Predictability and consequences of spontaneous extubation in a pediatric ICU.

To determine the incidence of, and the factors contributing to spontaneous extubation (SE), we followed prospectively all intubated children admitted to a pediatric ICU. Eleven potential risk factors were monitored and scored twice daily for 8 consecutive months. Using data from the first 204 patient admissions, we evaluated the risk factors by orthogonal discriminant analysis and found that four factors (patient age, amount of secretions, endotracheal tube slippage, and state of consciousness), when considered together, had good discriminating power for SE vs. intentional extubation. We tested this method on the next 45 patient admissions and identified all seven spontaneously extubated patients as high risk. Analysis of covariance revealed successful discrimination between low-risk and high-risk patients for up to three days after patient admission. Overall, the incidence of SE was 13% (33 of 249). The effect of extubation on gas exchange was the same for spontaneously and intentionally extubated patients. No morbidity or deaths were attributed to SE. Standard ventilator low-pressure alarms did not reliably signal the presence of SE, nor did upper extremity restraints keep patients from extubating themselves.

Recurrent pneumonia in children and its relationship to bronchial hyperreactivity.

To determine what conditions are most likely to cause persistent or recurrent pneumonia (PRP) in children, the records of 81 children referred to James Whitcomb Riley Hospital for Children for evaluation of PRP were reviewed. Twenty patients had an apparent underlying cause that predisposed them to PRP. Of the 61 remaining patients (mean age 3.8 years) without any apparent cause for PRP, 49% had a history of allergy or family history of asthma, 31% patients had a history of wheezing and 18% were wheezing during their initial visit. No patient had an elevated sweat chloride determination or immunoglobulin deficiency. Of the 12 patients who were able to be recalled for pulmonary function testing, three had airflow obstruction that responded to an inhaled bronchodilator (isoproterenol). Of the nine patients with normal function, eight responded to methacholine with a decrease from base line in the one-second forced expiratory volume of greater than 20%. In all, 92% of those tested had bronchial hyperreactivity. These results indicate that asthma is a common cause of PRP in children and that PRP may occur as the initial symptom even in the absence of wheezing.

Pulmonary function abnormalities in survivors of near drowning.

To determine the pulmonary status of children surviving near-drowning accidents, we studied the pulmonary function of ten asymptomatic children 6 months to 8.5 years (mean 3.3 years) after the accident. All ten children had normal FEF max, FVC, FEV1/FVC, FEF 50%, FRC, and RV/TLC. However, six patients had an elevated VisoV and five of these had a reduced delta Vmax 50%, indicating peripheral airway disease. Seventy percent of the patients had bronchial hyperactivity. Only one patient had completely normal pulmonary function. These results indicate that near drowning results in large and small airway dysfunction in children with no predisposition to lung disease, which may be present years after the initial insult. Such children may be at increased risk of developing chronic lung disease, especially if exposed to known airway irritants such as cigarette smoke.

Changing feeding trends as a cause of electrolyte depletion in infants with cystic fibrosis.

Between June 1979 and June 1980, 16 infants with cystic fibrosis (CF) were cared for at the James Whitcomb Riley Hospital for Children. Five of these children (average age 5.8 months) had a total of eight episodes of electrolyte depletion, with six episodes unassociated with high environmental temperature, fever, or significant gastrointestinal symptoms. Their primary symptoms were poor weight gain and anorexia. According to their dietary records, these five infants, at the time of their initial presentation, had an average electrolyte intake of 8 mEq of sodium, 12 mEq of potassium, and 10 mEq of chloride per day. All infants had been fed either standard infant formula or breast milk. Infant feeding surveys indicate that the estimated average sodium intake of 6-month-old infants has decreased from 45 mEq/day in 1965 to 15 mEq/day since 1977 when manufacturers stopped adding salt to baby foods. In addition, since 1971 the percentage of infants 6 months age receiving breast milk or standard infant formula rather than cow's milk, which is higher in sodium content, has increased from 33% to 72%. This decreased salt intake places the infant with CF at greater risk for electrolyte depletion than in the past. It is expected that a larger percentage of infants with CF will have electrolyte depletion as their initial symptom especially during periods of increased sweating or when electrolyte losses are experienced during gastrointestinal illnesses. CF should be suspected in any infant with electrolyte depletion, and infants known to have CF need daily salt supplementation. Serum electrolytes should be measured if the infant is experiencing weight loss or anorexia, particularly during periods of excessive salt losses.