Lung function in children following repair of tracheoesophageal fistula

Pulmonary outcome of esophageal atresia patients and its potential causes in early childhood

INTRODUCTION

The aim of this study was to illustrate the pulmonary long term outcome of patients with repaired esophageal atresia and to further examine causes and correlations that might have led to this outcome.

METHODS

Twenty-seven of 62 possible patients (43%) aged 5-20years, with repaired esophageal atresia were recruited. Body plethysmography and spirometry were performed to evaluate lung function, and the Bruce protocol treadmill exercise test to assess physical fitness. Results were correlated to conditions such as interpouch distance, gastroesophageal reflux or duration of post-operative mechanical ventilation.

RESULTS

Seventeen participants (63%) showed abnormal lung function at rest or after exercise. Restrictive ventilatory defects (solely restrictive or combined) were found in 11 participants (41%), and obstructive ventilatory defects (solely obstructive or combined) in 13 subjects (48%). Twenty-two participants (81%) performed the Bruce protocol treadmill exercise test to standard. The treadmill exercise results were expressed in z-score and revealed to be significantly below the standard population mean (z-score=-1.40). Moreover, significant correlations between restrictive ventilatory defects and the interpouch distance; duration of post-operative ventilation; gastroesophageal reflux disease; plus recurrent aspiration pneumonia during infancy; were described.

CONCLUSION

It was shown that esophageal atresia and associated early complications have significant impact on pulmonary long term outcomes such as abnormal lung function and, in particular restrictive ventilatory defects. Long-running and regular follow-ups of patients with congenital esophageal atresia are necessary in order to detect and react to the development and progression of associated complications such as ventilation disorders or gastroesophageal reflux disease.

LEVEL OF EVIDENCE

Prognosis study, Level II.

Longitudinal Follow-up of Chronic Pulmonary Manifestations in Esophageal Atresia: A Clinical Algorithm and Review of the Literature

In the past decades improved surgical techniques and better neonatal supportive care have resulted in reduced mortality of patients with esophageal atresia (EA), with or without tracheoesophageal fistula, and in increased prevalence of long-term complications, especially respiratory manifestations. This integrative review describes the techniques currently used in the pediatric clinical practice for assessing EA-related respiratory disease. We also present a novel algorithm for the evaluation and surveillance of lung disease in EA. A total of 2813 articles were identified, of which 1451 duplicates were removed, and 1330 were excluded based on review of titles and abstracts. A total of 32 articles were assessed for eligibility. Six reviews were excluded, and 26 original studies were assessed. Lower respiratory tract infection seems frequent, especially in the first years of life. Chronic asthma, productive cough, and recurrent bronchitis are the most common respiratory complaints. Restrictive lung disease is generally reported to prevail over the obstructive or mixed patterns, and, overall, bronchial hyperresponsiveness can affect up to 78% of patients. At lung imaging, few studies detected bronchiectasis and irregular cross-sectional shape of the trachea, whereas diffuse bronchial thickening, consolidations, and pleural abnormalities were the main chest X-ray findings. Airway endoscopy is seldom included in the available studies, with tracheomalacia and tracheobronchial inflammation being described in a variable proportion of cases. A complete diagnostic approach to long-term respiratory complications after EA is mandatory. In the presence of moderate-to-severe airway disease, patients should undergo regular tertiary care follow-up with functional assessment and advanced chest imaging.

Multidisciplinary care of children with repaired esophageal atresia and tracheoesophageal fistula

OBJECTIVES

Children with congenital esophageal atresia with tracheoesophageal fistula (TEF) require complex medical and surgical care, but few guidelines exist to guide the long term care of this population. The purpose of this study is to describe the findings and initial management of a comprehensive aerodigestive team in order to understand the ongoing needs of children with repaired TEF.

METHODS

A retrospective chart review was performed on children with TEF who were seen in the multidisciplinary Aerodigestive Clinic at Children's Hospital Colorado. Diagnostic studies were ordered based on physician discretion.

RESULTS

Twenty-nine children with TEF were evaluated (mean age 3.8 years) between 2010 and 2014. All children had symptoms attributed to breathing, swallowing, and digestive difficulties. Less than half of the children had seen a pulmonary or gastrointestinal specialist in the past year. Tracheomalacia was diagnosed in all children who had a bronchoscopy (23/23), and the presence of dysphagia was correlated with severe tracheomalacia. 7/25 children who had a swallow study had aspiration. 7/25 children had a diagnosis of active reflux despite current management. Four patients were diagnosed with bronchiectasis as a result of the multidisciplinary evaluation.

CONCLUSION

Although all children had persistent aerodigestive symptoms, over 50% had not been seen by an appropriate subspecialist in the year prior to the clinic visit. The multidisciplinary evaluation resulted in new diagnoses of bronchiectasis and active reflux, which can both lead to long-term morbidity and mortality. Children with TEF require evaluation by multiple subspecialists to manage not only current symptoms but also long term risks. Ongoing care should be guided by protocols based on known risks. Pediatr Pulmonol. 2016;51:576-581. © 2015 Wiley Periodicals, Inc.

Impaired peripheral airway function in adults following repair of esophageal atresia

BACKGROUND

Esophageal atresia (EA) often leads to persistent symptoms and impaired respiratory function in adulthood. The role of peripheral airways in this impairment has not been previously investigated. Furthermore, asthma-like symptoms are common in these patients.

PURPOSE

The purpose of this study was to investigate pulmonary outcome, including possible peripheral airway dysfunction, perhaps missed by conventional pulmonary function tests and to see if the diagnosis asthma was accurate.

METHODS

Twenty eight patients operated for EA in Gothenburg 1968-1983 answered a questionnaire regarding respiratory symptoms and underwent pulmonary function tests. Peripheral airway function was measured by multiple breath washout.

RESULTS

22/28 (79%) patients had a history of respiratory symptoms. Abnormal peripheral airway function was found in 17 (61%) patients, while only 6 (21%) patients displayed values indicating central obstruction. Nine patients had restrictive disease. Airway hyperresponsiveness was frequent and associated with atopy and airway inflammation. However, respiratory symptoms or doctor-diagnosed asthma did not correlate with any specific lung function test abnormality.

CONCLUSION

Different lung function abnormalities are present in EA survivors, and peripheral airway disease is common. Classical asthma seems to be difficult to diagnose in this patient group. Given the high prevalence of respiratory morbidity, long-term follow-up of pulmonary function, including peripheral airway function, is warranted.

Delayed diagnosis of high proximal tracheoesophageal fistula in esophageal atresia and a novel approach to the treatment of tracheomalacia by submanubrial tracheopexy

An infant with esophageal atresia (EA) had delayed diagnosis of proximal tracheoesophageal fistula (TEF) and severe tracheomalacia. We recommend bronchoscopy via laryngeal mask or rigid bronchoscopy to rule out associated TEF in infants diagnosed with esophageal atresia, as flexible bronchoscopy via endotracheal tube may not provide complete visualization of the trachea. We also describe a novel cervical approach to tracheopexy via neck incision for treatment of associated severe tracheomalacia in this infant.

The multifactorial origin of respiratory morbidity in patients surviving neonatal repair of esophageal atresia

Esophageal atresia with or without tracheoesophageal fistula (EA ± TEF) occurs in 1 out of every 3000 births. Current survival approaches 95%, and research is therefore focused on morbidity and health-related quality of life issues. Up to 50% of neonates with EA ± TEF have one or more additional malformations including those of the respiratory tract that occur in a relatively high proportion of them and particularly of those with vertebral, anal, cardiac, tracheoesophageal, renal, and limb association. Additionally, a significant proportion of survivors suffer abnormal pulmonary function and chronic respiratory tract disease. The present review summarizes the current knowledge about the nature of these symptoms in patients treated for EA ± TEF, and explores the hypothesis that disturbed development and maturation of the respiratory tract could contribute to their pathogenesis.

Long-term results of esophageal atresia: Helsinki experience and review of literature

Esophageal atresia (EA) affects one in 2,840 newborns, and over half have associated anomalies that typically affect the midline. After EA repair in infancy, gastroesophageal reflux (GER) and esophageal dysmotility and respiratory problems are common. Significant esophageal morbidity associated with EA extends into adulthood. Surgical complications, increasing age, and impaired esophageal motility predict the development of epithelial metaplasia after repair of EA. To date, worldwide, six cases of esophageal cancer have been reported in young adults treated for EA. According to our data, the statistical risk for esophageal cancer is not higher than 500-fold that of the general population. However, the overall cancer incidence among adults with repaired EA does not differ from that of the general population. Adults with repaired EA have had significantly more respiratory symptoms and infections, as well as more asthma and allergies than does the general population. Nearly half the patients have bronchial hyperresponsiveness. Thoracotomy-induced rib fusion and gastroesophageal reflux-associated columnar epithelial metaplasia are the most significant risk factors for the restrictive ventilatory defect that occurs in over half the patients. Over half the patients with repaired EA are likely to develop scoliosis. Risk for scoliosis is 13-fold after repair of EA in relation to that of the general population. Nearly half of the patients have had vertebral anomalies predominating in the cervical spine, and of these, most were vertebral fusions. The natural history of spinal deformities seems, however, rather benign, with spinal surgery rarely indicated.

Long-term respiratory symptoms following oesophageal atresia

Background

Oesophageal atresia (OA) is a congenital malformation that can lead to persistent respiratory symptoms in adulthood.

Aim

To describe the prevalence of respiratory symptoms in adulthood in a population-based study of patients with repaired OA and to compare this with the prevalence in the general population.

Methods

Of 80 patients operated for OA in Gothenburg in 1968–1983, 79 were located. The patients received a questionnaire on respiratory symptoms. Controls were 4979 gender- and age-matched subjects who answered the same questions.

Results

The questionnaire was answered by 73 of 79 (92%) patients. Physician-diagnosed asthma was reported by 30% in the OA group vs 10% in the control group (OR 4.1; 95% CI 2.4–6.8), and recurrent wheeze in 29% vs 5.5% (OR 6.9; 4.1–11.6). Also wheeze during the last year, asthma medication, a long-standing cough, cough with sputum production and chronic bronchitis were significantly more common among the patients with OA. In contrast, there was no significant difference regarding risk factors for asthma. The prevalence of respiratory symptoms did not appear to decrease with age.

Conclusion

A high prevalence of respiratory symptoms remains among adult patients with repaired OA. Many of the patients had an asthma diagnosis. However, asthma heredity or allergic rhinitis was not overrepresented.

Pulmonary function impairment after trachea-esophageal fistula: a minor role for gastro-esophageal reflux disease

BACKGROUND

Long-term impairment of pulmonary function in trachea-esophageal fistula (TEF) patients is, at least in part, commonly ascribed to gastro-esophageal reflux disease (GERD). The objective of this study was to examine the independent effects of the underlying condition and GERD on cardiopulmonary function.

METHODS

Cardiopulmonary function of TEF patients, who had (severe) GERD (s-GERD) requiring antireflux surgery (TEF + GERD, n = 11) and TEF patients who did not have s-GERD (group TEF-GERD, n = 20) were compared with control patients who had isolated s-GERD requiring antireflux surgery (group GERD, n = 13). All patients performed spirometry, lung volume measurements, measurement of diffusion capacity and maximal cardiopulmonary exercise testing (CPET).

RESULTS

Mean age of the participants was 13.8 ± 2.7 (group TEF + GERD). 13.2 ± 2.9 (group TEF-GERD), and 14.7 ± 1.5 years (group GERD). FVC and TLC were significantly lower in patients with TEF (with and without s-GERD) when compared to patients with isolated s-GERD. Most pulmonary function parameters were similarly affected in both TEF groups, but FEV(1) was lower in the TEF + GERD group than in the TEF-GERD group. Cardiopulmonary exercise parameters were similar in all groups.

CONCLUSIONS

TEF patients had restrictive lung function impairment when compared to patients with isolated s-GERD. This difference may be due to several causes, including thoracotomy. FEV(1) was lower in TEF + GERD when compared to TEF-GERD indicating that GERD may affect large airway function in TEF patients. Other differences between TEF patients with and without s-GERD were not significant, suggesting only a minor role for GERD.

Longitudinal follow-up of bronchial inflammation, respiratory symptoms, and pulmonary function in adolescents after repair of esophageal atresia with tracheoesophageal fistula

OBJECTIVE

To characterize symptoms, pulmonary function tests (PFT) and bronchial responsiveness (BR) in adolescents after repaired esophageal atresia with tracheoesophageal fistula and correlate these with endobronchial biopsy findings.

STUDY DESIGN

After a primary operation, 31 patients underwent endoscopies and bronchoscopies at the age of <3, 3 to 7, and >7 years. A questionnaire on respiratory and esophageal symptoms was sent to patients at a mean age of 13.7 years (range, 9.7-19.4). The questionnaire was completed by 27 of 31 patients (87%), and 25 of the 31 patients (81%) underwent clinical examination and pulmonary functioning tests. Endobronchial biopsies were analyzed for reticular basement membrane (RBM) thickness and inflammatory cells.

RESULTS

The prevalence of current respiratory and esophageal symptoms was 41% and 44%, respectively. "Doctor-diagnosed asthma" was present in 22% of patients. A restrictive and obstructive spirometric defect was observed in 32% and 30% of patients, respectively. Increased bronchial responsiveness, detected in 24% of patients, was weakly associated with current respiratory symptoms and low forced vital capacity. Mean exhaled nitric oxide was within predicted range. RBM thickness increased slightly with age, whereas inflammatory cell counts varied from normal to moderate, with intraindividual variation.

CONCLUSION

Inflammation of the airways in adolescents with a history of tracheoesophageal fistula, even in the presence of atopy, does not lead, in most cases, to the type of chronic inflammation and RBM changes seen in asthma.

Long-term complications of congenital esophageal atresia and/or tracheoesophageal fistula

Congenital esophageal atresia (EA) and/or tracheoesophageal fistula (TEF) are common congenital anomalies. Respiratory and GI complications occur frequently, and may persist lifelong. Late complications of EA/TEF include tracheomalacia, a recurrence of the TEF, esophageal stricture, and gastroesophageal reflux. These complications may lead to a brassy or honking-type cough, dysphagia, recurrent pneumonia, obstructive and restrictive ventilatory defects, and airway hyperreactivity. Aspiration should be excluded in children and adults with a history of EA/TEF who present with respiratory symptoms and/or recurrent lower respiratory infections, to prevent chronic pulmonary disease.

Respiratory function in childhood following repair of oesophageal atresia and tracheoesophageal fistula

AIM

To determine the relation between respiratory function in infancy and at school age in children who have undergone oesophageal atresia and tracheoesophageal fistula repair, and assess the value of infant respiratory function testing; and to examine the effect of bronchodilators.

METHOD

Fourteen children (6 girls, and 8 boys) who had undergone respiratory function testing in infancy were retested at school age (7-12 years). Measurements included lung volume, airways resistance, peak flow, and spirometry. Clinical problems were investigated by questionnaire. Twelve children had repeat measurements after taking salbutamol.

RESULTS

Predominant complaints were non-productive cough and dysphagia, but even those children with major problems in infancy reported few restrictions at school or in sport or social activities. Respiratory function and clinical findings at school age appeared unrelated to status in infancy, such that even the patients with severe tracheomalacia requiring aortopexy did not have lung function testing suggestive of malacia at school age. Most patients showed a restrictive pattern of lung volume which would appear to result from reduced lung growth after surgery rather than being a concomitant feature of the primary congenital abnormality. Although six children reported wheeze and four had a diagnosis of asthma, only one responded to salbutamol. This suggests that a tendency to attribute all lower respiratory symptoms to asthma may have led to an overdiagnosis of this condition in this patient group.

CONCLUSION

Respiratory function testing in infancy is of limited value in medium term prognosis, but may aid management of contemporary clinical signs. In children respiratory function testing is valuable in assessing suspected asthma and effects of bronchodilators.

Late pulmonary function following repair of tracheoesophageal fistula or esophageal atresia

Although tracheoesophageal fistula and esophageal atresia (TEF-EA) are surgically correctable, late respiratory complications have been reported. We administered a respiratory and gastrointestinal symptom questionnaire and performed standard pulmonary function tests (PF T's) and methacholine challenge testing on an unselected group of 25 subjects with TEF-EA who underwent surgery at our institution between 1963 and 1985. Results were compared to predicted normals, as well as 10 sibling controls. While the mean values of lung function test results for the TEF-EA group were within the normal range, they were significantly different from their siblings. Thirteen of the 25 TEF-EA group (52%), but none (0%) of the controls, had abnormal pulmonary function. This was classified as restrictive in 9 (36%), obstructive in 3 (12%), and mixed in 1. In addition, airway hyperreactivity [defined as a positive methacholine challenge (PC20 < or = 8 mg/mL)], was found in 6 of 18 TEF-EA subjects and 4 of the 9 controls who were evaluated. Comparison of TEF-EA subjects with normal and abnormal PFTs showed no difference in the incidence of tracheomalacia, esophageal strictures or dilatation, recurrent pneumonias, or gastroesophageal reflux. The respiratory symptom score in the subjects and controls was similar, and did not correlate with abnormal pulmonary function. The cause of the pulmonary function abnormalities remains unexplained.

Lung function abnormalities in repaired oesophageal atresia and tracheo-oesophageal fistula

BACKGROUND

Respiratory complications are common after neonatal repair of oesophageal atresia and tracheo-oesophageal fistula. The prevalence of lung function abnormalities and the relation between gastrointestinal complications and lung function has not been studied in a large number of patients.

METHODS

Lung volumes and flow-volume loops were measured in 155 patients without spinal curvature aged 6-37 years who had undergone surgery for oesophageal atresia and tracheo-oesophageal fistula.

RESULTS

Sixty four of the 155 patients had evidence of mild lower airways disease, with values for FEV1 more than two standardised scores below the predicted value in 39 (25%) and above 2 standardised scores for the residual volume (RV)/total lung capacity (TLC) ratio in 64 (41%). Restrictive lung disease (TLC more than 2 standardised scores below predicted) was present in 28 (18%). Severe lung function abnormalities were present in under 10% of the 155. Half the subjects had some evidence of extra-thoracic tracheal obstruction, with a high ratio of expiratory to inspiratory flow for peak flow in 76 (50%) and at 50% of vital capacity in 59 (38%). Patients with radiological gastro-oesophageal reflux in early childhood had more airways obstruction and smaller lung volumes. Patients with current gastrointestinal symptoms were similar in their lung function to symptom free patients.

CONCLUSIONS

Minor lung function abnormalities are common in patients after repair of oesophageal atresia. Early diagnosis and management of gastro-oesophageal reflux may help to minimise these lung function abnormalities.

The trachea and esophagus after repair of esophageal atresia and distal fistula: computed tomographic observations

Five patients, whose esophageal atresia and distal tracheoesophageal fistula had been repaired in infancy, were examined by computed tomography at age 2 to 21 because of recurrent or persistent tracheal or esophageal problems. Their tracheas generally failed to have the roughly circular cross-sectional shape found in controls. The pars membranacea was often unusually broad, with much more section-to-section variation in area than in controls. Change in cross-sectional area with respiratory phase, in the one patient assessed, was much greater than in a control. These tracheal abnormalities help to explain the tracheal symptoms found in these and similar patients. Their esophagi contained much air and fluid.

Adults who survived repair of congenital oesophageal atresia and tracheo-oesophageal fistula

One hundred and twenty five adults who were born before 1969 with oesophageal atresia or tracheo-oesophageal fistula or both and were managed at the Royal Children's Hospital, Melbourne, were reviewed. Most enjoyed a normal life. Though over half had difficulties in swallowing and symptoms of gastro-oesophageal reflux, the symptoms occurred only occasionally and were regarded as inconsequential by most. One third of the patients had wheeze and a quarter had at least one episode of bronchitis a year, but these interfered little with daily activities. Overall, these results are encouraging for young patients with oesophageal atresia and their families.

Etiologic factors in long-term respiratory function abnormalities following esophageal atresia repair

Recurrent respiratory illnesses are frequent in infants following repair of esophageal atresia and functional abnormalities of respiratory and esophageal function are often seen in older children. Recurrent aspiration is a potential cause of these respiratory abnormalities, but a relationship between abnormalities of gastrointestinal and respiratory mechanics has not been adequately investigated. We sought an association between lower esophageal sphincter (LES) incompetence, gastroesophageal reflux (GER), and respiratory function abnormalities in 18 subjects (age 12 to 21 years) following repair of esophageal atresia (Vogt type 111B). In each subject, measurements were made of spirometry, lung volumes assessed by plethysmography, esophageal manometry recorded using a constantly infused fluid-filled trilumen catheter to assess LES pressure and esophageal motility, and esophageal pH monitoring to detect GER. Subjects were grouped according to the presence or absence of a radiologically supported diagnosis of pneumonia in the first 4 years of life. Lung volumes were mildly but significantly decreased in the "pneumonia" group compared with the "nonpneumonia" group. There was no association between abnormalities of respiratory function and abnormal LES pressure or the presence of GER. These data suggest that pneumonia in esophageal atresia infants is associated with mild long-term lung damage. LES dysfunction and GER do not appear to play a major role in this process.

Long-term evaluation of esophageal and pulmonary function in patients with repaired esophageal atresia and tracheoesophageal fistula

Patients who have undergone repair of esophageal atresia and tracehoesophageal fistula as infants have been noted to have residual esophageal dysmotility and pulmonary dysfunction during their childhood years. However, limited information is available about the long-term follow-up of these patients. In this study we performed esophageal and pulmonary function studies on 12 adults who had required surgical repair of these defects in the first week of life. Most patients had symptoms of dysphagia and heartburn at time of evaluation. Pathologic gastroesophageal reflux was documented in 67% of patients and esophagitis was noted in 34%. All patients had esophageal motility abnormalities characterized by low-amplitude nonperistaltic waves throughout most of the esophagus. In addition, although most patients had no respiratory symptoms, mild restrictive lung volumes were noted in many patients. However, airflow obstruction and airway hyperreactivity were not present. These data demonstrate that clinical symptoms and abnormal esophageal manometry and pulmonary function persist well into the third and beginning of the fourth decade after repair of esophageal atresia and tracheoesophageal fistula in infancy.

Pulmonary function in older children and young adults with gastroesophageal reflux

A wide variety of types of pulmonary diseases and respiratory symptoms have been associated with gastroesophageal reflux (GER). Asthma, chronic bronchitis, bronchiectasis, and pulmonary fibrosis have all been linked to GER, but causal mechanisms have been difficult to establish. To characterize pulmonary function abnormalities in older children and young adults (age 7-23 years) with GER, lung function was evaluated in 22 patients being treated for reflux. The patients were divided into two groups: nine subjects (Group 1) had no history of pulmonary symptoms. Thirteen subjects (Group 2) had known pulmonary disease; all had diagnosed asthma, and five had a history of recurrent pneumonia. Lung volumes and spirometry were measured. Airway reactivity was assessed by measuring change in flows following isocapneic hyperventilation of subfreezing air. The presence of "small airway" disease was assessed by air-helium flow volume curves and the single breath oxygen test. Lung size, as indicated by measurement of total lung capacity, was normal in all patients. Flow rates, density dependence of maximal expiratory flow, single breath oxygen test, and tests of airway reactivity were abnormal only in Group 2 patients and were normal in the Group 1 patients. That not all children with GER have abnormal pulmonary function suggests that, if there is a causal relationship between GER and lung disease, it is multi-factorial in nature. Children with GER who do have lung disease have evidence of airway obstruction, maldistribution of ventilation, and increased airway reactivity, but do not have restricted lung volumes.

Pulmonary assessment of children after chlamydial pneumonia of infancy

We evaluated the pulmonary status of 18 children 7 to 8 years after their hospitalization for chlamydial pneumonia of infancy. Pulmonary function tests (PFTs) and respiratory questionnaire results in this group were compared with those in a control group of 19 comparable children from the same community, and with values that other investigators have reported for normal children. Significant limitations of expiratory airflow were found (FEV1, FEV1/FVC, PEF, and FEF 25%-75%), as well as signs of abnormally elevated volumes of trapped air (FRC and RV/TLC ratios). These obstructive patterns were responsive to inhalation of isoproterenol. Moreover, a significantly greater number of patients had physician-diagnosed asthma than in the control group. The obstructive PFT abnormalities could not be accounted for by recognized risk factors, such as exposure to smoking at home or family history of atopy. Our results show that chlamydial pneumonia of infancy is associated with PFT abnormalities and respiratory symptoms 7 to 8 years after recovery from the acute illness.

Residual small airways lesions after kerosene pneumonitis in early childhood

To assess residual lung damage after a single insult early in life, we studied 14 asymptomatic children, 10 years after an episode of kerosene pneumonitis. Immediately after kerosene ingestion all patients developed pulmonary symptoms. Eight had abnormal chest radiographs (group 1) whereas in six there were no radiographical changes (group 2). The average age at follow-up was 11.4 (range: 9.4-13.2). Lung volumes, expiratory flow-rates and their density dependence were measured and compared to an age, sex, and a height-matched control group. The volume of isoflow (Viso V) was significantly higher in patients in group 1 (27.75% +/- 6.7) when compared to group 2 (5.48% +/- 3.56) or controls (5.63% +/- 2.31) (P less than 0.02). The mean delta V max 50 was 13.5% +/- 3 for group 1, and 27.9% +/- 4.11 for group 2 (P less than 0.005). Airway reactivity assessed by an exercise test was normal in all children. Four of the eight patients from group 1 still had abnormal chest radiographs 10 years after kerosene pneumonitis. Thus, subclinical, prolonged small airway abnormalities after kerosene pneumonitis seem to be related to the severity of the acute insult.

Symptoms, atopy, and bronchial reactivity after lower respiratory infection in infancy

We studied the prevalence of subsequent respiratory symptoms and the relation between atopic status and bronchial reactivity in 200 index children and their controls 7 years after acute lower respiratory tract infections in infancy. Index children with recurrent symptoms differed from controls in respect of social and family characteristics and atopic background. Ventilatory function was diminished and bronchial reactivity increased. Symptom free index children also came from poorer environmental backgrounds, but did not otherwise differ from controls. 'Atopic' index children differed significantly from controls in respect of subsequent symptoms and ventilatory function and similar adverse trends were observed in 'non-atopic' index children. A comparable proportion of 'atopic' and 'non-atopic' index children showed bronchial reactivity (33.5% and 38.9% respectively). Index subgroups with and without bronchial reactivity had increased cough and wheeziness compared with respective matched controls. The former included children with 'established' asthma and the latter those with 'established' bronchitis. Atopic backgrounds were similar in both subgroups, with no differences between cases and controls. These findings suggest that atopic background and bronchial reactivity are not closely related but may contribute independently to the persistence of symptoms after respiratory infections in infancy. Bronchial reactivity may be a more useful basis than atopic status on which to separate children with episodic cough or wheeze, or both, into 'asthmatic' and 'bronchitic' subgroups.

Pulmonary function following staphylococcal pneumonia in children

Twenty three subjects with proven staphylococcal pneumonia (19 with empyema) were studied 12-25 years after the original infection. Clinical radiological, and lung function status and airway response to histamine inhalation was assessed. No clinical or radiological changes resulted from the original staphylococcal infection. No subject had physiological evidence of chronic lung disease and there was no evidence of an increased incidence of airways hyperreactivity.

Long term pulmonary consequences of oesophageal atresia with tracheo-oesophageal fistula

Lung function was studied in 20 children, aged 8-17 years, who had successfully repaired oesophageal atresia with tracheo-oesophageal fistula. Spirometry and plethysmography showed mild restrictive lung disease. Airways obstruction was assessed using maximal expiratory and inspiratory flow-volume loops in air and after breathing a helium-oxygen mixture. Analysis of the flow-volume data demonstrated significant obstruction at the level of the trachea and little evidence of small airways disease. Bronchial hyperreactivity, as assessed by histamine challenge, was present in 22% of subjects. Respiratory and oesophageal symptoms were common, but decreased in frequency with increasing age. The mechanisms involved in the frequent respiratory symptoms these children suffer are discussed in the light of the physiological findings.

Wheezing, asthma, and pulmonary dysfunction 10 years after infection with respiratory syncytial virus in infancy

Of the 180 children admitted to hospitals in Tyneside in the first year of life with proved respiratory syncytial virus lower respiratory tract infection, 130 were seen for review 10 years later and 34 of the remaining 50 children accounted for. Skin tests, lung function tests, and histamine-challenge and exercise tests for bronchial lability were undertaken in over 100 of the index children and a similar number of control children. A total of 55 (42%) of the 130 index children had had further episodes of wheeze, while only 21 (19%) out of 111 controls had ever wheezed; but few (6.2% v 4.5%) had troublesome symptoms at the age of 10. There was a threefold increase in the incidence of bronchial lability in the index children but no excess of atopy. Maximum expiratory air flow was reduced throughout the vital capacity manoeuvre in the index children, even when those with a history of recurrent wheeze were excluded. Results of single-breath nitrogen washout tests were normal, however, suggesting that ventilation was not appreciably uneven, even though expiratory flow was restricted. These differences might have been caused by infection damaging the growing lung but might also be explained by pre-existing differences in the airway, rendering certain children more susceptible to symptomatic infection when first challenged by the virus in infancy.

Pulmonary function abnormalities in survivors of near drowning

To determine the pulmonary status of children surviving near-drowning accidents, we studied the pulmonary function of ten asymptomatic children 6 months to 8.5 years (mean 3.3 years) after the accident. All ten children had normal FEF max, FVC, FEV1/FVC, FEF 50%, FRC, and RV/TLC. However, six patients had an elevated VisoV and five of these had a reduced delta Vmax 50%, indicating peripheral airway disease. Seventy percent of the patients had bronchial hyperactivity. Only one patient had completely normal pulmonary function. These results indicate that near drowning results in large and small airway dysfunction in children with no predisposition to lung disease, which may be present years after the initial insult. Such children may be at increased risk of developing chronic lung disease, especially if exposed to known airway irritants such as cigarette smoke.