Severe upper airway obstruction caused by ulcerative laryngitis

AIMS—To present our experience of severe upper airway obstruction caused by ulcerative laryngitis in children.
METHODS—Retrospective case note review of 263 children with severe upper airway obstruction and a clinical diagnosis of croup admitted to a paediatric intensive care unit (PICU) over a five year period.
RESULTS—A total of 148 children (56%) underwent microlaryngoscopy (Storz 3.0 rigid telescope). Laryngeal ulceration with oedema was documented in 15 of these children (10%), median age 14 months (range 10-36) and median weight 10 kg (range 6-12). Twenty seven of the children who underwent microlaryngoscopy (18%) also had ulcerative gingivostomatitis consistent with herpes simplex virus infection. Ulcerative laryngitis was documented in nine of 27(33%) children with, and in six of 121 (5%) children without, coexistent ulcerative gingivostomatitis. One of the 15 children did not require airway intervention. Nine children required nasotracheal intubation for a median of 4 days (range 3-11) and median PICU stay of 6 days (range 4-14). Five children required tracheostomy ab initio, with a median PICU stay of 30 days (range 20-36), and duration of tracheostomy in situ for a median of 19 days (range 15-253). All 15 children survived.
CONCLUSION—Ulcerative laryngitis is more common in our patient population than the few reports suggest. Early diagnostic microlaryngoscopy is recommended in children with severe croup who follow an atypical course.

     

Severe upper airway obstruction in the tropics requiring intensive care

BACKGROUND: The clinical profile of severe upper airway obstruction, a challenging acute pediatric emergency, has not been extensively documented in the developing nations of the tropics. METHODS: The diagnostic categories, severity of illness and outcome from 63 episodes of severe upper airway obstruction in 56 children admitted to the Pediatric Intensive Care Unit between January 1994 and December 1999 were reviewed. Outcome variables studied included requirement for ventilation, mortality and complications. Severity of illness was determined with the Pediatric Risk of Mortality (PRISM) II score. RESULTS: Viral croup (29%) was the most common diagnosis, followed by mediastinal malignancy (13%), bacterial tracheitis (11%) and Pierre Robin syndrome (11%). There were no admissions for acute epiglottitis. Thirty episodes (48%) required ventilation for a median duration of 4.0 days. Bacterial tracheitis (100%) and subglottic stenosis (100%) were the most likely diagnoses requiring ventilation. Difficulty in intubation was encountered in 13 episodes (43%) involving, in particular, patients with bacterial tracheitis (83%; P = 0.006). Only two patients required a tracheostomy. The overall mortality was 11%. The PRISM score for all categories was generally low (mean 10.3 +/- 1.0; median 9.0). Non-survivors had a significantly higher PRISM II score than survivors (27.4 +/- 9.7 vs 8.1 +/- 4.9, respectively; P = 0.002) and were more likely to include children with bacterial tracheitis and mediastinal malignancy. CONCLUSIONS: There is marked heterogeneity in the causes of upper airway obstruction in the tropics with viral croup remaining the most common. A significant proportion required ventilation, but outcome is generally favorable, except in those with bacterial tracheitis and mediastinal malignancy.     

Pediatric tracheostomies: a recent experience from one academic center.

OBJECTIVES: To describe the indications, surgical timing, length of stay, hospital charges, and discharge disposition of pediatric tracheostomy patients. DESIGN: Retrospective case series. SETTING: Large urban academic pediatric hospital. PATIENTS: Seventy children and adolescents undergoing tracheostomy placement over a 24-month period. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Hospital database records were used to determine demographics and readmission rates, tabulate charges, and confirm deaths. Indications for tracheostomies included airway obstruction, inadequate airway protection, chronic lung disease, neuromuscular weakness, and central hypoventilation. Surgical timing of the tracheostomy was grouped into three categories: prolonged mechanical ventilation, elective, or emergent. The overall median hospital stay was 46 days (range 14-254) with a median hospital charge of $136,718 (range $36,237-$913,934). The prolonged mechanical ventilation group underwent a tracheostomy after a median of 26 days (mean 37.5 days) on the ventilator. Eighty-one percent of children were discharged home; 63% of children were readmitted within 6 months, with 11% requiring four or more admissions. The six-month mortality rate was 13%; no deaths were related to the tracheostomy. CONCLUSIONS: Children with tracheostomies are a heterogeneous population. Children who require tracheostomy for long-term mechanical ventilation have longer hospital stays than children who receive a tracheotomy on an elective or emergent basis. Hospital readmissions should be anticipated in this complex group of patients.     

Acute Upper Airway Obstruction

Upper airway obstruction is defined as blockage of any portion of the airway above the thoracic inlet. Stridor, suprasternal retractions, and change of voice are the sentinel signs of upper airway obstruction. Most of the common causes among children presenting to emergency department are of acute infectious etiology. Among these, croup is the commonest while diphteria remains the most serious life-threatening cause. Recent reports indicate that bacterial tracheitis has become increasingly common. In ER evaluation the key clinical data in determining the cause and the site of obstruction are the onset, presence of fever, character of the stridor, retractions, the voice and the ability to handle secretions. After assessment of the severity of respiratory distress and resuscitative or supportive therapy including oxygen and emergent airway, specific treatment is directed at underlying etiology. All patients with audible stridor require early endotracheal intubation/tracheostomy. In croup the mainstay of treatment are cold humidified oxygen, budesonide nebulization ( in mild cases), Dexamethasone 0.6 mg/kg iv or im (in moderate and severe cases), and Adrenaline 5 ml 1:1000 (5 mg) solution as nebulization ( in severe cases). In diphtheria, early tracheostomy, anti-diphtheric serum and injectable penicillin are critical. Bacterial Tracheitis and Retropharyngeal abscess need early administration of injectable Cloxacillin, Amikacin and Clindamycin. ENT consultation should be obtained for early surgical drainage of retropharyngeal abscess. Angioneurotic edema is treated with subcutaneous adrenaline (1:1000, 0.01 ml/kg); hydrocortisone 10 mg/kg IV and antihistamines. Patients with severe obstruction and those with endotracheal tube/ trachesotomy should be transferred to PICU.     

Tracheostomy in children

We reviewed the records of 108 patients who had a tracheostomy performed over a 10-year period from July 1979 to April 1989. Median age at tracheostomy was 6 months (1 week–15 years). Indications for surgery were acquired subglottic stenosis (31.4%), bilateral vocal cord paralysis (22.2%), congenital airway malformations (22.2%) and tumours (11.1%). No epiglottis and no emergency situation had to be managed by tracheostomy. Operation was uneventful in all, but 8 patients (7.4%) developed a pneumothorax in the postoperative period. Twenty-one (19.5%) had severe complications during the cannulation period (tube obstruction in 11 patients with cardiorespiratory arrest in 4; dislocation of the tube in 6 patients). Fifteen patients (13.8%) had severe complications after decannulation (2 had a cardiorespiratory arrest); all 15 had to be recannulated. At the end of the study period 85 patients (78.7%) were successfully decannulated with a median period of tracheostomy of 486 days (8 days–6.6 years). The median hospital stay was 159 days (13 days–2.7 years). All patients could be discharged. Eight patients (7.4%) died but no death was related to tracheostomy. In summary the mortality rate is lower than reported in previous reviews and tracheostomy is a safe operation even in small children but cannula-related complications may lead to life-threatening events. The management of tracheostomized small children and infants in a highly staffed and monitored intensive care unit has allowed better handling of complications and has resulted in a reduction in cannula-related deaths.     

Review of Staphylococcus aureus infections requiring admission to a paediatric intensive care unit.

AIMS: To review clinical features and outcome of children with severe Staphylococcus aureus sepsis (SAS) presenting to a paediatric intensive care unit (PICU) with particular focus on ethnicity, clinical presentation, cardiac involvement, and outcome. METHODS: Retrospective chart review of patients coded for SAS over 10 years (October 1993 to April 2004). RESULTS: There were 58 patients identified with SAS over the 10 year study period; 55 were community acquired. This accounted for 4% of hospital admissions for SAS over this time; children with staphylococcal illness comprised 1% of all admissions to the PICU. Maori and Pacific children with SAS were overly represented in the PICU (81%) from a paediatric population where they contribute 21.6%. Musculoskeletal symptoms (79%) dominated presentation rather than isolated pneumonia (10%). An aggressive search for foci and surgical drainage of infective foci was required in 50% of children. Most children had multifocal disease (67%) and normal cardiac valves (95%); the few children (12%) presenting with methicillin resistant S aureus (MRSA) had community acquired infection. The median length of stay in the PICU was 3 (mean 5.8, SD 7.6, range 1-44) days. The median length of stay in hospital was 15 (mean 21, SD 22.7, range 2-149) days. Mortality due to SAS was 8.6% (95% CI 1.4-15.8%) compared with the overall mortality for the PICU of 6% (95% CI 5.3-6.7%). Ten children had significant morbidity after discharge. CONCLUSIONS: Community acquired SAS affects healthy children, is multifocal, and has high morbidity and mortality, in keeping with the high severity of illness scores on admission. It is imperative to look for sites of dissemination and to drain and debride foci. Routine echocardiography had low yield in the absence of pre-existing cardiac lesions, persisting fever, or persisting bacteraemia.     

Outcome of children with neuromuscular disease admitted to paediatric intensive care.

AIMS: To determine the outcome of children with neuromuscular disease (NMD) following admission to a tertiary referral paediatric intensive care (PICU). METHODS: All children with chronic NMD whose first PICU admission was between July 1986 and June 2001 were followed up from their first PICU admission to time of study. The outcomes recorded were death in or outside of PICU, duration of PICU admission, artificial ventilation during admission and following discharge from PICU, and readmission to PICU. RESULTS: Over 15 years, 28 children were admitted on 69 occasions. Sixteen (57%) children had more than one admission. The median duration of PICU admission was 4 days (range 0.5-42). Twenty three per cent of unplanned admissions resulted in the commencement of respiratory support that was continued after discharge from the PICU. Severity of functional impairment was not associated with longer duration of stay or higher PRISM scores. Ten children (36%) died, with four (14%) deaths in the PICU. A higher proportion of children with severe limitation of function were among children that died compared to survivors. CONCLUSION: Most children with NMD admitted to the PICU recover and are discharged without the need for prolonged invasive ventilation. However, in this group of children, the use of non-invasive home based ventilation is common and they are likely to require further PICU admission.     

Prolonged croup due to herpes simplex virus infection

Herpes simplex virus (HSV) is an uncommon cause of acute laryngitis in immunocompetent patients since it mostly occurs in immunocompromised subjects. We present two previously healthy children with prolonged gingivostomatitis and stridor (lasting 3 and 4 weeks) in whom HSV-1 was isolated from subglottal ulcers. Conclusion HSV should be considered a possible pathogen in cases of prolonged or atypical croup not only in immunocompromised or elderly patients but also in otherwise healthy children. Received: 10 March 1997 / Accepted: 20 September 1997     

The outcome of patients with upper airway obstruction transported to a regional paediatric intensive care unit

The diagnoses, transfer, management and outcome of patients with upper airway obstruction (UAO) admitted from district general hospitals (DGH) to a regional paediatric intensive care unit were retrospectively reviewed over a 3.5-year period. Sixty-seven patient episodes were analysed. Fifty-two cases (78%) underwent tracheal intubation prior to transport with a low morbidity for both procedures. The most common diagnosis was viral croup (n= 34, 51%) with a median duration of intubation of 5 days, with subglottic stenosis being the next most common category (n= 10, 15%), median duration of intubation 7 days. Inhaled budesonide was used prior to intubation in 12 (35%) of those with croup, and inhaled bronchodilators in 28%, possibly reflecting diagnostic uncertainty. Patients with croup treated with budesonide were significantly less likely to require intubation (P= 0.04). The re-intubation rate for patients with viral croup was uncomfortably high at 16% (4/25) despite the routine use of prednisolone throughout the intubation period. Successful extubation of patients with viral croup could not be predicted by age (P= 0.31), length of intubation (P= 0.94), endotracheal tube size, (P= 0.60) abnormalities on the chest X-ray (P= 1.0), or presence of secondary bacterial infection (P= 0.23). Conclusion Although viral croup remains the most common diagnostic category presenting at the DGH level with severe UAO, a wide range of other diagnoses is seen. Despite clear evidence of benefit, steroid administration to children presenting at the DGH with viral croup has not become routine practice. Once intubated, no reliable predictors of successful extubation were found amongst this patient group. Received: 10 November 1997 / Accepted: 2 March 1998     

Outcome of children with neuromuscular disease admitted to paediatric intensive care

Aims: To determine the outcome of children with neuromuscular disease (NMD) following admission to a tertiary referral paediatric intensive care (PICU). Methods: All children with chronic NMD whose first PICU admission was between July 1986 and June 2001 were followed up from their first PICU admission to time of study. The outcomes recorded were death in or outside of PICU, duration of PICU admission, artificial ventilation during admission and following discharge from PICU, and readmission to PICU. Results: Over 15 years, 28 children were admitted on 69 occasions. Sixteen (57%) children had more than one admission. The median duration of PICU admission was 4 days (range 0.5–42). Twenty three per cent of unplanned admissions resulted in the commencement of respiratory support that was continued after discharge from the PICU. Severity of functional impairment was not associated with longer duration of stay or higher PRISM scores. Ten children (36%) died, with four (14%) deaths in the PICU. A higher proportion of children with severe limitation of function were among children that died compared to survivors. Conclusion: Most children with NMD admitted to the PICU recover and are discharged without the need for prolonged invasive ventilation. However, in this group of children, the use of non-invasive home based ventilation is common and they are likely to require further PICU admission.     

Evolution of an adenovirus outbreak in a multidisciplinary children's hospital

OBJECTIVE: To describe the course of an evolving adenovirus outbreak in a multidisciplinary children's hospital with a high-risk patient population. METHODS: Observational study in a 280-bed university hospital during June 2002. Active case finding identified children with adenovirus infection. Data are median (interquartile range) or n (%). Adenovirus infection was diagnosed in 49 children, median age 12 months (4-33). RESULTS: New cases were diagnosed over 26 days and peaked on day 17 (n = 15). Total infected inpatients peaked on days 17-21 (n = 36). Twenty-three infections (47%) were community-acquired and 26 (53%) hospital-acquired. Thirty-three children (67%) had a coexistent high-risk condition. Median hospital stay before and after diagnosis was 9 days (3-18) and 9 days (4-29), respectively. Twenty-two children (45%) were admitted to PICU. Overall hospital mortality was 22% (n = 11) and mortality attributed to adenoviral disease 12% (n = 6). Hospital mortality was similar between community- and hospital-acquired infections (22% compared to 23%) (P = 1.0). Twenty children (41%) received intravenous immunoglobulin (IVIG). Children treated with IVIG had a longer hospital stay (median 40 days vs 14 days) than those who did not receive IVIG (P = 0.01). Neither PICU mortality (29% vs 12%), nor hospital mortality (35% vs 14%), differed significantly between IVIG treated and untreated children (P = 0.76 and P = 0.16, respectively). CONCLUSION: The rapid spread of hospital-acquired adenovirus underlines the importance of effective infection control measures. Despite nosocomial infection amongst high-risk patients, mortality was similar to that of community-acquired infection. Administration of immunoglobulin was not associated with demonstrable benefit. A prospective randomized trial would be required to resolve this issue.     

Review of Staphylococcus aureus infections requiring admission to a paediatric intensive care unit

Aims: To review clinical features and outcome of children with severe Staphylococcus aureus sepsis (SAS) presenting to a paediatric intensive care unit (PICU) with particular focus on ethnicity, clinical presentation, cardiac involvement, and outcome. Methods: Retrospective chart review of patients coded for SAS over 10 years (October 1993 to April 2004). Results: There were 58 patients identified with SAS over the 10 year study period; 55 were community acquired. This accounted for 4% of hospital admissions for SAS over this time; children with staphylococcal illness comprised 1% of all admissions to the PICU. Maori and Pacific children with SAS were overly represented in the PICU (81%) from a paediatric population where they contribute 21.6%. Musculoskeletal symptoms (79%) dominated presentation rather than isolated pneumonia (10%). An aggressive search for foci and surgical drainage of infective foci was required in 50% of children. Most children had multifocal disease (67%) and normal cardiac valves (95%); the few children (12%) presenting with methicillin resistant S aureus (MRSA) had community acquired infection. The median length of stay in the PICU was 3 (mean 5.8, SD 7.6, range 1–44) days. The median length of stay in hospital was 15 (mean 21, SD 22.7, range 2–149) days. Mortality due to SAS was 8.6% (95% CI 1.4–15.8%) compared with the overall mortality for the PICU of 6% (95% CI 5.3–6.7%). Ten children had significant morbidity after discharge. Conclusions: Community acquired SAS affects healthy children, is multifocal, and has high morbidity and mortality, in keeping with the high severity of illness scores on admission. It is imperative to look for sites of dissemination and to drain and debride foci. Routine echocardiography had low yield in the absence of pre-existing cardiac lesions, persisting fever, or persisting bacteraemia.     

Tracheostomy,respiratory support,and developmental outcomes in neonates with severe lung diseases: Retrospective study in one center

ObjectivesPediatric tracheostomy has evolved significantly in the past few decades and the optimal timing to perform it in children with respiratory assistance is still debated. The objective of this study was to describe the indications, timing, complications, and outcomes of infants on respiratory support who had a tracheostomy in a tertiary pediatric intensive care unit (PICU).MethodsAll children younger than 18 months of corrected age requiring respiratory support for at least 1 week and who had a tracheostomy between January 2005 and December 2015 were included. Their demographic and clinical data and their outcomes at 24 months of corrected age were collected and analyzed after approval from the CHU Sainte-Justine ethics committee.ResultsDuring the study period, 18 children (14 preterm infants, 4 polymalformative syndromes, and 2 diaphragmatic hernias) were included. The median corrected age at tracheostomy was 97 days (0–289 days) and 94.4% were elective. The indications for tracheostomy were ventilation for more than 7 days with (61.1%) or without (38.9%) orolaryngotracheal anomaly. The median number of consultants involved per patient was 16 consultants (10–23 consultants). The median hospital length of stay was 122 days (8–365 days) before tracheostomy and 235 days (22–891 days) after tracheostomy. The median invasive ventilation time was 68 days (8–168 days) before tracheostomy and 64 days (5–982 days) after tracheostomy. In terms of complications, there were nine cases of tracheitis and five cases of tracheal granulomas. At 24 months of corrected age, 17 of 18 children survived, one of/17 was still hospitalized, three of 17 were decannulated, three of 17 received respiratory support via their tracheostomy, 11 of 17 were fed with a gastrostomy, and all had neurodevelopmental delay.ConclusionTracheostomy in infants requiring at least 1 week of ventilation is performed for complex cases and is favored for orolaryngotracheal anomalies. Clinicians should anticipate the need for developmental care in this population.     

Outcome of patients requiring tracheostomy in a pediatric intensive care unit

Abstract Background : Although tracheostomy is a commonly performed procedure, there is a lack of studies in the pediatric intensive care unit (PICU) setting that describe its association with patient outcome and especially hospital mortality. Our goal was to evaluate the outcome of patients receiving a tracheostomy, while on mechanical ventilation (MV), in a PICU.
Methods : Records of 260 children were reviewed retrospectively regarding PICU mortality, PICU length of stay (PICU LOS), duration of MV and a cost indicator (weighted hospital days; WHD).
Results : Nineteen patients received tracheostomy (7.3%). The mortality of patients submitted to tracheostomy in the longer term was significantly higher compared to patients who were not (52.6% vs . 27.6%; P  = 0.04) despite having a significantly lower severity of illness at admission (Pediatric Risk of Mortality score – PRISM) (10.9 vs . 13.7; P  < 0.001). The mortality of patients without tracheostomy, however, was significantly higher within 30 days (24.8% vs . 5.2%, P  < 0.001). Tracheostomized patients had significantly higher mean PICU LOS (68 days vs . 8 days; P  < 0.001), duration of MV (62 days vs . 4 days; P  < 0.001) and higher WHD (171.5 vs . 21.5; P  < 0.001).
Conclusion : Contrary to findings in critically ill adult patients, ventilated children receiving a tracheostomy had less favorable outcomes compared with non-tracheostomized patients. In view of the greater use of resources, further studies are needed to confirm and to identify the subgroups of mechanically ventilated patients who will benefit most from this procedure.     

Review of intubation in severe laryngotracheobronchitis

Of 208 children who required relief of severe airway obstruction due to laryngotracheobronchitis by an artificial airway (nasotracheal intubation or tracheostomy) during a 10-year-period, 181 (87%) were intubated and later extubated. Twenty-seven children (13%) had tracheostomies performed. The tracheostomies were for severe subglottic narrowing precluding the passage of an adequate size endotracheal tube in 10 children, and for severe endotracheal tube trauma in 17 children. Five children developed acquired subglottic stenosis (2.4% of 208) and 1 of these has a retained tracheostomy. One child died of cardiac disease. The remaining 202 children had no long-term complications of laryngotracheobronchitis, intubation, or tracheostomy. It is concluded that nasotracheal intubation is a satisfactory artificial airway for laryngotracheobronchitis. Endoscopic evaluation in a selected group of these children will identify those with significant intubation trauma or severe subglottic narrowing in whom continued intubation may cause permanent subglottic damage. The low incidence of acquired subglottic stenosis in this series supports the practice of selective endoscopy and tracheostomy.     

Glycemic level in mechanically ventilated children with bronchiolitis.

OBJECTIVE: To evaluate in children with bronchiolitis requiring mechanical ventilation the association between blood glucose level and duration of mechanical ventilation and pediatric intensive care unit (PICU) stay. DESIGN: Retrospective cohort study. SETTING: University hospital PICU. PATIENTS: Children admitted to a university hospital PICU over a period of 3 yrs. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Demographic data, infection with respiratory syncytial virus, history of prematurity, mechanical ventilator settings, and use of inotrope during illness were noted. In addition, C-reactive protein, alanine transaminase, and glucose levels were recorded. Data from 50 children with median (interquartile range) age of 2.2 (1.3-4.7) months were analyzed. There were 37 boys, 21 children had been premature babies, and 30 children were positive for respiratory syncytial virus. Hyperglycemia at any time was frequent (peak glucose > or =6.1 mmol/L [110 mg/dL] in 98% and >8.3 mmol/L [150 mg/dL] in 72%). Children with sustained hyperglycemia were more likely to be boys with higher alanine transaminase and C-reactive protein, requiring inotrope (p < .05). These children are more likely to have required high-frequency oscillation ventilation, required higher airway pressures, and had longer duration of mechanical ventilation and PICU stay (p < .05). Peak glucose and sustained peak glucose were not independently associated with duration of mechanical ventilation or PICU stay. Multiple regression showed that age, C-reactive protein, the need for inotrope, and respiratory syncytial virus infection were independent factors associated with duration of PICU stay. Glucose level was not a factor. CONCLUSIONS: Our findings show that hyperglycemia is frequent in children with bronchiolitis requiring mechanical ventilation, but we failed to show that this phenomenon was independently associated with prolonged duration of mechanical ventilation or PICU stay. Our observations raise the question whether tight glycemic control should be used in children with bronchiolitis.     

Intravenous terbutaline in children

OBJECTIVE: The authors describe their experience with theuse of intravenous Beta2 adrenergic (IV terbutaline) in patientsadmitted to a PICU with severe lower airway obstruction. PATIENTS AND METHODS: A retrospective study of all admissions to a PICU was conducted in Santo Antonio Hospital in Porto Alegre (Brazil) during the winter of 1995. The files ofall the patients that were treated with intravenous Beta2 adrenergicas a bronchodilator were selected. The analysis included lengthof use, initial doses, maximal doses, associated phenomena,arterial blood gases and plasma level of potassium. RESULTS: During the three months of study 367 patients wereadmitted to the PICU and 38 (10.3%) used IV terbutaline. Thisgroup of patients had a mean age of 13.8-/+12.2 months old andused IV terbutaline for a mean length of 7.24-/+3.6 days. Theinitial rate of infusion was 0.55-/+0.25 mcg/kg/min with a meantherapeutic dose of 2.45-/+1.18 mcg/kg/min. Twelve patients(31.5%) had increase in their heart rate (over 180 bpm) thatprevented increases in the infusion rate. However this was atemporary effect. The patients under 12 months of age startedwith low infusion rates (0.45-/+0.22 mcg/kg/min), when comparedto children over 1 year old (0.57-/+0.3 mcg/kg/min), p <0.01. No patient developed pathologic heart rate attributed to the drug. The serum levels of potassium decreased significantly (p <0.01) only in the group of patients under 1 year (4.1-/+0.7 to 3.47-/+0.52 mEq/L), but this difference had no clinical relevance. COMMENTS: In view of these results the authors showed that the infusion of IV terbutaline in children is safe and presents alow risk if the criteria of administration and monitoring are followed. In this manner, IV terbutaline is an excellent therapeuticoption for children with severe lower airway obstruction andno response to the conventional treatment.     

Negative extrathoracic pressure ventilation in central hypoventilation syndrome

Nine patients with central hypoventilation syndrome (CHS) were treated with negative extrathoracic pressure ventilation (VNEP). Treatment with VNEP was started between 20 days and 57 months of age, which was two days to 47 months after diagnosis. The equipment to provide VNEP utilised a new system with a latex neck seal and Perspex chamber allowing easy access to the child. Seven patients are managed with VNEP at home by their parents. They did not have a tracheostomy when VNEP was started at ages of 22, 24, 31, 38, and 75 days, 5 and 57 months. They have continued to be successfully managed with VNEP and without tracheostomy. Short periods of intubation and positive pressure ventilation were required on 10 occasions (median duration 7 days, range 4 to 21 days) in four subjects during respiratory tract infections. Three patients required periods of continuous positive airway pressure (CPAP) via a nasal mask or a nasopharyngeal airway during sleep to overcome upper airway obstruction. In three patients the hypoventilation improved and two of these do not require regular ventilatory support at 1.3 and 3.4 years of age. Six of these seven patients are developing normally. In two patients with long term tracheostomies, VNEP could not be established at an age of 29 and 52 months because of tracheal obstruction after temporary removal of their tracheostomy cannula. VNEP is an effective, non-invasive, treatment in infants with CHS if initiated before tracheostomy. It may improve the children's quality of life during the daytime. If upper airway obstruction is a problem in the first year of life, it may be combined with nasal mask CPAP.     

Negative extrathoracic pressure ventilation in central hypoventilation syndrome.

Nine patients with central hypoventilation syndrome (CHS) were treated with negative extrathoracic pressure ventilation (VNEP). Treatment with VNEP was started between 20 days and 57 months of age, which was two days to 47 months after diagnosis. The equipment to provide VNEP utilised a new system with a latex neck seal and Perspex chamber allowing easy access to the child. Seven patients are managed with VNEP at home by their parents. They did not have a tracheostomy when VNEP was started at ages of 22, 24, 31, 38, and 75 days, 5 and 57 months. They have continued to be successfully managed with VNEP and without tracheostomy. Short periods of intubation and positive pressure ventilation were required on 10 occasions (median duration 7 days, range 4 to 21 days) in four subjects during respiratory tract infections. Three patients required periods of continuous positive airway pressure (CPAP) via a nasal mask or a nasopharyngeal airway during sleep to overcome upper airway obstruction. In three patients the hypoventilation improved and two of these do not require regular ventilatory support at 1.3 and 3.4 years of age. Six of these seven patients are developing normally. In two patients with long term tracheostomies, VNEP could not be established at an age of 29 and 52 months because of tracheal obstruction after temporary removal of their tracheostomy cannula. VNEP is an effective, non-invasive, treatment in infants with CHS if initiated before tracheostomy. It may improve the children's quality of life during the daytime. If upper airway obstruction is a problem in the first year of life, it may be combined with nasal mask CPAP.     

Presentation and outcome of severe anticholinesterase insecticide poisoning.

AIMS: To document the patterns of presentation and outcome of severe anticholinesterase insecticide poisoning in children requiring intensive care. METHODS: Retrospective case note review of all 5541 children admitted to the paediatric intensive care unit (PICU) of a university hospital during the 10 years from January 1990 to May 2000. Fifty four children (1%) with anticholinesterase insecticide poisoning were identified. Presenting features, route of exposure, treatment, complications, and mortality were recorded. Data were analysed by the Fisher's exact and Mann-Whitney tests. RESULTS: More children than expected were from a rural area (46% versus 25%). Decontamination occurred in 50% of children prior to PICU admission. Enteral exposure was most common (n = 27; 50%). Median pseudocholinesterase level was 185 IU/l (range 75-7404). Median total dose of atropine required to maintain mydriasis was 0.3 mg/kg (range 0.03-16.7) over a median of 10 hours (range 1-160). Complications included coma (31%), seizures (30%), shock (9%), arrhythmias (9%), and respiratory failure requiring ventilation (35%). No significant differences were detected in incidence of seizures, cardiac arrhythmias, respiratory failure, mortality, duration of ventilation, or PICU stay, according to route of exposure, or state of decontamination. Four children died (7%). Mortality was associated with the presence of a cardiac arrhythmia (likelihood ratio 8.3) and respiratory failure (likelihood ratio 3.3). CONCLUSION: The mortality and morbidity of severe anticholinesterase insecticide poisoning in childhood is not related to route of exposure, or to delay in decontamination. However, the presence of either a cardiac arrhythmia or respiratory failure is associated with a poor prognosis.