The radiology of chronic lung disease in children

Chronic lung disease in paediatric patients: Does magnetic resonance imaging has a role?

Background

Pediatric chronic lung disease (CLD) refers to a range of distinct clinical and pathological disorders that affect children. High-resolution CT (HRCT) is critical for detecting and characterizing parenchymal abnormalities as well as determining their nature and distribution. Although magnetic resonance imaging (MRI) shows promising results, however, due to its poor spatial resolution and signal-to-noise ratio, imaging of the lung parenchyma remains a challenge. As a result, in addition to the initial CT, a follow-up MRI is required. The goal of this paper is to highlight the main imaging features of children with CLD and to evaluate the efficacy of MRI lungs in the diagnosis and monitoring of pediatric CLD.

Results

There was a strong positive correlation between CT and MRI, with a significant P-value. Findings of HRCT and MRI showed a qualitative agreement of 78% complete agreement. MRI helped primary diagnosis in 54% of cases compared to CT in 91% of cases.

Conclusion

MRI lungs are an equivalent technique to HRCT in assessing pediatric CLD; using the modified Helbich–Bhalla score, a strong correlation is obvious between both in the overall assessment. MRI is beneficial for case surveillance rather than primary diagnosis.

Semi-quantitative assessment optimized the grading of pulmonary aspiration on salivagram in children

OBJECTIVE

Salivagram is one of the imaging modalities to detect pulmonary aspiration in children. This study aims to optimize the classification of pulmonary aspiration detected by salivagram with a semi-quantitative analytical method.

METHODS

This is a retrospective study involving 737 patients (471 males, 266 females; aged 1 month to 8 years; mean age 5.3 months, median age 3.0 months old) with suspected pulmonary aspiration, who had salivagram done between January 2018 and June 2019. Positive cases were divided into 10 groups (Grade 1, R2, L2, R2L2, R3, L3, R3L2, R2L3, R3L3, and 4) according to the scintigraphic findings. Aspiration index was determined as the ratio of the count in the respiratory tract to the total count in the image field of view and compared among different groups using the receiver operating characteristics (ROC) curve analysis.

RESULTS

A total of 180 cases had positive scintigraphic findings of various grades of aspiration (24.4%, 180/737). There is a high consistency among the two independent nuclear medicine physicians involved in the study, in determining both the disease gradings (κ = 0.919;95% CI: 0.915-0.923) and aspiration index (ICC = 0.994;95% CI: 0.993-0.996). There is no significant difference (p > 0.05) in aspiration index among the gradings in "mild" group (grade 1, R2, L2, L2R2), and "moderate" group (grade R3, R3L2, R3L3). After dividing the different grades into "mild", "moderate" and "severe" groups, the aspiration index of "mild" group is 4.40 ± 2.01, that of "moderate" group is 16.43 ± 8.20, and that of "severe" group is 46.94 ± 14.81. Difference in groups was statistically significant (p < 0.0001). In ROC curve analysis, AUC of "mild" and "moderate" groups is 0.970 and that of "moderate" and "severe" groups is 0.943; the cut-off value with highest diagnostic efficiency is 6.75 between "mild" and "moderate" groups and 38.00 between "moderate" and "severe" groups.

CONCLUSIONS

We introduced a semi-quantitative analytical method in pulmonary aspiration on salivagram, to optimize and supplement to the current classification of pulmonary aspiration.

The use of tissue Doppler imaging in the assessment of diastolic dysfunction in children with chronic lung diseases

Background

Chronic lung diseases (CLD) in children such as bronchiectasis and interstitial lung disease represent a major public health problem with limited therapeutic options. These patients develop pulmonary hypertension (and core-pulmonale in severe cases) because of the recurrent hypoxia and chronic inflammation; which results in right heart enlargement and ventricular hypertrophy. The early identification and convenient treatment of diastolic dysfunction can prevent further complications of the disease including diastolic heart failure and death. We aim to demonstrate the usefulness of tissue Doppler imaging echocardiography (TDI) in the detection of subtle myocardial affection in interstitial lung disease and bronchiectasis as subgroups of (CLD) in children. We studied echocardiographic parameters of 40 pediatric patients with chronic lung disease using conventional M mode and tissue Doppler imaging and compared them with 40 healthy controls of matching age and sex distribution.

Results

Myocardial performance index (MPI) showed that 28 subjects had abnormal right ventricular (RV) MPI (10 with severe affection ≥ 0.6) and 21 subjects had abnormal LV MPI (11 severe affections ≥ 0.6). Thirty percent (30%) of the cases had affected lateral E/E' and 47.5% had affected septal E/E' when compared to controls. Grades of diastolic dysfunction were: 0, 1, 2, 3 in 18, 15, 6, and 1 patients, respectively. MPI LV and MPI RV showed statistically higher values in patients compared to controls (P < 0.001).

Conclusion

This study proved that TDI can accurately detect subtle myocardial dysfunction in pediatric CLD patients.

Radioaerosol Imaging Predicts the Utility of Aerosolized Antifungal Therapy in Allergic Bronchopulmonary Aspergillosis

A 10-year-old girl with a history of complicated cystic fibrosis was hospitalized for pulmonary exacerbation with allergic bronchopulmonary aspergillosis and severe right upper lobe bronchiectasis diagnosed with chest radiograph and CT. She was started on itraconazole during the hospitalization in attempt to decrease her systemic steroid dose, but she had ongoing coughing and wheezing. The possibility was raised that the right upper lobe bronchiectasis may be a nidus for ongoing aspergillosis. Radioaerosol imaging was performed to determine whether the aerosolized antifungals would reach the area of bronchiectasis.

Chronic Pulmonary Aspiration in Children: Diagnosis and Management

Chronic pulmonary aspiration (CPA) is a common cause of morbidity in children with complex aerodigestive disorders. CPA can be caused by swallowing dysfunction, anatomic, or dynamic abnormalities of the airways, and/or other circumstances that overcome the child's natural capacity to protect the airway. Diagnostic evaluation for suspected aspiration aims to characterize the swallowing function, identify the etiology of aspiration, including anatomic and/or dynamic abnormalities causing aspiration, and evaluate for the development of aspiration sequelae (e.g., bronchiectasis). CPA management approach should be guided by the recognized risk factors and co-morbidities, and directed to decrease the events of aspiration, improve clearance of aspirated material, and limit the development of aspiration sequelae (e.g., chronic inflammation and recurrent infections). This article presents a practical approach for the diagnosis and management of chronic pulmonary aspiration (CPA) in children.

Structural and perfusion magnetic resonance imaging of the lung in cystic fibrosis

BACKGROUND

Because of its absence of ionising radiation and possibility for obtaining functional information, MRI is promising for assessing lung disease in children who require repetitive imaging for long-term follow-up.

OBJECTIVE

To describe MRI findings in children with cystic fibrosis and evaluate semi-quantitative dynamic contrast-enhanced lung perfusion.

MATERIALS AND METHODS

We retrospectively compared lung MRI in 25 children and young adults with cystic fibrosis (median age 3.7 years) to 12 children (median age 2 years) imaged for other pathologies. MRI at 1.5 T included respiratory-gated sequences and contrast-enhanced lung perfusion imaging. We described and graded any morphologic change. Signal enhancement and time to peak values of perfusion abnormalities were compared to those of normally enhancing lung parenchyma.

RESULTS

Frequent findings in patients with cystic fibrosis were bronchial wall thickening (24/25, 96%), areas of consolidation (22/25, 88%), enlarged lymph nodes (20/25, 80%), bronchiectasis (5/25, 20%) and mucus plugging (3/25, 12%). Compared to normally enhancing lung, perfusion defects (21/25, 84%), characterised by decreased enhancement, showed prolonged time to peak. Areas of consolidation showed increased enhancement. While time to peak of procedure-related atelectasis was not significantly different from that of normal lung, disease-related consolidation showed prolonged time to peak (P=0.01).

CONCLUSION

Lung MRI demonstrates structural and perfusion abnormalities in children and young people with cystic fibrosis. Semi-quantitative assessment of dynamic contrast-enhanced perfusion imaging might allow differentiation between procedure-related atelectasis and disease-related consolidation.

The EGFR-ADAM17 Axis in Chronic Obstructive Pulmonary Disease and Cystic Fibrosis Lung Pathology

Chronic obstructive pulmonary disease (COPD) and cystic fibrosis (CF) share molecular mechanisms that cause the pathological symptoms they have in common. Here, we review evidence suggesting that hyperactivity of the EGFR/ADAM17 axis plays a role in the development of chronic lung disease in both CF and COPD. The ubiquitous transmembrane protease A disintegrin and metalloprotease 17 (ADAM17) forms a functional unit with the EGF receptor (EGFR), in a feedback loop interaction labeled the ADAM17/EGFR axis. In airway epithelial cells, ADAM17 sheds multiple soluble signaling proteins by proteolysis, including EGFR ligands such as amphiregulin (AREG), and proinflammatory mediators such as the interleukin 6 coreceptor (IL-6R). This activity can be enhanced by injury, toxins, and receptor-mediated external triggers. In addition to intracellular kinases, the extracellular glutathione-dependent redox potential controls ADAM17 shedding. Thus, the epithelial ADAM17/EGFR axis serves as a receptor of incoming luminal stress signals, relaying these to neighboring and underlying cells, which plays an important role in the resolution of lung injury and inflammation. We review evidence that congenital CFTR deficiency in CF and reduced CFTR activity in chronic COPD may cause enhanced ADAM17/EGFR signaling through a defect in glutathione secretion. In future studies, these complex interactions and the options for pharmaceutical interventions will be further investigated.

Clinical Characteristics and Lung Function in Older Children Vertically Infected With Human Immunodeficiency Virus in Malawi

BACKGROUND

Antiretroviral therapy (ART) has led to increased survival of children with vertically acquired human immunodeficiency virus infection. Significant morbidity arises from respiratory symptoms, but aetiology and pulmonary function abnormalities have not been systematically studied.

METHODS

Human immunodeficiency virus-positive children aged 8-16 years were systematically recruited within clinics in Blantyre, Malawi. Clinical review, quality of life assessment, spirometry, and chest radiography were performed.

RESULTS

One hundred sixty participants had a mean of age 11.1 (range, 8-16) years and 50.0% were female. Cough was present in 60 (37.5%) participants, and 55 (34.4%) had moderate or severe dyspnoea. Thirty-four (22.1%) participants had digital clubbing. Thirty-three (20.6%) participants were hypoxic at rest. One hundred eighteen (73.8%) of the children were receiving ART; median CD4 count was 698 cells/µL in these compared with 406 cells/µL in ART-naive individuals (P < .001). From 145 spirometry traces (90.6%), mean forced expiratory volume in 1 second (FEV1) and forced vital capacity (FVC) were 1.06 and 0.89 standard deviations below predicted mean, respectively. Twenty-one (14.5%) traces demonstrated obstructive defects and 26 (17.9%) reduced FVC. Lung function abnormality was not associated with any clinical findings. Of the 51 individuals with abnormal lung function, the mean increase in FEV1 after salbutamol was 3.8% (95% confidence interval, 0.02-7.53). "Tramlines" and ring shadows were seen on chest radiographs in over half of cases.

CONCLUSIONS

Symptoms of chronic lung disease were highly prevalent with 2 main clinical phenotypes: "cough" and "hypoxia". Lung function abnormalities are common, poorly responsive to bronchodilators, and apparent throughout the age range of our cohort. Pathological causes remain to be elucidated. Cough and hypoxic phenotypes could be a useful part of diagnostic algorithms if further validated.

Children with chronic lung diseases have cognitive dysfunction as assessed by event-related potential (auditory P300) and Stanford-Binet IQ (SB-IV) test

Chronic lung disease (CLD) in children represents a heterogeneous group of many clinico-pathological entities with risk of adverse impact of chronic or intermittent hypoxia. So far, few researchers have investigated the cognitive function in these children, and the role of auditory P300 in the assessment of their cognitive function has not been investigated yet. This study was designed to assess the cognitive functions among schoolchildren with different chronic pulmonary diseases using both auditory P300 and Stanford-Binet test. This cross-sectional study included 40 school-aged children who were suffering from chronic chest troubles other than asthma and 30 healthy children of similar age, gender and socioeconomic state as a control group. All subjects were evaluated through clinical examination, radiological evaluation and spirometry. Audiological evaluation included (basic otological examination, pure-tone, speech audiometry and immittancemetry). Cognitive function was assessed by auditory P300 and psychological evaluation using Stanford-Binet test (4th edition). Children with chronic lung diseases had significantly lower anthropometric measures compared to healthy controls. They had statistically significant lower IQ scores and delayed P300 latencies denoting lower cognitive abilities. Cognitive dysfunction correlated to severity of disease. P300 latencies were prolonged among hypoxic patients. Cognitive deficits in children with different chronic lung diseases were best detected using both Stanford-Binet test and auditory P300. P300 is an easy objective tool. P300 is affected early with hypoxia and could alarm subtle cognitive dysfunction.

Common respiratory conditions of the newborn

KEY POINTS

Respiratory distress is a common presenting feature among newborn infants.Prompt investigation to ascertain the underlying diagnosis and appropriate subsequent management is important to improve outcomes.Many of the underlying causes of respiratory distress in a newborn are unique to this age group.A chest radiograph is crucial to assist in diagnosis of an underlying cause.

EDUCATIONAL AIMS

To inform readers of the common respiratory problems encountered in neonatology and the evidence-based management of these conditions.To enable readers to develop a framework for diagnosis of an infant with respiratory distress. The first hours and days of life are of crucial importance for the newborn infant as the infant adapts to the extra-uterine environment. The newborn infant is vulnerable to a range of respiratory diseases, many unique to this period of early life as the developing fluid-filled fetal lungs adapt to the extrauterine environment. The clinical signs of respiratory distress are important to recognise and further investigate, to identify the underlying cause. The epidemiology, diagnostic features and management of common neonatal respiratory conditions are covered in this review article aimed at all healthcare professionals who come into contact with newborn infants.

Newer Imaging Techniques for Bronchopulmonary Dysplasia

Imaging has played a vital role in the clinical assessment of bronchopulmonary dysplasia (BPD) since its first recognition. In this review, how chest radiograph, computerized tomography (CT), nuclear medicine, and MRI have contributed to the understanding of BPD pathology and how emerging advancements in these methods, including low-dose and quantitative CT, sophisticated proton and hyperpolarized-gas MRI, influence the future of BPD imaging are discussed.

Quantitative Magnetic Resonance Imaging of Bronchopulmonary Dysplasia in the Neonatal Intensive Care Unit Environment

RATIONALE

Bronchopulmonary dysplasia (BPD) is a prevalent yet poorly characterized pulmonary complication of premature birth; the current definition is based solely on oxygen dependence at 36 weeks postmenstrual age without objective measurements of structural abnormalities across disease severity.

OBJECTIVES

We hypothesize that magnetic resonance imaging (MRI) can spatially resolve and quantify the structural abnormalities of the neonatal lung parenchyma associated with premature birth.

METHODS

Using a unique, small-footprint, 1.5-T MRI scanner within our neonatal intensive care unit (NICU), diagnostic-quality MRIs using commercially available sequences (gradient echo and spin echo) were acquired during quiet breathing in six patients with BPD, six premature patients without diagnosed BPD, and six full-term NICU patients (gestational ages, 23-39 wk) at near term-equivalent age, without administration of sedation or intravenous contrast. Images were scored by a radiologist using a modified Ochiai score, and volumes of high- and low-signal intensity lung parenchyma were quantified by segmentation and threshold analysis.

MEASUREMENTS AND MAIN RESULTS

Signal increases, putatively combinations of fibrosis, edema, and atelectasis, were present in all premature infants. Infants with diagnosed BPD had significantly greater volume of high-signal lung (mean ± SD, 26.1 ± 13.8%) compared with full-term infants (7.3 ± 8.2%; P = 0.020) and premature infants without BPD (8.2 ± 6.4%; P = 0.026). Signal decreases, presumably alveolar simplification, only appeared in the most severe BPD cases, although cystic appearance did increase with severity.

CONCLUSIONS

Pulmonary MRI reveals quantifiable, significant differences between patients with BPD, premature patients without BPD, and full-term control subjects. These methods could be implemented to individually phenotype disease, which may impact clinical care and predict future outcomes.

[Chest computed tomography in children: indications, efficiency and effective dose]

INTRODUCTION

New multidetector row computed tomography (CT) has made the imaging of younger children more feasible and extending CT indications to a wide range of pediatric respiratory diseases in the last few years. However, CT is a source of radiation exposure. The aim of this study was to evaluate the main indications and the contribution of chest CT in pediatric pulmonology as well as induced radiation.

METHODS

This was an observational, prospective study. Children whose chest CTs were analyzed during multidisciplinary meetings (radiologist, pulmonary pediatrician) were included from November 2009 to April 2010. We collected demographic data, CT results, contribution of CT to diagnosis and management, and radiation doses (dose-length product [DLP] and effective dose). Radiation doses were compared according to the CT scans (Lille University Hospital with 128-slice dual-source CT or Lille University Hospital single-source 64-slice CT, or CT performed outside the university hospital).

RESULTS

One hundred thirty-five patients were included. The mean age was 6.4 years old. The main indications were analysis of bronchial disease (44%), infectious disease (16%), interstitial disease (14%), or a malformation (9%). The aim of CT was diagnosis (61%) or follow-up of previous lung diseases (39%). Diagnosis chest-CT directly contributed to diagnosis in 48% of cases and to treatment in 24%. Follow-up CT contributed to diagnosis in 38% and treatment in 19% of cases. DLP and effective doses were significantly lower for CT performed in the university hospital, especially with the 128-slice CT compared to the others (P<0.001). The effective doses were: 128-slice CT, 0.61 mSv ± 0.32; 64-slice CT, 1.24 mSv ± 0.97; outside university hospital, 2.56 mSv ± 1.98.

CONCLUSION

This study confirms the role played by chest CT in children, which contributes to diagnosis and management of lung diseases. The main concern of CT application, especially in children, is the radiation burden. Children are more susceptible to the effects of radiation than adults and have a longer life expectancy to develop complications. Both radiologists and pediatricians should be aware of a potential risk and have to conjugate their efforts in reducing this risk. The wide range of radiation doses in this study for the same CT procedures underlines the extensive efforts still needed to limit radiation exposure in children.

The Pediatric Lung and Aspiration

This article offers an over view of lung development, physiology, and evaluation of lung damage due to aspiration. Considerations specific to pediatric patients are discussed.

Chest CT in infants and children

Computed tomography (CT) is a powerful and irreplaceable imaging technique in the evaluation of thoracic disease in infants and children. Recent advances in CT technology, with multi-detector equipment now widely available in most institutions, allowing a highly detailed evaluation of the chest in a short time period has resulted in expanding indications of chest CT in paediatric patients. Its improved diagnostic yield along with a widespread availability has also resulted in an increased number of CT examinations in children, not always with beneficial impact on patient management and outcome. Accordingly with the ALARA concept, a judicious and correct use of CT is strongly advisable in order to reduce unnecessary high dose radiation exposure. The objective of this paper is to review the use of chest CT in paediatric patients focused mainly on basic technical aspects and clinical applications in the evaluation of the lungs, mediastinum and chest wall.

Paediatric multi-detector row chest CT: what you really need to know

Background

The emergence of multi-detector row CT (MDCT) has established and extended the role of CT especially in paediatric chest imaging. This has altered the way in which data is acquired and is perceived as the 'gold standard' in the detection of certain chest pathologies. The range of available post-processing tools provide alternative ways in which CT images can be manipulated for review and interpretation in order to enhance diagnostic accuracy.

Methodology

Paediatric imaging technique/protocol together with radiation dose reduction is discussed in detail. The use of different post-processing tools to best demonstrate the wide range of important congenital anomalies and thoracic pathologies is outlined and presented pictorially.

Conclusion

MDCT with its isotropic resolution and fast imaging acquisition times reduces the need for invasive diagnostic investigations. However, users must be vigilant in their imaging techniques to minimise radiation burden, whilst maintaining good image quality.

Main Messages

• CT examinations should be clinically justified by the referring clinician and radiologist.

• MDCT is invaluable for evaluating the central airway, mediastinal structures and lung parenchyma.

• MDCT is more sensitive than plain radiographs in detection of structural changes within the lungs.

Clinical, radiological, and physiological differences between obliterative bronchiolitis and problematic severe asthma in adolescents and young adults: the early origins of the overlap syndrome?

PURPOSE

Few reports have compared chronic obstructive lung diseases (OLDs) starting in childhood.

AIMS

To describe functional, radiological, and biological features of obliterative bronchiolitis (OB) and further discriminate to problematic severe asthma (PSA) or to diagnose a group with overlapping features.

RESULTS

Patients with OB showed a greater degree of obstructive lung defect and higher hyperinflation (P < 0.001). The most frequent high-resolution computed tomography (HRCT) features (increased lung volume, inspiratory decreased attenuation, mosaic pattern, and expiratory air trapping) showed significantly greater scores in OB patients. Patients with PSA have shown a higher frequency of atopy (P < 0.05). ROC curve analysis demonstrated discriminative power for the LF variables, HRCT findings and for atopy between diagnoses. Further analysis released five final variables more accurate for the identification of a third diagnostic group (FVC%t, post-bronchodilator ΔFEV(1) in ml, HRCT mosaic pattern, SPT, and D. pteronyssinus-specific IgE).

CONCLUSIONS

We found that OB and PSA possess identifiable characteristic features but overlapping values may turn them undistinguishable.

Bronchoscopic and high-resolution CT scan findings in children with chronic wet cough

BACKGROUND

Chronic wet cough strongly suggests endobronchial infection, which, if left untreated, may progress to established bronchiectasis. Our aim was to compare the effectiveness of chest high-resolution CT (HRCT) scanning and flexible bronchoscopy (FB) in detecting airway abnormalities in children with chronic wet cough and to explore the association between radiologic and bronchoscopic/BAL findings.

METHODS

We retrospectively evaluated a selected population of 93 children (0.6-16.4 years) with wet cough for > 6 weeks who were referred to a specialized center and deemed unlikely to have asthma. All patients were submitted to hematologic investigations, chest radiographs (CXRs), HRCT scanning, and FB/BAL. HRCT scans were scored with the Bhalla method, and bronchoscopic findings of bronchitis were grouped into five grades of severity.

RESULTS

Positive HRCT scan findings were present in 70 (75.2%) patients (P = .76). A positive correlation was found between Bhalla score and duration of cough (ρ = 0.23, P = .028). FB/BAL was superior to HRCT scan in detecting abnormalities (P < .001). The Bhalla score correlated positively with type III (OR, 5.44; 95% CI, 1.92-15.40; P = .001) and type IV (OR, 8.91; 95% CI, 2.53-15.42; P = .001) bronchoscopic lesions; it also correlated positively with the percentage of neutrophils in the BAL (ρ = 0.23, P = .036).

CONCLUSIONS

HRCT scanning detected airway wall thickening and bronchiectasis, and the severity of the findings correlated positively with the length of clinical symptoms and the intensity of neutrophilic inflammation in the airways. However, HRCT scanning was less sensitive than FB/BAL in detecting airway abnormalities. The two modalities should be considered complementary in the evaluation of prolonged wet cough.

Chronic diseases of lung parenchyma in children: the role of imaging

Chronic diseases of the lung parenchyma (CDoLP) in children encompass a vast number of distinct clinico-pathological conditions. The prevalence of CDoLP has continued to increase in the last 10-15 years and the paediatric radiologist will therefore have to become more familiar with the imaging appearances of CDoLP. This review highlights some of the key imaging appearances of CDoLP, focussing mainly on airways disease. We also explore issues around technique optimisation and dose minimisation that remain of paramount importance in children.

Post-infectious bronchiolitis obliterans: can CT scan findings at early age anticipate lung function?

BACKGROUND

The image findings of post-infectious bronchiolitis obliterans (PIBO) have been described, however, we do not know if such findings can predict lung function (LF) deterioration with increasing patient age.

AIM

To assess whether computed tomography (CT) abnormalities detected at an early stage of the disease can anticipate abnormal LF a decade later in children with PIBO.

METHODS

We compared CT scans of 21 children with PIBO, done within their first 3 years of life, and their actual LF. To evaluate CT scans we used a modified Bhalla score and, for LF, FEV1 as percentage of predicted values. We calculated prevalence ratios (PRs) by comparing the proportion of patients with worst CT score and worst LF, with the proportion of those with best CT score and worst LF.

RESULTS

PR was 1.17 (CI 1.02; 1.34, P = 0.02).

CONCLUSIONS

The CT finding early in the life of children with PIBO, when assessed by the Bhalla, score seem to anticipate future LF status.

Aspiration lung disease

The term aspiration lung disease describes several clinical syndromes, with massive aspiration and chronic lung aspiration being at two extremes of the clinical spectrum. Over the years, significant advances have been made in understanding the mechanisms underlying dysphagia, gastroesophageal function, and airway protective reflexes and new diagnostic techniques have been introduced. Despite this, characterizing the presence or absence of aspiration, and under what circumstances a child might be aspirating what, is extremely challenging. Many children are still not adequately diagnosed or treated for aspiration until permanent lung damage has occurred. A multidisciplinary approach is mandatory for a correct diagnosis in addition to timely and appropriate care.

Genetic causes of bronchiectasis: primary immune deficiencies and the lung

Primary immune deficiencies (PID) comprise a heterogeneous group of genetically determined disorders that affect development and/or function of innate or adaptive immunity. Consequently, patients with PID suffer from recurrent and/or severe infections that frequently involve the lung. While the nature of the immune defect often dictates the type of pathogens that may cause lung infection, there is substantial overlap of radiological findings, so that appropriate laboratory tests are mandatory to define the nature of the immune defect and to prompt appropriate treatment. At the same time, the recent identification of a large number of PID-causing genes now allows early, even presymptomatic diagnosis, thus representing an essential tool for prevention of lung damage. This review article describes the most common forms of PID, their cellular and molecular bases, and the associated lung abnormalities, and reports on available treatment.

Paediatric Northern Score centile charts for the chest radiograph in cystic fibrosis

AIM

To create the first national centile charts for the chest radiograph Northern Score using the UK Cystic Fibrosis (CF) Database (UKCFD).

MATERIALS AND METHODS

All active patients for 2002 from the UKCFD were analysed in 1-year cohorts from 0 to 18 years. Northern Score results from the annual review forms were used to construct centile lines for the 5th, 25th, 50th, 75th, 95th centiles.

RESULTS

There were 1806 patients with recorded Northern Score data for 2002 (927 male patients, male:female ratio 1.05). The centile chart demonstrates a quasi-linear rise throughout childhood. A Northern Score in excess of age in years equates to >95th centile in school-aged CF patients.

CONCLUSION

This centile chart provides a disease-specific reference range for monitoring individual patients or for evaluating therapeutic change using the dominant chest radiograph scoring system in the UK. Patients, parents and clinicians may find these useful during the annual review process.

Lung function in infants and young children with chronic lung disease of infancy: the next steps?

Over the past year, a series of papers have reviewed the literature concerning assessment and interpretation of lung function in infants and young children with chronic lung disease of infancy. This manuscript, which represents the final paper in that series, summarizes the findings to date and highlights key areas for future research. Despite the huge literature in this field, interpretation of results and their use in guiding clinical management are still limited by difficulties in 'normalizing data' according to body size and maturation and selection of appropriate control groups. Furthermore, sensitive tests that more closely reflect the underlying pathophysiology of 'new' bronchopulmonary dysplasia, together with simple and reliable methods of assessing lung maturity at birth and true oxygen requirements at specified time points are urgently required. Research in this field is also challenged by the need to separate the independent effects of genetic predisposition, gene-environment interactions, preterm delivery, neonatal respiratory disorders and various treatment strategies on the growing lung. The extent to which disruption of lung growth following premature exposure to the extra-uterine environment leads to an earlier or more aggravated decline in respiratory function in later adult life remains to be elucidated. Whatever its origin, given the increasing survival of smaller and more immature infants, the long term sequelae of neonatal lung disease, are likely to continue to change, requiring ongoing, carefully designed longitudinal studies. Future research strategies need to encompass a multicenter, multi-disciplinary, collaborative approach with closer links between clinicians and basic scientists, to ensure that the most relevant research questions are addressed using appropriate methodology and that findings are implemented into clinical practice in a more timely fashion.