Survey of respiratory sounds in infants

Background: Over the last decade there has been an apparent increase in childhood wheeze. We speculated that much of the reported increase may be attributed to the term wheeze being adopted by parents to describe a variety of other forms of noisy breathing. Aims: To investigate terminology used by parents to describe their children’s breath sounds. Methods: An interview was carried out with the parents of 92 infants with noisy breathing, beginning with an open question and then directed towards a more detailed description. Finally, the parents were asked to choose from a wheeze, ruttle, and stridor on imitation by the investigator and video clips of children. Results: Wheeze was the most commonly chosen word on initial questioning (59%). Only 36% were still using this term at the end of the interview, representing a decrease of one third, whereas the use of the word ruttles doubled. Conclusions: Our results reflect the degree of inaccuracy involved in the use of the term wheeze in clinical practice, which may be leading to over diagnosis. Imprecise use of this term has potentially important implications for therapy and clinical trials

Key paediatric messages from Amsterdam

The Paediatric Assembly of the European Respiratory Society (ERS) maintained its high profile at the 2015 ERS International Congress in Amsterdam. There were symposia on preschool wheeze, respiratory sounds and cystic fibrosis; an educational skills workshop on paediatric respiratory resuscitation; a hot topic session on risk factors and early origins of respiratory diseases; a meet the expert session on paediatric lung function test reference values; and the annual paediatric grand round. In this report the Chairs of the Paediatric Assembly’s Groups highlight the key mess

Saline in Acute Bronchiolitis RCT and Economic evaluation: hypertonic saline in acute bronchiolitis - randomised controlled trial and systematic review

BACKGROUND: Acute bronchiolitis is the most common cause of hospitalisation in infancy. Supportive care and oxygen are the cornerstones of management. A Cochrane review concluded that the use of nebulised 3% hypertonic saline (HS) may significantly reduce the duration of hospitalisation. OBJECTIVE: To test the hypothesis that HS reduces the time to when infants were assessed as being fit for discharge, defined as in air with saturations of > 92% for 6 hours, by 25%. DESIGN: Parallel-group, pragmatic randomised controlled trial, cost-utility analysis and systematic review. SETTING: Ten UK hospitals. PARTICIPANTS: Infants with acute bronchiolitis requiring oxygen therapy were allocated within 4 hours of admission. INTERVENTIONS: Supportive care with oxygen as required, minimal handling and fluid administration as appropriate to the severity of the disease, 3% nebulised HS every ± 6 hours. MAIN OUTCOME MEASURES: The trial primary outcome was time until the infant met objective discharge criteria. Secondary end points included time to discharge and adverse events. The costs analysed related to length of stay (LoS), readmissions, nebulised saline and other NHS resource use. Quality-adjusted life-years (QALYs) were estimated using an existing utility decrement derived for hospitalisation in children, together with the time spent in hospital in the trial. DATA SOURCES: We searched MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials and other databases from inception or from 2010 onwards, searched ClinicalTrials.gov and other registries and hand-searched Chest, Paediatrics and Journal of Paediatrics to January 2015. REVIEW METHODS: We included randomised/quasi-randomised trials which compared HS versus saline (± adjunct treatment) or no treatment. We used a fixed-effects model to combine mean differences for LoS and assessed statistical heterogeneity using the I (2) statistic. RESULTS: The trial randomised 158 infants to HS (n = 141 analysed) and 159 to standard care (n = 149 analysed). There was no difference between the two arms in the time to being declared fit for discharge [median 76.6 vs. 75.9 hours, hazard ratio (HR) 0.95, 95% confidence interval (CI) 0.75 to 1.20] or to actual discharge (median 88.5 vs. 88.7 hours, HR 0.97, 95% CI 0.76 to 1.23). There was no difference in adverse events. One infant developed bradycardia with desaturation associated with HS. Mean hospital costs were £2595 and £2727 for the control and intervention groups, respectively (p = 0.657). Incremental QALYs were 0.0000175 (p = 0.757). An incremental cost-effectiveness ratio of £7.6M per QALY gained was not appreciably altered by sensitivity analyses. The systematic review comprised 15 trials (n = 1922) including our own. HS reduced the mean LoS by -0.36 days (95% CI -0.50 to -0.22 days). High levels of heterogeneity (I (2) = 78%) indicate that the result should be treated cautiously. CONCLUSIONS: In this trial, HS had no clinical benefit on LoS or readiness for discharge and was not a cost-effective treatment for acute bronchiolitis. Claims that HS achieves small reductions in LoS must be treated with scepticism. FUTURE WORK: Well-powered randomised controlled trials of high-flow oxygen are needed. STUDY REGISTRATION: This study is registered as NCT01469845 and CRD42014007569. FUNDING DETAILS: This project was funded by the NIHR Health Technology Assessment (HTA) programme and will be published in full in Health Technology Assessment; Vol. 19, No. 66. See the HTA programme website for further project information

Ecological effects of experimental drought and prescribed fire in a southern California coastal grassland

How drought and fire disturbance influence different levels of biological organization is poorly understood but essential for robust predictions of the effects of environmental change. During a year of severe drought, we conducted a prescribed fire in a Mediterranean-type coastal grassland near Irvine, California. In the weeks following the fire we experimentally manipulated rainfall in burned and unburned portions of the grassland to determine how fire and drought interact to influence leaf physiological performance, community composition, aboveground net primary productivity (ANPP) and component fluxes of ecosystem CO2 exchange and evapotranspiration (ET). Fire increased leaf photosynthesis (A net) and transpiration (T) of the native perennial bunchgrass, Nassella pulchra and the non-native annual grass, Bromus diandrus but did not influence ANPP or net ecosystem CO2 exchange (NEE). Surprisingly, drought only weakly influenced A net and T of both species but strongly influenced ANPP and NEE. We conclude that despite increasing experimental drought severity, prescribed fire influenced leaf CO2 and H2O exchange but had little effect on the component fluxes of ecosystem CO2 exchange. The differential effects of prescribed fire on leaf and ecosystem processes with increasingly severe drought highlight the challenge of predicting the responses of biological systems to disturbance and resource limitation