Successful removal of distal persistent foreign body airway with CO2 cryotherapy in a child

We report a case of a nine-year-old boy with clinical evidence of foreign body (FB) aspiration with 3 months of delay in diagnosis. The bronchoscopy found soft tissue FB with surrounding inflamed granulation tissue at the entrance to the lateral segmental bronchus. Repeated attempts to remove the FB with flexible forceps were unsuccessful due to friable FB and granulation tissue. Ablation of the granulation tissue using nitrous oxide cryotherapy was then successfully performed and the distal and organic FB was extracted. Early diagnosis is important for minimizing granulation tissue development which complicates FB removal. Cryotherapy with a flexible bronchoscope is an option if organic FB cannot be removed using conventional bronchoscopic instrumentation

Colonización de la vía respiratoria de los niños diagnosticados de fibrosis quística por cribado neonatal : diferencias cuantitativas y cualitativas con la población de niños sanos /

Introducción La colonización bacteriana del pulmón es relevante en la progresión y pronóstico de la Fibrosis quística (FQ). El cribado neonatal y la obtención seriada de muestras orofaríngeas para cultivo microbiológico nos ofrece la posibilidad de observar la cronología de la colonización bacteriana de la vía aérea en estos pacientes. Esto hace necesario conocer la flora orofaríngea de los niños no afectos de Fibrosis quística (NOFQ). Objetivos 1) Conocer la cronología de la colonización bacteriana de la vía aérea en pacientes con FQ de 0 a 4 años de edad. 2) Compararla con una población sujetos NOFQ de las mismas edades. 3) Evaluar la afectación de la función pulmonar y la tomografía computarizada pulmonar de los niños con FQ con colonización bacteriana persistente por Pseudomonas aeruginosa o Staphylococcus aureus. Métodos Estudio observacional, prospectivo y longitudinal. Pacientes FQ: Niños diagnosticados de FQ por cribado neonatal, desde octubre de 1999 hasta febrero 2005 y seguidos hasta los cuatro años de edad. Las muestras para cultivo microbiológico se obtuvieron mensualmente y siempre que el paciente presentaba una exacerbación respiratoria Sujetos NOFQ: Niños de 0-4 años que precisaron cirugía menor programada. Las muestras orofaríngeas fueron tomadas durante la inducción anestésica. El estudio del grupo control es transversal. No se obtuvieron muestras mensuales por aspectos éticos. Las muestras se tomaron mediante la técnica de aspirado orofaríngeo (AOF). Se obtuvo consentimiento informado previo. Resultados Se incluyeron 18 pacientes afectos de fibrosis quística (76% niños), obtuvimos de estos 877 muestras de AOF para cultivo (mediana de 12,2 muestras/paciente/año) y se hicieron 438 aislamientos bacterianos. Se obtuvieron 104 muestras para cultivo de los sujetos NOFQ (1 por cada sujeto NOFQ incluido) y se realizaron 36 aislamientos bacterianos. Se aíslan microorganismos potencialmente patógenos en ambos grupos desde el primer mes de vida. La prevalencia de aislamientos bacterianos los primeros meses de vida es elevada y similar en pacientes FQ y sujetos NOFQ. Esta disminuye al aumentar la edad de los niños, pero el descenso es mayor en los sujetos NOFQ (p0.05), pero se observan diferencias en su cronología. En los pacientes FQ predomina la colonización por enterobacterias (Enterobacter spp., E. coli, Klebsiella spp.) los dos primeros años y por S. aureus a partir de los 36 meses de vida. En los sujetos NOFQ, sólo predominan enterobacterias el primer año de vida. En la vía aérea superior de los sujetos NOFQ se aíslan, también, los dos patógenos típicamente asociados a FQ, S. aureus y P. aeruginosa. El 83% de los pacientes FQ presentaron colonización por P. aeruginosa antes de los 3 años de vida, pero en ningún caso ha sido causa de colonización persistente. Se aisló S. aureus en el 72,2% de pacientes antes de los 2 años de vida. Hemos observado que la edad de colonización de S. aureus (mediana de 5 meses) precede a la de colonización por P. aeruginosa (mediana de 12 meses). La función pulmonar de todos los pacientes FQ fue normal. La colonización bacteriana persistente de la vía aérea por S. aureus no ha empeorado su función respiratoria ni su puntuación de TCAR, respecto a los que no la presentan. Conclusiones La colonización bacteriana de la vía aérea de los pacientes FQ y sujetos NOFQ se produce precozmente por las misma especies bacterianas. La cronología de los aislamientos difiere en ambos grupos al aumentar la edad de los niños. La colonización por S. aureus y P. aeruginosa no puede considerarse aisladamente sugestivo de FQIntroduction Pulmonary infection is the most common cause of morbidity and mortality in Cystic Fibrosis (CF). The newborn screening program and the routine oropharyngeal cultures allowed identifying the timing of bacterial colonization. Elucidate bacterial colonization in healthy children (HC) could be necessary. Aims 1) Identify the timing at which CF patients up to four year old acquire bacterial colonization. 2) Elucidate bacterial colonization in healthy infants of the same age. 3) Evaluate the lung function and the lung computerized tomography deterioration in CF patients who are persistently colonized by P. aeruginosa or S. aureus. Methods Observational, prospective and longitudinal study. CF Patients: infant with newly diagnosed cystic fibrosis disease diagnosed by neonatal screening, from October 1999 to February 2005 and followed until the age of four year. Specimens were taken monthly and every time the infant or children developed respiratory tract infection. HI: children under 4 years old, without respiratory pathology, that need minor surgery. Specimens were taken during anaesthesia induction. It was carried out a cross-sectional study for HC. Specimens were taken applying the oropharyngeal suction (OPS) technique. A signed consent was obtained previously. Results Eighteen CF patients were recruited (76% males), 877 OPS specimens were taken (12,2 specimens/patient/year) and 438 bacterial microorganisms were isolated. We took 104 OPS specimens from 104 HC (78,6% males) and 36 microorganisms were isolated. Microorganisms were isolated from both, the CF patients and the HC upper airway since, the first month of life. The prevalence of bacteria isolated during the first three months of life was high and similar at both groups, and was decreasing with age. This decrease was more important at HI than at CF patients (p< 0.05) The most frequently isolated microorganisms were the same species at both groups and no statistically significant differences were found. Nevertheless, the chronology would be different between CF patients and HC. Enterobacterias (Enterobacter spp., E. coli, Klebsiella spp.) were the most frequent bacteria isolated during the first and the second year of life in CF patients and S. aureus was the most prevalent since the fourth year of life. In HC, enterobacterias were the most frequently isolated bacteria only during the first year. We were able to detect S. aureus y P. aeruginosa from the upper airway of HC. At least one P. aeruginosa isolated was detected in 83,3% of CF patients at some time during the study, but we did not detect any persistent colonization by this microorganism. At least one S. aureus isolated was detected in 72,2% of CF patients before 24 months of life. We observed that the acquisition of S. aureus colonization (median 5 months) occurred before the P. aeruginosa colonization (median 12 months). Lung function of all the CF patients was normal. The persistent upper airway S. aureus colonization did not affect lung function neither TCAR punctuation. Conclusions The presence of microorganism in upper airway culture from CF patients and HC begins very early. The chronology of bacterial prevalence differs between CF patients and HC. The presence of PA in an upper airway culture should not be considerered patognomonic for CF

School children with chronic diseases; what are teachers worried about? Let’s not forget asthma!

Carta al director elaborada por el Grupo de trabajo Asma y Educación, de la Sociedad Española de Neumología Pediátrica en respuesta al artículo ‘Escolares con enfermedades crónicas, ¿qué lespreocupa a sus profesores?’. En ella ponen de manifiesto la ausencia en el estudio del asma, enfermedad crónica más frecuente en la edad pediátrica

A Case of Persistent Air Leak Managed by Selective Left Main Bronchus Intubation in an Infant with Pulmonary Tuberculosis

Unusual clinical course Persistent air leak, or persistent pneumothorax, is defined as a pneumothorax that persists beyond the first week, or air leak through a chest drain for more than 48 hours. The most common findings in pediatric pulmonary tuberculosis are parenchymal disease and mediastinal lymphadenopathy, but airway obstruction can cause emphysema and pneumothorax. A case is presented of persistent air leak in a 3-month-old infant with pulmonary tuberculosis that was managed by selective left main bronchus intubation. A 3-month-old boy presented with respiratory distress and fever. Imaging findings suggested pulmonary tuberculosis, and first-line anti-tuberculous treatment was initiated with isoniazid, rifampicin, pyrazinamide, and ethambutol (HRZE). He was discharged home after eight days, but was admitted four days later with respiratory distress. Chest X-rays showed a tension pneumothorax that required drainage and chest computed tomography (CT) showed right lung emphysema. Bronchoscopy found extrinsic obstruction of both main bronchi. Chest drains continued to leak air leak after 48 h. Right middle and lower lobectomy and drainage of multiple lymph nodes resulted in significant improvement. He developed pneumonia and acute respiratory distress syndrome, which prevented mechanical ventilation. The left main bronchus was selectively intubated to allow the air leak to heal and to ventilate the lung. He was extubated 10 days later and recovered completely. This case highlights that when medical management of persistent air leak associated with tuberculosis is not effective, surgery, active ventilation, and selective main bronchus intubation should be considered

Inhaled medications and inhalation chambers for childhood asthma. Spanish network of working groups on asthma in pediatrics (REGAP)

Asthma, the most prevalent chronic disease in pediatric age, continues to pose challenges in its management and treatment. National and international guidelines emphasize the importance of therapeutic education (TE) to achieve disease control. TE involves imparting knowledge and skills to the patient and their family, enhancing medication adherence, rectifying errors in inhalation technique, and tailoring treatment based on individual patient characteristics.It is essential for TE to be progressive, gradual, and personalized, spanning all levels of care. Training healthcare professionals in TE is crucial, particularly for pediatricians, who must also be aware of the extensive variability of available meds and inhalers and their respective age-specific indications.Addressing this need, the REGAP Group extensively reviewed inhalers currently available in Spain for pediatric asthma treatment. The review encompassed different inhalation systems and inhaled drugs used for pediatric asthma treatment. This review will be updated annually, providing information on medications, devices, inhalation chambers, indications, and financiation. The REGAP Group hopes that these tables will be a valuable help for pediatricians in their daily clinical practice and serve as an effective TE tool. Resumen: El asma, la enfermedad crónica más prevalente en la edad pediátrica, continúa planteando desafíos en su manejo y tratamiento.1 Guías nacionales e internacionales destacan la importancia de la educación terapéutica (ET) para lograr el control de esta enfermedad.2,3 Esta educación implica la transmisión de conocimientos y habilidades al paciente y su familia, mejorando la adherencia a la medicación, corrigiendo errores en la técnica de inhalación y ajustando el tratamiento según las características individuales de cada paciente.4,5Es esencial que la ET sea progresiva, gradual e individualizada, y que esté presente en todos los niveles asistenciales. La formación en ET de profesionales sanitarios es crucial, especialmente para los pediatras, quienes además deben conocer la extensa variabilidad de medicamentos e inhaladores disponibles y sus indicaciones para cada edad.6Para abordar esta necesidad, el Grupo REGAP ha revisado exhaustivamente los inhaladores actualmente disponibles en España para el tratamiento del asma en la edad pediátrica. La revisión incluye una revisión de los distintos sistemas de inhalación y los distintos fármacos inhalados, utilizados para el tratamiento del asma en la edad pediátrica. Esta revisión se actualizará anualmente, incluyendo información sobre fármacos, dispositivos, cámaras de inhalación, indicaciones y financiación. El Grupo REGAP espera que estas tablas sean una valiosa ayuda para los pediatras en su práctica clínica diaria y constituyen una eficaz herramienta de ET

Impact of treatment adherence and inhalation technique on asthma outcomes of pediatric patients: a longitudinal study

Introduction: We aimed to evaluate the longitudinal relationships, both at between- and within-person levels, that adherence to inhaled corticosteroid-based maintenance treatment and inhalation technique present with symptom control, exacerbations, and health-related quality of life (HRQoL) in children and adolescents with asthma.Methods: Participants (6–14 years old) from the ARCA (Asthma Research in Children and Adolescents) cohort—a prospective, multicenter, observational study (NCT04480242)—were followed for a period from 6 months to 5 years via computer-assisted telephone interviews and a smartphone application. The Medication Intake Survey–Asthma (MIS-A) was administered to assess the implementation stage of adherence, and the Inhalation Technique Questionnaire (InTeQ) was used to assess the five key steps when using an inhaler. Symptom control was measured with the Asthma Control Questionnaire (ACQ), and HRQL was measured with the EQ-5D and the Patient-Reported Outcomes Measurement Information System–Pediatric Asthma Impact Scale (PROMIS-PAIS). Multilevel longitudinal mixed models were constructed separately with symptom control, exacerbation occurrence, EQ-5D, and PROMIS-PAIS as the dependent variables.Results: Of the 360 participants enrolled, 303 (1,203 interviews) were included in the symptom control and exacerbation analyses, 265 (732) in the EQ-5D, and 215 (617) in the PROMIS-PAIS. Around 60% of participants were male subjects, and most of them underwent maintenance treatment with inhaled corticosteroids plus long-acting β-agonists in a fixed dose (73.3%). Within-person variability was 83.6% for asthma control, 98.6% for exacerbations, 36.4% for EQ-5D, and 49.1% for PROMIS-PAIS. At the within-person level, patients with higher adherence had better symptom control (p = 0.002) and HRQoL over time (p = 0.016). Patients with a better inhalation technique reported worse HRQoL simultaneously (p = 0.012), but they showed better HRQoL in future assessments (p = 0.012). The frequency of reliever use was associated with symptom control (p &lt; 0.001), exacerbation occurrence (p &lt; 0.001), and HRQoL (p = 0.042); and boys were more likely to present better symptom control and HRQoL than girls.Conclusion: Our results confirm longitudinal associations at the within-person level of the two indicators of quality use of inhalers: for adherence to maintenance treatment with symptom control and HRQoL, and for the inhalation technique with HRQoL. Although treatment adherence was shown to be excellent, a third of the participants reported a suboptimal inhalation technique, highlighting the need for actions for improving asthma management of the pediatric population

Measurement properties of the EQ-5D-Y administered through a smartphone app in children with asthma : a longitudinal questionnaire study

Asthma impacts children's physical, emotional, and psychosocial Health-Related Quality of Life (HRQL). The EQ-5D-Y is a generic econometric instrument developed to measure HRQL in children. Evaluation of feasibility, validity, reliability, and responsiveness of EQ-5D-Y descriptive system and utility index to allow the assessment of HRQL in children with asthma, aged 8-11 years (self-response version) or under 8 years old (proxy-response version). We used data from baseline to 10 months of follow-up of an observational, prospective study of children with persistent asthma recruited by pediatricians in Spain (2018-2020). HRQL instruments were administered through a smartphone application: ARCA app. The EQ-5D-Y is composed of a 5-dimension descriptive system, a utility index ranging from 1 to − 0.5392, and a general health visual analogue scale (EQ-VAS). The Pediatric Asthma Impact Scale (PROMIS-PAIS) includes 8 items, providing a raw score. Construct validity hypotheses were stated a priori, and evaluated following two approaches, multitrait-multimethod matrix and known groups' comparisons. Reliability and responsiveness subsamples were defined by stability or change in EQ-VAS and the Asthma Control Questionnaire (ACQ), to estimate the intraclass correlation coefficient (ICC) and the magnitude of change over time. The EQ-5D-Y was completed at baseline for 119 children (81 self-responded and 38 through proxy response), with a mean age of 9.1 (1.7) years. Mean (SD) of the EQ-5D-Y utility index was 0.93 (0.11), with ceiling and floor effects of 60.3% and 0%, respectively. Multitrait-multimethod matrix confirmed the associations previously hypothesized for the EQ-5D-Y utility index [moderate with PROMIS-PAIS (0.38) and weak with ACQ (0.28)], and for the EQ-5D-Y dimension "problems doing usual activities" [moderate with the ACQ item (0.35) and weak with the PROMIS-PAIS item (0.17)]. Statistically significant differences were found in the EQ-5D-Y between groups defined by asthma control, reliever inhalers use, and second-hand smoke exposure, with mostly moderate effect sizes (0.45-0.75). The ICC of the EQ-5D-Y utility index in the stable subsamples was high (0.81 and 0.79); and responsiveness subsamples presented a moderate to large magnitude of change (0.68 and 0.78), though without statistical significance. These results support the use of the EQ-5D-Y as a feasible, valid, and reliable instrument for evaluating HRQL in children with persistent asthma. Further studies are needed on the responsiveness of the EQ-5D-Y in this population. The online version contains supplementary material available at 10.1186/s12955-022-01955-

Montelukast in paediatric asthma and allergic rhinitis: a systematic review and meta-analysis

Background: We aim to assess the impact of montelukast on paediatric patients with asthma/allergic rhinitis, measured using patient-reported outcome measures, compared with other treatments or placebo. Methods: Protocol registration CRD42020216098 (www.crd.york.ac.uk/PROSPERO). MEDLINE and Embase databases were used to conduct the search. Two authors independently selected studies and extracted data, and a third reviewer resolved discrepancies. Meta-analyses were constructed to estimate the standardised mean difference (SMD) using a random-effects model. Results: Out of 3937 articles identified, 49 studies met the inclusion criteria, mostly randomised clinical trials (sample sizes: 21-689 patients). The SMD of change pooled estimators for the global, mental and physical domains of health-related quality of life were not statistically significant. For daytime and night-time symptoms scores, the SMD (95% CI) was in favour of inhaled corticosteroids (-0.12, -0.20- -0.05 and -0.23, -0.41- -0.06, respectively). The pooled estimator for global asthma symptoms was better for montelukast when compared with placebo (0.90, 0.44-1.36). Conclusions: The synthesis of the available evidence suggests that, in children and adolescents, montelukast was effective in controlling asthma symptoms when compared with placebo, but inhaled corticosteroids were superior in controlling symptoms, especially at night-time. These findings of our systematic review concur with current guidelines for asthma treatment

Measurement properties of the EQ-5D-Y administered through a smartphone app in children with asthma: a longitudinal questionnaire study

Background: Asthma impacts children's physical, emotional, and psychosocial Health-Related Quality of Life (HRQL). The EQ-5D-Y is a generic econometric instrument developed to measure HRQL in children. Objective: Evaluation of feasibility, validity, reliability, and responsiveness of EQ-5D-Y descriptive system and utility index to allow the assessment of HRQL in children with asthma, aged 8-11 years (self-response version) or under 8 years old (proxy-response version). Methods: We used data from baseline to 10 months of follow-up of an observational, prospective study of children with persistent asthma recruited by pediatricians in Spain (2018-2020). HRQL instruments were administered through a smartphone application: ARCA app. The EQ-5D-Y is composed of a 5-dimension descriptive system, a utility index ranging from 1 to - 0.5392, and a general health visual analogue scale (EQ-VAS). The Pediatric Asthma Impact Scale (PROMIS-PAIS) includes 8 items, providing a raw score. Construct validity hypotheses were stated a priori, and evaluated following two approaches, multitrait-multimethod matrix and known groups' comparisons. Reliability and responsiveness subsamples were defined by stability or change in EQ-VAS and the Asthma Control Questionnaire (ACQ), to estimate the intraclass correlation coefficient (ICC) and the magnitude of change over time. Results: The EQ-5D-Y was completed at baseline for 119 children (81 self-responded and 38 through proxy response), with a mean age of 9.1 (1.7) years. Mean (SD) of the EQ-5D-Y utility index was 0.93 (0.11), with ceiling and floor effects of 60.3% and 0%, respectively. Multitrait-multimethod matrix confirmed the associations previously hypothesized for the EQ-5D-Y utility index [moderate with PROMIS-PAIS (0.38) and weak with ACQ (0.28)], and for the EQ-5D-Y dimension "problems doing usual activities" [moderate with the ACQ item (0.35) and weak with the PROMIS-PAIS item (0.17)]. Statistically significant differences were found in the EQ-5D-Y between groups defined by asthma control, reliever inhalers use, and second-hand smoke exposure, with mostly moderate effect sizes (0.45-0.75). The ICC of the EQ-5D-Y utility index in the stable subsamples was high (0.81 and 0.79); and responsiveness subsamples presented a moderate to large magnitude of change (0.68 and 0.78), though without statistical significance. Conclusions: These results support the use of the EQ-5D-Y as a feasible, valid, and reliable instrument for evaluating HRQL in children with persistent asthma. Further studies are needed on the responsiveness of the EQ-5D-Y in this population