Analysis of guideline recommendations for treatment of asthma exacerbations in children: a Pediatric Emergency Research Networks (PERN) study

RATIONALE

There is significant practice variation in acute paediatric asthma, particularly severe exacerbations. It is unknown whether this is due to differences in clinical guidelines.

OBJECTIVES

To describe and compare the content and quality of clinical guidelines for the management of acute exacerbations of asthma in children between geographic regions.

METHODS

Observational study of guidelines for the management of acute paediatric asthma from institutions across a global collaboration of six regional paediatric emergency research networks.

MEASUREMENTS AND MAIN RESULTS

158 guidelines were identified. Half provided recommendations for at least two age groups, and most guidelines provided treatment recommendations according to asthma severity.There were consistent recommendations for the use of inhaled short-acting beta-agonists and systemic corticosteroids. Inhaled anticholinergic therapy was recommended in most guidelines for severe and critical asthma, but there were inconsistent recommendations for its use in mild and moderate exacerbations. Other inhaled therapies such as helium-oxygen mixture (Heliox) and nebulised magnesium were inconsistently recommended for severe and critical illness.Parenteral bronchodilator therapy and epinephrine were mostly reserved for severe and critical asthma, with intravenous magnesium most recommended. There were regional differences in the use of other parenteral bronchodilators, particularly aminophylline.Guideline quality assessment identified high ratings for clarity of presentation, scope and purpose, but low ratings for stakeholder involvement, rigour of development, applicability and editorial independence.

CONCLUSIONS

Current guidelines for the management of acute paediatric asthma exacerbations have substantial deficits in important quality domains and provide limited and inconsistent guidance for severe exacerbations.

Rib fracture secondary to cough-induced trauma

Early identification of rib fractures, even in young patients without chronic diseases, is essential. Prompt diagnosis facilitates appropriate management, aiding in pain control and addressing underlying causes such as persistent coughing. Additionally, vigilance for complications such as pneumothorax and rib displacement is crucial for optimizing patient care.

Use of neonatal lung ultrasound in European neonatal units: a survey by the European Society of Paediatric Research

OBJECTIVE

Regarding the use of lung ultrasound (LU) in neonatal intensive care units (NICUs) across Europe, to assess how widely it is used, for what indications and how its implementation might be improved.

DESIGN AND INTERVENTION

International online survey.

RESULTS

Replies were received from 560 NICUs in 24 countries between January and May 2023. LU uptake varied considerably (20%-98% of NICUs) between countries. In 428 units (76%), LU was used for clinical indications, while 34 units (6%) only used it for research purposes. One-third of units had <2 years of experience, and only 71 units (13%) had >5 years of experience. LU was mainly performed by neonatologists. LU was most frequently used to diagnose respiratory diseases (68%), to evaluate an infant experiencing acute clinical deterioration (53%) and to guide surfactant treatment (39%). The main pathologies diagnosed by LU were pleural effusion, pneumothorax, transient tachypnoea of the newborn and respiratory distress syndrome. The main barriers for implementation were lack of experience with technical aspects and/or image interpretation. Most units indicated that specific courses and an international guideline on neonatal LU could promote uptake of this technique.

CONCLUSIONS

Although LU has been adopted in neonatal care in most European countries, the uptake is highly variable. The main indications are diagnosis of lung disease, evaluation of acute clinical deterioration and guidance of surfactant. Implementation may be improved by developing courses and publishing an international guideline.

Occult solitary fibrous tumour of the pleura presenting as recurrent spontaneous pneumothorax

A woman in her 30s, non-smoker, presented at the emergency department two times because of spontaneous pneumothorax. The first episode was treated with small bore catheter drainage, while during the second episode-occurring only 1 week later-thoracoscopic talcage was attempted. The postoperative course was characterised by slow clinical and radiological resolution, and recurrence 3 days after discharge. Eventually, multiportal video-assisted thoracoscopic exploration identified an interfissural solid mass. Resection and further work-up revealed the diagnosis of 'low-risk' solitary fibrous tumour (SFT) stage pT1N0M0. The interdisciplinary tumour board advised no adjuvant therapy. A CT thorax was scheduled in 1 year for follow-up. The patient was discharged without complications and has had no recurrences of pneumothorax at 6 months of follow-up. This report shows that SFT can easily be missed on initial presentation and should be considered in the differential diagnosis of pneumothorax, especially when frequently recurring.

Airway inflammation accelerates pulmonary exacerbations in cystic fibrosis

Airway inflammation underlies cystic fibrosis (CF) pulmonary exacerbations. In a prospective multicenter study of randomly selected, clinically stable adolescents and adults, we assessed relationships between 24 inflammation-associated molecules and the future occurrence of CF pulmonary exacerbation using proportional hazards models. We explored relationships for potential confounding or mediation by clinical factors and assessed sensitivities to treatments including CF transmembrane regulator (CFTR) protein synthesis modulators. Results from 114 participants, including seven on ivacaftor or lumacaftor-ivacaftor, representative of the US CF population during the study period, identified 10 biomarkers associated with future exacerbations mediated by percent predicted forced expiratory volume in 1 s. The findings were not sensitive to anti-inflammatory, antibiotic, and CFTR modulator treatments. The analyses suggest that combination treatments addressing RAGE-axis inflammation, protease-mediated injury, and oxidative stress might prevent pulmonary exacerbations. Our work may apply to other airway inflammatory diseases such as bronchiectasis and the acute respiratory distress syndrome.

A pitfall in chest imaging

The key feature of Poland syndrome is asymmetry in the chest wall. Clinicians should be alert to abnormalities of the chest wall as well as the lungs if there is abnormal chest radiograph lucency.

Exacerbation Burden in COPD and Occurrence of Mortality in a Cohort of Italian Patients: Results of the Gulp Study

Objective

To describe the burden of moderate to severe exacerbations and all-cause mortality; the secondary objectives were to analyze treatment patterns and changes over follow-up.

Design

Observational, multicenter, retrospective, cohort study with a three year follow-up period.

Setting

Ten Italian academic secondary- and tertiary-care centers.

Participants

Patients with a confirmed diagnosis of COPD referring to the outpatient clinics of the participating centers were retrospectively recruited.

Primary and Secondary Outcome Measures

Annualized frequency of moderate and severe exacerbations stratified by exacerbation history prior to study enrollment. Patients were classified according to airflow obstruction, GOLD risk categories, and divided in 4 groups: A = no exacerbations; B = 1 moderate exacerbation; C = 1 severe exacerbation; D = ≥2 moderate and/or severe exacerbations. Overall all-cause mortality stratified by age, COPD category, and COPD therapy. A logistic regression model assessed the association of clinical characteristics with mortality.

Results

1111 patients were included (73% males), of which 41.5% had a history of exacerbations. As expected, the proportion of patients experiencing ≥1 exacerbation during follow-up increased according to pre-defined study risk categories (B: 79%, C: 84%, D: 97.4%). Overall, by the end of follow-up, 45.5% of patients without a history of exacerbation experienced an exacerbation (31% of which severe), and 13% died. Deceased patients were significantly older, more obstructed and hyperinflated, and more frequently active smokers compared with survivors. Severe exacerbations were more frequent in patients that died (23.5%, vs 10.2%; p-value: 0.002). Chronic heart failure and ischemic heart disease were the only comorbidities associated with a higher odds ratio (OR) for death (OR: 2.2, p-value: 0.001; and OR: 1.9, p-value: 0.007). Treatment patterns were similar in patients that died and survivors.

Conclusion

Patients with a low exacerbation risk are exposed to a significant future risk of moderate/severe exacerbations. Real life data confirm the strong association between mortality and cardiovascular comorbidities in COPD.

Mesenchymal hepatic hamartoma: A rare case of severe respiratory distress in a neonate

It is critical to consider intra-abdominal pathology in cases of neonatal respiratory distress. Accurate and prompt diagnosis via computed tomography is lifesaving. We have highlighted the effectiveness of rapid surgical intervention as curative.

The Feasibility of C-Reactive Protein Point-of-Care Testing to Reduce Overuse of Antibiotics in Children with Acute Respiratory Tract Infections in Rural Kyrgyzstan: A Pilot Study

Background

In Kyrgyzstan, the morbidity prevalence of and morbidity from acute respiratory tract infections (ARTI) in children is high. Local healthcare workers (HCW) often prescribe antibiotics that are not indicative due to a mix of professional and societal factors. It is suggested to precede with a decision on antibiotics by a point-of-care test (POCT) on the appropriateness of the treatment, eg, a measurement of C-reactive protein (CRP). CRP-guided antibiotic stewardship in children with ARTI has not previously been studied in Central Asia.

Purpose

This pilot study was conducted to examine the feasibility of the methods and procedures to be used in the upcoming randomised controlled COORDINATE clinical trial (NCT05195866) and in daily clinical practice in primary care.

Patients and methods

HCWs from three selected rural healthcare facilities were trained in the CRP POCT and in interpretation of results. Children aged 6 months to 12 years attending the primary healthcare facilities with respiratory symptoms were randomly assigned to CRP-guided management or standard care, guided by clinical findings only. Children were followed up for 14 days by scheduled telephone calls to caregivers.

Results

Eighty-one children participated in this pilot study. The CRP POCT and the trial procedures were acceptable to the target group as well as to the HCWs. Children from both groups recovered equally well, with an observed significant lower use of antibiotics in the CRP group. HCWs generally adhered to the CRP guidelines, and only once was an antibiotic prescribed despite low CRP results. No safety concerns were observed. Four parents provided wrong phone numbers impeding follow-up. We will collect all mobile phone numbers in the household for the main trial.

Conclusion

The pilot provided satisfactory results, suggesting that the COORDINATE trial of CRP POCT is effective, feasible with minor adjustments and without apparent safety concerns for the participants.

Risk of winter hospitalisation and death from acute respiratory infections in Scotland: national retrospective cohort study

OBJECTIVES

We undertook a national analysis to characterise and identify risk factors for acute respiratory infections (ARIs) resulting in hospitalisation during the winter period in Scotland.

DESIGN

A population-based retrospective cohort analysis.

SETTING

Scotland.

PARTICIPANTS

The study involved 5.4 million residents in Scotland.

MAIN OUTCOME MEASURES

Cox proportional hazard models were used to estimate adjusted hazard ratios (aHRs) and 95% confidence intervals (CIs) for the association between risk factors and ARI hospitalisation.

RESULTS

Between 1 September 2022 and 31 January 2023, there were 22,284 (10.9% of 203,549 with any emergency hospitalisation) ARI hospitalisations (1759 in children and 20,525 in adults) in Scotland. Compared with the reference group of children aged 6-17 years, the risk of ARI hospitalisation was higher in children aged 3-5 years (aHR = 4.55; 95% CI: 4.11-5.04). Compared with those aged 25-29 years, the risk of ARI hospitalisation was highest among the oldest adults aged ≥80 years (aHR = 7.86; 95% CI: 7.06-8.76). Adults from more deprived areas (most deprived vs. least deprived, aHR = 1.64; 95% CI: 1.57-1.72), with existing health conditions (≥5 vs. 0 health conditions, aHR = 4.84; 95% CI: 4.53-5.18) or with history of all-cause emergency admissions (≥6 vs. 0 previous emergency admissions, aHR = 7.53; 95% CI: 5.48-10.35) were at a higher risk of ARI hospitalisations. The risk increased by the number of existing health conditions and previous emergency admission. Similar associations were seen in children.

CONCLUSIONS

Younger children, older adults, those from more deprived backgrounds and individuals with greater numbers of pre-existing conditions and previous emergency admission were at increased risk for winter hospitalisations for ARI.

Comparison of two different oxygen saturation target ranges for automated oxygen control in preterm infants: a randomised cross-over trial

OBJECTIVE

To compare the effect of peripheral oxygen saturation (SpO2) target range (TR) (either 91%-95% and 92%-96%) on the frequency and duration of hypoxic and hyperoxic episodes while on automated oxygen control using the OxyGenie controller.

DESIGN

Randomised cross-over study.

SETTING

Tertiary-level neonatal unit in the Netherlands.

PATIENTS

Infants (n=27) with a median (IQR) gestational age of 27+0 (25+5-27+3) weeks and postnatal age of 16 (10-22) days, receiving invasive or non-invasive respiratory support.

INTERVENTIONS

In both groups supplemental oxygen was titrated to a TR of 91%-95% (TRlow) or 92%-96% (TRhigh) by the OxyGenie controller (SLE6000 ventilator) for 24 hours each, in random sequence. After a switch in TR, a 1-hour washout period was applied to prevent carry-over bias.

MAIN OUTCOME MEASURES

Frequency and duration of hypoxic (SpO2<80% for ≥1 s) and hyperoxic episodes (SpO2>98% for ≥1 s).

RESULTS

Hypoxic episodes were less frequent when the higher range was targeted (TRhigh vs TRlow: 2.5 (0.7-6.2)/hour vs 2.4 (0.9-10.2)/hour, p=0.02), but hyperoxic episodes were more frequent (5.3 (1.8-12.3)/hour vs 2.9 (1.0-7.1)/hour, p<0.001). The duration of the out-of-range episodes was not significantly different (hypoxia: 4.7 (2.8-7.1) s vs 4.4 (3.7-6.5) s, p=0.67; hyperoxia: 4.3 (3.3-4.9) s vs 3.9 (2.8-5.5) s, p=0.89).

CONCLUSION

Targeting a higher SpO2 TR with the OxyGenie controller reduced hypoxic episodes but increased hyperoxic episodes. This study highlights the feasibility of using an automated oxygen titration device to explore the effects of subtle TR adjustments on clinical outcomes in neonatal care.

TRIAL REGISTRATION NUMBER

NL9662.

Chest drainage, a basic but essential procedure

Chest drainage is a basic and important procedure in the treatment of pneumothorax. When properly implemented, even the most severely ill patients may be able to be treated without surgical intervention.

Psychosocial and Service Delivery Impacts of the COVID-19 Pandemic on Children With Respiratory Conditions, Their Parents and Their Health Care Providers

The COVID-19 pandemic imposed widespread impacts on the health and well-being of children with respiratory challenges and their families, as well as on the health care system that supports them. An exploratory qualitative study was undertaken to examine how the pandemic impacted families' and health care providers' daily lives and experiences of care. Four youth, 12 parents and 7 health care providers participated in interviews via telephone or online technology. Content analysis of transcribed interviews revealed participant experiences, including initial responses to the pandemic, adjustment to pandemic shifts, and anticipation of the future. While deleterious physical health impacts were minimal for children with pre-existing respiratory conditions, their mental health was negatively impacted by the pandemic and related health protocols. Families and health care providers experienced strain, yet demonstrated resilience. Pandemic-related shifts profoundly impacted daily life at home, school, and work. Pediatric pandemic planning in clinical care is recommended to better address the needs of children with respiratory conditions and their families as well as pediatric health care providers.

Hospital discharge using salbutamol as required after acute attacks of wheeze in children: a service evaluation

OBJECTIVE

Most UK hospitals discharge children after acute wheeze with advice to give regular salbutamol using a fixed dose weaning regime. We have introduced and evaluated the safety and efficacy of changing practice to using bronchodilators only as needed after 4 hourly assessments.

DESIGN

A multidisciplinary team of healthcare professionals worked with eight families of children who had needed hospital treatment with acute wheeze to develop guidance for the use of salbutamol on an as required basis after 4 hourly assessments. Data on salbutamol used with this approach were compared with a similar period in the previous year.

RESULTS

Data from 103 families showed a 73% reduction in salbutamol on day 1, 69% on day 2 and 50% on day 3 compared with what would have been used according to previous advice. Families found the advice easy to follow. There was a trend towards lower reattendance rates within 1 week compared with those recorded in the previous year. Those who had previously attended preferred this change in practice.

CONCLUSIONS

These data suggest that with information to support the use of salbutamol on an as required basis after hospital attendance, children can be safely managed by their parents/guardians with much lower doses of salbutamol than those recommended in commonly used fixed dose weaning regimes.

Paraquat ingestion in an adult with cystic fibrosis (CF): Diagnostic and management dilemmas

N,N'-dimethyl-4,4'bipyridinium dichloride (Paraquat) is a potent herbicide used widely in agriculture. We report the effects of an ingestion of paraquat by a 28 year old male with cystic fibrosis and the diagnostic and management challenges this posed in both the acute and longer term setting. We describe the effects of direct paraquat toxicity on the lung tissue secondary to aspiration and review the long-term sequelae of paraquat, namely osteonecrosis. Our case is the first to describe osteonecrosis of the knee in the context of paraquat toxicity. Survival following ingestion remains poor with a high associated mortality. However, timely treatment with NAC and immunosuppression may impact on survival. In those patients who do survive the acute phase post ingestion, follow-up over years may be required to detect the long-term effects of paraquat on bone health.

Navigating Compassion: A Comprehensive Review of Palliative Care in Respiratory Medicine

Palliative care has emerged as a crucial aspect of comprehensive healthcare, particularly in respiratory medicine. This review navigates the intricate landscape of palliative care in the context of respiratory diseases, including chronic obstructive pulmonary disease (COPD), idiopathic pulmonary fibrosis (IPF), and lung cancer. The exploration begins with a comprehensive examination of palliative care's definition, significance, and purpose in respiratory medicine. It progresses to understanding common respiratory diseases, their impact on patients' quality of life, and the nuances of disease progression and prognosis. Delving into the principles of palliative care, the review highlights the importance of a patient- and family-centered approach, emphasizing the multidisciplinary collaboration required for holistic care. Symptom management takes center stage, with a detailed exploration of dyspnea, cough, and pain, covering pharmacological and non-pharmacological interventions. The psychosocial and spiritual dimensions are then unveiled, recognizing the psychological impact of respiratory diseases and the significance of addressing spiritual needs with cultural sensitivity. Communication in palliative care is explored through breaking lousy news, advance care planning, and shared decision-making. The section acknowledges the complex considerations surrounding end-of-life care, including recognizing the end-of-life phase, establishing care goals, and withdrawing life-sustaining therapies. Recognizing the indispensable role of caregivers, the review underscores the importance of caregiver support. It delineates strategies for providing emotional and practical support alongside a crucial focus on self-care for caregivers who shoulder the responsibilities of providing palliative care. As the exploration concludes, the challenges in implementing palliative care in respiratory medicine are outlined, from late referrals to communication barriers. However, the review also envisions a future marked by innovation, with emerging approaches, such as telehealth and personalized medicine, offering promising avenues for improvement. Research gaps and areas for improvement are identified, emphasizing the need for a collaborative effort to enhance the quality of palliative care for individuals facing respiratory diseases. The review culminates in a call to action, urging early palliative care integration, investment in education and training, research initiatives, advocacy for accessible services, and collaboration across disciplines. By heeding this call, healthcare providers, researchers, and policymakers can collectively contribute to the evolution and enhancement of palliative care in the challenging landscape of respiratory medicine.

Multiple airway plasmacytomas: A rare cause of proximal airway obstruction requiring tumor debulking

Extramedullary plasmacytomas (EMP) can present as airway lesions causing central airway obstruction. Though typically solitary, EMPs should be considered in the evaluation of multifocal tracheobronchial tumors. Bronchoscopic tumor debulking and radiation therapy can be used for symptomatic relief.

Video laryngoscopy-assisted less-invasive surfactant administration quality improvement initiative

OBJECTIVE

To describe the use of quality improvement methodology in transitioning from delivery of surfactant by INSURE (INtubation-SURfactant administration-Extubation) to video laryngoscope-assisted LISA (less-invasive surfactant administration) for infants with respiratory distress syndrome (RDS) receiving non-invasive ventilatory support.

SETTING

Two large neonatal intensive care units (NICUs) at Northwell Health (New Hyde Park, New York, USA).

STUDY POPULATION

Infants with RDS receiving continuous positive airway pressure in the NICU and eligible for surfactant administration.

RESULTS

LISA was initiated in our NICUs in January 2021, after extensive guideline development, education programmes, hands-on training and provider credentialing. Our Specific, Measurable, Achievable, Relevant and Timely aim was to deliver surfactant by LISA for 65% of total doses by 31 December 2021. This goal was achieved within 1 month of go-live. In total, 115 infants received at least one dose of surfactant during the year. Of those, 79 (69%) received it via LISA and 36 (31%) via INSURE. Two Plan-Do-Study-Act cycles contributed to improved adherence to guidelines on timely surfactant administration and both written and video documentation.

CONCLUSIONS

Safe and effective introduction of LISA with the use of video laryngoscopy is achievable with careful planning, clear clinical guidelines, adequate hands-on training and comprehensive safety and quality control.

Cystic bronchiectasis in sarcoidosis

Pulmonary sarcoidosis can manifest in different radiologic patterns. Typical manifestations in high-resolution computed tomography are bilateral perihilar lymphadenopathy, micronodules, and fibrotic changes. Atypical manifestations are mass-like or alveolar opacities, honeycomb-like cysts, miliary opacities, tracheobronchial involvement, and pleural disease. Cystic bronchiectasis in pulmonary sarcoidosis is rare, with only a few reported cases in the literature. We present another case of cystic bronchiectasis with a honeycomb-like pattern in pulmonary sarcoidosis and with cardiac involvement. This case was presented as an abstract poster at the American Thoracic Society conference in 2022.

Antiviral activity of salt-coated materials against SARS-CoV-2

The SARS-CoV-2 pandemic demonstrated the importance of human coronaviruses and the need to develop materials to prevent the spread of emergent respiratory viruses. Coating of surfaces with antiviral materials is a major interest in controlling spread of viruses, especially in high-risk or high-traffic areas. A number of different coatings for surfaces have been proposed, each with their own advantages and disadvantages. Here we show that simple salt coating on a range of surfaces, including a novel biomass aerogel can reduce the infectivity of SARS-CoV-2 placed onto the surface. This suggests that a simple to apply coating could be applied to a range of materials and have an antiviral effect against SARS-CoV-2, as well as other potential emerging viruses.

Dual M. kansasii infection in one household: a reconsideration of our understanding of transmission routes

Mycobacterium kansasii is one of the the most common non-tuberculous mycobacteria responsible for opportunistic human infection. Unlike M. tuberculosis, transmission remains poorly understood; spread is assumed to be from a shared geographical source, such as domestic plumbing, and human-to-human transmission is generally not considered by clinicians when evaluating patients and their environments. We describe M. kansasii infection in a husband and wife in the same household and in the same period, suggesting, in these cases, that transmission occurred directly from one patient to the other. This possibility of human-to-human transmission may inform a clinician's scrutiny of risks to household contacts in cases of M. kansasii infection.

Solitary pulmonary nodule in an early adolescent

An early adolescent boy presented with 1-week history of left-sided chest pain, localised to the anterior aspect of seventh intercostal space. A chest radiograph revealed a round opacity measuring 2.6×2.4 cm in the left mid zone. A CT scan of the chest confirmed a solitary well-circumscribed pulmonary nodule measuring 2.7×2.4 cm in the central left upper lobe, adjacent to the anterior segmental bronchus. Positron emission tomography scan showed mild to moderate fluorodeoxyglucose uptake (maximum standardized uptake value 5.2) in the nodule. He underwent a video-assisted left upper lobectomy. Histology of the nodule was consistent with sclerosing pneumocytoma, a rare benign lung neoplasm that occurs predominantly in middle-aged women of Asian descent. This case highlights the challenges in diagnosis and management of solitary pulmonary nodules in children, especially those who remain symptomatic or only have minimal symptoms and provides a pragmatic approach to this condition.

Late permissive hypercapnia and respiratory stability among very preterm infants: a pilot randomised trial

OBJECTIVE

Determine if targeting higher transcutaneous carbon dioxide improves respiratory stability among very preterm infants on ventilatory support.

DESIGN

Single-centre pilot randomised clinical trial.

SETTING

The University of Alabama at Birmingham.

PATIENTS

Very preterm infants on ventilatory support after postnatal day 7.

INTERVENTIONS

Infants were randomised to two different transcutaneous carbon dioxide levels targeting 5 mm Hg (0.67 kPa) changes with four sessions each lasting 24 hours for 96 hours: baseline-increase-baseline-increase or baseline-decrease-baseline-decrease.

MAIN OUTCOME MEASURES

We collected cardiorespiratory data evaluating episodes of intermittent hypoxaemia (oxygen saturations (SpO2)<85% for ≥10 s), bradycardia (<100 bpm for ≥10 s), and cerebral and abdominal hypoxaemia on near-infrared spectroscopy.

RESULTS

We enrolled 25 infants with a gestational age of 24 w 6 d±11 d (mean±SD) and birth weight 645±142 g on postnatal day 14±3. Continuous transcutaneous carbon dioxide values (56.8±6.9 in the higher group vs 54.5±7.8 in the lower group; p=0.36) did not differ significantly between groups during the intervention days. There were no differences in intermittent hypoxaemia (126±64 vs 105±61 per 24 hours; p=0.30) or bradycardia (11±16 vs 15±23 per hour; p=0.89) episodes between groups. The proportion of time with SpO2<85%, SpO2<80%, cerebral hypoxaemia or abdominal hypoxaemia did not differ (all p>0.05). There was moderate negative correlation between mean transcutaneous carbon dioxide and bradycardia episodes (r=-0.56; p<0.001).

CONCLUSION

Targeting 5 mm Hg (0.67 kPa) changes in transcutaneous carbon dioxide did not improve respiratory stability among very preterm infants on ventilatory support but the intended carbon dioxide separation was difficult to achieve and maintain.

TRIAL REGISTRATION NUMBER

NCT03333161.

Primary intrapulmonary thymoma a case report

Primary intrapulmonary thymoma (PIT), defined as the presence of thymoma tissue in the lung without an accompanying mediastinal component, is uncommon and so offers a diagnostic quandary. We describe the case of PIT in an 81-year-old man.

Bronchodilator response by interrupter technique to guide management of preschool wheeze

OBJECTIVE

We examined relationships between clinical features and pulmonary function before and after inhaled corticosteroid (ICS) treatment in wheezy preschool children, and specifically, whether measuring bronchodilator response (BDR) could predict benefit from ICS.

DESIGN

Clinical non-randomised intervention study SETTING: Secondary care.

PATIENTS

Preschool children (2 years to <6 years) with recurrent wheeze.

INTERVENTIONS

Inhaled beta-agonist, ICS.

OUTCOME MEASURES

We measured prebronchodilator and postbronchodilator interrupter resistance (Rint) and symptom scores at 0 (V1), 4 (V2) and 12 (V3) weeks. At V2, those with a predetermined symptom level commenced ICS. Modified Asthma Predictive Index (mAPI) and parental perception of response to bronchodilator were recorded. Response to ICS was defined as a reduction in daily symptom score of >0.26. Positive BDR was defined as fall in Rint of ≥0.26 kPa.s/L, ≥35% predicted or ≥1.25 Z Scores.

RESULTS

Out of 138 recruited children, 67 completed the full study. Mean (SD) prebronchodilator Rint at V2 was 1.22 (0.35) kPa.s/L, and fell after starting ICS (V3) to 1.09 (0.33) kPa.s/L (p<0.001), while mean (SD) daily symptom score fell from 0.56 (0.36) to 0.28 (0.36) after ICS (p<0.001). Positive Rint BDR before ICS (at V1 and/or V2), using all three threshold criteria, was significantly associated with response to ICS on symptom scores at V3 (p<0.05). mAPI was not significantly associated with response to ICS, and parents' perception of response to bronchodilator was not related to measured Rint BDR .

CONCLUSIONS

Rint BDR may be helpful in selecting which wheezy preschool children are likely to benefit from ICS.

Observational cohort study of use of caffeine in preterm infants and association between early caffeine use and neonatal outcomes

OBJECTIVE

To quantify trends in caffeine use in infants born at <32 weeks' gestational age (GA), and to investigate the effects of early vs late caffeine on neonatal outcomes.

STUDY DESIGN

Retrospective propensity score matched cohort study using routinely recorded data from the National Neonatal Research Database of infants born at <32 weeks' GA admitted to neonatal units in England and Wales (2012-2020).

RESULTS

89% (58 913/66 081) of infants received caffeine. In 70%, caffeine was started early (on the day of birth or the day after), increasing from 55% in 2012 to 83% in 2020. Caffeine was given for a median (IQR) of 28 (17-43) days starting on day 2 (1-3) and continued up to 34 (33-34) weeks postmenstrual age.In the propensity score matched cohort of 13 045 pairs of infants, the odds of preterm brain injury (early caffeine, 2306/13 045 (17.7%) vs late caffeine, 2528/13 045 (19.4%), OR=0.89 (95% CI 0.84 to 0.95)) and bronchopulmonary dysplasia (BPD) (early caffeine, 4020/13 045 (32.8%) vs late caffeine, 4694/13 045 (37.7%), OR=0.81 (95% CI 0.76 to 0.85)) were lower in the group that received early caffeine compared with those who received it later.

CONCLUSIONS

Early use of caffeine has increased in England and Wales. This is associated with reduced risks of BPD and preterm brain injury. Randomised trials are needed to find the optimal timing of caffeine use and the groups of infants who will benefit most from early administration of caffeine.

Clinical characteristics of COVID-19 patients infected by the Omicron variants in Macao, China: A cross-sectional study

Background and Aims

The evolving mutants of SARS-CoV-2 have made the COVID-19 pandemic sustained for over 3 years. In 2022, BA.4 and BA.5 were the Omicron variants dominating the spread globally. Although COVID-19 was no longer a Public Health Emergency of International Concern (PHEIC) as announced by WHO, the SARS-CoV-2 variants remain a challenge to global healthcare under the circumstances of withdrawal and loosening of personal protective behavior in the post-quarantine era. This study aims to acknowledge the clinical characteristics caused by Omicron BA.4/BA.5 in COVID-19 naive people and analyze possible factors affecting disease severities.

Methods

In this retrospective study, we report and analyze the clinical features of 1820 COVID-19 patients infected with the BA.4/BA.5 Omicron variants of SARS-CoV-2 during a local outbreak that occurred in Macao SAR, China, from June to July 2022.

Results

A total of 83.5% of patients were symptomatic eventually. The most common symptoms were fever, cough, and sore throat. Hypertension, dyslipidemia, and diabetes mellitus were the leading comorbidities. There were significantly more elderly patients (p < 0.001), more patients with comorbidity (p < 0.001) and more patients without vaccination or not completing the series (p < 0.001) in the "Severe to Critical" group. All deceased patients were elderly with at least three comorbidities and were partial to totally dependent in their daily lives.

Conclusion

Our data are consistent with a milder disease caused by BA.4/5 Omicron variants in the general population, while patients with old age and comorbidities have developed severe to critical diseases. Complete vaccination series and booster doses are effective strategies to reinforce protection against severe diseases and avoid mortality.

A reflection on Salbutamol overuse in one GP practice in Islington: a community action project at Imperial College London

As 3rd-year medical students at Imperial College London, we investigated Salbutamol overuse in the community of Islington. We were inspired to carry out this project due to the high prevalence of Salbutamol overuse which became evident during our GP placement. This was part of our Community Action Project (CAP) which aims for students to investigate issues within their GP practice and patient population and create solutions to help overcome this, like a quality improvement project. This project focused on the local community around the GP practice. We spoke to 11 patients individually who were at high risk of severe asthma attacks, assessing their understanding of Salbutamol and their Salbutamol usage. Patients had varied responses, with some using their inhaler five times a day, to others using it very rarely. This project gave us newly found insight into the growing issue of Salbutamol overuse. Using the information gathered from these patient interviews, we produced an educational poster about Salbutamol inhaler usage.

Indwelling pleural catheters: evidence for and management

The incidence of pleural disease is increasing, and pleural medicine is increasingly recognised as a subspecialty within respiratory medicine. This often requires additional training time. Once underresearched, the last decade has seen an explosion in evidence related to the management of pleural disease. One of the cornerstones of pleural effusion management is the insertion of an indwelling pleural catheter. This allows patient-centred outpatient management and now has a robust evidence base. This article summarises evidence as well serves as a practical guide to the management of any complications related to an indwelling pleural catheter that might present on an acute take.

Developing a nomogram-based scoring model to estimate the risk of pulmonary embolism in respiratory department patients suspected of pulmonary embolisms

Objective

Pulmonary embolisms (PE) are clinically challenging because of their high morbidity and mortality. This study aimed to create a nomogram to accurately predict the risk of PE in respiratory department patients in order to enhance their medical treatment and management.

Methods

This study utilized a retrospective method to collect information on medical history, complications, specific clinical characteristics, and laboratory biomarker results of suspected PE patients who were admitted to the respiratory department at Affiliated Dongyang Hospital of Wenzhou Medical University between January 2012 and December 2021. This study involved a total of 3,511 patients who were randomly divided into a training group (six parts) and a validation group (four parts) based on a 6:4 ratio. The LASSO regression and multivariate logistic regression were used to develop a scoring model using a nomogram. The performance of the model was evaluated using receiver operating characteristic curve (AUC), calibration curve, and clinical decision curve.

Results

Our research included more than 50 features from 3,511 patients. The nomogram-based scoring model was established using six predictive features including age, smoke, temperature, systolic pressure, D-dimer, and fibrinogen, which achieved AUC values of 0.746 in the training cohort (95% CI 0.720-0.765) and 0.724 in the validation cohort (95% CI 0.695-0.753). The results of the calibration curve revealed a strong consistency between probability predicted by the nomogram and actual probability. The decision curve analysis (DCA) also demonstrated that the nomogram-based scoring model produced a favorable net clinical benefit.

Conclusion

In this study, we successfully developed a novel numerical model that can predict the risk of PE in respiratory department patients suspected of PE, which can not only appropriately select PE prevention strategies but also decrease unnecessary computed tomographic pulmonary angiography (CTPA) scans and their adverse effects.

Serial SOFA-score trends in ICU-admitted COVID-19 patients as predictor of 28-day mortality: A prospective cohort study

Background and Aim

The efficacy of Sequential Organ Failure Assessment (SOFA) score as predictor of clinical outcomes among ICU-admitted COVID-19 patients is still controversial. We aimed to assess whether SOFA-score in different time intervals could predict 28-day mortality compared with other well-acknowledged risk factors of COVID-19 mortality.

Methods

This observational prospective cohort was conducted on 1057 patients from March 2020 to March 2022 at Masih Daneshvari Hospital, Iran. The univariate and multivariate Cox proportional analysis were performed to assess the hazards of SOFA-score models. Receiver operating characteristic (ROC) curves were designed to estimate the predictive values.

Results

Mean SOFA-score during first 96 h (HR: 3.82 [CI: 2.75-5.31]), highest SOFA-score (HR: 2.70 [CI: 1.93-3.78]), and initial SOFA-score (HR: 1.65 [CI: 1.30-2.11]) had strongest association with 28-day mortality (p < .0001). In contrast, SOFA scores at 48 and 96 h as well as Δ-SOFA: 48-0 h and Δ-SOFA: 96-0 h did not show significant correlations. Among them, merely mean SOFA-score (HR: 2.28 [CI: 2.21-3.51]; p < .001) remained as independent prognosticator on multivariate regression analysis; though having less odds of predicting value compared with age (HR: 3.81 [CI: 1.98-5.21]), hypertension (HR: 3.11 [CI: 1.26-3.81]), coronary artery disease [CAD] (HR: 2.82 [CI: 1.51-4.8]), and diabetes mellitus (HR: 2.45 [CI: 1.36-2.99]). The area under ROC (AUROC) for mean SOFA-score (0.77) and highest SOFA-score (0.71) were larger than other SOFA intervals. Calculating the first 96 h of SOFA trends, it was obtained that fatality rate was <12.3% if the score dropped, between 28.8% and 46.29% if the score remained unchanged, and >50.45% if the score increased.

Conclusion

To predict the 28-day mortality among ICU-admitted COVID-19 patients, mean SOFA upon first 96 h of ICU stay is reliable; while having inadequate accuracy comparing with well-acknowledged COVID-19 mortality predictors (age, diabetes mellitus, hypertension, CAD). Notably, increased SOFA levels in the course of first 96 h of ICU-admission, prognosticate at least 50% fatality regardless of initial SOFA score.

Quality of life of children and young people with anterior chest wall deformity: a systematic review of the literature

OBJECTIVE

The aim of this study was to evaluate the current evidence regarding the quality of life (QoL) of children and young people with anterior chest wall deformity (ACWD).

METHODS

Using a defined search strategy, a systematic review of the literature was performed using Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines.

RESULTS

The search identified 305 articles, after refinement, the full text of 51 studies were reviewed and 10 included in the review. A total of eight studies described QoL associated with the correction of ACWD and two studies reported on QoL without correction. The surgical correction of ACWD was reported in six studies and non-surgical correction in two studies. A total of three disease-specific and 24 generic QoL measures were used. The variation in QoL outcome measures, together with a lack of consistency in the time scales of data collection, did not allow for direct comparison between studies. However, the improvement in psychosocial QoL following correction of ACWD is clear. The impact of ACWD on physical QoL is less defined and the influence of age, gender, severity and type of deformity is uncertain. The literature identified primarily surrounds QoL outcomes in relation to surgical correction and is therefore not representative of all children and young people with ACWD.

CONCLUSIONS

Correction of ACWD is associated with significant improvement in the psychosocial QoL of children and young people. Further work is required to standardise QoL data collection for all children with ACWD to achieve a greater understanding of the impact and guide future management.

Use of high‐flow cannula in pediatric patients with respiratory failure: A prospective cohort study in three high‐altitude hospitals

Background and Aims

Acute respiratory failure (ARF) is a common cause of morbimortality, and a frequent reason for admission to the pediatric intensive care unit (PICU). It requires a high‐flow oxygen device as treatment. Our aim is to determine the frequency and main indications for the use of high‐flow nasal cannula (HFNC), and the prevalence of HFNC failure and its main causes, in three hospitals

Methods

It is a multicenter prospective cohort study, developed in three hospitals in Bogota. Eligible patients were children older than 1 month and younger than 18 years who presented ARF and required management with an HFNC. The study was carried out between April 2020 and December 2021. The follow‐up was carried out at 1, 6, and 48 h after starting the management.

Results

Of 685 patients included in the study, 296 developed ARF. The prevalence of patients with ARF who required management with HFNC was 48%. The frequency of the pathologies that cause the ARF was: Bronchiolitis was the most frequent pathology (34.5%), followed by asthmatic crisis (15.5%) and pneumonia (12.7%). The average time of use of HFNC was 81.6 h. Regarding treatment failure with HFNC, 15 patients presented torpid evolution and required invasive mechanical ventilation, with a prevalence of therapeutic failure of the HFNC of 10.6%.

Conclusion

The use of HFNC is more frequent in patients with bronchiolitis, in children under 2 years of age and in males, which is in line with what has been reported in the literature. In addition, the failure rate of HFNC is low (10.6%), and it may be useful in other pathologies besides bronchiolitis, such as asthma, pneumonia, among others. It opens the possibility to continue evaluating the role of HFNC in pediatric pathology in new studies.

Optimising intravenous salbutamol in children: a phase 2 study

OBJECTIVE

The β2-agonists such as salbutamol are the mainstay of asthma management. Pharmacokinetic-pharmacodynamic (PKPD) models to guide paediatric dosing are lacking. We explored the relationship between salbutamol dose, serum concentration, effectiveness and adverse effects in children by developing a PKPD model.

DESIGN

A prospective cohort study of children admitted to hospital with acute asthma, who received intravenous salbutamol.

SETTING

Children were recruited in two cohorts: the emergency departments of two London hospitals or those retrieved by the Children's Acute Transport Service to three London paediatric intensive care units.

PATIENTS

Patients were eligible if aged 1-15 years, admitted for acute asthma and about to receive or receiving intravenous salbutamol.

INTERVENTIONS

Treatment was according to local policy. Serial salbutamol plasma levels were taken. Effectiveness measurements were recorded using the Paediatric Asthma Severity Score (PASS). Toxicity measurements included lactate, pH, glucose, heart rate, blood pressure and arrhythmias. PKPD modelling was performed with non-linear mixed-effect models.

MAIN OUTCOMES

Fifty-eight children were recruited with 221 salbutamol concentration measurements from 54 children. Median (range) age was 2.9 (1.1-15.2) years, and weight was 13.6 (8-57.3) kg. Ninety-five PASS measurements and 2078 toxicity measurements were obtained.

RESULTS

A two-compartment PK model adequately described the time course of salbutamol-plasma concentrations. An E_MAX (maximum drug effect) concentration-effect relationship described PASS and toxicity measures. PKPD simulations showed an infusion of 0.5 µg/kg/min (maximum 20 µg/min) for 4 hours after bolus achieves >90% maximal bronchodilation for 12 hours.

CONCLUSIONS

A paediatric PKPD model for salbutamol is described. An infusion of 0.5 µg/kg/min after bolus achieves effective bronchodilation. Higher rates are associated with greater tachycardia and hyperglycaemia.

Fifteen-minute consultation: A structured approach to children with parapneumonic effusion and empyema thoracis

Parapneumonic effusion is defined as the accumulation of pleural fluid associated with lung infection/pneumonia. Parapneumonic effusions can be uncomplicated or complicated. They are caused by the spread of infection and inflammation to the pleural space, and can develop into empyema thoracis-frank pus in the pleural space. Chest radiograph and thoracic ultrasound are the key imaging modalities for the diagnosis of parapneumonic effusion. Management aims are reducing inflammation and bacteria in the pleural cavity, and enabling full lung expansion. Broad-spectrum intravenous antibiotics, with the addition of chest tube drainage and fibrinolytic therapy for larger collections, are the mainstays of management. This article provides a clear, evidence-based and structured approach to the assessment and management of parapneumonic effusion/empyema thoracis in children and young people.

Cardiopulmonary fitness in children with asthma versus healthy children

OBJECTIVES

To evaluate, with a cardiopulmonary exercise test (CPET), the cardiopulmonary fitness of children with asthma, in comparison to healthy controls, and to identify the clinical and CPET parameters associated with the maximum oxygen uptake (VO_2max) in childhood asthma.

DESIGN

This cross-sectional controlled study was carried out in CPET laboratories from two tertiary care paediatric centres. The predictors of VO_2max were determined using a multivariable analysis.

RESULTS

A total of 446 children (144 in the asthma group and 302 healthy subjects) underwent a complete CPET. Mean VO_2max was significantly lower in children with asthma than in controls (38.6±8.6 vs 43.5±7.5 mL/kg/min; absolute difference (abs. diff.) of -4.9 mL/kg/min; 95% CI of (-6.5 to -3.3) mL/kg/min; p<0.01) and represented 94%±9% and 107%±17% of predicted values, respectively (abs. diff. -13%; 95% CI (-17 to -9)%; p<0.01). The proportion of children with an impaired VO_2max was four times higher in the asthma group (24% vs 6%, p<0.01). Impaired ventilatory efficiency with increased VE/VCO₂ slope and low breathing reserve (BR) were more marked in the asthma group. The proportion of children with a decreased ventilatory anaerobic threshold (VAT), indicative of physical deconditioning, was three times higher in the asthma group (31% vs 11%, p<0.01). Impaired VO_2max was associated with female gender, high body mass index (BMI), FEV1, low VAT and high BR.

CONCLUSION

Cardiopulmonary fitness in children with asthma was moderately but significantly altered compared with healthy children. A decreased VO_2max was associated with female gender, high BMI and the pulmonary function.

TRIAL REGISTRATION NUMBER

NCT04650464.

Use of ventilation/perfusion mismatch to guide individualised CPAP level selection in preterm infants: a feasibility trial

OBJECTIVE

To measure within-subject changes in ventilation/perfusion (V'/Q') mismatch in response to a protocol of individualised nasal continuous positive airway pressure (CPAP) level selection.

DESIGN

Single-arm, non-randomised, feasibility trial.

SETTING

Three centres in the Children's Hospital of Philadelphia neonatal care network.

PATIENTS

Twelve preterm infants of postmenstrual age 27-35 weeks, postnatal age >24 hours, and receiving a fraction of inspired oxygen (FiO₂) >0.25 on CPAP of 4-7 cm H₂O.

INTERVENTIONS

We applied a protocol of stepwise CPAP level changes, with the overall direction and magnitude guided by individual responses in V'/Q' mismatch, as determined by the degree of right shift (kilopascals, kPa) in a non-invasive gas exchange model. Best CPAP level was defined as the final pressure level at which V'/Q' improved by more than 5%.

MAIN OUTCOME MEASURES

Within-subject change in V'/Q' mismatch between baseline and best CPAP levels.

RESULTS

There was a median (IQR) within-subject reduction in V'/Q' mismatch of 1.2 (0-3.2) kPa between baseline and best CPAP levels, p=0.02. Best CPAP was observed at a median (range) absolute level of 7 (5-8) cm H₂O.

CONCLUSIONS

Non-invasive measures of V'/Q' mismatch may be a useful approach for identifying individualised CPAP levels in preterm infants. The results of our feasibility study should be interpreted cautiously and replication in larger studies evaluating the impact of this approach on clinical outcomes is needed.

TRIAL REGISTRATION NUMBER

NCT02983825.

Caffeine to prevent intermittent hypoxaemia in late preterm infants: randomised controlled dosage trial

OBJECTIVE

To establish the most effective and best tolerated dose of caffeine citrate for the prevention of intermittent hypoxaemia (IH) in late preterm infants.

DESIGN

Phase IIB, double-blind, five-arm, parallel, randomised controlled trial.

SETTING

Neonatal units and postnatal wards of two tertiary maternity hospitals in New Zealand.

PARTICIPANTS

Late preterm infants born at 34⁺⁰-36⁺⁶ weeks' gestation, recruited within 72 hours of birth.

INTERVENTION

Infants were randomly assigned to receive a loading dose (10, 20, 30 or 40 mg/kg) followed by 5, 10, 15 or 20 mg/kg/day equivolume enteral caffeine citrate or placebo daily until term corrected age.

PRIMARY OUTCOME

IH (events/hour with oxygen saturation concentration ≥10% below baseline for ≤2 min), 2 weeks postrandomisation.

RESULTS

132 infants with mean (SD) birth weight 2561 (481) g and gestational age 35.7 (0.8) weeks were randomised (24-28 per group). Caffeine reduced the rate of IH at 2 weeks postrandomisation (geometric mean (GM): 4.6, 4.6, 2.0, 3.8 and 1.7 events/hour for placebo, 5, 10, 15 and 20 mg/kg/day, respectively), with differences statistically significant for 10 mg/kg/day (GM ratio (95% CI] 0.39 (0.20 to 0.76]; p=0.006) and 20 mg/kg/day (GM ratio (95% CI] 0.33 (0.17 to 0.68]; p=0.003) compared with placebo. The 20 mg/kg/day dose increased mean (SD) pulse oximetry oxygen saturation (SpO₂) (97.2 (1.0) vs placebo 96.0 (0.8); p<0.001), and reduced median (IQR) percentage of time SpO₂ <90% (0.5 (0.2-0.8) vs 1.1 (0.6-2.4); p<0.001) at 2 weeks, without significant adverse effects on growth velocity or sleeping.

CONCLUSION

Caffeine reduces IH in late preterm infants at 2 weeks of age, with 20 mg/kg/day being the most effective dose.

TRIAL REGISTRATION NUMBER

ACTRN12618001745235.