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Lin CH, Johnson LR, Chang WT, Lo PY, Chen HW, Wu HD. Quantifiable features of a tidal breathing phenotype in dogs with severe bronchomalacia diagnosed by bronchoscopy. Vet Q 2023; 43:1-10. [PMID: 37616027 PMCID: PMC10478619 DOI: 10.1080/01652176.2023.2252518] [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: 05/24/2023] [Revised: 08/17/2023] [Accepted: 08/17/2023] [Indexed: 08/25/2023] Open
Abstract
Dynamic lower airway obstruction is the primary component of canine bronchomalacia, but the ventilatory function remains underinvestigated. This prospective study analyzed tidal breathing characteristics in 28 dogs, comprising 14 with severe bronchomalacia diagnosed by bronchoscopy versus 14 without respiratory disease. Spirometry was conducted in all dogs. Bronchoscopy with bronchoalveolar lavage or brush under anesthesia was performed in 14 dogs with cough and expiratory effort. Severe bronchomalacia was defined by the severity of collapse and total number of bronchi affected. Ventilatory characteristics were compared between groups. Results revealed that dogs with severe bronchomalacia had lower minute volume (218 vs 338 mL/kg, p = .039) and greater expiratory-to-inspiratory time ratio (1.55 vs 1.35, p = .01) compared to control dogs. The tidal breathing pattern of dogs with bronchomalacia was different from that of normal dogs, and the pattern differed from the concave or flat expiratory curves typical of lower airway obstruction. Compared to control dogs, dogs with severe bronchomalacia had a significantly prolonged low-flow expiratory phase (p < .001) on the flow-time plot and a more exponential shape of the expiratory curve (p < .001) on the volume-time plot. Flow-time index ExpLF/Te (>0.14) and volume-time index Vt-AUCexp (≤31%) had a high ROC-AUC (1.00, 95% confidence interval 0.88 to 1.00) in predicting severe bronchomalacia. In conclusion, the tidal breathing pattern identified here indicates abnormal and complicated ventilatory mechanics in dogs with severe bronchomalacia. The role of this pulmonary functional phenotype should be investigated for disease progression and therapeutic monitoring in canine bronchomalacia.
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Affiliation(s)
- Chung-Hui Lin
- National Taiwan University Veterinary Hospital, National Taiwan University, Taipei, Taiwan
- Graduate Institute of Veterinary Clinical Sciences, School of Veterinary Medicine, National Taiwan University, Taipei, Taiwan
- TACS-Alliance Research Center, Taipei, Taiwan
| | - Lynelle R. Johnson
- Department of Medicine and Epidemiology, The University of California School of Veterinary Medicine, Davis, CA, USA
| | - Wei-Tao Chang
- National Taiwan University Veterinary Hospital, National Taiwan University, Taipei, Taiwan
- TACS-Alliance Research Center, Taipei, Taiwan
| | - Pei-Ying Lo
- TACS-Alliance Research Center, Taipei, Taiwan
| | - Hui-Wen Chen
- Department of Veterinary Medicine, National Taiwan University, Taipei, Taiwan
| | - Huey-Dong Wu
- Section of Respiratory Therapy, Department of Integrated Diagnostics and Therapeutics, National Taiwan University Hospital, National Taiwan University, Taipei, Taiwan
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2
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Scotney E, Fleming L, Saglani S, Sonnappa S, Bush A. Advances in the pathogenesis and personalised treatment of paediatric asthma. BMJ MEDICINE 2023; 2:e000367. [PMID: 37841968 PMCID: PMC10568124 DOI: 10.1136/bmjmed-2022-000367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 05/05/2023] [Indexed: 10/17/2023]
Abstract
The diversity of pathology of severe paediatric asthma demonstrates that the one-size-fits-all approach characterising many guidelines is inappropriate. The term "asthma" is best used to describe a clinical syndrome of wheeze, chest tightness, breathlessness, and sometimes cough, making no assumptions about underlying pathology. Before personalising treatment, it is essential to make the diagnosis correctly and optimise basic management. Clinicians must determine exactly what type of asthma each child has. We are moving from describing symptom patterns in preschool wheeze to describing multiple underlying phenotypes with implications for targeting treatment. Many new treatment options are available for school age asthma, including biological medicines targeting type 2 inflammation, but a paucity of options are available for non-type 2 disease. The traditional reliever treatment, shortacting β2 agonists, is being replaced by combination inhalers containing inhaled corticosteroids and fast, longacting β2 agonists to treat the underlying inflammation in even mild asthma and reduce the risk of asthma attacks. However, much decision making is still based on adult data extrapolated to children. Better inclusion of children in future research studies is essential, if children are to benefit from these new advances in asthma treatment.
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Affiliation(s)
- Elizabeth Scotney
- National Heart and Lung Institute, Imperial College London, London, UK
- Royal Brompton Hospital, London, UK
| | - Louise Fleming
- National Heart and Lung Institute, Imperial College London, London, UK
- Royal Brompton Hospital, London, UK
- Centre for Paediatrics and Child Health, Imperial College London, London, UK
| | - Sejal Saglani
- National Heart and Lung Institute, Imperial College London, London, UK
- Royal Brompton Hospital, London, UK
- Centre for Paediatrics and Child Health, Imperial College London, London, UK
| | - Samatha Sonnappa
- National Heart and Lung Institute, Imperial College London, London, UK
- Royal Brompton Hospital, London, UK
- Centre for Paediatrics and Child Health, Imperial College London, London, UK
| | - Andrew Bush
- National Heart and Lung Institute, Imperial College London, London, UK
- Royal Brompton Hospital, London, UK
- Centre for Paediatrics and Child Health, Imperial College London, London, UK
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Koenigs M, Young C, Lillis A, Morrison J, Kelly N, Elmaraghy C, Krishnamurthy R, Chiang T. Dynamic Volumetric Computed Tomography Angiography is an Effective Method to Evaluate Tracheomalacia in Children. Laryngoscope 2023; 133:410-416. [PMID: 35411953 PMCID: PMC10792495 DOI: 10.1002/lary.30125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 03/09/2022] [Accepted: 03/14/2022] [Indexed: 01/19/2023]
Abstract
OBJECTIVE Standard methods to evaluate tracheal pathology in children, including bronchoscopy, may require general anesthesia. Conventional dynamic proximal airway imaging in noncooperative children requires endotracheal intubation and/or medically induced apnea, which may affect airway mechanics and diagnostic performance. We describe a technique for unsedated dynamic volumetric computed tomography angiography (DV-CTA) of the proximal airway and surrounding vasculature in children and evaluate its performance compared to the reference-standard of rigid bronchoscopy. METHODS Children who had undergone DV-CTA and bronchoscopy in one-year were retrospectively identified. Imaging studies were reviewed by an expert reader blinded to the bronchoscopy findings of primary or secondary tracheomalacia. Airway narrowing, if present, was characterized as static and/or dynamic, with tracheomalacia defined as >50% collapse of the tracheal cross-sectional area in exhalation. Pearson correlation was used for comparison. RESULTS Over a 19-month period, we identified 32 children (median age 8 months, range 3-14 months) who had undergone DV-CTA and bronchoscopy within a 90-day period of each other. All studies were unsedated and free-breathing. The primary reasons for evaluation included noisy breathing, stridor, and screening for tracheomalacia. There was excellent agreement between DV-CTA and bronchoscopy for diagnosis of tracheomalacia (κ = 0.81, p < 0.001), which improved if children (n = 25) had the studies within 30 days of each other (κ = 0.91, p < 0.001). CTA provided incremental information on severity, and cause of secondary tracheomalacia. CONCLUSION For most children, DV-CTA requires no sedation or respiratory manipulation and correlates strongly with bronchoscopy for the diagnosis of tracheomalacia. LEVEL OF EVIDENCE 3 Laryngoscope, 133:410-416, 2023.
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Affiliation(s)
- Maria Koenigs
- The Warren Alpert Medical School of Brown University, Providence, U.S.A
- Department of Otolaryngology - Head and Neck Surgery, Hasbro Children's Hospital, Providence, U.S.A
| | - Cody Young
- Department of Radiology, Nationwide Children's Hospital, Columbus, U.S.A
| | - Anna Lillis
- Department of Radiology, Nationwide Children's Hospital, Columbus, U.S.A
| | - Jessica Morrison
- Department of Radiology, Nationwide Children's Hospital, Columbus, U.S.A
| | - Natalie Kelly
- Department of Otolaryngology - Head and Neck Surgery, Nationwide Children's Hospital, Columbus, U.S.A
| | - Charles Elmaraghy
- Department of Otolaryngology - Head and Neck Surgery, Nationwide Children's Hospital, Columbus, U.S.A
| | - Rajesh Krishnamurthy
- Department of Otolaryngology - Head and Neck Surgery, Nationwide Children's Hospital, Columbus, U.S.A
| | - Tendy Chiang
- Department of Otolaryngology - Head and Neck Surgery, Nationwide Children's Hospital, Columbus, U.S.A
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CT findings of non-neoplastic central airways diseases. Jpn J Radiol 2021; 40:107-119. [PMID: 34398372 DOI: 10.1007/s11604-021-01190-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Accepted: 08/10/2021] [Indexed: 01/02/2023]
Abstract
Non-neoplastic lesions of central airways are uncommon entities with different etiologies, with either focal or diffuse involvement of the tracheobronchial tree. Clinical symptoms of non-neoplastic tracheobronchial diseases are non-specific, and diagnosis is difficult, especially in the early stages. Three-dimensional computed tomography (3D-CT) is an evaluable tool as it allows to assess and characterize tracheobronchial wall lesions and meanwhile it enables the evaluation of airways surrounding structures. Multiplanar reconstructions (MPR), minimum intensity projections (MinIP), and 3D Volume Rendering (VR) (in particular, virtual bronchoscopy) also provide information on the site and of the length of airway alterations. This review will be discussed about (1) primary airway disorders, such as relapsing polychondritis, tracheobronchophathia osteochondroplastica, and tracheobronchomegaly, (2) airway diseases, related to granulomatosis with polyangiitis, Chron's disease, Behcet's disease, sarcoidosis, amyloidosis, infections, intubation and transplantation, (3) tracheobronchial malacia, and (4) acute tracheobronchial injury. 3D-CT findings, especially with MPR and 3D VR reconstructions, allows us to evaluate tracheobronchial disease morphologically in detail.
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Fayon M, Beaufils F. The lower respiratory airway wall in children in health and disease. ERJ Open Res 2021; 7:00874-2020. [PMID: 34322550 PMCID: PMC8311136 DOI: 10.1183/23120541.00874-2020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Accepted: 03/24/2021] [Indexed: 02/06/2023] Open
Abstract
Alone or in association with other lung or thorax component disorders, the airway wall (AWW) remains one of the most frequently involved elements in paediatric lung diseases. A myriad of AWW disorders will present with similar symptomatology. It is thus important for the clinician to reappraise the normal development and structure of the AWW to better understand the underlying disease patterns. We herein provide an overview of the structure of the AWW and a description of its development from the fetal period to adulthood. We also detail the most common AWW changes observed in several acute and chronic respiratory disorders as well as after cigarette smoke or chronic pollution exposure. We then describe the relationship between the AWW structure and lung function. In addition, we present the different ways of investigating the AWW structure, from biopsies and histological analyses to the most recent noninvasive airway (AW) imaging techniques. Understanding the pathophysiological processes involved in an individual patient will lead to the judicious choice of nonspecific or specific personalised treatments, in order to prevent irreversible AW damage.
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Affiliation(s)
- Michael Fayon
- Université de Bordeaux, Centre de Recherche Cardio-Thoracique de Bordeaux, INSERM U1045, Bordeaux Imaging Center, Bordeaux, France
- CHU de Bordeaux, Département de Pédiatrie, Service d'Exploration Fonctionnelle Respiratoire, Bordeaux, France
- INSERM, Centre d'Investigation Clinique (CIC1401), Bordeaux, France
| | - Fabien Beaufils
- Université de Bordeaux, Centre de Recherche Cardio-Thoracique de Bordeaux, INSERM U1045, Bordeaux Imaging Center, Bordeaux, France
- CHU de Bordeaux, Département de Pédiatrie, Service d'Exploration Fonctionnelle Respiratoire, Bordeaux, France
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Su YT, Chiu CC, Lai SH, Hsia SH, Lin JJ, Chan OW, Chiu CY, Tseng PL, Lee EP. Risk Factors for Tracheobronchomalacia in Preterm Infants With Bronchopulmonary Dysplasia. Front Pediatr 2021; 9:697470. [PMID: 34249821 PMCID: PMC8270074 DOI: 10.3389/fped.2021.697470] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 06/04/2021] [Indexed: 11/13/2022] Open
Abstract
Aim: To identify the risk factors associated with the development of tracheobronchomalacia (TBM) in preterm infants with bronchopulmonary dysplasia (BPD). Methods: This was a retrospective cohort study using chart reviews of preterm infants born at ≤ 36 week's gestation who underwent flexible fiberoptic bronchoscopy in a tertiary pediatric referral center between January 2015 and January 2020. Indications for the bronchoscopy examination included lobar atelectasis on plain chest film, persistent CO2 retention, recurrent extubation failure, or abnormal breathing sounds such as wheeze or stridor. Optimal cutoff values for each risk factor were also determined. Results: Fifty-eight preterm infants with BPD were enrolled, of whom 29 (50%) had TBM. There were no significant differences in gestational age and birth weight between those with and without TBM. Significantly more of the patients with TBM had severe BPD compared to those without TBM (68.9 vs. 20.6%, p < 0.001). Clinical parameters that were significantly different between the two groups were included in multivariate analysis. Among these factors, severe BPD was the most powerful risk factor for the development of TBM (odds ratio 5.57, 95% confidence interval 1.32-23.5, p = 0.019). The areas under the receiver operating characteristic curves for peak inspiratory pressure (PIP) and the duration of intubation were 0.788 and 0.75, respectively. The best predictive cutoff values of PIP and duration of intubation for TBM were 18.5 mmHg and 82 days, respectively. Conclusion: Preterm infants with severe BPD are at high risk for the development of TBM, and the risk is even higher in those who receive a higher PIP or are intubated for longer. Bronchoscopy examinations should be considered for the early diagnosis and management of TBM in infants with these risk factors.
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Affiliation(s)
- Ya-Ting Su
- Chang Gung University College of Medicine, Taoyuan, Taiwan.,Division of Pediatric Endocrinology and Genetics, Department of Pediatrics, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Chun-Che Chiu
- Chang Gung University College of Medicine, Taoyuan, Taiwan.,Department of Pediatrics, Tucheng Composite Municipal Hospital, New Taipei City, Taiwan
| | - Shen-Hao Lai
- Chang Gung University College of Medicine, Taoyuan, Taiwan.,Division of Pediatric Pulmonology, Department of Pediatrics, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan
| | - Shao-Hsuan Hsia
- Chang Gung University College of Medicine, Taoyuan, Taiwan.,Division of Pediatric Critical Care Medicine, Department of Pediatrics, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan
| | - Jainn-Jim Lin
- Chang Gung University College of Medicine, Taoyuan, Taiwan.,Division of Pediatric Critical Care Medicine, Department of Pediatrics, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan
| | - Oi-Wa Chan
- Chang Gung University College of Medicine, Taoyuan, Taiwan.,Division of Pediatric Critical Care Medicine, Department of Pediatrics, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan
| | - Chih-Yung Chiu
- Chang Gung University College of Medicine, Taoyuan, Taiwan.,Division of Pediatric Pulmonology, Department of Pediatrics, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan
| | - Pei-Ling Tseng
- College of Nursing, Taipei Medical University, Taipei, Taiwan
| | - En-Pei Lee
- Chang Gung University College of Medicine, Taoyuan, Taiwan.,Division of Pediatric Pulmonology, Department of Pediatrics, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan.,Division of Pediatric Critical Care Medicine, Department of Pediatrics, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan
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Douros K, Everard ML. Time to Say Goodbye to Bronchiolitis, Viral Wheeze, Reactive Airways Disease, Wheeze Bronchitis and All That. Front Pediatr 2020; 8:218. [PMID: 32432064 PMCID: PMC7214804 DOI: 10.3389/fped.2020.00218] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Accepted: 04/14/2020] [Indexed: 12/11/2022] Open
Abstract
The diagnosis and management of infants and children with a significant viral lower respiratory tract illness remains the subject of much debate and little progress. Over the decades various terms for such illnesses have been in and fallen out of fashion or have evolved to mean different things to different clinicians. Terms such as "bronchiolitis," "reactive airways disease," "viral wheeze," and many more are used to describe the same condition and the same term is frequently used to describe illnesses caused by completely different dominant pathologies. This lack of clarity is due, in large part, to a failure to understand the basic underlying inflammatory and associated processes and, in part, due to the lack of a simple test to identify a condition such as asthma. Moreover, there is a lack of insight into the fact that the same pathology can produce different clinical signs at different ages. The consequence is that terminology and fashions in treatment have tended to go around in circles. As was noted almost 60 years ago, amongst pre-school children with a viral LRTI and airways obstruction there are those with a "viral bronchitis" and those with asthma. In the former group, a neutrophil dominated inflammation response is responsible for the airways' obstruction whilst amongst asthmatics much of the obstruction is attributable to bronchoconstriction. The airways obstruction in the former group is predominantly caused by airways secretions and to some extent mucosal oedema (a "snotty lung"). These patients benefit from good supportive care including supplemental oxygen if required (though those with a pre-existing bacterial bronchitis will also benefit from antibiotics). For those with a viral exacerbation of asthma, characterized by bronchoconstriction combined with impaired b-agonist responsiveness, standard management of an exacerbation of asthma (including the use of steroids to re-establish bronchodilator responsiveness) represents optimal treatment. The difficulty is identifying which group a particular patient falls into. A proposed simplified approach to the nomenclature used to categorize virus associated LRTIs is presented based on an understanding of the underlying pathological processes and how these contribute to the physical signs.
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Affiliation(s)
- Konstantinos Douros
- Third Department of Paediatrics, Attikon Hospital, University of Athens School of Medicine, Athens, Greece
| | - Mark L. Everard
- Division of Paediatrics and Child Health, Perth Children's Hospital, University of Western Australia, Nedlands, WA, Australia
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