The long duration of extracorporeal membrane oxygenation in a child with acute severe hypoxic respiratory failure treated in a resource-limited center

Veno-venous extracorporeal membrane oxygenation (VV-ECMO) has been indicated in patients with severe refractory respiratory failure from various causes for more than 30 years, even for the small infant.(1) Improved outcome from using ECMO for respiratory failure has been reported worldwide, ranging from 15% to over 50% in recent reviews.(1,2) The rationale of this therapy is to allow time for the lungs to heal, minimizing further lung injury from positive pressure ventilation.(3,4) We describe a case of severe acute respiratory distress syndrome (ARDS) with extensive barotrauma supported by VV-ECMO for 96 days in a resource-limited center. This is likely the longest ECMO support ever reported in a child.

Prevalence, clinical presentations and complications among hospitalized children with influenza pneumonia

Viral respiratory tract infections are a major cause of hospitalization in children. Influenza is common but often not laboratory proven. We report a prospective study of children admitted with a clinical diagnosis of pneumonia. Infants and children (ages 1 month-15 years) who were hospitalized with community-acquired pneumonia were enrolled in the study. Their nasopharyngeal aspirated samples were analyzed for common respiratory viruses, including influenza virus, by reverse transcription-polymerase chain reaction (RT-PCR) or PCR. Out of 257 patients, we identified 127 (49.4%) cases with respiratory viruses, and influenza was found in 32 of these cases (12.5%). Other common respiratory viruses included respiratory syncytial virus in 42 (16.3%), human metapneumovirus in 24 (9.3%), adenovirus in 17 (6.6%) and parainfluenza virus in 12 (4.7%). The median age of the influenza group was 2 years and 3 months, and 27 (84%) of children in this group were under the age of 5. Asthma was the most common co-morbidity (4/32, 12.5%). Common clinical presentations were fever and cough (100%) with crepitations (90%). The median length of hospitalization was 6 days. Three patients developed respiratory failure, with one mortality (3.1%). One child developed infection-associated hemophagocytic syndrome. Our study demonstrated that young children had a high risk of hospitalization due to influenza pneumonia, which contributed to a significant morbidity.

Mycoplasma pneumoniae and Chlamydophila pneumoniae in children with community-acquired pneumonia in Thailand

BACKGROUND

The prevalence of community-acquired pneumonia (CAP) caused by atypical pathogens in Thai children is unknown.

OBJECTIVE

To examine the prevalence of Mycoplasma pneumoniae and Chlamydophila pneumoniae infections in paediatric patients (aged 2-15 years) with CAP in three academic hospitals using standardised laboratory techniques. The characteristics of atypical pneumonia were also compared with other causes of CAP.

METHODS

Diagnosis of current infection was based on a four-fold or more rise in antibody serum samples or persistently high antibody titres together with the presence of mycoplasmal or chlamydial DNA in secretions.

RESULTS

Of 245 patients with CAP, 17.5% of cases were caused by atypical pathogens (M. pneumoniae 14.3%, C. pneumoniae 2.8% and co-infection 0.4%). We also found atypical pathogens in young children aged 2-5 years. The clinical and laboratory findings did not distinguish atypical pneumonia from other CAPs. Segmental or lobar consolidation on chest X-rays was more common in atypical pneumonia, while dyspnoea was more prominent in other CAPs.

CONCLUSION

Our data show a high prevalence of M. pneumoniae and C. pneumoniae in Thai children with CAP, including in children aged 2-5 years.

Randomized controlled trial of salbutamol aerosol therapy via metered dose inhaler-spacer vs. jet nebulizer in young children with wheezing

The jet nebulizer is a common device used for administering aerosol medication in young children. However, compared to a metered dose inhaler-spacer (MDI-spacer), it takes more time and personnel. This study aimed to compare the efficacy of salbutamol aerosol therapy given via these two devices in young wheezing children. A prospective randomized, double-blind, placebo-controlled trial was performed in children up to 5 years old who had acute wheezing and were admitted to the Department of Pediatrics, King Chulalongkorn Memorial Hospital. Patients were randomly divided into two groups. The first group received 2 puffs of placebo via MDI-spacer, followed by 0.15 mg/kg salbutamol respiratory solution via jet nebulizer. The second group received 2 puffs (100 microg/puff) of salbutamol via MDI-spacer, followed by placebo via jet nebulizer. Clinical scores and tidal breathing pulmonary function test were evaluated before and after treatment. Pulmonary function parameters included those derived from flow volume loops (volume to peak tidal expiratory flow over total expiratory volume, V(PTEF)/V(E); time to peak tidal expiratory flow over total expiratory time, T(PTEF)/T(E); and ratio of tidal expiratory flow at 25% remaining expiration to peak expiratory flow, 25/PF), compliance (Crs), and resistance (Rrs) of the respiratory system. The efficacy of both methods was compared by using analysis of covariance. Forty-seven wheezing children were studied (24 received salbutamol via MDI-spacer, and 23 received it via jet nebulizer). There was no statistical difference between the two groups regarding clinical scores and all pulmonary function parameters. However, heart rate was significantly increased after treatment in the jet nebulizer group when compared to those in the MDI-spacer group (P = 0.004). In conclusion, the efficacy of salbutamol aerosol therapy via MDI-spacer compared to jet nebulizer in young wheezing children was not different in terms of clinical score and postbronchodilator pulmonary function parameters. However, salbutamol aerosol therapy via jet nebulizer significantly increased the heart rate when compared to the MDI-spacer.

PRISM score and factors predicting mortality of patients with respiratory failure in the pediatric intensive care unit

A total of 96 patients with respiratory failure who required mechanical ventilation admitted to the PICU, Chulalongkorn Hospital from July 1998 to June 1999 were reviewed to evaluate the PRISM score for mortality prediction and to identify factors that might influence the outcome. The statistical difference in outcome between the 2 groups (survivors and non-survivors) were underlying diseases, age, maximum positive inspiratory pressure (PIP), maximum positive end expiratory pressure (PEEP), maximum fractional inspiratory oxygen (FiO2) and PRISM score (p < 0.05). However, based on the original logistic regression equation, the predicted mortality from PRISM score in our study was much lower than our actual mortality (2.4% vs 26.0%). The sensitivity and specificity of mortality predicted by PRISM score calculated at cut-off r = 0.0 (expected mortality = 50%) was 4 per cent and 97 per cent respectively. In conclusion, the original PRISM score underpredicted the mortality outcome in our patients with respiratory failure. This suggests that PRISM score is population dependent and should be modified before being used with our patients.

Clinical score and arterial oxygen saturation in children with wheezing associated respiratory illness (WARI)

OBJECTIVES

To determine the correlation between clinical score (based on respiratory rate, chest wall retractions, air entry, wheezing, consciousness and audible wheezing) and arterial oxygen saturation (SaO2: measured by pulse oximetry) as well as the most appropriate total score for predicting hypoxemia (SaO2 < or = 95%) in children diagnosed to have wheezing associated respiratory illness (WARI).

SUBJECTS

70 children (1 month-5 years old) hospitalized in the Department of Pediatrics, Chulalongkorn Hospital with the diagnosis of WARI from January 1, 1996 to December 31, 1996 were studied. Half of them were diagnosed to have acute lower respiratory tract infection (LRI) with wheezing while the remainder had reactive airway disease (RAD).

DESIGN

Cross sectional, analytical study.

METHODS

In each group of patients, the clinical score and SaO2 were assessed by the same pediatrician throughout the study. The correlation between the clinical signs and SaO2 as well as the cut off point of total score for predicting hypoxemia were analyzed. The sensitivity, specificity and accuracy of that total score in predicting hypoxemia were also calculated.

RESULT

In both groups of patients (acute LRI with wheezing and RAD group), the clinical signs correlated with SaO2 were wheezing (rs = -0.67 and -0.47 respectively) and chest wall retractions (rs = -0.57 and -0.59 respectively). Total score was also correlated with SaO2 (rs = -0.68 and -0.5 respectively). The cut off point of total score in predicting hypoxemia was 4 providing 80 per cent sensitivity in both groups with accuracy 74.3 per cent and 80 per cent respectively.

CONCLUSION

This clinical score may be used to assess the severity of hypoxemia in WARI patients. Wheezing, chest wall retractions and total score correlated well with SaO2. The total score > 4 was most appropriate in predicting hypoxemia in both children with RAD and wheezing associated with LRI.

Chlamydia pneumoniae infection in Thai children: serological diagnosis

Recent Chlamydia pneumoniae infections were investigated in children with respiratory tract infections and in normal children. Four groups of sera were tested for C. pneumoniae antibody IgG and IgM serum fraction by the method of MIF test. A total of 7 cases of recent infection were detected, 3 of 116 with pneumonia, 3 of 123 with other respiratory tract infections, 1 of 263 normal school children and none in sera from cord blood. The cases with recent C. pneumoniae infection were as young as 24 days and 2 months old.

Risk factors of streptococcal colonization in school age children

We studied the factors influencing the colonization of Streptococcus in school age children aged 6-11 years from 2 low socioeconomic schools of the Bangkok Metropolitan area. 4,055 throat swab cultures were performed. Beta hemolytic Streptococcus (BHS) and beta hemolytic Streptococcus group A (BHSA) were isolated in 1,747 (43%) and 744 (18%) respectively. 1,547 questionnaires were returned from the children. Of these, 750 and 570 were found to have BHS and BHSA in the throat, respectively. Among the risk factors, considered, teeth brushing of one time or none per day was significant for BHS positive in the throat as compared with the BHS negative group, while personal hygiene such as sharing glass with other, playing in dirty water, poor housing sanitation and low family income was significantly associated with the BHSA positive group. With the combination of certain clinical manifestations, these factors may increase the accuracy of predicting streptococcal infection.

Predictors of bronchodilator responsiveness in infants with wheezing associated respiratory tract infection

The responsiveness to bronchodilator is variable in infants with wheezing associated respiratory illness (WARI). Factors for prediction of the response will lead to more rational use of the bronchodilator in these infants. We examined the possible predictive factors in 44 children under 2 years of age who had their first episode of WARI. All of them were treated with 0.15 mg/kg of nebulized salbutamol. Thirty patients (68%) with decreasing clinical score > or = 3 after treatment were considered as the responders while the remainder (14 infants) were non responders. By using Chi-square test, Fisher exact test and Mann-Whitney U test to compare the data of the 2 groups, the significant factors for the responders were older than 6 months and history of previous LRI (p < 0.01). The significant factors for the non-responders included concurrent diarrhea, patchy pulmonary infiltration and positive RSV in the nasopharyngeal secretion (p < 0.01). These results suggested effective bronchodilator therapy in infants older than 6 months or having a history of previous LRI. Those who had acute RSV infection or patchy infiltration in chest X-ray and associated diarrhea were less likely to respond.

Lymphomatoid granulomatosis with upper airway obstruction: a case report

A case of lymphomatoid granulomatosis in a previously healthy 13-year-old Thai girl presenting with right sixth cranial nerve palsy and severe upper airway obstruction was reported. Cranial nerve palsy later disappeared spontaneously but the patient developed multiple pulmonary nodules and cavity leading to pulmonary insufficiency. Her course was complicated with septicemia which limited the use of corticosteroid and cytotoxic drugs. She finally expired with pseudomonas sepsis in addition to pulmonary and liver involvement. This is the first case of lymphomatoid granulomatosis in a child ever reported in Thailand. Lymphomatoid granulomatosis should be included in the differential diagnosis of upper airway obstruction with pulmonary nodules and cavity and multi-organ involvement in children.

Group A beta-hemolytic streptococcal type M11 sepsis and empyema: a case report

A case of serious suppurative disease caused by GABHS in a previously well 2-month-old Thai female presenting with clinical features of sepsis and right pleural effusion was reported. Treatment was initially with cloxacillin and a right side intercostal drainage. When subsequent cultures of blood and pleural fluid grew GABHS; intravenous penicillin was substituted. She made an uneventful recovery. Typing of the GABHS revealed non typable T-antigen and M-protein 11 GABHS, although very sensitive to penicillin, can cause severe and rapidly progressive disease in a very young infant. This is the first case of GABHS type M11 causing pleural effusion and sepsis in an infant ever reported in Thailand. Epidemiologic study might be indicated if an epidemic should occur.

Afebrile pneumonia associated with chlamydial infection in infants less than 6 months of age: initial results of a three year prospective study

During the year 1986-1988, 112 infants younger than 6 months of age with the diagnosis of afebrile pneumonia were studied at Chulalongkorn Hospital, Bangkok, Thailand. Thirty cases (26.78%) were caused by Chlamydia trachomatis. The clinical and laboratory findings which differed significantly from pneumonia caused by other organisms included longer duration of symptoms (greater than 1 week), younger age of onset (less than 12 weeks), history of conjunctivitis after birth, no wheezing detected, white blood cell count greater than or equal to 10,000 cells/microliters with eosinophilic count greater than or equal to 300 cells/microliters and reticulonodular infiltration on the chest x-ray.

Cystic fibrosis in blacks in Washington, DC: fifteen years' experience

Controversies exist regarding the clinical presentation and characteristics of cystic fibrosis (CF) in American blacks. Between 1971 and 1986, 188 patients with CF (165 whites, 20 blacks, and 3 others) seen at Children's Hospital National Medical Center, Washington, DC, were evaluated for age at diagnosis, duration of symptoms prior to diagnosis, clinical presentations, initial sputum culture results, and weight and height at diagnosis. Comparisons between black and white patients revealed no statistically significant differences in average age at diagnosis, average duration of symptoms prior to diagnosis, average sweat electrolyte concentrations, or sputum culture results. A breakdown of presenting symptoms by race showed some points of disparity. About twice as many black patients as white patients (40% v 22%) presented with only pulmonary symptoms, whereas slightly more whites presented with only gastrointestinal symptoms (46% v 35%). Those patients presenting with a combination of symptomatology were equally distributed by race (25% black, 21% white). At diagnosis, age-adjusted weight percentiles were significantly lower for black patients than for white patients (chi 2 = 9.60, P less than or equal to 0.05). Although the authors agree that CF is relatively rare among blacks, a high index of suspicion is essential for early diagnosis.