Lung Function of Children Following an Intensive Care Unit Admission for Asthma.

Background: To determine the lung function of children admitted to the intensive care unit (ICU) for a severe asthma exacerbation in the medium- to long-term following hospital discharge. Methods: We performed a retrospective chart review of children ≥6 years of age admitted to the ICU for a severe asthma exacerbation at a tertiary care center from January 1, 2000, to December 31, 2013. Lung function was ascertained during outpatient follow-up visits at 3-12 months and 12-24 months postdischarge. A total of 72 subjects met the inclusion criteria. Results: Subjects were predominantly boys (56.9%) and had a mean (standard deviation [SD]) age at admission of 10.3 years (3.4 years). The median (interquartile range) length of stay in the ICU was 1 day (1-3 days). Thirty-eight and 28 subjects performed pulmonary function tests with acceptable technique at the 3-12 months and 12-24 months postdischarge visits, respectively. At 3-12 months, the mean (SD) predicted forced expiratory volume in 1 s (FEV1) and forced expiratory flow between 25% and 75% of vital capacity (FEF25-75) percent were 95.9 (16.7) and 76.7 (25.8), respectively, and 97.4 (17.6) and 70.5 (24.9), respectively, at 12-24 months. FEV1/forced vital capacity (FEV1/FVC) was 81.7 (8.3) at 3-12 months and 79.3 (7.7) at 12-24 months. A paired t-test on 20 subjects who performed acceptable spirometry at both visits showed a significant intraindividual decrease in FEV1 (P = 0.008), FEF25-75 (P = 0.02), and FEV1/FVC (P = 0.01) between the 2 time points. Conclusion: Although prospective studies are required to confirm our findings, our study suggests that children admitted to the ICU for severe asthma exacerbations may be at risk for declining pulmonary function in the medium- to long-term postdischarge.

Cardiorespiratory Monitoring Data during Sleep in Healthy Canadian Infants.

Rationale: Sleep study interpretation in children needs to be based on age-specific normal values. Although several studies have reported normal cardiorespiratory parameters during sleep in children and adolescents, few have included younger children.Objectives: To describe cardiopulmonary indices, specifically oxygen saturation and heart rate, as well as frequency of obstructive and central apneas in healthy 1-year-old Canadian infants during sleep.Methods: Home sleep cardiorespiratory monitoring was performed among infants participating in the Edmonton subcohort of the CHILD (Canadian Healthy Infant Longitudinal Development) study at their 1-year follow-up visit. A portable sleep monitoring device, which included a nasal pressure cannula, an oronasal thermal airflow sensor, a pulse oximeter, and respiratory inductance plethysmography belts, was used to collect sleep architecture and cardiorespiratory data during one night of monitoring in the home. Sleep scoring was done in blocks of 5 minutes using a novel pilot sleep scoring algorithm.Results: Among the 562 subjects (mean ± standard deviation age 1.1 ± 0.2 yr) who attempted home sleep cardiorespiratory monitoring, 91% provided technically acceptable data with no loss of signal preventing analysis of any parameter. Obstructive and central apneas were rare, with a median obstructive apnea index of 0.0 events/h (10th percentile, 0.0; 90th percentile, 0.5) and a median central apnea index of 2.5 events/h (10th percentile, 0.6; 90th percentile, 7.1). Median oxygen saturation was 97.0% (10th percentile, 95.4; 90th percentile, 97.9). The oxygen desaturation index was 6.7 events/h (10th percentile, 1.4; 90th percentile, 15.8), with infants spending only 0.1% (10th percentile, 0.0; 90th percentile, 0.6) of the time with an oxygen saturation below 92%.Conclusions: These results provide important reference data for healthy infants undergoing cardiorespiratory monitoring during sleep.

Respiratory Dysfunction and Sleep-Disordered Breathing in Children With Myasthenia Gravis.

OBJECTIVES: The purpose of this study was to prospectively evaluate sleep patterns and the presence of sleep-disordered breathing in children with myasthenia gravis. We further aimed to examine the relationship between sleep and daytime respiratory function using spirometry tests including upright and supine forced vital capacity, sniff nasal inspiratory pressure, and maximal inspiratory pressure. METHODS: Eleven children between 3 and 18 years old with confirmed myasthenia gravis were recruited from The Hospital for Sick Children Neuromuscular Clinic in this prospective observational study. After informed consent was obtained, patients underwent a comprehensive clinical assessment with collection of anthropometric data. Following this, all subjects performed pulmonary function tests, overnight polysomnography and completed the Epworth Sleepiness Scale questionnaire. RESULTS: Two of eleven children who reported no symptoms of sleep disordered breathing were diagnosed with mild to moderate obstructive sleep apnea. Pulmonary function tests showed abnormal maximal inspiratory pressure in 6 of 11 patients, whereas seated forced vital capacity as well as seated to supine forced vital capacity ratios were normal in the entire group. CONCLUSIONS: In our small group of pediatric myasthenia gravis subjects, there was an unexpected finding of obstructive sleep apnea in 2 of the 11 patients studied. Maximal inspiratory pressure appears to be a more sensitive method of detecting abnormalities compared to upright or seated forced vital capacity. A larger multicenter study is needed to validate our findings and to determine the impact of obstructive sleep apnea in the pediatric myasthenia gravis population as well as risk factors associated with sleep disordered breathing.

High-flow nasal cannula for the treatment of life-threatening plastic bronchitis.

Plastic bronchitis (PB) is characterized by the formation of bronchial casts. It most frequently occurs in children with congenital heart disease, particularly post-Fontan procedure. Several medical and surgical therapies have been described in the literature with variable success. To our knowledge, this is the first time that overnight use of home high-flow nasal cannula is reported as a therapy to prevent recurrence of bronchial cast production in a child with PB post-Fontan.

Home high-flow nasal cannula as a treatment for severe tracheomalacia: A pediatric case report.

Tracheomalacia refers to a softness of the tracheal cartilage that makes the airway more susceptible to collapse. In contrast to milder cases where conservative therapy is preferred, severe tracheomalacia is often a life threatening condition requiring more aggressive management. For children with this condition, a variety of treatment options are available. To our knowledge, this is the first report of home high-flow nasal cannula as an alternative therapy to continuous positive airway pressure (CPAP) and surgical procedures in a pediatric patient with severe extensive tracheomalacia.

Inhaled anticholinergics and short-acting beta(2)-agonists versus short-acting beta2-agonists alone for children with acute asthma in hospital.

BACKGROUND: Inhaled anticholinergics given in addition to ß2-agonists are effective in reducing hospital admissions in children presenting to the emergency department with a moderate to severe asthma exacerbation. It seems logical to assume a similar beneficial effect in children hospitalised for an acute asthma exacerbation. OBJECTIVES: To assess the efficacy and safety of anticholinergics added to ß2-agonists as inhaled or nebulised therapy in children hospitalised for an acute asthma exacerbation. To investigate the characteristics of patients or therapy, if any, that would influence the magnitude of response attributable to the addition of anticholinergics. SEARCH METHODS: We identified trials from the Cochrane Airways Group Specialised Register of trials (CAGR), which is derived through systematic searches of bibliographic databases including the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, CINAHL, AMED and PsycINFO and through handsearching of respiratory journals and meeting abstracts. The search is current to November 2013. SELECTION CRITERIA: Randomised trials comparing the combination of inhaled or nebulised anticholinergics and short-acting ß2-agonists versus short-acting ß2-agonists alone in children one to 18 years of age hospitalised for an acute asthma exacerbation were eligible. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed the methodological quality of trials and extracted data; disagreement was resolved by consensus or with the input of a third review author, when needed. Primary outcomes were duration of hospital stay and serious adverse events. Secondary outcomes included admission and duration of stay in the intensive care unit (ICU), ventilation assistance, time to short-acting ß2-agonists spaced at four hours or longer, supplemental asthma therapy, duration of supplemental oxygen, change from baseline in asthma severity, relapse after discharge, adverse health effects and withdrawals. MAIN RESULTS: Seven randomised trials were included, four of which reported usable data on 472 children with asthma one to 18 years of age who were admitted to paediatric wards. No trials included patients admitted to the ICU. The anticholinergic used, ipratropium bromide 250 µg, was given every one to eight hours over a period from four hours to the entire length of the hospital stay. Two of four trials (50%) contributing data were deemed of high methodological quality. The addition of anticholinergics to ß2-agonists showed no evidence of effect on the duration of hospital admission (mean difference (MD) -0.28 hours, 95% confidence interval (CI) -5.07 to 4.52, 3 studies, 327 participants, moderate quality evidence) and no serious or non-serious adverse events were reported in any included trials. As a result of the similarity of trials, we could not explore the influence of age, admission site, intensity of anticholinergic treatment and co-interventions on primary outcomes. No statistically significant group difference was noted in other secondary outcomes, including the need for supplemental asthma therapy, time to short-acting ß2-agonists spaced at four hours or longer, asthma clinical scores, lung function and overall withdrawals for any reason. AUTHORS' CONCLUSIONS: In children hospitalised for an acute asthma exacerbation, no evidence of benefit for length of hospital stay and other markers of response to therapy was noted when nebulised anticholinergics were added to short-acting ß2-agonists. No adverse health effects were reported, yet the small number of trials combined with inadequate reporting prevent firm reassurance regarding the safety of anticholinergics. In the absence of trials conducted in ICUs, no conclusion can be drawn regarding children with impending respiratory failure. These findings support current national and international recommendations indicating that healthcare practitioners should refrain from using anticholinergics in children hospitalised for acute asthma.