Daniel Trachsel

Management of acute bronchiolitis: can evidence based guidelines alter clinical practice?

Background: Acute bronchiolitis is the most common lower respiratory tract infection in infants and there is no evidence that drug treatment alters its natural course. Despite this, most Swiss paediatricians reported in 2001 prescribing bronchodilators and inhaled corticosteroids (ICS). This situation led to the creation of national guidelines followed by a tailored implementation programme. The aim of this study was to examine if treatment practices changed after the implementation of the new guidelines. Methods: A questionnaire on treatment of bronchiolitis was sent to all Swiss paediatricians before (2001) and after (2006) creation and implementation of national guidelines (2003–2005). Guidelines were created in collaboration with all paediatric pulmonologists and implemented carefully using a multifaceted approach. Results: Questionnaires were returned by 541 paediatricians (58%) in 2001 and by 639 (54%) in 2006. While both surveys showed a wide variation in the treatment of bronchiolitis between physicians, reported drug prescription decreased significantly between the two surveys. For outpatients, general use (for all patients) of bronchodilators dropped from 60% to 23%, and general use of ICS from 34% to 6%. For inpatients, general use of bronchodilators and ICS dropped from 55% to 18% and from 26% to 6%, respectively (all p<0.001). The decrease was evident in all regions, among hospital and primary care physicians, and among general paediatricians and paediatric pulmonologists. Conclusions: National guidelines together with a tailored implementation programme can have a major impact on medical management practices in a country.

Laryngeal damage due to an unexpectedly large and inappropriately designed cuffed pediatric tracheal tube in a 13-month-old child.

PurposeTo present a case of laryngeal damage in an infant caused by a too large and inappropriately designed cuffed tracheal tube.Clinical featuresA 13-month-old child undergoing cardiac surgery was intubated with an uncuffed endotracheal tube with an internal diameter (ID) of 4.0 mm. Because of an important air leak around the tracheal tube during mechanical ventilation, a cuffed endotracheal tube lD 4.0 mm was inserted. The air leak with the tube cuff not inflated was acceptable at 25 cm H2O airway pressure. After extubation on the third postoperative day the patient showed increasing stridor and respiratory deterioration. Fibreoptic laryngoscopy of the spontaneously breathing patient showed a large intra-laryngeal web. After surgical removal of the web, the child rapidly recovered and was discharged from the hospital on the 12th postoperative day.Inspection of the 4.0 mm (ID) cuffed tracheal tube revealed a cuff positioned inappropriately high and an increase of 0.7 mm in outer tube diameter compared to the 4.0 mm (lD) uncuffed tracheal tube from the same manufacturer. The tube cuff is likely to be situated within the larynx when placed in accordance to insertion depth formulas or radiological criteria, as used for uncuffed tracheal tubes in children.ConclusionThe larger than expected tracheal tube with its intralaryngeal cuff position in a 13-month-old child likely caused mucosal damage and an inflammatory reaction within the larynx resulting in granulation tissue formation and fibrous healing around the tracheal tube.RésuméObjectifPrésenter un cas de lésion laryngée causée, chez un enfant, par un tube trachéal à ballonnet, trop grand et mal conçu. Élémentscliniques : Un enfant de 13 mois devant subir une intervention cardiaque a été intubé avec un tube endotrachéal sans ballonnet d’un diamètre interne (Dl) de 4,0 mm. Étant donné l’importante fuite d’air autour du tube trachéal pendant la ventilation mécanique, un tube endotrachéal à ballonnet de 4,0 mm de Dl a été inséré. La fuite d’air notée autour du ballonnet non gonflé était acceptable pour une pression des voies aériennes de 25 cm H2O. Après l’extubation, au troisième jour postopératoire, le patient a présenté un stridor croissant et une détérioration respiratoire. La fibroscopie du larynx pendant la respiration spontanée a montré une grande membrane intralaryngée. Après le retrait chirurgical de la membrane, l’enfant s’est rapidement rétabli et a quitté l’hôpital le 12e jour.Lexamen du tube à ballonnet de 4,0 mm a révélé un ballonnet placé trop haut et une augmentation de 0,7 mm du diamètre extérieur du tube, comparé au tube sans ballonnet de 4,0 mm réalisé par le même fabricant. Le ballonnet se situe à l’intérieur du larynx quand on place le tube selon les formules d’insertion ou les critères radiologiques, comme on le fait avec les tubes trachéaux sans ballonnets chez les enfants.ConclusionLe tube trachéal, plus gros que prévu, placé dans le larynx dans la position indiquée pour un tube à ballonnet chez un enfant de 13 mois, a causé une lésion de la muqueuse et une réaction inflammatoire dans le larynx, ce qui a entraîné la formation de tissu de granulation et une cicatrisation fibreuse autour du tube trachéal.

Procalcitonin guidance to reduce antibiotic treatment of lower respiratory tract infection in children and adolescents (ProPAED): a randomized controlled trial.

Background Antibiotics are overused in children and adolescents with lower respiratory tract infection (LRTI). Serum-procalcitonin (PCT) can be used to guide treatment when bacterial infection is suspected. Its role in pediatric LRTI is unclear. Methods Between 01/2009 and 02/2010 we randomized previously healthy patients 1 month to 18 years old presenting with LRTI to the emergency departments of two pediatric hospitals in Switzerland to receive antibiotics either according to a PCT guidance algorithm established for adult LRTI or standard care clinical guidelines. In intention-to-treat analyses, antibiotic prescribing rate, duration of antibiotic treatment, and number of days with impairment of daily activities within 14 days of randomization were compared between the two groups. Results In total 337 children, mean age 3.8 years (range 0.1–18), were included. Antibiotic prescribing rates were not significantly different in PCT guided patients compared to controls (OR 1.26; 95% CI 0.81, 1.95). Mean duration of antibiotic exposure was reduced from 6.3 to 4.5 days under PCT guidance (−1.8 days; 95% CI −3.1, −0.5; P = 0.039) for all LRTI and from 9.1 to 5.7 days for pneumonia (−3.4 days 95% CI −4.9, −1.7; P<0.001). There was no apparent difference in impairment of daily activities between PCT guided and control patients. Conclusion PCT guidance reduced antibiotic exposure by reducing the duration of antibiotic treatment, while not affecting the antibiotic prescribing rate. The latter may be explained by the low baseline prescribing rate in Switzerland for pediatric LRTI and the choice of an inappropriately low PCT cut-off level for this population. Trial Registration Controlled-Trials.com ISRCTN17057980 ISRCTN17057980

A vote for inhaled adrenaline in the treatment of severe upper airway obstruction caused by piercing of the tongue in hereditary angioedema

also have indicated a hollow viscus perforation. Furthermore, pneumoperitoneum occurred without pneumoretroperitoneum, which is occasionly described as a consequence of pulmonary barotrauma [3]. In our case, pneumoperitoneum was associated with an abdominal compartment syndrome [5]. In conclusion, pneumoperitoneum occurrence should be kept in mind after PDT, even if major mediastinal emphysema is missing, and a laryngeal mask should be used with caution when performing PDT.

Use of continuous positive airway pressure during flexible bronchoscopy in young children

Young children are at increased risk for hypoxaemia and hypercapnia during flexible bronchoscopy due to the small size and increased collapsibility of their airways. Various strategies are used to prevent hypoventilation and to provide oxygen during the procedure. The aim of this study was to assess the impact of continuous positive airway pressure (CPAP) on ventilation during flexible bronchoscopy in infants and young children. Tidal breathing was measured in 16 spontaneously breathing and deeply sedated children, aged 3–25 months, by ultrasound spirometry via an airway endoscopy mask. Measurements were made with the tip of the bronchoscope positioned in the pharynx with no CPAP, and in mid-trachea with 0, 5 and 10 cmH2O of CPAP. Transition of the bronchoscope through the vocal cords was associated with significant decreases of tidal volumes (5.0±0.5 versus 3.4±0.5 mL·kg−1), peak tidal expiratory flows (78±12 versus 52±10 mL·s−1) and peak tidal inspiratory flows (98±15 versus 66±12 mL·kg−1). CPAP (5–10 cmH2O) induced almost complete reversal of these changes. In conclusion, it is shown here that flexible bronchoscopy in spontaneously breathing young children is associated with significant decreases in tidal volume and respiratory flow. These changes are largely reversible with continuous positive airway pressure.

False normal Lung Clearance Index in infants with cystic fibrosis due to software algorithms

Lung clearance index (LCI), a marker of ventilation inhomogeneity, is elevated early in children with cystic fibrosis (CF). However, in infants with CF, LCI values are found to be normal, although structural lung abnormalities are often detectable. We hypothesized that this discrepancy is due to inadequate algorithms of the available software package.

Comparability of a hand-held nitric oxide analyser with online and offline chemiluminescence-based nitric oxide measurement

Practicability is crucial for successful implementation of fractional exhaled nitric oxide (FeNO) measurement into asthma management. The study aimed at comparing a conventional chemiluminescence NO analyser (EcoMedics®) with a hand‐held device (NIOX MINO®) and offline FeNO measurement using a commercially available system in an unselected cohort of children aged 6–16 yr. A secondary objective was to confirm FeNO stability over time in 15 samples from adult volunteers obtained using the offline system. Sixty‐six children (mean ± s.d. age 11.8 ± 3.0 yr) underwent single breath FeNO measurement in triplets with each device. Offline collected FeNO was measured after offline breath collection into a Mylar balloon and subsequent analysis using the chemiluminescence NO analyser. Variability and between‐method agreement were assessed, and stability over time within the Mylar balloons was tested by repeated hourly measurements. FeNO levels ranged from 2 to 113 p.p.b. Intra‐class correlation was excellent (r = 0.98, p < 0.001 for each pair). Bland–Altman plots and back‐transformation of logarithmic mean differences revealed fair agreement between methods. Stability over time was confirmed over 10 h both at room temperature and when stored under cooling conditions. FeNO values obtained using the chemiluminescence NO analyser, the portable NIOX MINO® system and the offline collection technique show between‐method agreement within clinically acceptable range.

Mannitol dry powder challenge in comparison with exercise testing in children.

Mannitol dry powder (MDP) challenge is an indirect bronchial provocation test, which is well studied in adults but not established for children.

Exercise testing in children with lung diseases

Exercise is an important aspect of health and development in children. By placing the pulmonary system under stress, exercise testing may reveal subtle dynamic abnormalities that are not apparent on conventional static pulmonary function tests. Furthermore, exercise testing assesses the functional impact of respiratory disease on children. Exercise testing has been used in children with a variety of respiratory diseases such as exercise induced bronchoconstriction, asthma, cystic fibrosis and bronchopulmonary dysplasia to assess the severity of disease as well as response to various interventions. Furthermore, there is good evidence that exercise testing is a useful tool to help determine prognosis in patients with cystic fibrosis. In addition to the clinical utility, exercise testing is also becoming an increasingly important outcome measure in research studies.

The Value of Exhaled Nitric Oxide in Predicting Bronchial Hyperresponsiveness in Children

Reduced attention span and motor skills in children limit the practicability of bronchial provocation tests. To assess exhaled nitric oxide (FeNO) as a surrogate for bronchial hyperresponsiveness (BHR) in children with possible reactive airway disease, FeNO was measured using the single-breath method in 169 successive outpatients 11 ± 5 years of age before lung function testing and subsequent bronchial provocation by exercise (n = 165) and methacholine (n = 134). Baseline forced expiratory volume in 1 second (FEV1) less than 80% of predicted and/or BHR were seen in 59%. FeNO correlated weakly with PD20 to methacholine (r = −0.24, p < 0.05), but not with the change in FEV1 due to exercise-induced bronchoconstriction (EIB) (r = 0.1, p > 0.05). The negative predictive value of FeNO less than 10 ppb for EIB was 94%, but overall accuracy for predicting BHR was low. Measurement of FeNO is not a substitute for bronchial provocation in children.