of cancer chemotherapy. Six patients died due to underlying disease, whereas IRA was either in remission or stable disease. Four patients were lost due to IRA. The remission rate for IRA was 82%. Survival at 37 months was 55% (95% confidence interval 25-47 months). The amount of time that absolute neutrophil count after initiation of treatment for IRA remained at zero was found to be an independent prognostic factor on survival (P = .01). These results suggest that early diagnosis and aggressive treatment may increase the successful outcome of IRA.

Diaphragmatic paralysis after pediatric heart surgery: usefulness of non-invasive ventilation.

Diaphragmatic paralysis after cardiac surgery is an important complication especially in infants. We report a child who developed diaphragmatic paralysis, atelectasis, bronchomalasia and respiratory failure following cardiac surgery. Ventilatory support alleviated respiratory distress in this child. This report illustrates the usefulness of invasive and non-invasive ventilatory support for a pediatric patient with diaphragmatic paralysis.

Flexible bronchoscopy as a valuable tool in the evaluation of persistent wheezing in children.

BACKGROUND: Persistent wheezing is a common problem in early childhood and leads to a diagnostic dilemma, excessive investigations, drug administration and additional cost. OBJECTIVE: To determine the efficacy and the safety of FOB in children with persistent wheezing despite bronchodilator and inhaled steroid therapy. METHODS: Patients with persistent wheezing that lasted at least 6 weeks and did not respond to bronchodilator and inhaled steroid therapy and to whom flexible bronchoscopy was performed were included to the study. RESULTS: Between 1997 and 2009; 113 patients were enrolled to the study. Sixty-three percent of the children were male. Median age was 14 months at presentation and median duration of symptoms was 5 months. Bronchoscopy revealed pathological findings in 48% of the patients. Thirty-eight patients had malacia disorders, 14 had foreign body aspiration and two had external compression of airways which were later diagnosed as vascular ring. Major and minor complications were not seen in 92% of the patients while transient hypoxia was seen in 6%, stridor in 1% and tachycardia in 1% of the patients. CONCLUSION: Flexible bronchoscopy provided rapid and definitive diagnosis for our patients with persistent wheezing without any major complications. This study is one of the largest studies concerning persistent wheezing. Early bronchoscopic evaluation can reduce cost by providing rapid and accurate diagnosis and preventing unnecessary investigations and drug administration. Flexible bronchoscopy is a safe procedure and should be considered in the evaluation of children with persistent wheezing.

Flexible bronchoscopy for diagnosis and follow up of childhood endobronchial tuberculosis.

BACKGROUND: In this study, our aim was to determine the clinical and bronchoscopic outcome of the endobronchial tuberculosis (ETB). METHODS: Patients with suspected tuberculosis (TB) or TB patients with an inadequate response to 8 weeks of antituberculosis treatment were enrolled in the study. RESULTS: Seventy patients were included to the study and 118 flexible bronchoscopies were performed. ETB was present in 33 (47%) patients. There was isolated compression in 14 cases, caseous lesions in 13, granuloma formation in 6, polypoid lesions in 2, adenopathy protrusion in 1, and mucosal erosion in 1 case. The mean duration of bronchoscopic resolution of endobronchial lesions was 5.50 +/- 2.74 months. Mycobacterium tuberculosis was isolated from gastric lavage in 10% and from bronchoalveolar lavage in 12.8% of 70 cases. When both of the procedures were performed concurrently, the isolation rate increased to 20%. Transient hypoxia resolving with nasal O2 was observed in 3 patients as a complication of bronchoscopy. CONCLUSIONS: Bronchoscopy offered a safe and rapid means of confirming the diagnosis of ETB.

Comparison of three neonatal pain scales during minor painful procedures.

OBJECTIVE: There is no single or widely accepted method to define pain in neonates. The aim of this study was to compare three different neonatal pain scales in the estimation of the pain response to minor painful stimuli in healthy term neonates. METHOD: Thirty healthy neonates were included in the study. Video recordings of infants during heel prick blood sampling were evaluated by two observers according to the Neonatal Infant Pain Scale (NIPS), the Neonatal Facial Coding System (NFCS), and the Douleur Aiguë du Nouveau-né (DAN). Crying times of infants were recorded, and the correlation between the three pain scales and crying time was calculated. The pain scores and inter-observer variability were analyzed. RESULTS: The highest correlation between the crying time and each of the three different neonatal pain scales was found for NIPS (r = 0.74, p<0.001), while similar results were found for the DAN scale (r = 0.67, p <0.001) and the NFCS (r = 0.67, p<0.001). Inter-observer variability was similar for the three scales (NFCS r = 0.95; DAN r = 0.97; NIPS r = 0.96). NFCS had a coefficient of variation (CV) of 59.8 +/- 32.2%. The DAN scale and NIPS had similar CV values (41.5 +/- 26.1% and 43.2 +/- 31.6%, respectively), but these values were significantly lower than that of NFCS. CONCLUSION: All three scales provided comparable results, with a slight difference favoring NIPS. Therefore, NIPS can be used to evaluate pain during minor painful procedures in neonates.