Prophylactic inhaled corticosteroids for the management of recurrent croup

OBJECTIVES

Croup is characterized by a barky cough, inspiratory stridor, hoarseness and varying degrees of respiratory distress. Acute croup episodes are often treated with oral, inhaled, or intravenous corticosteroids. Recurrent croup, defined as more than 2-3 episodes of acute croup in the same patient, can mimic asthma. We hypothesized that inhaled corticosteroids (ICS) given at the first sign of a respiratory viral prodrome can be a safe treatment to reduce the frequency of recurrent croup episodes in children without fixed airway lesions.

METHODS

A retrospective chart review of patients being treated over an 18-month period was performed at a large tertiary care pediatric hospital following Institutional Review Board (IRB) approval. Patients under 21 years old referred to Pediatric Pulmonology, Otolaryngology, or Gastroenterology for recurrent croup were analyzed for their demographics, medical history, evaluation, treatment and clinical improvement. A Fisher's two-tailed exact test was used to compare the number of croup episodes before and after interventions.

RESULTS

124 patients were included in our analysis: 87 male and 34 female with a mean age of 54 months. Of these, 78 had >5 episodes of croup, 45 had 3-5, and 3 had 2 episodes prior to their first visit for recurrent croup. Operative direct laryngoscopy/bronchoscopy was performed in 35 patients (27.8%), with 60% showing a normal exam without fixed lesions. Ninety-two patients (74.2%) were treated with ICS, 24 were lost to follow up. Of the remaining 68 treated patients, 59 (86.7%) saw improvement with reduced severity and overall number of episodes of croup. Additionally, patients with >5 episodes of croup (47) as compared to <5 (12) were more likely to improve with ICS, (p = 0.003). There were no adverse reactions reported with ICS treatment.

CONCLUSION

The novel initiation of ICS at the earliest sign of a viral upper respiratory infection shows promise as a safe preventative treatment to mitigate the frequency of recurrent croup episodes.

Asthma in Children: A Brief Review for Primary Care Providers

Pediatric asthma is a common chronic condition with wide-ranging implications for children's health, their families, and the health care system. The diagnosis may be relatively straightforward for the child with characteristic symptoms, triggers, and response to therapy, but there are other less common presentations that can make the diagnosis challenging. Diagnosing asthma in a toddler with recurrent wheezing can be particularly difficult. Treating asthma in a step-wise fashion usually reduces symptom frequency and improves asthma control. Asthma exacerbations and poor outcomes from acute exacerbations remain an area in which we have room for improvement. This article provides an overview of the diagnosis and management of childhood asthma for the primary care provider. [Pediatr Ann. 2019;48(3):e103-e109.].

Marijuana medusa: The many pulmonary faces of marijuana inhalation in adolescent males

Marijuana use has risen dramatically over the past decade. Over this same time period, pediatric hospitals have seen an increase in presentation of adolescents with acute respiratory symptoms after recent marijuana inhalation. We report a case series of three adolescent males with significant findings of bilateral pulmonary nodules and ground glass opacities on chest imaging associated with recent marijuana inhalation. Lung biopsies in two of the three patients confirmed silica-induced pneumoconiosis. The third patient was diagnosed with acute hypersensitivity pneumonitis without lung biopsy. Improvement in clinical symptoms and lung function testing were noted in two of three patients after marijuana inhalation cessation. This case series highlights the variety of severe pulmonary presentations in adolescents following recent marijuana inhalation. Future studies are required to assess whether these presenting pulmonary complications are from direct marijuana exposure or indirect associations with marijuana inhalation injuries.

The use of light's criteria in hospitalized children with a pleural effusion of unknown etiology

OBJECTIVE

Pleural effusions are common in pediatrics. When the etiology of a pleural effusion remains unknown, adult literature recommends the use of Light's criteria to differentiate a transudate from an exudate. Pediatricians may rely on adult literature for the diagnostic management of pleural effusions as Light's criteria has not been validated in children. The purpose of this study was to review the use of Light's criteria in hospitalized children with a pleural effusion of unknown etiology.

METHODS

Retrospective review was performed on children hospitalized with a pleural effusion requiring chest tube placement or thoracentesis between January 1, 2016 to January 1, 2017 at Children's Hospital Colorado. Charts were reviewed for primary team, use of Light's criteria, pleural effusion diagnosis, and 30-day recurrence of repeat intervention or fluid analysis.

RESULTS

Sixty-eight patients were hospitalized with a pleural effusion of unknown etiology requiring intervention. Only 16 pleural effusions (24%) were classified using Light's criteria. In those patients for whom Light's criteria was used, a diagnosis or change in management occurred in 10 of 16 patients (63%). Pleural effusions were most common on the cardiology service (26/68). Use of Light's criteria was most frequent on the oncology service (7/8). Thirty-day need for repeat intervention was lower in those with Light's criteria (13%) compared to those without (27%).

CONCLUSIONS

Light's criteria were utilized infrequently in hospitalized children with a pleural effusion of unknown etiology at a single institution. There was considerable practice variation among provider teams. When utilized, Light's criteria assisted in making a diagnosis or changing management in many patients, and may lead to a reduction in 30-day recurrence requiring repeat intervention.

Uremic pleuritis: A case report and review of recurrent exudative pleural effusions in children

Despite similar mechanisms driving pleural fluid accumulation, the causes of pleural effusions in children differ significantly from that of adults. When a pleural effusion re-occurs in an adult, literature recommends early thoracentesis, and consideration for pleuroscopy with biopsy to guide the diagnostic evaluation. In children, there is a paucity of literature for guiding management of recurrent exudative pleural effusion. We present an unusual pediatric case of uremic pleuritis with recurrent pericardial and exudative pleural effusions.

Measuring Pediatric Bronchoscopy Outcomes Using an Electronic Medical Record

RATIONALE

Bronchoscopy procedures should be tracked for safety, quality improvement, and federal regulations.

OBJECTIVE

The aim of this study was to develop and test a method for evaluating flexible bronchoscopy use and outcomes using the electronic medical record (EMR) system in current clinical use at a large children's hospital.

METHODS

We created a custom bronchoscopy procedure note for our EMR system (Epic Systems Corporation) to track demographics, bronchoscopist, coordinated procedures, and outcome. Unplanned outcomes in children were defined as a disposition (admission to the hospital or elevation of care) after flexible bronchoscopy that differed from the preoperative plan. Readmissions to the hospital and emergency visits within our hospital system were also tracked electronically. Unplanned outcomes and readmissions were evaluated by a bronchoscopy quality team.

MEASUREMENTS AND MAIN RESULTS

Over 2.5 years, we tracked 1,297 bronchoscopic procedures performed on 1,161 patients (60% male, 78% American Society of Anesthesiologists class 2 or 3, mean age 5.5 yr [range, 0.02-40 yr]). Overall, 27 unplanned outcomes occurred (2.1%). The risk of unplanned outcomes did not appear to be different between procedures performed by a trainee with faculty oversight and those performed by a faculty member alone. Patients with multiple same-day procedures were more likely to have unplanned outcomes (21 of 27 [78%], P = 0.004) than were patients who had flexible bronchoscopy alone. The relative risk (RR) of having an unplanned outcome was not different from flexible bronchoscopy alone in the subset of patients with multiple procedures coordinated through our multidisciplinary aerodigestive clinic (RR 0.7; 95% CI, 0.1-3.4). The risk of unplanned events was significantly elevated in children with coordinated procedures scheduled outside the aerodigestive group (RR, 5.8; 95% CI, 2.4-14.5). Ten patients (<1%) were readmitted or seen urgently within 1 week; three of these unplanned outcomes were attributed to complications of the bronchoscopy.

CONCLUSIONS

An EMR system may be used to track procedural outcomes. Unplanned outcomes after flexible bronchoscopy were infrequent at our institution. Children who underwent multiple procedures had unplanned outcomes more often; however, the subset of children who underwent coordinated procedures through our multidisciplinary aerodigestive clinic did not demonstrate this increased risk.

Primary Ciliary Dyskinesia in Children: A Review for Pediatricians, Allergists, and Pediatric Pulmonologists

Primary ciliary dyskinesia (PCD) is a rare genetic condition that causes impaired mucociliary clearance due to poorly functioning cilia. PCD is one disease manifestation of the many recently recognized associations with ciliary malfunction, referred to as "ciliopathies." Manifestations of PCD commonly begin in the neonatal period with cough, pneumonia, and chronic ear infections or effusions. Approximately half of the affected individuals have situs inversus totalis. The diagnosis is often made in later childhood or early adulthood, because symptoms mimic more common childhood illnesses and because the definitive diagnosis of PCD can be challenging. Treatment recommendations are largely based on therapies used for other conditions with impaired mucociliary clearance in the absence of evidence-based research specific for PCD. Early recognition and initiation of both otolaryngologic and pulmonary management might reduce potential long-term morbidities. The purpose of this article is to update primary care providers, allergists, and pediatric pulmonologists on recent advances in this interesting condition.

Cystic fibrosis patients with and without central nervous system complications following lung transplantation

Central nervous system (CNS) complications occur more frequently in cystic fibrosis (CF) patients than other lung transplant recipients. The purpose of this study was to compare CF patients with and without CNS complications following lung transplantation, to identify risk factors for CNS events. Records of 21 patients with CF who underwent lung transplant between 1991-1996 were reviewed. Data were collected on multiple variables, including: age at transplant; gender; cytomegalovirus (CMV) status; cholesterol and triglyceride levels; sinusitis; percent ideal body weight (IBW); body mass index (BMI); augmented immunosuppression, acute lung rejection episodes (ALR); cyclosporine doses; electrolytes; magnesium, blood urea nitrogen (BUN), and creatinine levels; and 6-month survival. CNS complications identified were seizures, severe headaches (HA), strokes, or confusional episodes. Eleven of 21 patients (52%) with CF had CNS events: eight had seizures, five HA, three strokes, and one confusional episode. There was no difference in age at transplant, pretransplant percent IBW or BMI, cholesterol and triglyceride levels, or number of ALR. CMV mismatch and clinical sinusitis had no effect. Cyclosporine doses did not differ between groups at 30 days, or 3 or 6 months posttransplant. Both BUN and creatinine concentrations showed a rise over time that did not differ between groups. Potassium levels were within normal limits for both groups. While sodium levels did not differ between groups pretransplant, or at 30 days or 6 months posttransplant, a decrease in sodium values was seen at the time of CNS events. There was no difference in 6-month survival. We could not identify any pre- or posttransplant risk factors that predicted CNS events. It is likely that cyclosporine toxicity is the major cause of CNS complications. Despite the high rate of CNS events, the overall prognosis was good, and 6-month survival was not affected.

Photopheresis in the treatment of refractory bronchiolitis obliterans complicating lung transplantation

Photopheresis has been successfully used to treat heart allograft rejection and has had some initial success in the treatment of bronchiolitis obliterans (BO) following lung transplantation. This report describes five patients treated with photopheresis after the failure of augmented immunosuppression for BO. Four patients had a temporary stabilization of their airflow obstruction, and minimal side effects of the procedure were noted, although there were consequences from additional augmented immunosuppression (principally sepsis). Photopheresis may provide a safe modality for the treatment of BO that is unresponsive to standard and augmented immunosuppression.

Airway responsiveness to inhaled albuterol in patients with pulmonary hypertension

We studied patients with pulmonary hypertension who had evidence of bronchial responsiveness to inhaled albuterol. The records of all patients evaluated for lung transplantation were reviewed: the charts of patients with pulmonary hypertension, either primary (PPH, n = 46) or Eisenmenger's syndrome (n = 12), were abstracted. Measurements of lung function revealed equal numbers of patients with normal, restrictive, obstructive, and mixed abnormalities. None were more than moderate. Airway responsiveness was defined as an increase of forced expiratory volume in 1 second (FEV1) > 15% or forced expiratory flow between 25% and 75% of the vital capacity (FEF25-75) > 25%. Of the 24 PPH and nine Eisenmenger's patients, 14 and four, respectively, had reversible airflow obstruction. These patients were more likely to have a history of atopic disease and to have responded to calcium channels blockers during hemodynamic monitoring. They did not have more severe pulmonary hypertension, as measured by hemodynamic monitoring. Four patients had a history of asthma, which required hospitalization in three. Reversible airflow obstruction occurred in half of the patients with pulmonary hypertension and was clinically important in at least three.

Cytomegalovirus infection is a risk factor for invasive aspergillosis in lung transplant recipients

Invasive aspergillosis (IA) remains a major cause of morbidity and mortality following solid organ transplantation. To assess the incidence of IA following lung transplantation and to identify risk factors for its occurrence, we performed a case-control study involving 101 patients undergoing lung transplantation at our institution from 1990 to 1995 and reviewed the findings. Fourteen patients (14%) developed IA. The mean time from transplantation to diagnosis was 15 months. Nine patients died; the mean time to death from diagnosis was 13 days. Risk factors associated with developing IA included concomitant cytomegalovirus (CMV) pneumonia or viremia and culture isolation of Aspergillus species from a respiratory tract specimen after lung transplantation. Optimal strategies to prevent IA in lung transplant recipients remain to be determined, but prevention of aspergillus airway colonization and CMV viremia and disease after transplantation may be important targets for prophylactic interventions.

Central nervous system complications after lung transplantation

PURPOSE

This study describes the central nervous system (CNS) events after lung transplantation.

METHODS

A chart review of all lung transplant recipients (LTR) to collect the clinical and neuroimaging data for CNS events defined as seizures, severe headaches, confusion, or stroke.

RESULTS

Twenty-six patients of 100 LTRs from 1990 through 1995 had a CNS event; more than one event occurred in 5 patients for a total of 32 events. Severe headache was most common, occurring in 14 patients, followed by seizures in 10, stroke in 5, and confusion in 3. The CNS event was related to infection in three of the 26 patients. Of all evaluations performed, magnetic resonance imaging (MRI) identified the most abnormalities, the most common being white matter changes consistent with cyclosporine toxicity. Cyclosporine levels were elevated in slightly more than half of the patients. Hypomagnesemia was present in three of 10 patients with seizures. Prognosis for recovery from these complications was good, with only five patients having ongoing problems with headaches, one requiring long term anticonvulsant therapy, three having minor or no limitations from stroke and no long-term problems with confusion. One patient with seizures resulting from an aspergilloma died.

CONCLUSION

CNS events occur commonly in LTRs, mostly related to cyclosporine toxicity or infection. MRI identifies more abnormalities than computed tomography. These events were not consistently associated with documented high cyclosporine levels and hypomagnesemia. In spite of significantly abnormal MRIs, the functional outcome is favorable.

Pediatric lung transplantation

Pediatric lung transplantation is becoming more common, and with increasing experience there is increasing success. The most common indications for considering lung transplantation are cystic fibrosis, pulmonary vascular disease (usually due to congenital heart disease), and fibrotic lung disease. The contraindications and complications are similar to adult transplant patients, although post-transplant lymphoproliferative disease and airway complications may occur more frequently. The patients with cystic fibrosis face additional obstacles to the success of transplantation: airway colonization with Gram-negative organisms, pancreatic insufficiency, glucose intolerance, and osteoporosis. The survival for children is comparable to adults, reaching about 65% at 1 year, and 69% at 2 years.

Diagnostic yield and therapeutic impact of flexible bronchoscopy in lung transplant recipients

BACKGROUND

Bronchoalveolar lavage and transbronchial biopsy are often used for definitive diagnosis of lung rejection and infection in lung transplant recipients. Although protected specimen brushing is of value in nosocomial bacterial pneumonia, its role in lung transplant recipients had not been widely reported. The aim of the study is to review the diagnostic yield and therapeutic impact of flexible bronchoscopy with the use of a combination of bronchoalveolar lavage, protected specimen brushing, and transbronchial biopsy in lung transplant recipients.

METHODS

We reviewed flexible bronchoscopy data in 83 transplant recipients between February 1990 and March 1995. Only those with bronchoalveolar lavage, protected specimen brushing, and transbronchial biopsy were included in the analysis. There were 282 bronchoscopies performed for clinically suspected lung rejection or infection (clinical bronchoscopy) and 38 bronchoscopies for follow-up of a previously detected histologic abnormality (follow-up bronchoscopy).

RESULTS

The total yields for rejection and infection for clinical and follow-up bronchoscopies were 67.4% and 58.9%, respectively. Acute rejection was detected with transbronchial biopsy in 26.2% and 34.2% of clinical and follow-up bronchoscopies, respectively. Cytomegalovirus pneumonitis was detected with transbronchial biopsy in 4.0% and 11.4% of clinical and follow-up bronchoscopies, respectively. Overall, bacteria was the most common cause of lower respiratory tract infection. When used together, protected specimen brushing and bronchoalveolar lavage were complementary techniques for detection of bacterial lower respiratory tract infection with a significantly higher proportion detected with protected specimen brushing ( > or = 10(3) colony forming units/ml) compared with bronchoalveolar lavage ( > or = 10(5) colony forming units/ml) (p < 0.001). Complications were hemorrhage (1.9%), pneumothorax (2.5%) and transient hypoxemia (10.5%). The results had an impact on management of rejection and infection in 57.8% of clinical and 39.5% of follow-up bronchoscopies.

CONCLUSIONS

We conclude that bronchoscopy, with the use of a combination of bronchoalveolar lavage, protected specimen brushing, and transbronchial biopsy, is safe with a high diagnostic yield and therapeutic impact for treating lung transplant recipients.

Aspiration complicating bronchopulmonary dysplasia

The purpose of this study was to study the relationship of aspiration with ongoing respiratory difficulties in infants with bronchopulmonary dysplasia (BPD). Twelve infants with BPD were identified out of 314 children who had flexible bronchoscopy between 1987 and 1990; 11 of 12 had bronchoalveolar lavage (BAL). The lipid index (LI) was used to quantify the degree of lipid-laden macrophages in the BAL fluid as a marker of aspiration. The age range at the time of bronchoscopy was 3 months to 5 years. The LI was considered positive in 6 of 11 subjects. A pH probe study was done on seven subjects with concordant findings in five. Other findings included dynamic or structural airway abnormalities in 10 of the 12 subjects. These data suggest that aspiration frequently is associated with BPD in addition to the previously recognized dynamic and structural airway problems. The predisposition to gastroesophageal reflux and laryngeal injury probably accounts for the increased aspiration risk in children with BPD.

Thoracic organ transplantation in children. The state of heart, heart-lung, and lung transplantation

Heart, heart-lung, and lung transplantation have become accepted modalities for treatment in children with serious cardiopulmonary disease. Although early deaths secondary to infection and/or acute rejection have been reduced dramatically, there is still an early mortality related to cardiac complications and a late mortality related to rejection and infection. The management of hypoplastic left heart syndrome remains a special problem and is outlined in the review. There is much less experience in the newer modalities of heart-lung and lung transplantation in children and the results of these operative procedures are similar to what was seen in heart transplantation some 10 years ago. Ongoing and significant improvement continues, however, in all forms of transplantation dealing with the lung.

The ventilator-dependent child: issues in diagnosis and management

Infants, children, and adolescents with chronic respiratory failure are surviving in increasing numbers and, thereby, producing a significant population of ventilator-dependent pediatric patients. Chronic respiratory failure can occur as a complication of a wide variety of disease states; in pathophysiologic terms, it generally results from either decreased central nervous system output or inadequate force generated by the respiratory pump. Its laboratory hallmark is hypercapnia with or without hypoxemia. Stabilization of the patient with mechanical ventilatory support may permit long-term survival. Management of the ventilator-dependent pediatric patient is a complex task that must begin with an accurate prognostication of each patient's survival and quality of life. Once a decision is made concerning the practicality and appropriateness of long-term ventilatory support, informed choices must be made with respect to need for an artificial airway, mode of ventilation, and location of care. Many younger patients, especially those with intrinsic lung disease (like bronchopulmonary dysplasia), may require a hospital setting for long-term care, whereas others with neuromuscular or central disorders may benefit from being discharged to home. The patient's family must be thoroughly educated in the child's care, and they must be involved in decision-making. A multidisciplinary team of physicians, therapists, nurses, and other professionals is required to deliver optimal care. Outcome is good for most patients who are carefully selected.

Effectiveness of open-circuit and oxyhood delivery of helium-oxygen

The combination of helium with oxygen is less dense than air and as such has been beneficial to patients with airflow obstruction within the large airways. The purpose of this study was to evaluate the effectiveness of delivering He-O2 by open-circuit systems by measuring DD50 in five adult volunteers. The mean (+/- SD) DD50 with a nonrebreathing mask was 1.32 +/- 0.89, with a simple mask was 1.21 +/- 0.87, and with a nasal cannula was 1.00 +/- 0.13; the DD50 with the nonrebreathing mask and the simple mask was statistically greater than with the cannula (p less than 0.05). Two infant oxygen hoods were assessed by measuring the nitrogen concentration at different locations in the hoods. The N2 concentration increased progressively from top to bottom, indicating that the helium was concentrated at the top. We conclude that the nonrebreathing mask and simple masks are probably satisfactory He-O2 delivery systems, that the infant oxyhood may be suboptimal, and that the nasal cannula is ineffective.

Endotracheal tobramycin in gram-negative pneumonitis

This report describes the treatment of resistant gram-negative pneumonitis in a compromised host by the combined use of intravenous and endotracheal tobramycin. The endotracheal administration appeared to have an effect on the serum concentration and elimination rate, necessitating a reduction in the amount of drug given intravenously. The only apparent clinical complication of endotracheal drug administration was transient coughing. The addition of endotracheal aminoglycosides to intravenous antibiotics may be useful in pediatric patients with unresponsive (or other difficult-to-treat) pneumonitis caused by resistant microorganisms. The potential contribution of endotracheal aminoglycosides to the serum level and/or disposition profile must be recognized, and therapeutic drug monitoring guided accordingly when this route of administration is used.

Individualizing gentamicin dosage in patients with cystic fibrosis: limitations to pharmacokinetic approach

Gentamicin serum concentrations were measured in 15 children and seven adults with cystic fibrosis and in eight children with other diseases. Potentially toxic trough concentrations occurred in three of the first nine patients studied, in whom the dose and a 4-hour dosing interval were prescribed on the basis of one-compartment pharmacokinetic calculations (Sawchuck-Zaske method). In contrast, final concentrations were within the accepted target ranges for the remaining 13 patients with cystic fibrosis, in whom the dose and interval were adjusted empirically on the basis of a single pair of "peak" and trough values. The mean +/- SD final dosage required to achieve target concentrations was 13.8 +/- 2.9 mg/kg/d for children and 11.8 +/- 1.1 mg/kg/d for adults (P greater than 0.05), generally divided into four doses at 6-hour intervals. Mean half-life and incremental increase in serum concentration from previous trough to subsequent "peak," an indirect measurement of volume of distribution, were not significantly different between children or adults with cystic fibrosis and pediatric control subjects; there was little interpatient variability in these values. Thus the high dosage requirements were related more to the higher target concentrations than to altered pharmacokinetic disposition in patients with cystic fibrosis. We conclude that the initial dose of gentamicin to achieve a peak of 8 to 12 micrograms/mL and a trough of less than 2.0 micrograms/mL in patients with cystic fibrosis should be 3 mg/kg administered every 6 hours in children and every eight hours in adults. Subsequent dosage adjustment should be made on the basis of a pair of peak and trough serum concentration measurements obtained after the fifth dose. Dosing intervals in this patient population generally should be no shorter than every 6 hours, even if the initial trough concentration is less than 1 microgram/mL.

Rapid estimation of serum theophylline clearance in children with acute asthma

Serum theophylline clearance was estimated prior to reaching steady state in 29 asthmatic children, aged 1-14 years, using methods described by Chiou et al. and Vozeh et al. Comparison of the estimated clearance by the Vozeh method (0.094 +/- 0.005 L/kg/h) did not differ significantly from that estimated by the Chiou method (0.094 +/- 0.005 L/kg/h). Neither estimate of serum theophylline clearance differed significantly from the calculated clearance at steady state (0.092 +/- 0.006 L/kg/h). Linear correlations between predicted and observed serum theophylline clearances were found for both the Chiou (p = 0.002, r = 0.54) and Vozeh (p = 0.02, r = 0.49) methods. Estimates of the steady-state serum theophylline concentrations by the Vozeh method (10.32 +/- 0.56 mg/L) and the Chiou method (10.28 +/- 0.52 mg/L) did not differ significantly from each other or from the observed steady-state serum theophylline concentration (10.54 +/- 0.48 mg/L). A linear correlation between predicted and observed serum theophylline concentrations was found for both the Chiou (p = 0.02, r = 0.43) and Vozeh (p = 0.001, r = 0.57) methods. These results suggest that either method of estimating serum theophylline clearance can be used to rapidly individualize therapy in children with acute asthma.

Limited thoracotomy in the pediatric patient

Thirty-one children underwent 33 limited thoracotomies between 1973 and 1979. Adequate tissue for diagnosis was obtained in each case, and subsequent therapy was influenced in 91%. The preoperative diagnosis was confirmed in 61% and corrected in 36%. One death may have been hastened by the procedure, but all others were related to the underlying disease process. There were very few complications, the most common being pneumothorax. The routine use of a chest tube postoperatively seems to reduce the frequency of pneumothoraces. The average duration of the operation was 50 minutes. We believe that limited thoracotomy is a safe and rapid method of obtaining lung tissue and almost always ensures adequate tissue for diagnosis.

Desquamative interstitial pneumonitis in children

Interstitial pneumonitis in children is a rare and poorly understood disease. Controversy exists as to whether the varoius histologic changes encountered represent different disease or a spectrum of the same disease. Fourteen biopsy-confirmed cases of desquamative interstitial pneumonitis in children were seen at the Mayo Clinic between 1953 and 1975. A search of the literature revealed 14 additional cases but no series of exclusively desquamative interstitial pneumonitis. The most frequent symptoms were retardation of growth and dyspnea, often accompanied by cough. Tachypnea was the most common finding on examination; rales, cyanosis, and clubbing were variably present. The chest roentgenogram was distinctly abnormal in all cases; it usually revealed a combined interstitial and alveolar pattern extending bilaterally from the hilus to the base. Results of laboratory studies were nonspecific for desquamative interstitial pneumonitis. All 28 patients in this review were treated with corticosteroids; 17 (61 percent) survived. Desquamative interstitial pneumonitis was found in association with a variety of other major illnesses. The cause remains unknown.