Preference matters: New aspects on how foreign bodies should and could be removed from a child's airway

BACKGROUND

Foreign body aspiration in children is a potentially life-threatening event that can be diagnosed and treated by airway endoscopy. We aimed to analyze the influence of the examiner's experience and preference on the choice of the technique and the resulting complication rate.

METHODS

In this international study, experts in the field documented their preferred and applied technique as well as the outcome of each case of foreign body removal. Personal data of the bronchoscopists and their medical center were collected via an online questionnaire separately from the case specifics.

RESULTS

A total of 399 foreign body removals were performed by 64 examiners. A total of 279 removals were performed using rigid endoscopy, and 120 procedures were performed by flexible. When a difficulty was expected, flexible endoscopy was used significantly more often (χ² (1) = 11.06, p < 0.001). Complications occurred significantly less often when the bronchoscopist used their preferred technique (χ² (1) = 6.41, p = 0.011), had more than 5 years of experience (χ² (1) = 5.13, p = 0.023) or performed more than 100 removals (χ² (2) = 11.51, p = 0.003). In medical centers, complication rates significantly decreased if more than 200 bronchoscopies were performed in children, compared to the centers that perform 50-200 bronchoscopies per year (χ² (1) = 24.56, p < 0.001).

CONCLUSION

Preference and experience of a bronchoscopist and his/her medical center with flexible or rigid foreign body removal distinctively affect the outcome of the procedure and cannot be neglected in the discourse on the appropriate technique. This link also emphasizes the importance of a structured training program.

Safety, feasibility and diagnostic value of Clinical Swallow Examination and FEES in children between 0 and 24 months

BACKGROUND

Clinical Swallowing Examination (CSE) and Fiberoptic Endoscopic Evaluation of Swallowing (FEES) are relevant diagnostic methods in pediatric dysphagia. Satisfactory and comprehensive healthcare is still not part of the standard diagnostic process.

AIMS

The purpose of this article is to evaluate the safety, feasibility, and diagnostic value of CSE and FEES in children 0-24 months of age.

STUDY DESIGN

A retrospective cross-sectional study which was conducted at the pediatric clinic of the University Hospital Düsseldorf, Germany, between 2013 and 2021.

SUBJECTS

A total of 79 infants and toddlers with suspected dysphagia were included.

OUTCOME MEASURES

Analyses of the cohort and FEES pathologies were performed. Dropout criterion, complications and change of diet were recorded. Chi-square identified associations between clinical symptoms and FEES results.

RESULTS

All FEES examinations were performed without complications and with a completion rate of 93.7 %. Anatomical abnormalities in the laryngeal region were diagnosed in 33 children. Wet voice was significantly associated with premature spillage (p = .028).

CONCLUSIONS

CSE and FEES are important and uncomplicated examinations for children with suspected dysphagia between 0 and 24 months. They are equally helpful for differential diagnosis of feeding disorders and anatomical abnormalities. The results underline the added value of combining both examinations and their importance for individual nutritional management. History taking and CSE are mandatory as they reflect the everyday eating situation. This study adds essential knowledge to the diagnostic work-up of dysphagic infants and toddlers. Standardizing the examinations and validating dysphagia scales are future tasks.

Complication rates in rigid vs. flexible endoscopic foreign body removal in children

While foreign body aspiration remains a frequent and preventable cause of morbidity and mortality in children, recommendations on the appropriate removal technique do often not match the lived practice and expertise of the performing examiners. As there is a scarcity of data regarding success and complication rates of the procedure, the aim of this study was to set up a classification system for procedure-related complications, prospectively record and analyze them. Specialists in the field of foreign body removal contributed cases anonymously. Information regarding procedural details of the bronchoscopy, type, and severity of complications as well as patient characteristics were classified and recorded. Correlations were calculated using Pearson's Chi Square test. A total of 314 rigid and 178 flexible bronchoscopies were compared. Complications were categorized and their severity was defined by the anesthesiologist's assessment of whether to interrupt or terminate the procedure. The overall complication rate was similar in rigid vs. flexible bronchoscopy (19.1% vs. 24.2%, p = 0.232), while respiratory complications occurred significantly less frequent during rigid bronchoscopy (9.2% vs. 16.3%, p = 0.025). This is the largest pediatric case collection recording and comparing complications between rigid and flexible foreign body removal. The higher rate of respiratory complications in flexible bronchoscopy has been shown for the first time and validates some of the concerns about its use for foreign body removal. Flexible bronchoscopy is a safe procedure when extended respiratory monitoring and the possibility of an immediate switch to a secured airway are assured.

Cryotherapy in the paediatric airway: Indications, success and safety

BACKGROUND AND OBJECTIVE

Cryotherapy in interventional bronchoscopy is a new treatment modality, which has recently been made available for the paediatric airway. Lack of experience and safety concerns have led to hesitant adaptation. The aim of this study was to assess indications, success rates and complications of airway cryotherapy in children.

METHODS

Bronchoscopists from medical centre performing cryotherapy in patients between 0 and 18 years were invited to participate in a prospective study based on an online questionnaire. Patient and participant data were collected between June 2020 and June 2021.

RESULTS

A total of 69 cryotherapy procedures were performed in 57 patients a for three main indications: Biopsy (30), restoration of airway patency (23) and foreign body aspiration (16). The overall success rate was 93%, the remaining 7% were performed for foreign body removal and required a switch of technique. Restoration of airway patency was successfully applied in various pathologies, including mucus plugs, bronchial casts and post traumatic stenosis. The diagnostic yield of transbronchial biopsies was 96%. No severe complications were encountered; one pneumothorax following a cryobiopsy required a chest drain for 48 h. No child was admitted to intensive care or died from a procedural complication.

CONCLUSION

In this largest paediatric case collection to date, cryotherapy was safe and carried a high success rate. Cryobiopsy compares favourably to the widely used forceps biopsy and could replace it in the future. Paediatric bronchoscopists are encouraged to add cryotherapy to their armamentarium of airway interventions.

ERS International Congress 2021: highlights from the Paediatric Assembly

In this review, Early Career Members of the European Respiratory Society (ERS) and the Chairs of the ERS Assembly 7: Paediatrics present the highlights in paediatric respiratory medicine from the ERS International Congress 2021. The eight scientific Groups of this Assembly cover respiratory physiology and sleep, asthma and allergy, cystic fibrosis (CF), respiratory infection and immunology, neonatology and intensive care, respiratory epidemiology, bronchology, and lung and airway development. We here describe new developments in lung function testing and sleep-disordered breathing diagnosis, early life exposures affecting pulmonary function in children and effect of COVID-19 on sleep and lung function. In paediatric asthma, we present the important role of the exposome in asthma development, and how biologics can provide better outcomes. We discuss new methods to assess distal airways in children with CF, as some details remain blind when using the lung clearance index. Moreover, we summarise the new ERS guidelines for bronchiectasis management in children and adolescents. We present interventions to reduce morbidity and monitor pulmonary function in newborns at risk of bronchopulmonary dysplasia and long-term chronic respiratory morbidity of this disease. In respiratory epidemiology, we characterise primary ciliary dyskinesia, identify early life determinants of respiratory health and describe the effect of COVID-19 preventive measures on respiratory symptoms. Also, we describe the epidemiology of interstitial lung diseases, possible consequences of tracheomalacia and a classification of diffuse alveolar haemorrhage in children. Finally, we highlight that the characterisation of genes and pathways involved in the development of a disease is essential to identify new biomarkers and therapeutic targets.

Laryngeal sensation and its association with aspiration and cough in children with neurological impairment

BACKGROUND

Aspirations are frequent in children with neurological impairment. They significantly increase the risk for acute and chronic respiratory insufficiencies leading to high morbidity and mortality. Laryngeal sensation deficits have been linked to aspirations in adults and are a suspected cause for dysphagia in children. In a similar neurological circuit as swallowing, laryngeal receptors trigger coughing as a protective airway reflex. The aim of this study was to examine the association between impaired laryngeal sensation (ILS), aspiration, and coughing in neurologically impaired children.

DESIGN AND METHODS

In a retrospective study, 110 children with suspected dysphagia underwent a clinical evaluation of swallowing and a flexible endoscopic evaluation of swallowing (FEES) between 2013 and 2019 in the children's university clinic Düsseldorf were analyzed. Laryngeal sensation was tested by the endoscopic touch method. Associations were computed using χ² -test.

RESULTS

Fifty-four patients (49.1%) had a neurological impairment, 56 patients (50.9%) had no or other comorbidities and served as a control cohort. Children with neurological impairment suffered from ILS significantly more often than children with no or other comorbidities (χ²(1) = 4.63, p = .031). ILS was associated with all other FEES variables but did not correlate with coughing. The symptom coughing correlated with aspiration in the group of neurologically impaired children and in children ILS.

CONCLUSION

ILS is a potential cause of aspirations in children with neurological impairment. Physicians need to pay special attention to the occurrence of coughing in children with neurological impairment and/or ILS since it signals aspirations that took place.

The use of pediatric flexible bronchoscopy in the COVID-19 pandemic era

On March 11, 2020, the World Health Organization (WHO) declared the pandemic because of a novel coronavirus, called severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). In January 2020, the first transmission to healthcare workers (HCWs) was described. SARS-CoV-2 is transmitted between people because of contact, droplets, and airborne. Airborne transmission is caused by aerosols that remain infectious when suspended in air over long distances and time. In the clinical setting, airborne transmission may occur during aerosol generating procedures like flexible bronchoscopy. To date, although the role of children in the transmission of SARS-CoV-2 is not clear the execution of bronchoscopy is associated with a considerably increased risk of SARS-CoV-2 transmission to HCWs. The aim of this overview is to summarize available recommendations and to apply them to pediatric bronchoscopy. We performed systematic literature searches using the MEDLINE (accessed via PubMed) and Scopus databases. We reviewed major recommendations and position statements published at the moment by the American Association for Bronchology and Interventional Pulmonology, WHO, European Center for Disease Prevention and Control and expert groups on the management of patients with COVID-19 to limit transmission among HCWs. To date there is a lack of recommendations for safe bronchoscopy during the pandemic period. The main indications concern adults and little has been said about children. We have summarized available recommendations and we have applied them to pediatric bronchoscopy.

Pediatric Airway Endoscopy: Recommendations of the Society for Pediatric Pneumology

For many decades, pediatric bronchoscopy has been an integral part of the diagnosis and treatment of acute and chronic pulmonary diseases in children. Rapid technical advances have continuously influenced the performance of the procedure. Over the years, the application of pediatric bronchoscopy has considerably expanded to a broad range of indications. In this comprehensive and up-to-date guideline, the Special Interest Group of the Society for Pediatric Pneumology reviewed the most recent literature on pediatric bronchoscopy and reached a consensus on a safe technical performance of the procedure.

ERS International Congress 2020: highlights from the Paediatric Assembly

In this review, the Paediatric Assembly of the European Respiratory Society (ERS) presents a summary of the highlights and most relevant findings in the field of paediatric respiratory medicine presented at the virtual ERS International Congress 2020. Early Career Members of the ERS and Chairs of the different Groups comprising the Paediatric Assembly discuss a selection of the presented research. These cover a wide range of research areas, including respiratory physiology and sleep, asthma and allergy, cystic fibrosis, respiratory infection and immunology, neonatology and intensive care, epidemiology, bronchology and lung and airway development. Specifically, we describe the long-term effect in lung function of premature birth, mode of delivery and chronic respiratory conditions such as cystic fibrosis. In paediatric asthma, we present risk factors, phenotypes and their progression with age, and the challenges in diagnosis. We confirm the value of the lung clearance index to detect early lung changes in cystic fibrosis. For bronchiectasis treatment, we highlight the importance of identifying treatable traits. The use of biomarkers and genotypes to identify infants at risk of long-term respiratory morbidity is also discussed. We present the long-term impact on respiratory health of early life and fetal exposures to maternal obesity and intrauterine hypoxia, mechanical ventilation hyperoxia, aeroallergens, air pollution, vitamin A deficient intake and bronchitis. Moreover, we report on the use of metabolomics and genetic analysis to understand the effect of these exposures on lung growth and alveolar development. Finally, we stress the need to establish multidisciplinary teams to treat complex airway pathologies.

Are uterine natural killer and plasma cells in infertility patients associated with endometriosis, repeated implantation failure, or recurrent pregnancy loss?

PURPOSE

Infertility is a debilitating situation that millions of women around the world suffer from, but the causal relationship between infertility and endometriosis is still unclear. We hypothesize that the immune cell populations of uterine natural killer cells (uNK) and plasma cells (PC) which define chronic endometritis could differ in patients with or without endometriosis and therefore be the link to endometriosis-associated infertility.

METHODS

Our retrospective study includes 173 patients that underwent an endometrial scratching in the secretory phase of the menstrual cycle and subsequently immunohistochemical examination for uNK cells and PC. Sixty-seven patients were diagnosed with endometriosis, 106 served as the control cohort.

RESULTS

The risk for an elevated number of uNK cells in women with endometriosis is not increased as compared to the control group. Our findings suggest that patients with endometriosis are 1.3 times more likely to have chronic endometritis (CE) as compared to those without and that the treatment with doxycycline might increase pregnancy rates. Endometriosis and an increased number of uNK cells seem to be unrelated.

CONCLUSIONS

In contrast to the lately published connection between endometriosis, infertility and increased uNK cells, we could not find any evidence that patients with endometriosis are more prone to elevated uterine uNK cells. Counting of PC in endometrial biopsies might be a new approach in the search of biomarkers for the nonsurgical diagnosis of endometriosis since our findings suggest a connection.

Sensomotorisches Potenzial vom intakten und traumatisierten vorderen und hinteren Kreuzband - eine tierexperimentelle, neurophysiologische Studie

AIM

This neurophysiological study is intended to investigate the sensomotor potential of the anterior cruciate ligament (ACL) and the posterior cruciate ligament (PCL) which may provide joint stabilization via a ligamentomuscular reflex arch. In addition, the role of ligamentous injury on the sensomotor potential has been investigated.

METHOD

The sensomotor potential was investigated using 24 knee joints in a sheep model under in-vivo conditions. The cruciate ligaments were mechanically loaded and the muscular activities of the hamstrings and the quadriceps were recorded simultaneously via electromyography. Injury to the ligaments was simulated by defined mechanical elongation of the ACL and PCL to failure.

RESULTS

The results confirm the hypothesis of the existence of a ligamentomuscular reflex loop between ligamentary mechanoreceptors and the joint-stabilizing muscles. Mechanical loading of the ACL triggered mainly the activity of the hamstrings, whereas loading of the PCL led to the activation of the quadriceps. The rate of elongation which caused disturbances to the sensomotor potential was significantly smaller as compared to the elongation to failure.

CONCLUSION

The cruciate ligaments provide dynamic joint stabilization via a ligamentomuscular reflex arch. It was demonstrated that the sensomotor potential of both structures is significantly more susceptible to ligament injury than the biomechanical potential.

[Sensorimotor deficit after capsulolabral reconstruction in chronic instability of the shoulder. A clinical experimental study]

The anterior capsulolabral reconstruction technique described by Jobe is a modified Bankart repair. The capsular shift is performed in a horizontal direction via a subscapularis split approach avoiding any incision of the muscle. Of 43 patients with posttraumatic anterior shoulder instability treated by anterior capsulolabral reconstruction, 35 were examined after 3.7+/-1.4 years, and of these, 29 (82.9%) had no pain; the external rotation deficit was 4.1+/-2.9 degrees . The average Constant-Murley score was 92.4+/-7.1 and the average ASES score was 93.3+/-8.4. The reluxation rate was 7.7%. This technique was shown to provide good clinical results, but only 69% of the patients were able to return to their prior sporting activity level. This particular problem was addressed by investigating the joint proprioception and the activity of the periarticular muscles. The results confirmed a persistent deficit of proprioception as well as a pathologic EMG pattern after anterior capsulolabral reconstruction, which may explain the problem of incomplete restoration of the function of the shoulder joint.

Hypertension as a risk factor for cerebral injury during cardiopulmonary bypass. Protein S100B and transcranial Doppler findings

We studied 22 patients aged 53-78 years scheduled for cardiac surgery under cardiopulmonary bypass. Blood pressure, cardiac output, transcranial Doppler blood flow velocity, arterial blood gases, body temperature and protein S100B, as a marker for cerebral integrity, were evaluated in normotensive and hypertensive patients. Pre-operative mean (SD) arterial blood pressure was 93 (11) mmHg in the normotensive group compared with 116 (15) mmHg in the hypertensive group. We found an increase in protein S100B levels in both groups. Serum protein S100B concentrations in the hypertensive group were significantly higher than in the normotensive group (p < 0.001). The highest mean (SD) values were 2.04 (0.65) micromol x l(-1) in the normotensive group and 7.02 (4.55) micromol x l(-1) in the hypertensive group. These results suggest that cardiopulmonary bypass is associated with a significantly higher rate of cerebral injury in hypertensive patients than in normotensive patients. This may be due to altered autoregulation and insufficient cerebral perfusion. Modifications of cardiopulmonary bypass management for hypertensive patients might be made to decrease the risk of cerebral injury.

"Activated"-RecA protein affinity chromatography of LexA repressor and other SOS-regulated proteins

We have developed an affinity column to study the interaction of LexA repressor and other substrates with the activated form of RecA protein. Nucleoprotein complexes of RecA protein, (dT)25-30, and adenosine 5'-[gamma-S]thio-triphosphate were formed in solution and bound to RecA protein-agarose columns. These "activated"-RecA nucleoprotein complexes were retained by strong hydrophobic interactions. Purified LexA protein bound tightly to these activated RecA columns, whereas the LexA protein bound poorly to RecA-agarose alone. Once bound, LexA protein underwent specific proteolysis, and the fragments were released from the complex. The mutant LexA protein, LexA-SA119, which cannot carry out self-cleavage or RecA-mediated cleavage in solution, bound efficiently to the activated RecA column but was not cleaved, indicating that these columns can be used to identify residues involved in RecA-LexA binding. As an example of this use, nucleoprotein complexes were prepared using the RecA430 protein. In vivo the recA430 mutation blocks induction of the SOS response. LexA protein was not efficiently retained on the immobilized RecA430 complexes, suggesting that Gly-204 is required for efficient repressor binding. These results show that activated RecA affinity columns can be used to investigate the binding and cleaving properties of mutationally altered RecA and LexA proteins. Additionally, these activated RecA columns have been used to investigate binding interactions of phage lambda repressor, as well as the UmuC protein, which is required for chemical mutagenesis.

Affinity chromatography of RecA protein and RecA nucleoprotein complexes on RecA protein-agarose columns

We have analyzed the nature of RecA protein-RecA protein interactions using an affinity column prepared by coupling RecA protein to an agarose support. When radiolabeled soluble proteins from Escherichia coli are applied to this column, only the labeled RecA protein from the extract was selectively retained and bound tightly to the affinity column. Efficient binding of purified 35S-labeled RecA protein required Mg2+, and high salt did not interfere with the binding of RecA protein to the column. Complete removal of the bound enzyme from the affinity column required treatment with guanidine HCl (5 M) or urea (8 M). These and other properties suggest that hydrophobic interactions contribute significantly to RecA protein subunit recognition in solution. Using a series of truncated RecA proteins synthesized in vitro, we have obtained evidence that at least some of the sequences involved in protein recognition are localized within the first 90 amino-terminal residues of the protein. Based on the observation that RecA proteins from three heterologous bacteria are specifically retained on the E. coli RecA affinity column, it is likely that this binding domain is highly conserved and is required for interaction and association of RecA protein monomers. Stable ternary complexes of RecA protein and single-stranded DNA were formed in the presence of the nonhydrolyzable ATP analog adenosine 5'-O-(thiotriphosphate) and applied to the affinity columns. Most of the complexes formed with M13 DNA could be eluted in high salt, whereas a substantial fraction of those formed with the oligonucleotide (dT)25-30 remained bound in high salt and were quantitatively eluted with guanidine HCl (5 M). The different binding properties of these RecA protein-DNA complexes likely reflect differences in the availability of a hydrophobic surface on RecA protein when it is bound to long polynucleotides compared to short oligonucleotides.

[Viruses as causal agents of gastroenteritis in infants and young children (author's transl)]

Electron microscopic examination of stool samples from 195 infants and young children with acute gastroenteritis revealed rota virus in 31 samples (= 16%), corona virus in 44 samples (= 23%) and adenovirus in 13 samples (= 7%). Viruses were excreted for between 4 and 8 days in patients infected with rota virus and corona virus respectively. An outbreak of acute gastroenteritis in a premature baby unit with 24 cases is reported: corona virus was found in the stools of 15 infants. It is suggested that corona virus as well as rota virus may cause gastroenteritis in infants and small children.