Bronchiolitis, bronchitis, asthma exacerbation, bronchopneumonia, pneumonia: A didactic stepwise approach

Background: The clinical presentation of lower respiratory tract illness in children frequently resembles more than one disease entities of those described in textbooks. Not uncommonly, terms like “bronchiolitis”, “bronchitis”, “asthma exacerbation”, “bronchopneumonia” and “pneumonia” are used interchangeably. Methods: In this article, a didactic simplified algorithm for the management of the child from the community presenting with cough and fever is described after systematic review of the literature. Results: In step 1 of the algorithm, findings from the physical examination are used to localize the diseased anatomic part(s) of the lower respiratory tract i.e. trachea, bronchi, bronchioles or alveoli. In step 2, speculations are made regarding the infectious agent most likely affecting the lower respiratory tract based on the patient’s symptoms and past medical history and the known epidemiology of respiratory disorders. In step 3, the appropriate treatment plan is selected taking under consideration the affected anatomic part(s) and the speculated pathogen. Finally, in step 4, clinical response is evaluated and the diagnostic assumptions and treatment strategy are modified accordingly. Conclusion: When findings from the physical examination are matched with information from the current and past medical history and the known epidemiology of respiratory disorders, speculations regarding the most likely etiologic agents can be made and appropriate treatment interventions can be selected. © 2017 Bentham Science Publishers

Parental history of adenotonsillectomy is associated with obstructive sleep apnea severity in children with snoring

Objective To test the hypothesis that history of adenoidectomy and/or tonsillectomy (AT) in at least 1 of the parents during childhood, is a risk factor for moderate-to-severe obstructive sleep apnea (OSA) (apnea-hypopnea index [AHI] >5 episodes/hour) in the offspring with snoring. Study design Data of children with snoring who were referred for polysomnography over 12 years by primary care physicians were reviewed. Results Data of 798 children without history of prior AT, neuromuscular, or genetic disorders or craniofacial abnormalities were analyzed. Of these children, 69.3% had tonsillar hypertrophy, 25.8% were obese, 26.8% had at least 1 parent with history of AT, and 22.1% had AHI >5 episodes/hour. Parental history of AT was significantly associated with moderate-to-severe OSA (logit model including sex, tonsillar hypertrophy, obesity, and physician-diagnosed wheezing; OR [95% CI], 1.70 [1.18-2.46]; P <.01). When significant variables from the logit model (tonsillar hypertrophy, obesity, parental history of AT) were considered independently or in combination, tonsillar hypertrophy combined with history of AT in at least 1 of the parents had high specificity (84.4%) and the highest positive likelihood ratio (1.78) for identifying children with AHI >5 episodes/hour. Conclusions Among children with snoring who are referred for polysomnography by primary care physicians, those with tonsillar hypertrophy and parental history of AT have increased risk of moderate-to-severe OSA and represent 1 of the subgroups that should be prioritized for a sleep study in settings with limited resources. © 2014 Elsevier Inc. All rights reserved

Effects of adenotonsillectomy on R-R interval and brain natriuretic peptide levels in children with sleep apnea: A preliminary report

Objectives: Obstructive sleep apnea is associated with decreased R-R interval length and overall R-R interval variability in the electrocardiogram along with increased morning brain natriuretic peptide (BNP) blood levels. These findings indicate enhanced sympathetic tone and cardiac strain. In this study, it was hypothesized that adenotonsillectomy (AT) in children with sleep apnea is accompanied by improvement in polysomnography indices, increase in length and variability of R-R interval, and reduction in BNP levels. Methods: Polysomnography and measurements of morning BNP levels were performed before and 46 months after AT. Mean and standard deviation of R-R interval were calculated from polysomnography electrocardiogram recordings. Results: Twenty-one children were studied. Apnea-hypopnea index and log-transformed BNP levels decreased postoperatively from 8.4 +/- 7.6 episodes/h and 2.2 +/- 0.7, to 1.8 +/- 1.4 episodes/h and 1.9 +/- 0.3, respectively (p < 0.05). Mean R-R interval increased from 703.2 +/- 137.4 ms (Stage 2), 699.3 +/- 135.8 ms (Stage 3), 707.4 +/- 128.9 ms (Stage 4) and 660.5 +/- 140.1 ms (Stage REM), to 773.5 +/- 122.7 ms (Stage 2), 765.7 +/- 73.7 ms (Stage 3), 771.2 +/- 71.6 ms (Stage 4), and 738.6 +/- 81.7 ms (Stage REM), respectively (p < 0.05 for comparisons pre- vs. post-operatively). Standard deviation of R-R in Stage 2 increased from 88.5 +/- 29.6 to 122.7 +/- 67 ms (p = 0.045). Conclusions: Increase in nocturnal length of R-R interval and decrease in BNP levels after AT for sleep apnea may reflect postoperative reduction in sympathetic tone and cardiac strain. (C) 2011 Elsevier B.V. All rights reserved

Serum leukotriene B4 levels, tonsillar hypertrophy and sleep-disordered breathing in childhood

Objectives: In children with snoring, increased production of leukotriene B4 (LTB4) may promote tonsillar hypertrophy and sleep-disordered breathing (SDB) or conversely SDB may enhance LTB4 synthesis. We explored whether: i) high LTB4 serum levels predict tonsillar hypertrophy; and ii) SDB severity correlates with LTB4 serum concentration. Methods: Normal-weight children with SDB or controls underwent polysomnography and measurement of LTB4 serum concentration. Tonsillar hypertrophy was the main outcome measure and high LTB4 serum level (&amp;gt;75 t h percentile value in controls) was the primary explanatory variable. Odds ratio (OR) and the corresponding 95% confidence intervals (CI) for tonsillar hypertrophy in children with versus without high LTB4 level were calculated. The control subgroup and subgroups of subjects with increasing SDB severity were compared regarding LTB4 concentration by Kruskal-Wallis test. Spearman&apos;s correlation co-efficient was applied to assess the association of LTB4 concentration with SDB severity. Results: A total of 104 children with SDB and mean obstructive apnea-hypopnea index-AHI of 4.8 ± 5.3 episodes/h (primary snoring: n = 19; mild SDB: n = 49; moderate/severe SDB: n = 36) and 13 controls (no snoring; AHI: 0.4 ± 0.2 episodes/h) were recruited. The four study subgroups were similar regarding LTB4 serum concentration (P = 0.64). High LTB4 (&amp;gt;170.3 pg/mL) was a significant predictor of tonsillar hypertrophy after adjustment for age and gender (OR 3.0 [1.2–7.2]; P = 0.01). There was no association between AHI or desaturation index and LTB4 serum concentration (r = −0.08; P = 0.37 and r = −0.1; P = 0.30, respectively). Conclusion: No association was identified between SDB severity and LTB4 levels, but high LTB4 concentration predicted tonsillar hypertrophy. © 2018 Elsevier B.V

Viral Croup: Diagnosis and a Treatment Algorithm

Viral croup is a frequent disease in early childhood. Although it is usually self-limited, it may occasionally become life-threatening. Mild croup is characterized by the presence of stridor without intercostal retractions, whereas moderate-to-severe croup is accompanied by increased work of breathing. A single dose of orally administered dexamethasone (0.15-0.6mg/kg) is the mainstay of treatment with addition of nebulized epinephrine only in cases of moderate-to-severe croup. Nebulized budesonide (2mg) can be given alternatively to children who do not tolerate oral dexamethasone. Exposure to cold air or administration of cool mist are treatment interventions for viral croup that are not supported by published evidence, but breathing heliox can potentially reduce the work of breathing related to upper airway obstruction. In summary, corticosteroids may decrease the intensity of viral croup symptoms irrespective to their severity on presentation to the emergency department. Pediatr Pulmonol. 2014; 49:421-429. (c) 2013 Wiley Periodicals, Inc

Serum leukotriene B4 levels, tonsillar hypertrophy and sleep-disordered breathing in childhood

Objectives: In children with snoring, increased production of leukotriene B4 (LTB4) may promote tonsillar hypertrophy and sleep-disordered breathing (SDB) or conversely SDB may enhance LTB4 synthesis. We explored whether: i) high LTB4 serum levels predict tonsillar hypertrophy; and ii) SDB severity correlates with LTB4 serum concentration. Methods: Normal-weight children with SDB or controls underwent polysomnography and measurement of LTB4 serum concentration. Tonsillar hypertrophy was the main outcome measure and high LTB4 serum level (&gt;75 t h percentile value in controls) was the primary explanatory variable. Odds ratio (OR) and the corresponding 95% confidence intervals (CI) for tonsillar hypertrophy in children with versus without high LTB4 level were calculated. The control subgroup and subgroups of subjects with increasing SDB severity were compared regarding LTB4 concentration by Kruskal-Wallis test. Spearman's correlation co-efficient was applied to assess the association of LTB4 concentration with SDB severity. Results: A total of 104 children with SDB and mean obstructive apnea-hypopnea index-AHI of 4.8 ± 5.3 episodes/h (primary snoring: n = 19; mild SDB: n = 49; moderate/severe SDB: n = 36) and 13 controls (no snoring; AHI: 0.4 ± 0.2 episodes/h) were recruited. The four study subgroups were similar regarding LTB4 serum concentration (P = 0.64). High LTB4 (&gt;170.3 pg/mL) was a significant predictor of tonsillar hypertrophy after adjustment for age and gender (OR 3.0 [1.2–7.2]; P = 0.01). There was no association between AHI or desaturation index and LTB4 serum concentration (r = −0.08; P = 0.37 and r = −0.1; P = 0.30, respectively). Conclusion: No association was identified between SDB severity and LTB4 levels, but high LTB4 concentration predicted tonsillar hypertrophy. © 2018 Elsevier B.V

Family History of Adenotonsillectomy as a Risk Factor for Tonsillar Hypertrophy and Snoring in Childhood

ObjectiveAccumulating evidence supports a role for familial predisposition in the pathogenesis of OSA. In this study, it was hypothesized that parental history of adenoidectomy and/or tonsillectomy (AT), which is the standard treatment for pediatric OSA is a risk factor for tonsillar hypertrophy and habitual snoring (&gt;3 nights/week) in the offspring. MethodsChildren were recruited from the emergency department and the pediatric pulmonology clinic. Paternal or maternal history of AT (explanatory variables) and habitual snoring (outcome) were recorded and presence of tonsillar hypertrophy (outcome) was assessed. ResultsTwo hundred ninety-two children (2-14 y.o.) were recruited; 37 (12.7%) of them had paternal history of AT, 39 (13.4%) maternal history of AT, 60 (20.5%) tonsillar hypertrophy, and 48 (16.4%) habitual snoring. Maternal and paternal history of AT were significantly associated with the presence of tonsillar hypertrophy even after adjustment for age, gender, obesity, passive smoking, and physician-diagnosed wheezing requiring treatment with inhaled medications over the past year [odds ratios (95% confidence interval): 3.52 (1.54-8.06); P&lt;0.01 and 4.70 (2.13-10.36); P&lt;0.01, respectively]. Only maternal history of AT predicted history of snoring [4.12 (1.86-9.12); P&lt;0.01]. When entered in the same multivariate logistic regression analysis model, tonsillar hypertrophy was a stronger predictor of habitual snoring than maternal history of AT [4.00 (1.97-8.14) vs. 2.73 (1.20-6.20)]. ConclusionsChildren with parental history of AT have more frequently tonsillar hypertrophy than those without such history. Tonsillar hypertrophy mediates at least in part the association between maternal history of AT and habitual snoring in childhood. Pediatr Pulmonol. 2014; 49:366-371. (c) 2013 Wiley Periodicals, Inc

Oxidative stress and inflammatory markers in the exhaled breath condensate of children with OSA

Obstructive sleep apnea (OSA) in children has been associated with systemic inflammation and oxidative stress. Limited evidence indicates that pediatric OSA is associated with oxidative stress and inflammation in the airway. The objective of this study is to assess the hypothesis that levels of oxidative stress and inflammatory markers in the exhaled breath condensate (EBC) of children with OSA are higher than those of control subjects. Participants were children with OSA and control subjects who underwent overnight polysomnography. Morning levels of hydrogen peroxide (H2O2) and sum of nitrite and nitrate (NO (x) ) in EBC of participants were measured. Twelve subjects with moderate-to-severe OSA (mean age +/- standard deviation: 6.3 +/- 1.7 years; apnea-hypopnea index-AHI, 13.6 +/- 10.1 episodes/h), 22 subjects with mild OSA (6.7 +/- 2.1 years; AHI, 2.8 +/- 1 episodes/h) and 16 control participants (7.7 +/- 2.4 years; AHI, 0.6 +/- 0.3 episodes/h) were recruited. Children with moderate-to severe OSA had higher log-transformed H2O2 concentrations in EBC compared to subjects with mild OSA, or to control participants: 0.4 +/- 1.1 versus -0.9 +/- 1.3 (p = 0.015), or versus -1.2 +/- 1.2 (p = 0.003), respectively. AHI and % sleep time with oxygen saturation of hemoglobin < 95% were significant predictors of log-transformed H2O2 after adjustment by age and body mass index z score (p < 0.05). No significant differences were demonstrated between the three study groups in terms of EBC NO (x) levels. Children with moderate-to-severe OSA have increased H2O2 levels in morning EBC, an indirect index of altered redox status in the respiratory tract