Objective: To investigate the effect of caffeine citrate (methyxanthine) on the pattern of breathing and lung mechanics in extremely low birth weight (ELBW) infants with apnea of prematurity (AOP), during mechanical ventilation and following extubation while breathing spontaneously. Methods: In this pilot prospective observational study 39 ELBW infants were monitored: Twenty AOP diagnosed with respiratory distress syndrome (RDS) and 19 controls. Infants with AOP were assessed on mechanical ventilation before caffeine administration and immediately after extubation which occurred at 11-14 days postcaffeine citrate commencement. Control infants were compared to the postcaffeine group. Breathing pattern parameters, lung mechanics and work of breathing were assessed. Results: Caffeine citrate seemed to markedly increase Tidal Volume (VT) in the post caffeine group when compared to the control group (7.3 ± 2.0 ml/kg and 5.7 ± 1.5 ml/kg respectively) and slightly decreased breathing rate (64 ± 17 and 70 ± 19 breaths/min), respectively. Minute Ventilation (VE) and Expiratory Time (TE) increased (P<0.001) and Total Breathing Time (TTOT) also increased (P=0.187) but caffeine did not seem to have an effect on Inspiratory Time (TI) (P=0.09). Subsequently, Time Cycle (TI/TTOT) decreased (P<0.001). Work of Breathing (W) also increased (P=0.001). Conclusions: These findings advocate that administration of caffeine citrate in ELBW infants with AOP increased VT although this occurred at the cost of an elevated W. The longterm effects of caffeine on lung function were positive (following administration every 24 hours at 5 mg/kg) after a period of 11-14 days PCA from the initial administration of the drug.

BACKGROUND:The implementation of international pediatric asthma guidelines hinges on the distinction between intermittent and persistent phenotypes and the prescription of recommended phenotype-specific pharmacotherapy. OBJECTIVES:To ascertain key factors associated with specialist-confirmed phenotype and document physicians' adherence to practice recommendations in an academic pediatric asthma center. DESIGN/METHODS:Using electronic health records, we identified a cohort of children aged 1-17 years who presented to a tertiary-care asthma center between 2002 and 2007 and received a diagnosis of asthma from a pediatric specialist. Outcomes included: determinants of phenotypes and conformity with phenotype-specific treatment recommendations. RESULTS:Of the 3490 eligible children (11,119 visits), most (47%) were preschoolers, 35% were 6-11 years and 18%, 13-17 years. Of children with confirmed asthma, 59% were classified on presentation as having intermittent, 41% as persistent, asthma. The within-patient phenotype varied over time with a consistency index of 0.76 (best=1); the latter was significantly lower in preschoolers than older children (p<0.0001). The persistent phenotype was highly physician-dependent; it was also positively associated with child's age, asthma severity, multiple triggers, calendar year, and duration of follow-up. Compared to 33% of children with intermittent asthma, 82% of those with persistent asthma were prescribed a maintenance controller, most as monotherapy; combination therapy was usually prescribed after a trial of monotherapy. CONCLUSION:Pediatric asthma specialists were highly adherent to phenotype-specific pharmacotherapy. However, even in an academic center, the notable degree of intra-patient and between-physician variation in phenotype, particularly in preschoolers, was an important impediment to prescribing a maintenance controller. The findings underline the importance of developing validated and standardized means of assessing phenotypes, applicable to the whole pediatric age spectrum.

We present a direct anterior sternal split expansion as a surgical option for a case of severe Thoracic Insufficiency Syndrome (TIS) in an arthrogryposis-like patient. This patient’s clinical features were published as a newly described syndrome: Adam Robert Wright Syndrome. The patient born with this syndrome displays characteristic craniofacial abnormalities, severe thoracic insufficiency syndrome, cleft palate, limb contractures, arthrogryposis, pulmonary hypoplasia, cryptorchidism, ophthalmoplegia and retinopathy, with normal intelligence. His severe thoracic insufficiency necessitated an urgent life-saving surgical intervention for a progressively worsening sleep apnoea and respiratory distress. We present a review of published data of sternal expansion thoracoplasty from 1965 to 2007 found in the literature. We demonstrate that direct anterior sternal split thoracoplasty with autogenous rib grafts is an effective technique for the acute management of thoracic insufficiency syndrome in this specific case. This procedure provided our patient with symptomatic benefit. To our knowledge, this is the only reported surgical management of thoracic insufficiency syndrome demonstrating a statistical improvement in chest wall compliance and tidal volume. We show that direct anterior sternal split expansion is a surgical treatment option in some patients with thoracic insufficiency syndrome. Our surgical strategy for the management of severe thoracic insufficiency syndrome in Adam Robert Wright Syndrome provided symptomatic relief and favourable long-term results.

BACKGROUNDAlthough virus-induced wheezing is common in preschool-age children, optimal management remains elusive. We examined the efficacy and safety of preemptive treatment with high-dose fluticasone in reducing the severity of recurrent virus-induced wheezing in children.METHODSWe randomly assigned 129 children who were 1 to 6 years of age to receive 750 microg of fluticasone propionate (ex-valve [manufacturer-measured] dose) or placebo twice daily, beginning at the onset of an upper respiratory tract infection and continuing for a maximum of 10 days, over a period of 6 to 12 months. The primary outcome was rescue oral corticosteroid use. Secondary outcomes included symptoms, use of beta(2)-agonists, acute care visits, hospitalizations, discontinuation of the study drug, change in growth and bone mineral density, basal cortisol level, and adverse events.RESULTSOver a median period of 40 weeks, 8% of upper respiratory tract infections in the fluticasone group led to treatment with rescue systemic corticosteroids, as compared with 18% in the placebo group (odds ratio, 0.49; 95% confidence interval [CI], 0.30 to 0.83). Children who were treated with fluticasone, as compared with those who were given placebo, had smaller mean (+/-SD) gains from baseline in height (6.23+/-2.62 cm [unadjusted value]; z score, -0.19 +/-0.42 vs. 6.56+/-2.90 cm [unadjusted value]; z score, 0.00+/-0.48; difference between groups in z score from baseline to end point, -0.24 [95% CI, -0.40 to -0.08]) and in weight (1.53+/-1.17 kg [unadjusted value]; z score, -0.15+/-0.48 vs. 2.17+/-1.79 kg [unadjusted value]; z score, 0.11+/-0.43; difference between groups in z score from baseline to end point, -0.26 [95% CI, -0.41 to -0.09]). There were no significant differences between the groups in basal cortisol level, bone mineral density, or adverse events.CONCLUSIONSIn preschool-age children with moderate-to-severe virus-induced wheezing, preemptive treatment with high-dose fluticasone as compared with placebo reduced the use of rescue oral corticosteroids. Treatment with fluticasone was associated with a smaller gain in height and weight. Given the potential for overuse, this preventive approach should not be adopted in clinical practice until long-term adverse effects are clarified. (ClinicalTrials.gov number, NCT00238927.)

Rationale: Although home cardiorespiratory monitors have been used for a few decades, they do not give information on oxygenation status during events. Pulse oximeters with low false-alarm rates are now available but with no standards for alarm adjustment. Objective: To determine, in a population of children monitored at home with a pulse oximeter, whether the chosen alarm levels could safely identify potentially significant events early on but also limit the number of alarms for non-significant events. Methods: Retrospective cohort study of all children monitored at home with a pulse oximeter (n = 37) between 2002 and 2007. Clinical information and Hb-O-2 saturation (SPO2) recordings were reviewed. Audible alarm was set-up when SPO2 reached 85% with a delay of 5 or 10 sec. Results: A total of 24,127 hr of valid data were available for analysis. There were 13,228 events >4 sec of which 9177 (69%) were events lasting < 10 sec. We determine that, with an audible alarm being triggered when SPO2 reached 85% with no delay or a delay of 5 or 10 sec, audible alarms would have occurred at a rate of 3.6, 0.9, and 0.2 alarm/night (median), respectively. Thirteen patients needed intervention following alarms. Ten patients were readmitted to the hospital on the basis of increased frequency of alarms confirmed as true events on the recordings, but in the absence of clinical deterioration. Conclusion: The monitor was able to alert parents as to potentially dangerous events while the alarm adjustment limited the number of alarms for non-significant events.

Mechanical ventilation is a common form of support in the modern day intensive care unit (ICU). In order for the clinician better to understand and apply mechanical ventilation, it is important that they understand the physiological principles of ventilation. This review describes these basic concepts; parameters of mechanical ventilation, high frequency ventilation and non-invasive ventilation. An overview of ventilatory strategies for four common diseases seen in paediatric and neonatal ICUs will be discussed.

Nicole Beydon, Stephanie D. Davis, Enrico Lombardi, Julian L. Allen, Hubertus G. M. Arets, Paul Aurora, Hans Bisgaard, G. Michael Davis, Francine M. Ducharme, Howard Eigen, Monika Gappa, Claude Gaultier, Per M. Gustafsson, Graham L. Hall, Zoltán Hantos, Michael J. R. Healy, Marcus H. Jones, Bent Klug, Karin C. Lødrup Carlsen, Sheila A. McKenzie, François Marchal, Oscar H. Mayer, Peter J. F. M. Merkus, Mohy G. Morris, Ellie Oostveen, J. Jane Pillow, Paul C. Seddon, Michael Silverman, Peter D. Sly, Janet Stocks, Robert S. Tepper, Daphna Vilozni, and Nicola M. Wilson, on behalf of the American Thoracic Society/ European Respiratory Society Working Group on Infant and Young Children Pulmonary Function Testing

Indications, timing, and interventions to the airway resulting in tracheostomy are poorly characterised. There are no promulgated standards of care for tracheostomy in children. This paper addresses the issues associated with decision for tracheostomy, the timing of the intervention, the care for the tracheostomy in both the acute and chronic phase and the necessities for care at home. The paper attempts to describe some of the apparent problems associated with tracheostomy and practical techniques for treatment of the inadvertent complications.

OBJECTIVES:To generate reference equations in North American children to be used for assessing respiratory function through the forced oscillation (Rfo) technique, and to determine the changes in oscillatory resistance, reactance, and resonant frequency (Fres) in relation to age, body height, and weight.DESIGN/SETTING:A prospective cross-sectional study performed on healthy children selected according to strict criteria of American Thoracic Society and European Respiratory Society recommendations.MEASUREMENTS:Triplicate measures were obtained of resistance and reactance at 5, 10, 15, 20, 25, and 35 Hz as well as Fres through the impulse oscillometer (MasterScreen IOS; Jaeger/Toennies; Höchberg, Germany). Two hundred twenty-two white children--normally distributed within the 3- to 10-year age range and 100 to 150 cm in height--were recruited in Montreal, Canada. We used regression analysis to generate multiple predictive equations separately per gender and frequency on age, height, and body weight.RESULTS:Stepwise multiple regression in both natural and logarithmic forms for height, weight, age, and gender showed that standing height was the only significant predictor for all variables. Minimal variability was noted in each subject among the triplicate measurements (p = 0.68 to 0.96). Coherence was > 0.9 at all oscillating frequencies except 5 Hz (< 0.72), with tendencies to lower values in young children.CONCLUSIONS:Resistance and Fres decrease by height, but also by age; and reactance increases. As opposed to our past experience with spirometry in compatible age groups, the Rfo technique was well accepted by preschool children.

BACKGROUND:There is an urgent need to bridge the large gap between optimal and observed asthma control among Canadian children.OBJECTIVES:To adapt the criteria of asthma control proposed in the 1999 Asthma Consensus Statement for children and validate the proposed cut-offs in children with asthma.METHODS:Six clinical criteria of asthma control were phrased as questions and response options, and pretested for clarity. A cross-sectional study was conducted in children one to 17 years of age presenting to the hospital's asthma clinics. Children nine years of age or older and their parents were asked to complete The Asthma Quiz for Kidz separately, and then together, before the medical visit. Parents of younger children completed the questionnaire with their child. Physicians were not informed of the results of the quiz.RESULTS:The mean age of the 343 participants was 8.0+/-4.4 (SD) years with a mean baseline forced expiratory volume in 1 s of 96+/-15% of predicted values. Asthma severity was rated as mild (67%), moderate (29%) or severe (4%). Overall, 57% of subjects endorsed at least two of the six criteria of poor control. The median (interquartile range) Asthma Quiz score was significantly higher when the physician's assessment of asthma control was poor than when the physician's assessment of asthma control was good (3 [1, 5] versus 1 [0, 2], P<0.001), but it did not correlate with the spirometry. A score of at least 2 out of 6 had 73% sensitivity and 59% specificity for identifying poor control.INTERPRETATION:The Asthma Quiz score provides complementary information to, but does not replace, lung function testing. A score of 2 or more out of 6 suggests poor asthma control and should prompt patients to consult their physician for reassessment.

The interpretation of pulmonary function testing is based on the comparison of an individual's performance to predicted normal values. However, the computation of these normal values considers parameters of standing height, weight, age, sex and race; all of these anthropometric characteristics are subject to change with age and clinical condition.. For the past three-quarters of the century numerous equations have been generated providing reference values for adults and occasionally children. To unify these equations we developed a neural network, the performance of which we compared to that of a regression model. Application on 2225 caucasian, black and hindi children aged 7 to 17 years indicated superiority of the neural (r2=0.90) to regression modeling (r2=0.88).

Objectives: To determine, in preschool children with an acute asthma exacerbation, the responsiveness to change of respiratory resistance measurements obtained by the forced oscillation (Rfo) technique, and to identify the magnitude of change indicative of airway obstruction reversibility.Design/setting: A prospective observational study of 114 children, aged 3 to 17 years, untrained in the Rfo technique and treated for acute asthma in a tertiary-care pediatric emergency department (ED).Measurements: A physical examination followed by three measurements of respiratory resistance by forced oscillation were obtained at 8 Hz (Rfo(8)) and at 16 Hz (Rfo(16)). In cooperative children, routine spirometry that included FEV1 was also performed on the Gusto Vit R (Custo Med; Munich, Germany). All measurements were obtained twice during the course of the ED treatment, before and after treatment with nebulized bronchodilators.Results: The Rfo(8) and Rfo(16) measurements were highly reproducible (reproducibility coefficients >0.85). Both the Rfo(8) and Rfo(16) were at least as responsive to change (responsiveness coefficients of 2.3 and 1.2, respectively) as was FEV1 (2.0) and the four clinical signs most sensitive to change (0.6 to 1.0). A 19% change in Rfo(8) was suggestive of significant reversibility.Conclusions: In the assessment of children aged greater than or equal to 3 years with acute asthma exacerbation, the respiratory resistance measurements are highly reproducible and responsive to change, particularly when obtained at 8 Hz. A 19% change from baseline Rfo(8) is suggestive of reversibility. This technique appears to be an attractive alternative in the evaluation of children who are too young or too sick to perform spirometry reproducibly.

Society of Critical Care Medicine; 27th Educational and Scientific Symposium; San Antonio, Texas, USA; February 4-8, 1998: Poster Hall: Thursday, February 5, 1998 5: 45-7: 15 pm; Friday, February 6, 1998 11: 40 am-1: 00 pm; Saturday, February 7, 1998 11: 40 am-1: 00 pm: Poster Presentations: Pulmonary