101
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De Boeck K, Bulteel V, Tiddens H, Wagner T, Fajac I, Conway S, Dufour F, Smyth AR, Lee T, Sermet I, Kassai B, Elborn S. Guideline on the design and conduct of cystic fibrosis clinical trials: the European Cystic Fibrosis Society-Clinical Trials Network (ECFS-CTN). J Cyst Fibros 2011; 10 Suppl 2:S67-74. [PMID: 21658644 DOI: 10.1016/s1569-1993(11)60010-6] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
We describe the rationale for disease specific research networks in general as well as the aims and function of the European Cystic Fibrosis Society-Clinical Trials Network (ECFS-CTN) specifically. The ECFS-CTN was founded in 2009 with the aim of improving the quality and quantity of clinical research in the area of cystic fibrosis (CF) in Europe. A network of 18 clinical trial sites in 8 European countries was established according to uniform state-of-the-art quality criteria. To support the ECFS-CTN in the acquisition, planning and conduct of clinical trials, the network is equipped with a coordinating centre, steering and executive committees, and committees for protocol review, standardization, training and networking as well as a data safety monitoring board. A strong partnership with European CF patient parent organizations aims to increase awareness of the need for efficient clinical research and the participation of patients in clinical trials.
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Affiliation(s)
- K De Boeck
- Department of Pediatrics, University Hospital of Leuven, Leuven, Belgium.
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102
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Ranganathan SC, Davis SD, Rosenfeld M. Monitoring of Structure and Function in Early Cystic Fibrosis Lung Disease. PEDIATRIC ALLERGY IMMUNOLOGY AND PULMONOLOGY 2011; 24:133-137. [DOI: 10.1089/ped.2011.0079] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
- Sarath C. Ranganathan
- Department of Respiratory Medicine, Royal Children's Hospital Melbourne, Parkville, Victoria, Australia
- Brighton and Sussex Medical School, Brighton, United Kingdom
- Infection and Immunity, Murdoch Children's Research Unit, Melbourne, Victoria, Australia
- Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
| | | | - Margaret Rosenfeld
- Seattle Children's Hospital and University of Washington, Seattle, Washington
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103
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Stick SM, Sly PD. Exciting new clinical trials in cystic fibrosis: infants need not apply. Am J Respir Crit Care Med 2011; 183:1577-8. [PMID: 21693709 DOI: 10.1164/rccm.201102-0251ed] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
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104
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Lesnick BL, Davis SD. Infant pulmonary function testing: overview of technology and practical considerations--new current procedural terminology codes effective 2010. Chest 2011; 139:1197-1202. [PMID: 21540218 DOI: 10.1378/chest.10-1423] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
Infant pulmonary function testing has evolved from a research technique into a diagnostic tool. As such, new current procedural terminology (CPT) codes have been created and are available for use as of January 1, 2010. The technology now available has a range of applications. Through a series of vignettes, this article illustrates the methodology of the tests, some of their applications, and how to code and bill for the procedures.
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Affiliation(s)
- Burton L Lesnick
- From Georgia Pediatric Pulmonary Associates, Atlanta, GA; Morehouse School of Medicine, Chapel Hill, NC.
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105
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Pillarisetti N, Williamson E, Linnane B, Skoric B, Robertson CF, Robinson P, Massie J, Hall GL, Sly P, Stick S, Ranganathan S. Infection, Inflammation, and Lung Function Decline in Infants with Cystic Fibrosis. Am J Respir Crit Care Med 2011; 184:75-81. [DOI: 10.1164/rccm.201011-1892oc] [Citation(s) in RCA: 217] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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106
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Stafler P, Davies JC, Balfour-Lynn IM, Rosenthal M, Bush A. Bronchoscopy in cystic fibrosis infants diagnosed by newborn screening. Pediatr Pulmonol 2011; 46:696-700. [PMID: 21365781 DOI: 10.1002/ppul.21434] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2010] [Revised: 12/12/2010] [Accepted: 12/16/2010] [Indexed: 11/07/2022]
Abstract
BACKGROUND There is evidence of early functional and structural changes in babies with cystic fibrosis (CF) diagnosed on newborn screening (NBS). The aim of the present study was to determine the yield of bronchoalveolar lavage (BAL) microbiology and cytology, and 24 hr pH monitoring in a group of CF infants diagnosed on NBS. METHODS Infants referred to a tertiary pediatric respiratory center between July 2007 and November 2009 underwent surveillance fiber-optic bronchoscopy (FOB), BAL, and insertion of a 24 hr dual pH probe under a single general anesthetic. RESULTS We studied 33 infants, median age of 100 days (47-215 days) at the time of FOB. In 9 of 33 (27%) bacterial organisms were identified. Seven of the nine patients (78%) were asymptomatic and only one had had a positive cough swab prior to FOB. Neutrophilia was identified in 18/27 (67%) cases with a median of 11% (6-73%). 13/31 (42%) had an abnormal pH study with a pH index >12%. CONCLUSIONS The high yield of microbiology, cytology, and pH probe investigations in NBS infants justifies invasive surveillance. Longitudinal studies to determine if early aggressive treatment results in improved outcome are awaited.
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Affiliation(s)
- Patrick Stafler
- Department of Paediatric Respiratory Medicine, Royal Brompton Hospital, London, UK
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107
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Lum S, Stocks J. Reply: To PMID 20648666. Pediatr Pulmonol 2011; 46:519-20. [PMID: 21438175 DOI: 10.1002/ppul.21406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2010] [Accepted: 09/15/2010] [Indexed: 11/07/2022]
Affiliation(s)
- Sooky Lum
- UCL Institute of Child Health, London, Portex Unit: Respiratory Physiology and Medicine, London, UK.
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108
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Óscar Fielbaum C. Avances en fibrosis quística. REVISTA MÉDICA CLÍNICA LAS CONDES 2011. [DOI: 10.1016/s0716-8640(11)70407-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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109
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Cohen-Cymberknoh M, Shoseyov D, Kerem E. Managing cystic fibrosis: strategies that increase life expectancy and improve quality of life. Am J Respir Crit Care Med 2011; 183:1463-71. [PMID: 21330455 DOI: 10.1164/rccm.201009-1478ci] [Citation(s) in RCA: 200] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
The survival of patients with cystic fibrosis (CF) continues to improve. The discovery and cloning of the CFTR gene more than 21 years ago led to the identification of the structure and function of the CFTR chloride channel. New therapies based on the understanding of the function of CFTR are currently under development. The better clinical status and improved survival of patients with CF is not only a result of understanding of the molecular mechanisms of CF but also a result of the development of therapeutic strategies that are based on insights into the natural course of the disease. Current CF treatments that target respiratory infections, inflammation, mucociliary clearance, and nutritional status are associated with improved pulmonary function and reduced exacerbations. Patients benefit from treatment at a specialized CF center by a multidisciplinary dedicated team with emphasis being placed on frequent visits, periodic testing, and monitoring adherence to therapy. The purpose of this review is to survey recent developments in CF care that are responsible for the improved survival and quality of life of patients with CF.
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Affiliation(s)
- Malena Cohen-Cymberknoh
- Department of Pediatrics and CF Center, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
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110
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Reix P, Bellon G. Mucoviscidose, les stratégies actuelles ne préviennent pas l’atteinte respiratoire : il faut intervenir plus tôt chez les nourrissons dépistés ! Arch Pediatr 2011; 18:125-7. [DOI: 10.1016/j.arcped.2010.10.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2010] [Accepted: 10/08/2010] [Indexed: 11/29/2022]
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111
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Accurso FJ, Moss RB, Wilmott RW, Anbar RD, Schaberg AE, Durham TA, Ramsey BW. Denufosol tetrasodium in patients with cystic fibrosis and normal to mildly impaired lung function. Am J Respir Crit Care Med 2010; 183:627-34. [PMID: 21169471 DOI: 10.1164/rccm.201008-1267oc] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
RATIONALE Intervention for cystic fibrosis lung disease early in its course has the potential to delay or prevent progressive changes that lead to irreversible airflow obstruction. Denufosol is a novel ion channel regulator designed to correct the ion transport defect and increase the overall mucociliary clearance in cystic fibrosis lung disease by increasing chloride secretion, inhibiting sodium absorption, and increasing ciliary beat frequency in the airway epithelium independently of cystic fibrosis transmembrane conductance regulator genotype. OBJECTIVES To evaluate the efficacy and safety of denufosol in patients with cystic fibrosis who had normal to mildly impaired lung function characteristic of early cystic fibrosis. METHODS A total of 352 patients greater than or equal to 5 years old with cystic fibrosis who had FEV(1) greater than or equal to 75% of predicted normal were randomized to receive inhaled denufosol, 60 mg, or placebo three times daily in a Phase 3, randomized, double-blind, placebo-controlled, 24-week trial. MEASUREMENTS AND MAIN RESULTS Main outcome measures included change in FEV(1) from baseline to Week 24 endpoint and adverse events. Mean change from baseline to Week 24 endpoint in FEV(1) (primary efficacy endpoint) was 0.048 L for denufosol (n = 178) and 0.003 L for placebo (n = 174; P = 0.047). No significant differences between groups were observed for secondary endpoints including exacerbation rate and other measures of lung function. Denufosol was well tolerated with adverse event and growth profiles similar to placebo. CONCLUSIONS Denufosol improved lung function relative to placebo in cystic fibrosis patients with normal to mildly impaired lung function. Clinical trial registered with www.clinicaltrials.gov (NCT00357279).
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Affiliation(s)
- Frank J Accurso
- University of Colorado Denver, 13123 East 16th Avenue, B395, Aurora, CO 80045.
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112
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Stocks J, Modi N, Tepper R. Need for Healthy Control Subjects when Assessing Lung Function in Infants with Respiratory Disease. Am J Respir Crit Care Med 2010; 182:1340-2. [DOI: 10.1164/rccm.201008-1338ed] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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113
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Rock MJ, Sharp JK. Cystic fibrosis and CRMS screening: what the primary care pediatrician should know. Pediatr Ann 2010; 39:759-68. [PMID: 21162484 DOI: 10.3928/00485713-20101117-06] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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114
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Lum S, Hoo AF, Hulskamp G, Wade A, Stocks J. Potential misinterpretation of infant lung function unless prospective healthy controls are studied. Pediatr Pulmonol 2010; 45:906-13. [PMID: 20648666 DOI: 10.1002/ppul.21255] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
UNLABELLED SUMMARY RATIONALE: Reliable interpretation of pulmonary function tests relies on appropriate reference data, which remain very limited for infants. OBJECTIVES This study aimed to assess the validity of published reference equations for forced expiratory flow-volume (FEFV) data in infants when using current, commercially available equipment, and how this could impact on interpretation of results from infants with lung disease. METHODS The Jaeger Masterscreen BabyBody (v4.67) equipment was used to perform partial and raised volume FEFV maneuvers in healthy infants and those with cystic fibrosis (CF). Results were initially expressed as Z-scores using published reference equations. Multilevel modeling was used to calculate differences, if any, from predicted scores in healthy infants. RESULTS Data were available from 66 healthy full term infants on 89 test occasions; [median (range) postnatal age 49.4 (12-101) weeks. All FEFV outcomes were significantly lower than predicted, with mean (SD) Z-score differences of -0.4 (1.1) for FVC; -0.6 (1.0) for FEV(0.5); -1.0 (1.0) for FEF(25-75) and -1.4 (1.1) for V'(maxFRC). After adjustments using multilevel modeling, mean Z-scores were within 0.1 (SD approximately 1.0) predicted for all outcomes in healthy infants. Among 50 infants with CF, studied on 85 test occasions, results were "abnormal" (<-1.96 Z-scores) on 35 (41%) and 37 (45%) test occasions for FEV(0.5) and FEF(25-75), respectively, when using published equations. This fell to 24 (28%) and 20 (24%), respectively, after adjustment. CONCLUSIONS Dependence on published equations for interpreting FEFV data in infants may lead to misinterpretation of lung function status, which could impact adversely both in the research setting and on clinical management. Use of a contemporary control group or establishment of equipment-specific reference data is essential for meaningful interpretation of infant lung function data.
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Affiliation(s)
- Sooky Lum
- Portex Unit, Respiratory Physiology and Medicine, UCL, Institute of Child Health, London, UK.
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115
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Davis SD, Rosenfeld M, Kerby GS, Brumback L, Kloster MH, Acton JD, Colin AA, Conrad CK, Hart MA, Hiatt PW, Mogayzel PJ, Johnson RC, Wilcox SL, Castile RG. Multicenter evaluation of infant lung function tests as cystic fibrosis clinical trial endpoints. Am J Respir Crit Care Med 2010; 182:1387-97. [PMID: 20622043 DOI: 10.1164/rccm.200908-1236oc] [Citation(s) in RCA: 79] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE The conducting of clinical trials in infants with cystic fibrosis (CF) has been hindered by lack of sensitive outcome measures. OBJECTIVES To evaluate safety, feasibility, and ability to detect abnormalities in lung function of serial pulmonary function tests (PFTs) in infants with CF. METHODS Multicenter observational study using a commercial device, rigorous training, ongoing quality control, and over-reading of data by an independent panel. Raised volume rapid thoracoabdominal compression technique and plethysmography were performed at enrollment and at 6 and 12 months, with an additional 1-month reproducibility visit. MEASUREMENTS AND MAIN RESULTS A total of 342 procedures were performed in 100 infants with CF at 10 centers. FRC measurements were acceptable at a higher proportion of study visits (89%) than raised volume (72%) or fractional lung volume (68%) measurements. Average Z scores for many parameters differed significantly from historical control values. Mean (95% confidence interval) Z scores were: -0.52 (-0.78 to -0.25) for forced expiratory flow at 75% (FEF₇₅) for FVC; 1.92 (1.39-2.45) for FRC; 1.22 (0.68-1.76) for residual volume; 0.87 (0.60-1.13) for FRC/total lung capacity; and 0.66 (0.27-1.06) for residual volume/total lung capacity. For future multicenter clinical trials using infant PFTs as primary endpoints, minimum detectable treatment effects are presented for several sample sizes. CONCLUSIONS In this 10-center study, key PFT measures were significantly different in infants with CF than in historical control subjects. However, infant PFTs do not yet appear ready as primary efficacy endpoints for multicenter clinical trials, particularly at inexperienced sites, based on acceptability rates, variability, and potentially large sample sizes required to detect reasonable treatment effects.
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Affiliation(s)
- Stephanie D Davis
- Department of Pediatrics, North Carolina Children’s Hospital, University of North Carolina at Chapel Hill, USA.
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116
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Inhaled medication and inhalation devices for lung disease in patients with cystic fibrosis: Three areas for future research. J Cyst Fibros 2010; 9:296-7. [PMID: 20435528 DOI: 10.1016/j.jcf.2010.03.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2009] [Revised: 03/23/2010] [Accepted: 03/24/2010] [Indexed: 11/21/2022]
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117
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Ghdifan S, Couderc L, Michelet I, Leguillon C, Masseline B, Marguet C. Bolus methylprednisolone efficacy for uncontrolled exacerbation of cystic fibrosis in children. Pediatrics 2010; 125:e1259-64. [PMID: 20385626 DOI: 10.1542/peds.2009-2042] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
We present here the clinical course of 4 children with cystic fibrosis, deltaF508/deltaF508, who were admitted with severe respiratory distress and in whom no improvement was obtained by intensive antibiotic therapy and systemic corticosteroids. Chest computed-tomography scans showed hyperinflation and atelectasis. The severity of these exacerbations was explained neither by visible mucus plugging nor by allergic bronchopulmonary aspergillosis. We hypothesized that these clinical features were related to a severe inflammatory process in small airways. Therefore, a high-dose short course of methylprednisolone (1 g/1.73 m(2) per day for 3 days) was given; all the patients' conditions were dramatically improved, and the therapy was safe. To our knowledge, this is the first reported use of bolus methylprednisolone in the treatment of uncontrolled pulmonary exacerbation in children with cystic fibrosis.
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Affiliation(s)
- Sufian Ghdifan
- CF Reference Centre, Charles Nicolle University Hospital, Rouen, France
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118
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Pillarisetti N, Linnane B, Ranganathan S. Early bronchiectasis in cystic fibrosis detected by surveillance CT. Respirology 2010; 15:1009-11. [PMID: 20456672 DOI: 10.1111/j.1440-1843.2010.01765.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
There is emerging evidence that cystic fibrosis lung disease begins early in infancy. Newborn screening allows early detection and surveillance of pulmonary disease and the possibility of early intervention in this life-shortening condition. We report two children with cystic fibrosis who underwent a comprehensive assessment from diagnosis that included measurement of lung function, limited-slice high-resolution CT and BAL performed annually. Early aggressive surveillance enabled significant lung disease and bronchiectasis to be detected during the first few years of life and led to a change in management, highlighting a clinical role for CT scanning during the preschool years in children with cystic fibrosis.
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Affiliation(s)
- Naveen Pillarisetti
- Department of Respiratory Medicine, Royal Children's Hospital, Melbourne, Victoria, Australia
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119
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120
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Morris MG. Comprehensive integrated spirometry using raised volume passive and forced expirations and multiple-breath nitrogen washout in infants. Respir Physiol Neurobiol 2010; 170:123-40. [PMID: 19897058 PMCID: PMC2858579 DOI: 10.1016/j.resp.2009.10.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2009] [Revised: 10/29/2009] [Accepted: 10/29/2009] [Indexed: 12/15/2022]
Abstract
With the rapid somatic growth and development in infants, simultaneous accurate measurements of lung volume and airway function are essential. Raised volume rapid thoracoabdominal compression (RTC) is widely used to generate forced expiration from an airway opening pressure of 30 cmH(2)O (V(30)). The (dynamic) functional residual capacity (FRC(dyn)) remains the lung volume most routinely measured. The aim of this study was to develop comprehensive integrated spirometry that included all subdivisions of lung volume at V(30) or total lung capacity (TLC(30)). Measurements were performed on 17 healthy infants aged 8.6-119.7 weeks. A commercial system for multiple-breath nitrogen washout (MBNW) to measure lung volumes and a custom made system to perform RTC were used in unison. A refined automated raised volume RTC and the following two novel single maneuvers with dual volume measurements were performed from V(30) during a brief post-hyperventilation apneic pause: (1) the passive expiratory flow was integrated to produce the inspiratory capacity (IC) and the static (passive) FRC (FRC(st)) was estimated by initiating MBNW after end-passive expiration; (2) RTC was initiated late during passive expiration, flow was integrated to produce the slow vital capacity ((j)SVC) and the residual volume (RV) was measured by initiating MBNW after end-expiration while the jacket (j) was inflated. Intrasubject FRC(dyn) and FRC(st) measurements overlapped (p=0.6420) but neither did with the RV (p<0.0001). Means (95% confidence interval) of FRC(dyn), IC, FRC(st), (j)SVC, RV, forced vital capacity and tidal volume were 21.2 (19.7-22.7), 36.7 (33.0-40.4), 21.2 (19.6-22.8), 40.7 (37.2-44.2), 18.1 (16.6-19.7), 40.7 (37.1-44.2) and 10.2 (9.6-10.7)ml/kg, respectively. Static lung volumes and capacities at V(30) and variables from the best forced expiratory flow-volume curve were dependent on age, body length and weight. In conclusion, we developed a comprehensive physiologically integrated approach for in-depth investigation of lung function at V(30) in infants.
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Affiliation(s)
- Mohy G Morris
- Department of Pediatrics, Pulmonary Medicine Section, College of Medicine, University of Arkansas for Medical Sciences, Arkansas Children's Hospital Research Institute, Little Rock, AR 72202, USA.
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121
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Tiddens HAWM, Donaldson SH, Rosenfeld M, Paré PD. Cystic fibrosis lung disease starts in the small airways: can we treat it more effectively? Pediatr Pulmonol 2010; 45:107-17. [PMID: 20082341 DOI: 10.1002/ppul.21154] [Citation(s) in RCA: 135] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
The aims of this article are to summarize existing knowledge regarding the pathophysiology of small airways disease in cystic fibrosis (CF), to speculate about additional mechanisms that might play a role, and to consider the available or potential options to treat it. In the first section, we review the evidence provided by pathologic, physiologic, and imaging studies suggesting that obstruction of small airways begins early in life and is progressive. In the second section we discuss how the relationships between CF transmembrane conductance regulator (CFTR), ion transport, the volume of the periciliary liquid layer and airway mucus might lead to defective mucociliary clearance in small airways. In addition, we discuss how chronic endobronchial bacterial infection and a chronic neutrophilic inflammatory response increase the viscosity of CF secretions and exacerbate the clearance problem. Next, we discuss how the mechanical properties of small airways could be altered early in the disease process and how remodeling can contribute to small airways disease. In the final section, we discuss how established therapies impact small airways disease and new directions that may lead to improvement in the treatment of small airways disease. We conclude that there are many reasons to believe that small airways play an important role in the pathophysiology of (early) CF lung disease. Therapy should be aimed to target the small airways more efficiently, especially with drugs that can correct the basic defect at an early stage of disease.
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Affiliation(s)
- Harm A W M Tiddens
- Department of Pediatric Pulmonology and Allergology, Erasmus MC-Sophia, Rotterdam, the Netherlands.
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122
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Borowitz D, Robinson KA, Rosenfeld M, Davis SD, Sabadosa KA, Spear SL, Michel SH, Parad RB, White TB, Farrell PM, Marshall BC, Accurso FJ. Cystic Fibrosis Foundation evidence-based guidelines for management of infants with cystic fibrosis. J Pediatr 2009; 155:S73-93. [PMID: 19914445 PMCID: PMC6324931 DOI: 10.1016/j.jpeds.2009.09.001] [Citation(s) in RCA: 270] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Newborn screening for cystic fibrosis (CF) offers the opportunity for early medical and nutritional intervention that can lead to improved outcomes. Management of the asymptomatic infant diagnosed with CF through newborn screening, prenatal diagnosis, or sibling screening is different from treatment of the symptomatically diagnosed individual. The focus of management is on maintaining health by preventing nutritional and respiratory complications. The CF Foundation convened a committee to develop recommendations based on a systematic review of the evidence and expert opinion. These guidelines encompass monitoring and treatment recommendations for infants diagnosed with CF and are intended to help guide families, primary care providers, and specialty care centers in the care of infants with CF.
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123
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Marshall BC, Campbell PW. Improving the care of infants identified through Cystic Fibrosis newborn screening. J Pediatr 2009; 155:S71-2. [PMID: 19914444 DOI: 10.1016/j.jpeds.2009.09.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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124
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Current World Literature. Curr Opin Pulm Med 2009; 15:638-44. [DOI: 10.1097/mcp.0b013e3283328a80] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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125
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126
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Rodrigues R, Magalhaes P, Fernandes M, Gabetta C, Ribeiro A, Pedro K, Valdetaro F, Santos J, Souza RD, Pazin Filho A, Maciel L. Neonatal screening for cystic fibrosis in São Paulo State, Brazil: a pilot study. Braz J Med Biol Res 2009; 42:973-8. [DOI: 10.1590/s0100-879x2009005000017] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2008] [Accepted: 07/16/2009] [Indexed: 11/22/2022] Open
Affiliation(s)
| | | | | | | | | | - K.P. Pedro
- Associação de Pais e Amigos dos Excepcionais, Brasil
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127
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Davies JC, Alton EW. Monitoring respiratory disease severity in cystic fibrosis. Respir Care 2009; 54:606-17. [PMID: 19393105 DOI: 10.4187/aarc0493] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Measurements of disease severity provide a guide for the physician to tailor therapies, for the patient and family to gauge progress, and are required for clinical trials. For many respiratory diseases, including cystic fibrosis, sensitive, noninvasive measurements are few, and some of those that are available are applicable only to certain subgroups of patients or lack sufficient sensitivity. We discuss currently available measurements in 4 groups: physiology, infection, inflammation, and radiology. For each group we highlight strengths and weaknesses, ask how we could improve upon these, and provide details of alternative methods.
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Affiliation(s)
- Jane C Davies
- Department of Gene Therapy, Imperial College, Emmanuel Kaye Building, Manresa Road, London SW3 6NP, United Kingdom.
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Peterson-Carmichael SL, Harris WT, Goel R, Noah TL, Johnson R, Leigh MW, Davis SD. Association of lower airway inflammation with physiologic findings in young children with cystic fibrosis. Pediatr Pulmonol 2009; 44:503-11. [PMID: 19382221 DOI: 10.1002/ppul.21044] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND The relationship between lower airway markers of inflammation and infection with physiologic findings is poorly understood in young children with cystic fibrosis (CF). The goal of this study was to evaluate the association of bronchoalveolar lavage fluid (BALF) markers of infection and inflammation, including mediators linked to airway remodeling, to infant lung function values in young children with CF undergoing clinically indicated bronchoscopy. METHODS Plethysmography and the raised volume rapid thoracoabdominal compression (RVRTC) technique were performed in 16 sedated infants and young children with CF prior to bronchoscopy. BALF was collected and analyzed for pathogen density, cell count, % neutrophils, transforming growth factor beta 1 (TGF-beta(1)), matrix metalloproteinases (MMP), and interleukin-8 (IL-8). RESULTS There was a significant direct correlation between functional residual capacity (FRC), the ratio of residual volume to total lung capacity (RV/TLC) and FRC/TLC with % neutrophils (P < 0.05). Forced expiratory flows were inversely correlated to % neutrophils (P < 0.01). Lung function parameters did not differentiate those with and without lower airway infection; however, pathogen density directly correlated with FRC and inversely correlated with flows (P < 0.05). In a subset of the population, MMP-2 directly correlated with RV/TLC and inversely correlated with flows (P < 0.05) and TGF-beta(1) directly correlated with FRC (P < 0.05). CONCLUSIONS Results from this study suggest that lower airway inflammation as well as mediators linked to airway remodeling play an active role in pulmonary deterioration in CF infants and young children undergoing clinically indicated bronchoscopy.
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Affiliation(s)
- Stacey L Peterson-Carmichael
- Division of Pulmonology, Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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Sly PD, Brennan S, Gangell C, de Klerk N, Murray C, Mott L, Stick SM, Robinson PJ, Robertson CF, Ranganathan SC. Lung disease at diagnosis in infants with cystic fibrosis detected by newborn screening. Am J Respir Crit Care Med 2009; 180:146-52. [PMID: 19372250 DOI: 10.1164/rccm.200901-0069oc] [Citation(s) in RCA: 406] [Impact Index Per Article: 27.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE The promise of newborn screening (NBS) for cystic fibrosis (CF) has not been fully realized, and the extent of improvement in respiratory outcomes is unclear. We hypothesized that significant lung disease was present at diagnosis. OBJECTIVES To determine the extent of lung disease in a geographically defined population of infants with CF diagnosed after detection by NBS. METHODS Fifty-seven infants (median age, 3.6 mo) with CF underwent bronchoalveolar lavage and chest computed tomography (CT) using a three-slice inspiratory and expiratory protocol. MEASUREMENTS AND MAIN RESULTS Despite the absence of respiratory symptoms in 48 (84.2%) of infants, a substantial proportion had lung disease with bacterial infection detected in 12 (21.1%), including Staphylococcus aureus (n = 4) and Pseudomonas aeruginosa (n = 3); neutrophilic inflammation (41. 4 x 10(3) cells/ml representing 18.7% of total cell count); proinflammatory cytokines, with 44 (77.2%) having detectable IL-8; and 17 (29.8%) having detectable free neutrophil elastase activity. Inflammation was increased in those with infection and respiratory symptoms; however, the majority of those infected were asymptomatic. Radiologic evidence of structural lung disease was common, with 46 (80.7%) having an abnormal CT; 11 (18.6%) had bronchial dilatation, 27 (45.0%) had bronchial wall thickening, and 40 (66.7%) had gas trapping. On multivariate analysis, free neutrophil elastase activity was associated with structural lung disease. Most children with structural lung disease had no clinically apparent lung disease. CONCLUSIONS These data support the need for full evaluation in infancy and argue for new treatment strategies, especially those targeting neutrophilic inflammation, if the promise of NBS for CF is to be realized.
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Affiliation(s)
- Peter D Sly
- Division of Clinical Sciences, Telethon Institute for Child Health Research, PO Box 855, W. Perth, WA 6872, Australia.
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Affiliation(s)
- Felix Ratjen
- University of Toronto, Division of Respiratory Medicine, The Hospital for Sick Children, 555 University Avenue, Toronto ON M5G1X8, Canada.
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