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Mondardini MC, Pezzato S, Meneghini L, Agostiniani R, De Cassai A, D'Errico I, Minardi C, Sagredini R, Sbaraglia F, Testoni C, Toni F, Vason M, Amigoni A. Procedural sedation and analgesia in pediatric diagnostic and interventional radiology: An expert DELPHI consensus document developed by the ITALIAN scientific society of anesthesia, analgesia, resuscitation and intensive care (SIAARTI). Paediatr Anaesth 2024. [PMID: 38808388 DOI: 10.1111/pan.14936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Revised: 05/09/2024] [Accepted: 05/13/2024] [Indexed: 05/30/2024]
Abstract
BACKGROUND Children undergoing diagnostic and interventional radiology procedures often require sedation to achieve immobility and analgesia if the procedure is painful. In the past decades, leading scientific organizations have developed evidence-based guidelines for procedural sedation and analgesia in children outside of the operating room. Their recommendations are being applied to procedural sedation in radiology. However, some questions remain open regarding specific aspects contextualized to the radiology setting, such as elective prone sedation, the urgency of the procedure, when venous access or airway protection is required, and others. AIMS To address the unresolved issues of procedural sedation and analgesia in pediatric diagnostic and interventional radiology. METHODS An expert panel of pediatricians, pediatric anesthesiologists, intensivists, and neuroradiologists selected topics representative of current controversies and formulated research questions. Statements were developed by reviewing the literature for new evidence, comparing expertise and experience, and expressing opinions. Panelists' agreement with the statements was collected anonymously using the DELPHI method. RESULTS Twelve evidence-based or expert opinion incorporate are presented, considering risks, benefits, and applicability. CONCLUSIONS This consensus document, developed by a multidisciplinary panel of experts involved in the field, provides statements to improve the quality of decision-making practice in procedural sedation and analgesia in pediatric radiology.
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Affiliation(s)
| | - Stefano Pezzato
- Intensive Care Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Luisa Meneghini
- Department of Pediatric Surgery, University Hospital of Padova, Padova, Italy
| | | | - Alessandro De Cassai
- Department of Medicine, Anaesthesia and Intensive Care Unit, University Hospital of Padova, Padova, Italy
| | - Ignazio D'Errico
- Department of Neuroradiology, University Hospital of Padova, Padova, Italy
| | - Carmelo Minardi
- Department of Anesthesiology, AOU Policlinico-Vittorio Emanuele, University of Catania, Catania, Italy
| | - Raffaella Sagredini
- Institute for Maternal and Child Health, IRCCS Burlo Garofolo, Trieste, Italy
| | - Fabio Sbaraglia
- Department of Anesthesia and Intensive Care, Fondazione Policlinico Gemelli IRCCS, Sacro Cuore Catholic University, Rome, Italy
| | - Caterina Testoni
- IRCCS, Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Francesco Toni
- IRCCS, Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Milo Vason
- Department of Emergency, Anaesthesiology and Intensive Care Unit, Arcispedale Sant'Anna, University of Ferrara, Cona, Italy
| | - Angela Amigoni
- Pediatric Intensive Care Unit, University Hospital of Padova, Padova, Italy
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2
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Ozdemir S, Ayyildiz TK. The effect of video-based education program applied before children's pediatric Magnetic Resonance Imaging (MRI) on anxiety in Turkey: A randomized controlled study. J Pediatr Nurs 2024:S0882-5963(24)00111-8. [PMID: 38637174 DOI: 10.1016/j.pedn.2024.03.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Revised: 03/20/2024] [Accepted: 03/20/2024] [Indexed: 04/20/2024]
Abstract
OBJECTIVE This study is a randomized controlled trial conducted to examine the effects of a Turkish video-based education program on scanned image quality and child and parent anxiety during Magnetic Resonance Imaging (MRI). DESIGN AND METHODS The study was conducted with 66 children aged between 4 and 15 years at Zonguldak Bulent Ecevit University Health Practice and Research Hospital, between January 2019 and December 2019. A video-based educational program was applied to an intervention group before MRI. RESULTS The video-based education program reduced children's anxiety and fear (p < 0.001). The study also showed a significant reduction in parental stress (p < 0.001). The image quality in the intervention group was better than that in the control group (control group: 3.24 ± 1.20; intervention group: 4.18 ± 0.81) (p = 0.001). Significantly fewer children refused to enter the MRI room in the intervention group than in the control group (p < 0.05). CONCLUSION Child-friendly and video-based educational programs can be organized for children and parents in diagnostic and treatment procedures for children in hospitals. PRACTICE IMPLICATIONS MRI scans can be uncomfortable for children and require transport to a better-equipped hospital for sedation. They can also cause financial loss for children and their parents and disrupt facility workflow. An educational program to adjust the children and their families will improve the scanning process and its success rate.
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Affiliation(s)
- Sumeyye Ozdemir
- Zonguldak Bülent Ecevit University, Health Sciences Institute, Department of Pediatric Nursing, Zonguldak, Turkey.
| | - Tulay Kuzlu Ayyildiz
- Zonguldak Bülent Ecevit University, Faculty of Health Sciences, Department of Nursing, Zonguldak, Turkey
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Verma N, Dahake JS. Evaluating Sedation Strategies for Magnetic Resonance Imaging: A Comprehensive Review of Intravenous Fentanyl, Butorphanol, and Midazolam in Adult and Pediatric Populations. Cureus 2024; 16:e58593. [PMID: 38770500 PMCID: PMC11102870 DOI: 10.7759/cureus.58593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2024] [Accepted: 04/19/2024] [Indexed: 05/22/2024] Open
Abstract
Magnetic resonance imaging (MRI) is a critical diagnostic tool that often requires patient sedation to ensure optimal image quality and patient comfort, particularly in those with anxiety or an inability to remain still. This comprehensive review examines the efficacy, safety, and practical considerations of three commonly used intravenous sedatives, namely, fentanyl, butorphanol, and midazolam, in adult populations undergoing MRI procedures. This review highlights the pharmacological profiles, advantages, and limitations associated with each sedative agent through a detailed analysis of current literature, clinical guidelines, and practice-based evidence. Fentanyl is noted for its potent analgesic properties and rapid onset of action, making it suitable for painful procedures. Butorphanol, with its unique opioid agonist-antagonist activity, presents an alternative with a balance between analgesia and sedation, potentially offering a safer profile for certain patient populations. Midazolam, widely recognized for its anxiolytic and amnestic effects, remains a staple in managing procedure-related anxiety. The review further discusses patient selection criteria, dosing strategies, and the importance of individualized sedation planning to enhance patient experience and procedural outcomes. Future directions highlight the potential of emerging sedation agents and non-pharmacological approaches to improve patient comfort and compliance. The findings underscore the necessity for healthcare providers to adapt sedation practices to the specific needs of each patient, considering both the clinical context and the inherent characteristics of the sedative agents. This review aims to guide clinicians in selecting the most appropriate sedation strategy for adult patients undergoing MRI, optimizing patient care and diagnostic efficacy.
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Affiliation(s)
- Neeta Verma
- Anesthesiology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education & Research, Wardha, IND
| | - Janhavi S Dahake
- Anesthesiology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education & Research, Wardha, IND
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Gil LA, Knaus ME, Stanek JR, Srivatsa S, Patterson KN, Wood RJ, Minneci PC, Ranalli MA, Aldrink JH. Variability in Surveillance Strategies Following Resection of Sacrococcygeal Teratoma. J Surg Res 2024; 295:423-430. [PMID: 38070256 DOI: 10.1016/j.jss.2023.11.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 10/17/2023] [Accepted: 11/12/2023] [Indexed: 02/25/2024]
Abstract
INTRODUCTION Surveillance following sacrococcygeal teratoma (SCT) resection varies. The purpose of this study was to describe the clinical characteristics and outcomes of patients undergoing SCT resection and examine current institutional practices to detect recurrence. METHODS A single-institution retrospective review of children who underwent resection of an SCT from January 1, 2010 to December 31, 2020 was performed. Data were summarized and surveillance strategies compared between histopathologic subtypes using nonparametric methods. RESULTS Thirty six patients (75.0% female) underwent SCT removal at a median age of 8 d. Histopathology revealed 27 mature teratomas (75.0%), eight immature teratomas (22.2%), and one malignant germ cell tumor (2.8%). Median postoperative follow-up was 3.17 y (interquartile range [IQR]: 2.31-4.38 y). Patients had a median of 2.32 clinic visits per year (IQR: 2.00-2.70), alpha-fetoprotein levels were obtained at a median of 2.01 times per year (IQR: 0-1.66), and surveillance imaging was performed at a median of 2.31 times per year (IQR: 0-2.84). Patients with immature teratomas had alpha-fetoprotein laboratories obtained more frequently than patients with mature teratomas (3.10 times/year versus 0.93 times/year, P = 0.001). There was no significant difference in the number of imaging studies obtained between groups. Two patients (5.6%) developed recurrence, which were identified on magnetic resonance imaging at 191 and 104 d postresection, respectively. CONCLUSIONS Postoperative surveillance practices varied widely. Recurrence was noted in a single malignant case in the first year following resection. Multi-institutional studies are needed to determine the optimal surveillance strategy to detect recurrence of SCT.
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Affiliation(s)
- Lindsay A Gil
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, Ohio; Department of Pediatric Surgery, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, Ohio
| | - Maria E Knaus
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, Ohio; Department of Pediatric Surgery, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, Ohio
| | - Joseph R Stanek
- Department of Pediatric Hematology/Oncology, Nationwide Children's Hospital, Columbus, Ohio
| | - Shachi Srivatsa
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, Ohio; Department of Pediatric Surgery, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, Ohio
| | - Kelli N Patterson
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, Ohio; Department of Pediatric Surgery, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, Ohio
| | - Richard J Wood
- Department of Pediatric Surgery, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, Ohio; Department of Pediatric Colorectal and Pelvic Reconstructive Surgery, Nationwide Children's Hospital, Columbus, Ohio
| | - Peter C Minneci
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, Ohio; Department of Pediatric Surgery, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, Ohio
| | - Mark A Ranalli
- Department of Pediatric Hematology/Oncology, Nationwide Children's Hospital, Columbus, Ohio
| | - Jennifer H Aldrink
- Department of Pediatric Surgery, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, Ohio.
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Greer MLC, Gee MS, Pace E, Sotardi S, Morin CE, Chavhan GB, Jaimes C. A survey of non-sedate practices when acquiring pediatric magnetic resonance imaging examinations. Pediatr Radiol 2024; 54:239-249. [PMID: 38112762 DOI: 10.1007/s00247-023-05828-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 11/27/2023] [Accepted: 11/30/2023] [Indexed: 12/21/2023]
Abstract
BACKGROUND Improving access to magnetic resonance imaging (MRI) in childhood can be facilitated by making it faster and cheaper and reducing need for sedation or general anesthesia (GA) to mitigate motion. Some children achieve diagnostic quality MRI without GA through the use of non- practices fostering their cooperation and/or alleviating anxiety. Employed before and during MRI, these variably educate, distract, and/or desensitize patients to this environment. OBJECTIVE To assess current utilization of non-sedate practices in pediatric MRI, including variations in practice and outcomes. MATERIALS AND METHODS A survey-based study was conducted with 1372 surveys emailed to the Society for Pediatric Radiology members in February 2021, inviting one response per institution. RESULTS Responses from 50 unique institutions in nine countries revealed 49/50 (98%) sites used ≥ 1 non-sedate practice, 48/50 (96%) sites in infants < 6 months, and 11/50 (22%) for children aged 6 months to 3 years. Non-sedate practices per site averaged 4.5 (range 0-10), feed and swaddle used at 47/49 (96%) sites, and child life specialists at 35/49 (71%). Average success rates were moderate (> 50-75%) across all sites and high (> 75-100%) for 20% of sites, varying with specific techniques. Commonest barriers to use were scheduling conflicts and limited knowledge. CONCLUSION Non-sedate practice utilization in pediatric MRI was near-universal but widely variable across sites, ages, and locales, with room for broader adoption. Although on average non-sedate practice success rates were similar, the range in use and outcomes suggest a need for standardized implementation guidelines, including patient selection and outcome metrics, to optimize utilization and inform educational initiatives.
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Affiliation(s)
- Mary-Louise C Greer
- Department of Diagnostic and Interventional Radiology, The Hospital for Sick Children, Department of Medical Imaging, University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada.
| | - Michael S Gee
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Erika Pace
- Department of Radiology, Royal Marsden NHS Foundation Trust, London, England, UK
| | - Susan Sotardi
- Department of Radiology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Cara E Morin
- Department of Radiology, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Govind B Chavhan
- Department of Diagnostic and Interventional Radiology, The Hospital for Sick Children, Department of Medical Imaging, University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
| | - Camilo Jaimes
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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Inhestern L, Herrmann J, Schürmann J, Meister RL, Nawka MT, Mynarek M, Linhart D, Bergelt C. Child-centredness in paediatric magnetic resonance imaging: Information needs and experiences of children requiring magnetic resonance imaging and their parents. Child Care Health Dev 2024; 50:e13157. [PMID: 37581953 DOI: 10.1111/cch.13157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 06/30/2023] [Accepted: 07/03/2023] [Indexed: 08/17/2023]
Abstract
BACKGROUND Assessing patient experiences is essential to provide high quality health-care. The objectives of this study were to examine (1) child- and parent-reported information status before magnetic resonance imaging (MRI), (2) experiences during an MRI and (3) needs and suggestions for improvement. METHODS Children (≥8 years) and parents answered questionnaires (before and after planned MRI examination) covering mental condition, information status/needs, preparation for MRI, and potential stressors. Before MRI n = 132 accompanying parents and n = 91 children provided data (after MRI: n = 93 parents; n = 71 children). The mean age of the children undergoing MRI was 10.5 years (SD = 4.9). Children had on average seven previous MRIs before our survey (Range: 1-33). Twenty-three percent of the children were to be sedated during the examination. RESULTS Parents and children reported low to medium levels of burden, high knowledge and high information status. For the children, most stressful factors during the MRI were boredom and noise. Main information resources were the radiologists or self-searches. Parents of children with their first MRI reported higher anxiety levels in their children and stated a worse information status (main information source: self-searches/internet). Parents reported needs regarding organization of the MRI (e.g., reduction of waiting times), age-appropriate information and communication during the MRI. Children wished to visit the MRI room prior the examination (44%) and to get more information (44%). Children suggested improvements such as better sound quality of films/music, more transparency about the procedure, being in contact with a parent and shorter examinations. CONCLUSION Results suggest that preparation, information provision and care is perceived positively by families. Needs and suggestions for improvement were, for example, higher transparency of procedures, better communication and reduction of stress. Findings indicate that preparation in routine-care should follow an individualized child-focused approach, should focus on families without previous MRIs and should address children with high anxiety levels.
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Affiliation(s)
- Laura Inhestern
- Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jochen Herrmann
- Section of Pediatric Radiology, Department of Diagnostic and Interventional Radiology and Nuclear medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jana Schürmann
- Faculty of Educational Science, University of Education Freiburg, Breisgau, Germany
| | - Rieke Lisa Meister
- Section of Pediatric Radiology, Department of Diagnostic and Interventional Radiology and Nuclear medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Marie Teresa Nawka
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Martin Mynarek
- Department for Pediatric Hematology and Oncology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Mildred Scheel Cancer Career Center HaTriCS4, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Dieter Linhart
- Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department for Pediatric Hematology and Oncology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Corinna Bergelt
- Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of Medical Psychology, University Medicine Greifswald, Greifswald, Germany
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Kuwabara MS, Sitzman TJ, Szymanski KA, Perry JL, Miller JH, Cornejo P. The Pediatric Neuroradiologist's Practical Guide to Capture and Evaluate Pre- and Postoperative Velopharyngeal Insufficiency. AJNR Am J Neuroradiol 2023; 45:9-15. [PMID: 38164545 PMCID: PMC10756579 DOI: 10.3174/ajnr.a8055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 10/03/2023] [Indexed: 01/03/2024]
Abstract
Up to 30% of children with cleft palate will develop a severe speech disorder known as velopharyngeal insufficiency. Management of velopharyngeal insufficiency typically involves structural and functional assessment of the velum and pharynx by endoscopy and/or videofluoroscopy. These methods cannot provide direct evaluation of underlying velopharyngeal musculature. MR imaging offers an ideal imaging method, providing noninvasive, high-contrast, high-resolution imaging of soft-tissue anatomy. Furthermore, focused-speech MR imaging techniques can evaluate the function of the velum and pharynx during sustained speech production, providing critical physiologic information that supplements anatomic findings. The use of MR imaging for velopharyngeal evaluation is relatively novel, with limited literature describing its use in clinical radiology. Here we provide a practical approach to perform and interpret velopharyngeal MR imaging examinations. This article discusses the velopharyngeal MR imaging protocol, methods for interpreting velopharyngeal anatomy, and examples illustrating its clinical applications. This knowledge will provide radiologists with a new, noninvasive tool to offer to referring specialists.
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Affiliation(s)
- Michael S Kuwabara
- From the Radiology Department (M.S.K., J.H.M., P.C.), Phoenix Children's Hospital, Phoenix, Arizona
| | - Thomas J Sitzman
- Plastic Surgery Division (T.J.S.), Phoenix Children's Hospital, Phoenix, Arizona
| | - Kathryn A Szymanski
- Creighton University School of Medicine (K.A.S.), Phoenix Regional Campus, Phoenix, Arizona
| | - Jamie L Perry
- Department of Communication Sciences and Disorders (J.L.P.), East Carolina University, Greenville, North Carolina
| | - Jeffrey H Miller
- From the Radiology Department (M.S.K., J.H.M., P.C.), Phoenix Children's Hospital, Phoenix, Arizona
| | - Patricia Cornejo
- From the Radiology Department (M.S.K., J.H.M., P.C.), Phoenix Children's Hospital, Phoenix, Arizona
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Deng X, Zhuang D, Liu J, Su C, Huang X. Application of intelligent pacifying strategy information system in reducing short-duration MRI sedation rate in children. Sci Rep 2023; 13:19003. [PMID: 37923781 PMCID: PMC10624830 DOI: 10.1038/s41598-023-44049-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2022] [Accepted: 10/03/2023] [Indexed: 11/06/2023] Open
Abstract
Exploring and analyzing the effectiveness of an intelligent pacifying strategy information system based on assisted decision-making in reducing the sedation rate of children in short-duration magnetic resonance scans. A total of 125 children aged 3-5 years who underwent MRI scans at a children's hospital from July to December 2021 participated in this study, during which 62 children were assigned to a control group from July to September, and 63 children were assigned to an intervention group from October to December. In the intervention group, the pacifier used the intelligent pacifying strategy information system based on assisted decision-making to assess children's temperament, and utilization of a system-generated pacification plan according to assessment results. In the control group, the pacification plan was formulated by the pacifier based on their own experience and discussion with families of the participating children. The success rate of pacification, duration of pacification, and image quality of the two groups were compare. Compared with the control group, the intervention group had a higher success rate of pacification and lower duration of pacification, with statistically significant differences (P < 0.05). There was no difference in image quality between the two groups (P > 0.05). The intelligent pacifying strategy information system can help reduce the use of the sedative drugs in children aged 3-5 years who underwent a short-duration MRI scan.
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Affiliation(s)
- Xiaofang Deng
- Children's Hospital of Fudan University (Xiamen Branch), Xiamen Children's Hospital, Xiamen, China
| | - Deyi Zhuang
- Children's Hospital of Fudan University (Xiamen Branch), Xiamen Children's Hospital, Xiamen, China
- Fujian Key Laboratory of Neonatal Diseases, Xiamen, China
| | - Jungang Liu
- Children's Hospital of Fudan University (Xiamen Branch), Xiamen Children's Hospital, Xiamen, China
| | - Cuimin Su
- Jinjiang Municipal Hospital, Jinjiang, China
| | - Xianghui Huang
- Children's Hospital of Fudan University (Xiamen Branch), Xiamen Children's Hospital, Xiamen, China.
- Fujian Key Laboratory of Neonatal Diseases, Xiamen, China.
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Hayatghaibi SE, Kandil AI, Zhang B, Alves VV, Ayyala RS, Dillman JR, Trout AT. Trends in Anesthesia/Sedation for Computed Tomography and Magnetic Resonance Imaging Encounters in Pediatric Emergency Departments, 2012-2022. JAMA Pediatr 2023; 177:1105-1107. [PMID: 37578776 PMCID: PMC10425861 DOI: 10.1001/jamapediatrics.2023.2832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 05/27/2023] [Indexed: 08/15/2023]
Abstract
This cross-sectional study assesses trends over time in sedation/anesthesia use for computed tomography (CT) and magnetic resonance imaging (MRI) across pediatric emergency departments (EDs).
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Affiliation(s)
- Shireen E. Hayatghaibi
- Department of Radiology, Cincinnati Children’s Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio
| | - Ali I. Kandil
- Department of Anesthesiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Bin Zhang
- Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Vinicius V. Alves
- Department of Radiology, Cincinnati Children’s Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio
| | - Rama S. Ayyala
- Department of Radiology, Cincinnati Children’s Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio
| | - Jonathan R. Dillman
- Department of Radiology, Cincinnati Children’s Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio
| | - Andrew T. Trout
- Department of Radiology, Cincinnati Children’s Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio
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Thestrup J, Hybschmann J, Madsen TW, Bork NE, Sørensen JL, Afshari A, Borgwardt L, Berntsen M, Born AP, Aunsholt L, Larsen VA, Gjærde LK. Nonpharmacological Interventions to Reduce Sedation and General Anesthesia in Pediatric MRI: A Meta-analysis. Hosp Pediatr 2023; 13:e301-e313. [PMID: 37727937 DOI: 10.1542/hpeds.2023-007289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/21/2023]
Abstract
CONTEXT Nonpharmacological strategies are increasingly used in pediatric procedures, but in pediatric MRI, sedation and general anesthesia are still commonly required. OBJECTIVES To evaluate the effectiveness of nonpharmacological interventions in reducing use of sedation and general anesthesia in pediatric patients undergoing MRI, and to investigate effects on scan time, image quality, and anxiety. DATA SOURCES We searched Ovid Medline, CINAHL, Embase, and CENTRAL from inception through October 10, 2022. STUDY SELECTION We included randomized controlled trials and quasi-experimental designs comparing the effect of a nonpharmacological intervention with standard care on use of sedation or general anesthesia, scan time, image quality, or child and parental anxiety among infants (<2 years), children, and adolescents (2-18 years) undergoing MRI. DATA EXTRACTION Standardized instruments were used to extract data and assess study quality. RESULTS Forty-six studies were eligible for the systematic review. Limited to studies on children and adolescents, the meta-analysis included 20 studies with 33 873 patients. Intervention versus comparator analysis showed that nonpharmacological interventions were associated with reduced need for sedation and general anesthesia in the randomized control trials (risk ratio, 0.68; 95% confidence interval, 0.48-0.95; l2 = 35%) and nonrandomized studies (risk ratio, 0.58; 95% confidence interval, 0.51-0.66; l2 = 91%). The effect was largest among children aged 3 to 10 years when compared with older children and adolescents aged 11 to 18 years. LIMITATIONS There was substantial heterogeneity among nonrandomized studies. CONCLUSIONS Nonpharmacological interventions must be considered as standard procedure in infants, children, and adolescents undergoing MRI.
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Affiliation(s)
| | | | | | | | - Jette L Sørensen
- Juliane Marie Centre and Mary Elizabeth's Hospital
- Department of Clinical Medicine, Faculty of Health and Medicine Sciences
| | | | | | | | | | - Lise Aunsholt
- Neonatology
- Comparative Pediatrics and Nutrition, Department of Veterinary and Animal Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Vibeke A Larsen
- Radiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Line K Gjærde
- Juliane Marie Centre and Mary Elizabeth's Hospital
- Pediatrics and Adolescent Medicine, Neuropaediatric Unit
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11
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Saliba T, Boitsios G. Another Way to Perform a Pediatric MRI Avoiding Sedation After Hours When Anesthesia Is Less Accessible: The Skin-to-Skin Technique. Cureus 2023; 15:e46929. [PMID: 38021770 PMCID: PMC10640666 DOI: 10.7759/cureus.46929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/12/2023] [Indexed: 12/01/2023] Open
Abstract
This innovative system for conducting pediatric MRI describes a method of calming children by allowing them to rest on their accompanying adult's abdomen during the examination. This approach reduces their agitation, enabling the acquisition of diagnostic images when anesthesia is either unavailable or not advisable.
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Affiliation(s)
- Tom Saliba
- Radiology, Hôpital Universitaire des Enfants Reine Fabiola, Brussels, BEL
| | - Grammatina Boitsios
- Pediatric Neuroradiology, Hôpital Universitaire des Enfants Reine Fabiola, Brussels, BEL
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Zanette B, Greer MLC, Moraes TJ, Ratjen F, Santyr G. The argument for utilising magnetic resonance imaging as a tool for monitoring lung structure and function in pediatric patients. Expert Rev Respir Med 2023; 17:527-538. [PMID: 37491192 DOI: 10.1080/17476348.2023.2241355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 07/06/2023] [Accepted: 07/24/2023] [Indexed: 07/27/2023]
Abstract
INTRODUCTION Although historically challenging to perform in the lung, technological advancements have made Magnetic Resonance Imaging (MRI) increasingly applicable for pediatric pulmonary imaging. Furthermore, a wide array of functional imaging techniques has become available that may be leveraged alongside structural imaging for increasingly sensitive biomarkers, or as outcome measures in the evaluation of novel therapies. AREAS COVERED In this review, recent technical advancements and modern methodologies for structural and functional lung MRI are described. These include ultrashort echo time (UTE) MRI, free-breathing contrast agent-free, functional lung MRI, and hyperpolarized gas MRI, amongst other techniques. Specific examples of the application of these methods in children are provided, principally drawn from recent research in asthma, bronchopulmonary dysplasia, and cystic fibrosis. EXPERT OPINION Pediatric lung MRI is rapidly growing, and is well poised for clinical utilization, as well as continued research into early disease detection, disease processes, and novel treatments. Structure/function complementarity makes MRI especially attractive as a tool for increased adoption in the evaluation of pediatric lung disease. Looking toward the future, novel technologies, such as low-field MRI and artificial intelligence, mitigate some of the traditional drawbacks of lung MRI and will aid in improving access to MRI in general, potentially spurring increased adoption and demand for pulmonary MRI in children.
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Affiliation(s)
- Brandon Zanette
- Translational Medicine Program, The Hospital for Sick Children, Toronto, ON, Canada
| | - Mary-Louise C Greer
- Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, ON, Canada
- Department of Medical Imaging, University of Toronto, Toronto, ON, Canada
| | - Theo J Moraes
- Translational Medicine Program, The Hospital for Sick Children, Toronto, ON, Canada
- Department of Pediatrics, Hospital for Sick Children, Toronto, ON, Canada
| | - Felix Ratjen
- Translational Medicine Program, The Hospital for Sick Children, Toronto, ON, Canada
- Division of Respiratory Medicine, The Hospital for Sick Children, Toronto, ON, Canada
| | - Giles Santyr
- Translational Medicine Program, The Hospital for Sick Children, Toronto, ON, Canada
- Department of Medical Biophysics, University of Toronto, Toronto, ON, Canada
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13
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Frush DP, Callahan MJ, Coley BD, Nadel HR, Guillerman RP. Comparison of the different imaging modalities used to image pediatric oncology patients: A COG diagnostic imaging committee/SPR oncology committee white paper. Pediatr Blood Cancer 2023; 70 Suppl 4:e30298. [PMID: 37025033 PMCID: PMC10652359 DOI: 10.1002/pbc.30298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 02/24/2023] [Indexed: 04/08/2023]
Abstract
Diagnostic imaging is essential in the diagnosis and management, including surveillance, of known or suspected cancer in children. The independent and combined roles of the various modalities, consisting of radiography, fluoroscopy, ultrasonography (US), computed tomography (CT), magnetic resonance imaging (MRI), and nuclear medicine (NM), are both prescribed through protocols but also function in caring for complications that may occur during or subsequent to treatment such as infection, bleeding, or organ compromise. Use of a specific imaging modality may be based on situational circumstances such as a brain CT or MR for a new onset seizure, chest CT for respiratory signs or symptoms, or US for gross hematuria. However, in many situations, there are competing choices that do not easily lend themselves to a formulaic approach as options; these situations depend on the contributions of a variety of factors based on a combination of the clinical scenario and the strengths and limitations of the imaging modalities. Therefore, an improved understanding of the potential influence of the imaging decision pathways in pediatric cancer care can come from comparison among the individual diagnostic imaging modalities. The purpose of the following material to is to provide such a comparison. To do this, pediatric imaging content experts for the individual modalities of radiography and fluoroscopy, US, CT, MRI, and NM will discuss the individual modality strengths and limitations.
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Affiliation(s)
- Donald P. Frush
- Department of Radiology, Box 3808, Duke University Medical Center, Durham, NC 27710
| | - Michael J. Callahan
- Department of Radiology, Boston Children’s Hospital, 300 Longwood Ave, Boston, MA 02115
| | - Brian D. Coley
- Division of Radiology and Medical Imaging, 3333 Burnet Avenue MLC 15017., Children’s Hospital Medical Center, Cincinnati, OH 45229
| | - Helen R. Nadel
- Pediatric Radiology, Lucile Packard Children’s Hospital at Stanford, Stanford University School of Medicine, 725 Welch Rd, MC 5913, Palo Alto, CA 94304
| | - R. Paul Guillerman
- Department of Radiology, Texas Children’s Hospital, 6701 Fannin Street, Suite 470, Houston, TX 77030
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Turnaround time and efficiency of pediatric outpatient brain magnetic resonance imaging: a multi-institutional cross-sectional study. Pediatr Radiol 2022; 53:1144-1152. [PMID: 36526870 PMCID: PMC9758026 DOI: 10.1007/s00247-022-05563-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 10/28/2022] [Accepted: 12/01/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND Aside from single-center reports, few data exist across pediatric institutions that examine overall MRI turnaround time (TAT) and the determinants of variability. OBJECTIVE To determine average duration and determinants of a brain MRI examination at academic pediatric institutions and compare the duration to those used in practice expense relative value units (RVUs). MATERIALS AND METHODS This multi-institutional cross-sectional investigation comprised four academic pediatric hospitals. We included children ages 0 to < 18 years who underwent an outpatient MRI of the brain without contrast agent in 2019. Our outcome of interest was the overall MRI TAT derived by time stamps. We estimated determinants of overall TAT using an adjusted log-transformed multivariable linear regression model with robust standard errors. RESULTS The average overall TAT significantly varied among the four hospitals. A sedated brain MRI ranged from 158 min to 224 min, a non-sedated MRI from 70 min to 112 min, and a limited MRI from 44 min to 70 min. The most significant predictor of a longer overall TAT was having a sedated MRI (coefficient = 0.71, 95% confidence interval [CI]: 0.66-0.75; P < 0.001). The median MRI scan time for a non-sedated exam was 38 min and for a sedated exam, 37 min, approximately double the duration used by the Relative Value Scale (RVS) Update Committee (RUC). CONCLUSION We found considerable differences in the overall TAT across four pediatric academic institutions. Overall, the significant predictors of turnaround times were hospital site and MRI pathway (non-sedated versus sedated versus limited MRI).
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Gallo-Bernal S, Bedoya MA, Gee MS, Jaimes C. Pediatric magnetic resonance imaging: faster is better. Pediatr Radiol 2022:10.1007/s00247-022-05529-x. [PMID: 36261512 DOI: 10.1007/s00247-022-05529-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 08/29/2022] [Accepted: 10/03/2022] [Indexed: 10/24/2022]
Abstract
Magnetic resonance imaging (MRI) has emerged as the preferred imaging modality for evaluating a wide range of pediatric medical conditions. Nevertheless, the long acquisition times associated with this technique can limit its widespread use in young children, resulting in motion-degraded or non-diagnostic studies. As a result, sedation or general anesthesia is often necessary to obtain diagnostic images, which has implications for the safety profile of MRI, the cost of the exam and the radiology department's clinical workflow. Over the last decade, several techniques have been developed to increase the speed of MRI, including parallel imaging, single-shot acquisition, controlled aliasing techniques, compressed sensing and artificial-intelligence-based reconstructions. These are advantageous because shorter examinations decrease the need for sedation and the severity of motion artifacts, increase scanner throughput, and improve system efficiency. In this review we discuss a framework for image acceleration in children that includes the synergistic use of state-of-the-art MRI hardware and optimized pulse sequences. The discussion is framed within the context of pediatric radiology and incorporates the authors' experience in deploying these techniques in routine clinical practice.
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Affiliation(s)
- Sebastian Gallo-Bernal
- Department of Radiology, Massachusetts General Hospital, Boston, MA, USA.,Department of Radiology, Harvard Medical School, Boston, MA, USA
| | - M Alejandra Bedoya
- Department of Radiology, Harvard Medical School, Boston, MA, USA.,Department of Radiology, Boston Children's Hospital, 300 Longwood Ave., 2nd floor, Main Building, Boston, MA, 02115, USA
| | - Michael S Gee
- Department of Radiology, Massachusetts General Hospital, Boston, MA, USA.,Department of Radiology, Harvard Medical School, Boston, MA, USA
| | - Camilo Jaimes
- Department of Radiology, Harvard Medical School, Boston, MA, USA. .,Department of Radiology, Boston Children's Hospital, 300 Longwood Ave., 2nd floor, Main Building, Boston, MA, 02115, USA.
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Improving protocols for whole-body magnetic resonance imaging: oncological and inflammatory applications. Pediatr Radiol 2022:10.1007/s00247-022-05478-5. [PMID: 35982340 DOI: 10.1007/s00247-022-05478-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 06/16/2022] [Accepted: 07/29/2022] [Indexed: 10/15/2022]
Abstract
Whole-body MRI is increasingly used in the evaluation of a range of oncological and non-oncological diseases in infants, children and adolescents. Technical innovation in MRI scanners, coils and sequences have enabled whole-body MRI to be performed more rapidly, offering large field-of-view imaging suitable for multifocal and multisystem disease processes in a clinically useful timeframe. Together with a lack of ionizing radiation, this makes whole-body MRI especially attractive in the pediatric population. Indications include lesion detection in cancer predisposition syndrome surveillance and in the workup of children with known malignancies, and diagnosis and monitoring of a host of infectious and non-infectious inflammatory conditions. Choosing which patients are most likely to benefit from this technology is crucial, but so is adjusting protocols to the patient and disease to optimize lesion detection. The focus of this review is on protocols and the elements impacting image acquisition in pediatric whole-body MRI. We consider the practical aspects, from scanner and coil selection to patient positioning, single-center generic and indication-specific protocols with technical parameters, motion reduction strategies and post-processing. When optimized, collectively these lead to better standardization of whole-body MRI, and when married to systematic analysis and interpretation, they can improve diagnostic accuracy.
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Magnetic resonance imaging protocols for pediatric acute hematogenous osteomyelitis. Pediatr Radiol 2022:10.1007/s00247-022-05435-2. [PMID: 35794288 DOI: 10.1007/s00247-022-05435-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 05/17/2022] [Accepted: 06/15/2022] [Indexed: 10/17/2022]
Abstract
Pediatric musculoskeletal infection can be a challenging clinical diagnosis. MRI protocols should be tailored appropriately to diagnose and localize sites of infection, to determine alternative pathologies that could explain the child's presentation, and to identify complications that could alter treatment or lead to devastating consequences in growing bones. In this review, we discuss MRI protocols tailored for suspected acute appendicular musculoskeletal infection in children. These protocols are based on patient age in order to generally reflect the developmental stage of the child, the corresponding relevant anatomy and physiology, and the skeletal maturity-dependent physiopathology of musculoskeletal infections.
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Non-inferiority of a non-gadolinium-enhanced magnetic resonance imaging follow-up protocol for isolated optic pathway gliomas. Pediatr Radiol 2022; 52:539-548. [PMID: 34751813 DOI: 10.1007/s00247-021-05226-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 09/15/2021] [Accepted: 10/12/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Pediatric patients with optic pathway gliomas (OPGs) typically undergo a large number of follow-up MRI brain exams with gadolinium-based contrast media (GBCM), which have been associated with gadolinium tissue retention. Therefore, careful consideration of GBCM use in these children is warranted. OBJECTIVE To investigate whether GBCM is necessary for OPG MR imaging response assessment using a blinded, non-inferiority, multi-reader study. MATERIALS AND METHODS We identified children with OPG and either stable disease or change in tumor size on MRI using a regional cancer registry serving the U.S. Pacific Northwest. For each child, the two relevant, consecutive MRI studies were anonymized and standardized into two imaging sets excluding or including GBCM-enhanced images. Exam pairs were compiled from 42 children with isolated OPG (19 with neurofibromatosis type 1), from a population of 106 children with OPG. We included 28 exam pairs in which there was a change in size between exams. Seven pediatric radiologists measured tumor sizes during three blinded sessions, spaced by at least 1 week. The first measuring session excluded GBCM-enhanced sequences; the others did not. The primary endpoint was intra-reader agreement for ≥ 25% change in axial cross-product measurement, using a 12% non-inferiority threshold. RESULTS Analysis demonstrated an overall 1.2% difference (95% confidence interval, -3.2% to 5.5%) for intra-reader agreement using a non-GBCM-enhanced protocol and background variability. CONCLUSION A non-GBCM-enhanced protocol was non-inferior to a GBCM-enhanced protocol for assessing change in size of isolated OPGs on follow-up MRI exams.
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19
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Landini N, Ciet P, Janssens HM, Bertolo S, Ros M, Mattone M, Catalano C, Majo F, Costa S, Gramegna A, Lucca F, Parisi GF, Saba L, Tiddens HAWM, Morana G. Management of respiratory tract exacerbations in people with cystic fibrosis: Focus on imaging. Front Pediatr 2022; 10:1084313. [PMID: 36814432 PMCID: PMC9940849 DOI: 10.3389/fped.2022.1084313] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Accepted: 12/28/2022] [Indexed: 02/09/2023] Open
Abstract
Respiratory tract exacerbations play a crucial role in progressive lung damage of people with cystic fibrosis, representing a major determinant in the loss of functional lung tissue, quality of life and patient survival. Detection and monitoring of respiratory tract exacerbations are challenging for clinicians, since under- and over-treatment convey several risks for the patient. Although various diagnostic and monitoring tools are available, their implementation is hampered by the current definition of respiratory tract exacerbation, which lacks objective "cut-offs" for clinical and lung function parameters. In particular, the latter shows a large variability, making the current 10% change in spirometry outcomes an unreliable threshold to detect exacerbation. Moreover, spirometry cannot be reliably performed in preschool children and new emerging tools, such as the forced oscillation technique, are still complementary and need more validation. Therefore, lung imaging is a key in providing respiratory tract exacerbation-related structural and functional information. However, imaging encompasses several diagnostic options, each with different advantages and limitations; for instance, conventional chest radiography, the most used radiological technique, may lack sensitivity and specificity in respiratory tract exacerbations diagnosis. Other methods, including computed tomography, positron emission tomography and magnetic resonance imaging, are limited by either radiation safety issues or the need for anesthesia in uncooperative patients. Finally, lung ultrasound has been proposed as a safe bedside option but it is highly operator-dependent and there is no strong evidence of its possible use during respiratory tract exacerbation. This review summarizes the clinical challenges of respiratory tract exacerbations in patients with cystic fibrosis with a special focus on imaging. Firstly, the definition of respiratory tract exacerbation is examined, while diagnostic and monitoring tools are briefly described to set the scene. This is followed by advantages and disadvantages of each imaging technique, concluding with a diagnostic imaging algorithm for disease monitoring during respiratory tract exacerbation in the cystic fibrosis patient.
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Affiliation(s)
- Nicholas Landini
- Department of Radiological, Oncological and Pathological Sciences, Policlinico Umberto I Hospital, "Sapienza" Rome University, Rome, Italy
| | - Pierluigi Ciet
- Department of Radiology and Nuclear Medicine, Erasmus MC - Sophia, Rotterdam, Netherlands.,Department of Radiology, University Cagliari, Cagliari, Italy.,Department of Pediatrics, division of Respiratory Medicine and Allergology, Erasmus MC - Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Hettie M Janssens
- Department of Pediatrics, division of Respiratory Medicine and Allergology, Erasmus MC - Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Silvia Bertolo
- Department of Radiology, S. Maria Ca'Foncello Regional Hospital, Treviso, Italy
| | - Mirco Ros
- Department of Pediatrics, Ca'Foncello S. Maria Hospital, Treviso, Italy
| | - Monica Mattone
- Department of Radiological, Oncological and Pathological Sciences, Policlinico Umberto I Hospital, "Sapienza" Rome University, Rome, Italy
| | - Carlo Catalano
- Department of Radiological, Oncological and Pathological Sciences, Policlinico Umberto I Hospital, "Sapienza" Rome University, Rome, Italy
| | - Fabio Majo
- Pediatric Pulmonology & Cystic Fibrosis Unit Bambino Gesú Children's Hospital, IRCCS Rome, Rome, Italy
| | - Stefano Costa
- Department of Pediatrics, Gaetano Martino Hospital, Messina, Italy
| | - Andrea Gramegna
- Department of Pathophisiology and Transplantation, University of Milan, Milan, Italy.,Respiratory Disease and Adult Cystic Fibrosis Centre, Internal Medicine Department, IRCCS Ca' Granda, Milan, Italy
| | - Francesca Lucca
- Regional Reference Cystic Fibrosis Center, University Hospital of Verona, Verona, Italy
| | - Giuseppe Fabio Parisi
- Pediatric Pulmonology Unit, Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Luca Saba
- Department of Radiology, University Cagliari, Cagliari, Italy
| | - Harm A W M Tiddens
- Department of Radiology and Nuclear Medicine, Erasmus MC - Sophia, Rotterdam, Netherlands.,Department of Pediatrics, division of Respiratory Medicine and Allergology, Erasmus MC - Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Giovanni Morana
- Department of Radiology, S. Maria Ca'Foncello Regional Hospital, Treviso, Italy
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