Noninvasive positive-pressure ventilation in children with lower airway obstruction.

STUDY OBJECTIVES: Mechanical ventilation of patients with severe lower airway obstruction presents significant risks; therefore, avoiding the intubation in these patients has been a principal goal of clinical management. Noninvasive positive-pressure ventilation has been shown to be effective in treating adults with chronic obstructive pulmonary disease, but its use has not been studied prospectively in children with acute obstructive lower airways disease. The objective of this study was to determine whether noninvasive mask ventilation improved respiratory function in children with asthma and other obstructive lower airways diseases. STUDY DESIGN: A prospective, randomized, crossover study. PATIENTS: A total of 20 children admitted to the pediatric intensive care unit with acute lower airway obstruction. METHODS: Children were randomized to receive either 2 hrs of noninvasive ventilation followed by crossover to 2 hrs of standard therapy or 2 hrs of standard therapy followed by 2 hrs of noninvasive ventilation. RESULTS: Using a Clinical Asthma Score, we found that noninvasive ventilation decreased signs of work of breathing such as respiratory rate, accessory muscle use, and dyspnea as compared with standard therapy. There was no serious morbidity associated with noninvasive ventilation. CONCLUSIONS: We conclude that noninvasive ventilation can be an effective treatment for children with acute lower airway obstruction.     

Late presentation of upper airway obstruction in Pierre Robin sequence.

A retrospective review was carried out of 11 consecutive patients with the Pierre Robin sequence referred to a tertiary paediatric referral centre over a five year period from 1993 to 1998. Ten patients were diagnosed with significant upper airway obstruction; seven of these presented late at between 24 and 51 days of age. Failure to thrive occurred in six of these seven infants at the time of presentation, and was a strong indicator of the severity of upper airway obstruction. Growth normalised on treatment of the upper airway obstruction with nasopharyngeal tube placement. All children had been reviewed by either an experienced general paediatrician or a neonatologist in the first week of life, suggesting that clinical signs alone are insufficient to alert the physician to the degree of upper airway obstruction or that obstruction developed gradually after discharge home. The use of polysomnography greatly improved the diagnostic accuracy in assessing the severity of upper airway obstruction and monitoring the response to treatment. This report highlights the prevalence of late presentation of upper airway obstruction in the Pierre Robin sequence and emphasises the need for close prospective respiratory monitoring in this condition. Objective measures such as polysomnography should be used, as clinical signs alone may be an inadequate guide to the degree of upper airway obstruction.     

Late presentation of upper airway obstruction in Pierre Robin sequence

A retrospective review was carried out of 11 consecutive patients with the Pierre Robin sequence referred to a tertiary paediatric referral centre over a five year period from 1993 to 1998. Ten patients were diagnosed with significant upper airway obstruction; seven of these presented late at between 24 and 51 days of age. Failure to thrive occurred in six of these seven infants at the time of presentation, and was a strong indicator of the severity of upper airway obstruction. Growth normalised on treatment of the upper airway obstruction with nasopharyngeal tube placement. All children had been reviewed by either an experienced general paediatrician or a neonatologist in the first week of life, suggesting that clinical signs alone are insufficient to alert the physician to the degree of upper airway obstruction or that obstruction developed gradually after discharge home. The use of polysomnography greatly improved the diagnostic accuracy in assessing the severity of upper airway obstruction and monitoring the response to treatment. This report highlights the prevalence of late presentation of upper airway obstruction in the Pierre Robin sequence and emphasises the need for close prospective respiratory monitoring in this condition. Objective measures such as polysomnography should be used, as clinical signs alone may be an inadequate guide to the degree of upper airway obstruction.     

Helium-Oxigen (Heliox) mixture in airway obstruction

OBJECTIVE: Demonstrate the effectiveness and the good outcome of the patients treated with helium-oxygen (Heliox) mixture. This mixture (Heliox) has been used in patients with airway obstruction, from different ethiologies, who did not respond to a conventional treatment with oxygen. METHODS: Case report of five patients that received Heliox as treatment for airway obstruction. All of them had good results without side effects during the treatment. CONCLUSION: Heliox is a promising treatment for severe airway obstruction with good results in a short period of time, until the final treatment is established.     

Nasal obstruction in neonates and infants

The main functions of the nasal airway are respiration and olfaction. The nose and sinuses condition air before reaching the lower respiratory tract by providing almost 100% humidification, warming, filtering and trapping of foreign particles. The airway epithelium contributes to the host defense system. Any alteration of this clearance system may produce significant problems, particularly in neonates, who are obligate nasal breathers until they are at least two months old. Nasal obstruction, and the inability to remove nasal secretion by nose blowing, may have serious consequences, such as respiratory distress or discomfort, altered sleep cycle, increased risk of obstructive apnoea and feeding difficulties. Most cases of nasal obstruction in neonates and infants are due to generalized nasal airway obstruction associated with neonatal rhinitis, viral upper respiratory tract infections, and possibly milk/soy allergies. Saline nasal lavage is recommended as an adjunct therapy for rhinosinusitis and allergic rhinitis, and in most cases of nasal congestion or obstruction in newborns, infants and children. In two recent experiences, was deemed to be the Narhinel method safe and effective for treatment of nasal congestion in babies with viral infections of the upper respiratory tract, or for the prevention of acute otitis media (AOM) and acute rhinosinusitis (AR) in children. Due to the efficacy, ease of use, tolerability and the lack of alternative medications in children younger than 12 years of age, nasal irrigation with physiological saline solution, followed by gentle aspiration, represent an effective method for the prevention and control of nasal congestion or obstruction in term or preterm neonates, infants and children.     

Upper airway obstruction

The airways in infants and children are anatomically different from adults, thus predisposing them to more acute upper airway obstruction. The causes of upper airway obstruction may be infective or non-infective. The presence of dysphonia, dysphagia, abnormal respiratory pattern, cough and abnormal posture suggests upper airway obstruction. The general management consist of supportive care with minimal invasive procedures. The specific treatment depends on the causes and is discussed in text.     

Noninvasive treatment of bronchomalacia, successful ventilation of a severely ill infant

Noninvasive treatment of bronchomalacia.Successful ventilation of a severely ill infant. AIM: To describe an effective treatment of a boy with bronchomalacia by noninvasive mechanical ventilation support. METHODS: We describe a case of a severely ill patient with bronchomalacia from the time he was born and until the age of five. Bi-level positive airway pressure given through a specially adapted full face mask was used to treat his respiratory condition. RESULT: Our patient responded well to the noninvasive treatment of bronchomalacia. CONCLUSION: We found that noninvasive mechanical ventilation support is a low risk and highly effective treatment of infants and children with respiratory distress caused by bronchomalacia.     

Laryngeal papillomatosis presenting as acute airway obstruction in a child

Upper airway obstruction, regardless of cause, can masquerade or be misdiagnosed as lower airway disease in children. In such cases, therapeutic trials of antibiotics, bronchodilators, and over-the-counter medications for symptom relief routinely fail; however, the original diagnosis often goes unchallenged. If the obstructive process is progressive, then acute occlusion of the airway may occur, rapidly leading to suffocation and death if resuscitation is unsuccessful. Outlined in this report is the case of a young female with a history of asthma, poorly responsive to outpatient treatment, who presented with respiratory arrest. The cause of the respiratory collapse was later identified as a large laryngeal papilloma, a condition rarely encountered by emergency physicians.     

Abnormalities of breathing control and airway maintenance in infants and children as a cause of cor pulmonale

Summary Respiratory control abnormalities may result in cor pulmonale. This report summarizes the clinical history, diagnostic evaluation, treatment, and outcome of 16 infants and children presenting with cor pulmonale subsequently found to be due to sleep-dependent hypoventilation. Eleven patients had cardiomegaly and electrocardiographic evidence of right ventricular hypertrophy (RVH) while 5 had only severe RVH or biventricular hypertrophy (BVH). Four infants with central hypoventilation syndrome (CHS)—absence of sleep-related ventilatory drive—had severe sleep-dependent asphyxia and resultant acute respiratory failure; all were ultimately treated with phrenic nerve pacing. One patient with alveolar hypoventilation syndrome (AHS)—a partial deficit in ventilatory drive during sleep—presented with severe pulmonary hypertension and ultimately died despite symptomatic relief with respiratory stimulants. Eleven patients presented with obstructive sleep apnea (OSA) and sleep-dependent asphyxia secondary to intermittent complete or to prolonged partial upper airway obstruction. Localized airway obstruction due to an anomalous innominate artery in 1 child was corrected by arteriopexy. Four children underwent adenotonsillectomy (T&A) with disappearance of symptoms in 1, clinical improvement in 2 and no clinical improvement in another. This unimproved patient and the 6 remaining OSA children improved dramatically after tracheostomy to bypass the sleep-dependent airway obstruction; none presently has evidence of cor pulmonale. In summary, early recognition and appropriate treatment of respiratory control disorders will improve sleep ventilation, eliminate asphyxia during sleep, and prevent the development of cor pulmonale.Supported in part by Children's Research Guild, Otho S. Sprague Foundation and NIH Grant RR-05475-14This paper was part of the Ray C. Anderson Symposium     

Unilateral submandibular suppurative sialadenitis in a premature infant

Isolated submandibular suppurative sialadenitis is extremely rare in newborn infants and is associated with prematurity and prolonged gavage feeding. This report describes a premature infant who developed a life-threatening airway obstruction due to suppurative submandibular sialadenitis. The diagnosis was made on clinical grounds and confirmed by ultrasonography. Staphylococcus aureus was grown from the pus expressed from the Wharton's duct orifice. Upper airway obstruction and respiratory failure were managed with intubation and mechanical ventilation, and the sialadenitis resolved quickly and completely with flucloxacillin treatment. Possible causes of sialadenitis include dehydration, decreased saliva flow and stasis during gavage feeding, duct obstruction by stones and direct bacterial inoculation. Ultrasonography is the diagnostic imaging of choice to exclude congenital tumours, lymphadenitis, congenital malformations of the Wharton's duct or the gland itself, and subcutaneous fat necrosis. Conclusion: Early diagnosis and antibiotic treatment of suppurative submandibular sialadenitis may prevent complications such as abscess formation, septicaemia and respiratory failure.     

Chronic lung disease of prematurity and respiratory outcome at eight years of age

AIM: The study aimed to determine the respiratory outcome of children who had chronic lung disease of prematurity (CLD) compared with a preterm control group of children at school age. METHODS: Fifty-two preterm infants with CLD born between 26 and 33 weeks gestation were assessed regarding respiratory illness with 47 having lung function testing. Information regarding respiratory illness was obtained from 52 children in the birthweight-matched control group of whom 45 had lung function testing. The results were compared between the CLD and control groups. RESULTS: There was no difference in respiratory symptomatology between CLD groups and control preterm infants. On lung function testing, a significantly lower mean forced expiratory flow at 25-75% of vital capacity was identified compared with the preterm controls (P=0.024). This significant difference did not persist after bronchodilator therapy. There was no evidence of increased air trapping or bronchial hyper-reactivity in the CLD children compared with the controls. CONCLUSION: Lung function in CLD children is largely normal in comparison with preterm controls, apart from some evidence of reversible small airway obstruction. Respiratory symptomatology is not increased in chronic disease children in comparison with control preterm children.     

Using continuous nasal airway pressure in infants with craniofacial malformations

Obstructive sleep apnea (OSA) is common in infants and children with craniofacial malformations. Continuous positive airway pressure (CPAP) represents an effective noninvasive treatment for severe upper airway obstruction in these children, reducing the need of surgery or a tracheostomy. The decision to start CPAP should be discussed by a multidisciplinary team in order to decide the optimal individualized treatment strategy. CPAP initiation depends on patients’ clinical characteristics and local practices, with an increase tendency towards an outpatient program. Follow-up and monitoring strategy varies among centers but benefits from the analysis of built-in software data in order to assess objective adherence and breathing parameters, reducing the need of in-hospital sleep studies. The possibility to wean CPAP should be periodically checked after surgical treatment or when spontaneous resolution is suspected. Finally, these infants with craniofacial malformations should have a long term follow up because of the risk of OSA recurrence over time.     

Respiratory virus infection and airway hyperreactivity in children

A significant portion of infants and young children develop acute lower airway obstruction (wheezing) accompanying viral lower respiratory infections. These wheezing-associated respiratory illnesses, particularly bronchiolitis, are often associated with evidence of prolonged airway obstruction and airway hyperreactivity following the initial infection. The factors that determine the type of clinical infection that initially develops and long-term respiratory consequences of this infection are complex, including the genetic background of the child, the age at the time of infection, the respiratory virus involved, and environmental factors such as exposure to cigarette smoke. Several animal models have been developed to describe the pathophysiology of viral respiratory infection and have helped to define several potential mechanisms for the resulting airway obstruction. Data from these studies and studies in humans emphasize the importance of the immune system and of neural modulation of airway smooth muscle tone in determining the outcome of respiratory virus infection. These observations also help define the pivotal role of the airway epithelium in the regulation of airway smooth muscle tone and the host inflammatory response in the airway. Consequently, the interplay of host and environmental factors, as well as the relative importance of the different mechanisms potentially active in airway obstruction, determine the acute clinical outcome of infection for an individual child and the propensity of that child to develop recurrent episodes of wheezing (asthma).     

重症毛细支气管炎的治疗

毛细支气管炎主要发生于2岁以下婴幼儿,主要由呼吸道病毒尤其是呼吸道合胞病毒感染所致。临床上有自限性,其治疗以对症及支持治疗为主,包括监测病情变化、供氧以及保持水电解质内环境稳定。重症感染患儿在常规吸氧、吸痰及雾化等处理无缓解时,需采取其他措施积极治疗。包括给予肾上腺素、糖皮质激素、高渗盐水雾化吸入及积极抗感染治疗,重症毛细支气管炎患儿无创通气的应用越来越受到重视,早期使用持续气道正压通气可降低有创气管插管率,有效改善呼吸窘迫,减少呼吸做功,缩短住院时间。对具有危险因素的患儿,要密切监测病情变化,并及时处理病情的加重和恶化。     

Congenital upper airway obstruction

Most causes of upper airway obstruction are rare in the neonatal period and during infancy. They may, however, cause major respiratory problems either initially or during the first few weeks of life. It is important to recognise these problems at an early stage so that appropriate measures to overcome airway obstruction can be initiated, thus avoiding significant hypoxia-related complications. Specific treatment includes the use of nasal stents, a nasopharyngeal airway or, in severe cases, tracheostomy. Many such infants have associated feeding problems secondary to the airway obstruction and associated swallowing difficulties, which can lead to recurrent aspiration. The anomalies seen in clinical practice are best classified anatomically. Treatment is aimed at overcoming the mechanical effects of airway obstruction and maximising nutritional input so as to promote growth of the airway and long-term recovery of normal upper airway function.     

An approach to the diagnosis and treatment of membranous laryngotracheobronchitis in infants and children.

The purpose of this study is to report 18 cases of membranous laryngotracheobronchitis (MLTB) and to review 143 published cases in order to accurately characterize the epidemiology, presentation, clinical course, treatment, and outcome of patients with this disorder. The male:female ratio was 2:1; mean age was four years. Most patients presented with acute onset of respiratory distress with fever, toxicity, and stridor after a prodrome of upper respiratory tract infection lasting a few days. White blood cell counts varied over a wide range, and blood culture results were rarely positive. Respiratory cultures commonly yielded Staphylococcus aureus or Haemophilus influenzae. Diagnosis was usually confirmed by airway radiographs or endoscopy. An artificial airway was required in 83% of patients. Complications included respiratory failure, toxic shock syndrome, anoxic encephalopathy, and death. MLTB is a serious, potentially fatal cause of acute infectious airway obstruction in infants and children that requires an organized approach to diagnosis and management.     

The release of leukotrienes in the respiratory tract during infection with respiratory syncytial virus: role in obstructive airway disease

Samples of nasopharyngeal secretions from a group of 73 infants with bronchiolitis or upper respiratory illness alone during infection with respiratory syncytial virus were analyzed for leukotriene C4 (LTC4) content using a reverse-phase high-pressure liquid chromatography assay with confirmation by radioimmunoassay. Titers of respiratory syncytial virus (RSV)-specific IgE in nasopharyngeal secretion (NPS) specimens were determined using an enzyme-linked immunosorbent assay. The highest concentrations of LTC4 were found in the first 3 to 8 days after the onset of illness, and LTC4 was detectable in progressively lower concentrations in samples obtained up to 28 days after the onset of illness. LTC4 was detected in samples of NPS obtained in the acute phase of illness from 67% of infants with bronchiolitis due to RSV and in 33% of samples of NPS obtained during the same interval from infants with upper respiratory illness alone (p less than 0.025). Concentrations of LTC4 in children with bronchiolitis were 5-fold higher (1271 pg/ml) than the mean concentration of LTC4 in children with upper respiratory illness (224 pg/ml, p less than 0.02). LTC4 was detected in 83% of the children developing an RSV-IgE response and in 24% of subjects not developing an RSV-IgE response (p less than 0.001). Quantities of LTC4 measured in NPS were directly correlated with the magnitude of the RSV-IgE response in secretions (r = 0.33, p less than 0.02). These studies lend support to previous investigations suggesting that severe bronchiolitis due to RSV results from IgE-mediated hypersensitivity reactions to viral antigens, with release of chemical mediators of airway obstruction.(ABSTRACT TRUNCATED AT 250 WORDS)     

Basic life support in pediatrics

Basic life support (BLS) is the combination of maneuvers that identifies the child in cardiopulmonary arrest and initiates the substitution of respiratory and circulatory function, without the use of technical adjuncts, until the child can receive more advanced treatment. BLS includes a sequence of steps or maneuvers that should be performed sequentially: ensuring the safety of rescuer and child, assessing unconsciousness, calling for help, positioning the victim, opening the airway, assessing breathing, ventilating, assessing signs of circulation and/or central arterial pulse, performing chest compressions, activating the emergency medical service system, and checking the results of resuscitation. The most important changes in the new guidelines are the compression: ventilation ratio and the algorithm for relieving foreign body airway obstruction. A compression/ ventilation ratio of 30:2 will be recommended for lay rescuers of infants, children and adults. Health professionals will use a compression: ventilation ratio of 15:2 for infants and children. If the health professional is alone, he/she may also use a ratio of 30:2 to avoid fatigue. In the algorithm for relieving foreign body airway obstruction, when the child becomes unconscious, the maneuvers will be similar to the BLS sequence with chest compressions (functioning as a deobstruction procedure) and ventilation, with reassessment of the mouth every 2 min to check for a foreign body, and evaluation of breathing and the presence of vital signs. BLS maneuvers are easy to learn and can be performed by anyone with adequate training. Therefore, BLS should be taught to all citizens.     

Sleep apnoea in infants

Infancy is characterized by an instability of the control of breathing. Apnoeas of short duration are common, mostly central and more frequent during rapid eye movement sleep. Obstructive apnoeas are rare in healthy infants. Triggering factors, such as respiratory syncytial virus infection, can increase the frequency and duration of apnoeas. Upper airway problems are responsible for obstructive apnoeas as well as for episodes of partial airway obstruction or upper airway resistance syndrome. In some infants, apparent life-threatening events have been related to upper airway anomalies. Congenital central hypoventilation syndrome, a rare respiratory control disorder, may present with apnoeas. Polysomnography is the gold standard for diagnosing sleep-disordered breathing in infants. Nasal continuous positive airway pressure is feasible in infants, and the early diagnosis of abnormal breathing during sleep is of critical importance for neurocognitive development in infants.     

Heliox administration in the pediatric intensive care unit: an evidence-based review.

OBJECTIVE: To provide a comprehensive, evidence-based review of helium-oxygen gas mixtures (heliox) in the management of pediatric respiratory diseases. Data Source: A thorough, computerized bibliographic search of the preclinical and clinical literature regarding the properties of helium and its application in pediatric respiratory disease states. DATA SYNTHESIS: After an overview of the potential benefits and technical aspects of helium-oxygen gas mixtures, the role of heliox is addressed for asthma, aerosolized medication delivery, upper airway obstruction, postextubation stridor, croup, bronchiolitis, and high-frequency ventilation. The available data are objectively classified based on the value of the therapy or intervention as determined by the study design from which the data are obtained. CONCLUSIONS: Heliox administration is most effective during conditions involving density-dependent increases in airway resistance, especially when used early in an acute disease process. Any beneficial effect of heliox should become evident in a relatively short period of time. The medical literature supports the use of heliox to relieve respiratory distress, decrease the work of breathing, and improve gas exchange. No adverse effects of heliox have been reported. However, heliox must be administered with vigilance and continuous monitoring to avoid technical complications.