RESUMO
Although adenotonsillectomy is the first line treatment for children with obstructive sleep apnea syndrome (0SAS),1 improvement in objectively documented outcomes is often inadequate and a substantial number of children have residual disease. Early recognition and treatment of children with persistent OSAS is required to prevent long-term morbidity. The management of these children is frequently complex and a multidisciplinary approach is required as most of them have additional risk factors for OSAS and comorbidities. In this paper, we first provide an overview of children at risk for persistent disease following adenotonsillectomy. Thereafter, we discuss different diagnostic modalities to evaluate the sites of persistent upper airway obstruction and the currently available treatment options. Pediatr Pulmonol. 2017;52:699-709. © 2016 Wiley Periodicals, Inc.
Assuntos
Adenoidectomia , Apneia Obstrutiva do Sono/cirurgia , Tonsilectomia , Criança , Pré-Escolar , Humanos , Fatores de Risco , Resultado do TratamentoRESUMO
Presence of a nasogastric tube is a risk factor for the development of ventilator-associated pneumonia (VAP). Alternatively, gastrostomy can be used for administration of enteral feedings. To determine whether early performance of gastrostomy affects frequency of VAP, a randomised, controlled study was carried out in patients mechanically ventilated for stroke or head injury. In the gastrostomy group, patients underwent the procedure within 24 h of intubation. A nasogastric tube was inserted in controls. Individual subjects were studied for 3 weeks. In total, 20 subjects (mean age 48+/-15.2 yrs) were allocated to the gastrostomy group, and 21 to the control group (46.6+/-15.4 yrs). Of these groups, two (10%) and eight (38.1%) developed VAP, respectively. Four patients with gastrostomy and three controls did not complete the study (due to weaning from ventilatory support or death). After excluding these subjects, difference in VAP frequency persisted: two out of 16 subjects with gastrostomy had VAP (12.5%) versus eight out of 18 controls (44.4%). There were no differences in duration of hospitalisation or mortality between the two groups. In conclusion, in patients mechanically ventilated for stroke or head injury early gastrostomy is associated with a lower frequency of ventilator-associated pneumonia compared with a nasogastric tube.
Assuntos
Traumatismos Craniocerebrais/complicações , Gastrostomia/métodos , Pneumonia Bacteriana/epidemiologia , Respiração Artificial/efeitos adversos , Acidente Vascular Cerebral/complicações , APACHE , Adulto , Distribuição por Idade , Estudos de Casos e Controles , Distribuição de Qui-Quadrado , Estudos de Coortes , Traumatismos Craniocerebrais/diagnóstico , Estado Terminal , Infecção Hospitalar/epidemiologia , Infecção Hospitalar/prevenção & controle , Feminino , Escala de Coma de Glasgow , Humanos , Incidência , Escala de Gravidade do Ferimento , Masculino , Pessoa de Meia-Idade , Pneumonia Bacteriana/etiologia , Pneumonia Bacteriana/prevenção & controle , Probabilidade , Prognóstico , Valores de Referência , Respiração Artificial/métodos , Medição de Risco , Distribuição por Sexo , Acidente Vascular Cerebral/diagnóstico , Fatores de Tempo , Resultado do TratamentoRESUMO
Elevated fibrinogen level is a predictor of cardiovascular disease in adults, and it is associated with sleep-disordered breathing. Levels of fibrinogen in adults are affected by other co-existing cardiovascular risk factors, which are not usually present in children. To investigate the association between fibrinogen and sleep-disordered breathing, a case-control study was carried out in children with and without habitual snoring. All snoring children underwent polysomnography. Morning fibrinogen values in 30 children with snoring and an apnoea-hypopnoea index (AHI) > or =5 episodes x h(-1) (median (interquartile range) 318 mg x dL(-1) (290-374)) were similar to values in 61 children with snoring and an AHI <5 episodes x h(-1) (307 (269-346)). Both groups had higher fibrinogen values than those in 23 controls without snoring (271 mg x dL(-1) (244-294)). There was no correlation between fibrinogen values and AHI, respiratory movement/arousal index or haemoglobin desaturation index. In conclusion, fibrinogen values are higher in children with snoring than in controls, but there is no association between these values and polysomnography indices.
Assuntos
Fibrinogênio/análise , Síndromes da Apneia do Sono/metabolismo , Estudos de Casos e Controles , Criança , Pré-Escolar , Feminino , Humanos , Masculino , Polissonografia , TempoRESUMO
A randomised double-blind placebo-controlled study was designed to evaluate the effects of a semisynthetic macrolide antibiotic, clarithromycin, on bronchial hyperresponsiveness to methacholine in patients with a diagnosis of asthma. Adult asthma patients undergoing treatment with budesonide 400 microg b.i.d. and salbutamol 200 microg p.r.n. less than twice weekly were studied. Arm A (16 males/six females, aged 48 +/- 16 yrs) received clarithromycin 250 mg b.i.d. for 8 weeks, arm B (eight males/12 females, aged 42 +/- 12 yrs) clarithromycin 250 mg t.id. and arm C (six males/15 females, aged 41 +/- 16 yrs) placebo dextrose tablets. Bronchial hyperresponsiveness was quantified by measurement of the provocative dose of methacholine causing a 20% fall in forced expiratory volume in one second (PD20). Median (interquartile range) PD20 in the three groups before and after treatment with clarithromycin were: arm A: 0.3 (0.1-1) and 1.3 (0.6-2) mg; arm B: 0.4 (0.1-0.9) and 2 (2-2) mg; and arm C: 0.4 (0.1-0.9) and 0.3 (0.1-0.6) mg, respectively. Serum free cortisol levels were determined and remained unchanged from baseline in the clarithromycin-treated patients. It is concluded that clarithromycin reduces the degree of bronchial hyperresponsiveness in patients with asthma.
Assuntos
Antibacterianos/uso terapêutico , Asma/complicações , Hiper-Reatividade Brônquica/tratamento farmacológico , Hiper-Reatividade Brônquica/etiologia , Claritromicina/uso terapêutico , Adulto , Hiper-Reatividade Brônquica/fisiopatologia , Testes de Provocação Brônquica , Broncoconstritores , Método Duplo-Cego , Feminino , Volume Expiratório Forçado , Humanos , Masculino , Cloreto de Metacolina , Pessoa de Meia-Idade , Espirometria , Fatores de Tempo , Resultado do TratamentoAssuntos
Anticorpos Antibacterianos/sangue , Bronquite/diagnóstico , Síndromes de Imunodeficiência/sangue , Rinite/diagnóstico , Bronquite/sangue , Bronquite/microbiologia , Bronquite Crônica/sangue , Bronquite Crônica/diagnóstico , Bronquite Crônica/microbiologia , Pré-Escolar , Humanos , Síndromes de Imunodeficiência/diagnóstico , Síndromes de Imunodeficiência/imunologia , Masculino , Infecções Pneumocócicas/imunologia , Rinite/microbiologia , Streptococcus pneumoniae/imunologiaRESUMO
Obstruction at the airway anastomosis is a recognized complication of adult heart-lung transplantation (HLT) and lung transplantation (LT). Data for pediatric transplantation have been scarce. We reviewed our experience in pediatric HLT and LT to determine the frequency of airway complications and to document the therapeutic modalities used for their treatment. Fifty-three patients (median age: 13.8 yr; range: 1.3 to 28.2 yr) underwent HLT (n = 25), SLT (n = 3), DLT (n = 25), or repeat DLT (n = 3) and survived for more than 72 h. Major anastomotic airway complications requiring intervention affected one of the 25 HLT (4%) and seven of the 28 LT (SLT + DLT) patients (25%) (p = 0.05). Four patients with granulation tissue occluding the airway were treated with forceps resection, laser ablation, or balloon dilatation. Three patients with fibrotic strictures received silicone stents, laser ablation, or balloon dilatation. Two patients with bronchomalacia or diffuse stricture below the anastomosis underwent metal stent placement. Five of seven patients who were treated for anastomotic complications had satisfactory relief of airway obstruction. As compared with previously studied adults, pediatric heart-lung transplant recipients had the same or a lower frequency, and pediatric lung transplant recipients had a higher frequency of major anastomotic airway complications. A variety of treatment modalities were necessary to achieve adequate relief of airway obstruction.
Assuntos
Transplante de Coração-Pulmão/efeitos adversos , Transtornos Respiratórios/etiologia , Adolescente , Adulto , Anastomose Cirúrgica/efeitos adversos , Criança , Pré-Escolar , Feminino , Humanos , Masculino , Prevalência , Transtornos Respiratórios/epidemiologia , Transtornos Respiratórios/terapia , Fatores de Risco , Taxa de SobrevidaRESUMO
With the use of constant flow, end-inspiratory airway occlusion, respiratory system resistance (Rrs) can be partitioned into a flow resistive component (Rint) and an additional component (deltaR), reflecting viscoelasticity and time constant inequality. Similarly, respiratory system elastance (Edyn) can be partitioned into static elastance (Est) and elastance due to viscoelasticity and time constant inequality (deltaE). We measured Rrs and Edyn and their subdivisions (Rint and deltaR, Est and deltaE, respectively) and studied their flow and volume dependence in eight otherwise healthy children (median age 3.6 y; range 1.9-5.2 y) undergoing general anesthesia for oral rehabilitation. With a constant inspiratory flow (VI) of approximately 15 mL/s/kg and tidal volume of 12 mL/kg, the mean values of Rrs, Rint, and deltaR were: 0.20, 0.11, and 0.10 cmH2O/mL/s.kg. Under the same conditions, the mean Est and deltaE were: 1.04 and 0.12 cmH2O/mL/kg. With increasing VI and under constant VT, deltaR decreased (p < 0.001) progressively. Rint also decreased paradoxically (p < 0.001). Hence, Rrs decreased (p < 0.001) with increasing VI. Est decreased (p < 0.001) with increasing VI, whereas delta E increased (p < 0.005). With increasing VT and under constant VI, Rint decreased (p < 0.001) and deltaR tended to increase (p = 0.058); Rrs did not change. With increasing VT under constant VI, both Est and deltaE decreased (p < 0.001 and p = 0.001, respectively). Thus, in contrast to the findings in adults, Rint and Est decreased in children with increasing flow and under constant tidal volume, probably reflecting decreased functional residual capacity in anesthetized children, compared with adults. The flow and volume dependence of deltaR and deltaE were similar to those in adults, whereas Rrs did not necessarily follow the direction of changes of deltaR.
Assuntos
Mecânica Respiratória , Resistência das Vias Respiratórias , Anestesia Geral , Pré-Escolar , Feminino , Humanos , Lactente , Complacência Pulmonar , Medidas de Volume Pulmonar , Masculino , Testes de Função RespiratóriaRESUMO
Using end-inspiratory airway occlusion, respiratory system resistance (Rrs) can be partitioned into a flow-resistive component (Rint), and an additional component (DeltaR), reflecting viscoelasticity and time constant inequalities. We studied flow and volume dependence of Rrs and its subdivisions (Rint and DeltaR) in 13 children, seven mechanically ventilated for pulmonary insufficiency (Group 1; six with parenchymal lung disease; one with lower airway obstruction) and six without primary lung disorder (Group 2). In comparison with healthy children, Rint was increased in the patient with lower airway obstruction and five of six patients without primary lung disorder but in only one of six with parenchymal lung disease. DeltaR was increased in all seven patients in Group 1 and in four of six patients in Group 2. The directions of changes in Rint and Rrs with increasing flow (isovolume conditions) and with increasing volume (isoflow conditions) were variable. DeltaR decreased exponentially (p < 0.05) with increasing flow in 11 of 13 subjects and increased with increasing tidal volume (VT) in 12 of 13. Thus, DeltaR was increased in most children on mechanical ventilation with or without primary lung disease; its volume and flow dependence were opposite to that of airway resistance.
Assuntos
Resistência das Vias Respiratórias/fisiologia , Insuficiência Respiratória/fisiopatologia , Adolescente , Criança , Pré-Escolar , Feminino , Humanos , Lactente , Recém-Nascido , Intubação Intratraqueal , Complacência Pulmonar/fisiologia , Doenças Pulmonares Intersticiais/complicações , Doenças Pulmonares Intersticiais/fisiopatologia , Doenças Pulmonares Intersticiais/terapia , Pneumopatias Obstrutivas/complicações , Pneumopatias Obstrutivas/fisiopatologia , Pneumopatias Obstrutivas/terapia , Masculino , Respiração com Pressão Positiva , Insuficiência Respiratória/etiologia , Insuficiência Respiratória/terapia , Volume de Ventilação Pulmonar/fisiologia , Inconsciência/complicações , Inconsciência/fisiopatologia , Inconsciência/terapiaAssuntos
Crupe , Broncodilatadores/administração & dosagem , Broncodilatadores/uso terapêutico , Crupe/diagnóstico , Crupe/terapia , Crupe/virologia , Diagnóstico Diferencial , Serviços Médicos de Emergência , Epiglotite/diagnóstico , Epinefrina/administração & dosagem , Epinefrina/uso terapêutico , Glucocorticoides/administração & dosagem , Glucocorticoides/uso terapêutico , Humanos , Umidade , Intubação Intratraqueal , Nebulizadores e Vaporizadores , Oximetria , Traqueíte/diagnósticoRESUMO
BACKGROUND: Perinuclear antineutrophil cytoplasmic antibodies occur frequently in adult patients with chronic pouchitis after colectomy and ileal pouch-anal anastomosis for ulcerative colitis. The purpose of the study was to determine the prevalence of perinuclear antineutrophil cytoplasmic antibodies and cytoplasmic antineutrophil cytoplasmic antibody in children and adolescents who undergo colectomy and ileal pouch-anal anastomosis for ulcerative colitis and familial adenomatous polyposis. METHODS: Five groups of children and adolescents (age, <20 years) were studied, with the following histories: acute pouchitis and history of ulcerative colitis; chronic pouchitis and history of ulcerative colitis; pouchitis with Crohn's disease features and a history of ulcerative colitis; no pouchitis and a history of ulcerative colitis; and familial adenomatous polyposis, with or without pouchitis. Antineutrophil cytoplasmic antibody levels and titers were detected in postoperative sera by enzyme-linked immunosorbent assay, and positive results were subtyped by indirect immunofluorescence. RESULTS: The frequency of perinuclear antineutrophil cytoplasmic antibodies and cytoplasmic antineutrophil cytoplasmic antibody in patients with a history of ulcerative colitis were 67% and 15%, compared with a 0% presence in patients with familial adenomatous polyposis (p < 0.001). There was no significant correlation between the frequency of perinuclear antineutrophil cytoplasmic antibodies and ulcerative colitis patient subgroups (patients with and without pouchitis, 66% and 75%). Similarly, there was no significant correlation between the frequency of cytoplasmic antineutrophil cytoplasmic antibodies among ulcerative colitis patient subgroups (patients with and without pouchitis, 19% and 8%). The frequency of cytoplasmic antineutrophil cytoplasmic antibody in patients with Crohn's disease features (50%), was increased, but this difference was not significant. CONCLUSIONS: There is a high frequency of perinuclear antineutrophil cytoplasmic antibodies in children and adolescents who undergo ileal pouch-anal anastomosis for ulcerative colitis, whether or not they have pouchitis. The frequency of cytoplasmic antineutrophil cytoplasmic antibody is lower in this patient population. Additional studies will be required to determine whether the presence of cytoplasmic antineutrophil cytoplasmic antibody is associated with the postoperative development of features of Crohn's disease.
Assuntos
Anastomose Cirúrgica , Anticorpos Anticitoplasma de Neutrófilos/sangue , Colite Ulcerativa/imunologia , Colite Ulcerativa/cirurgia , Proctocolectomia Restauradora , Polipose Adenomatosa do Colo/imunologia , Polipose Adenomatosa do Colo/cirurgia , Adolescente , Adulto , Anticorpos Anticitoplasma de Neutrófilos/classificação , Criança , Pré-Escolar , Ensaio de Imunoadsorção Enzimática , Técnica Indireta de Fluorescência para Anticorpo , Humanos , Ileíte/etiologia , Ileíte/imunologia , Ileíte/cirurgia , Proctocolectomia Restauradora/efeitos adversosRESUMO
BACKGROUND: The optimal number of blood cultures and the volume of blood for pediatric blood cultures have not been defined. In 1990 such criteria were established at our institution. We retrospectively reviewed records of all pediatric oncology patients who were admitted for febrile episodes in 1989 and in 1991 and 1992 to determine whether there was an increase in the detection of bacteremia and fungemia. METHODS: Blood was drawn via venipuncture and central intravascular catheters and inoculated into the designated blood culture bottles. Each patient had a minimum of two separate blood draws, i.e. two separate cultures; the volume was determined by the patient's weight. In all cases < 1% of the patient's blood volume was drawn per culture. Patients' records were reviewed regarding type of malignancy, chemotherapy and neutropenia. RESULTS: The rate of bacteremic patients increased from 12% (13 of 113) in 1989 to 22% (27 of 123) in 1991. This increase continued through 1992 with 23% (27 of 118) of patients having positive blood cultures. Gram-positive bacteria predominated throughout the study period. CONCLUSIONS: Although factors such as more aggressive chemotherapy or a different spectrum of malignant diseases may contribute to the statistically significant increase in identification of bacteremic patients, a standardized method of blood culture collection is merited. The consistent volumes of blood per culture and the minimum of two cultures per febrile episode follow the principles of blood culture collection established for adults. The same principles should apply to pediatric patients.
Assuntos
Bacteriemia/complicações , Sangue/microbiologia , Febre de Causa Desconhecida/etiologia , Fungemia/complicações , Técnicas Microbiológicas , Manejo de Espécimes/métodos , Adolescente , Adulto , Bacteriemia/sangue , Distribuição de Qui-Quadrado , Criança , Pré-Escolar , Fungemia/sangue , Humanos , Lactente , Masculino , Estudos RetrospectivosRESUMO
Unilateral clubbing has been associated with local vascular lesions of the arm, axilla, and thoracic outlet and with hemiplegia. We describe a patient with Takayasu's arteritis, a disease that affects the aorta and its major branches, who presented with unilateral digital clubbing. A review of the literature on unilateral clubbing is included.