Eliezer Nussbaum

Association of lipid-laden alveolar macrophages and gastroesophageal reflux in children

The association of lipid-laden alveolar macrophages (LLAM) and gastroesophageal reflux (GER) was investigated prospectively in 115 patients in two groups. Group 1 included 74 children with chronic respiratory tract disorders and documented GER by prolonged esophageal pH monitoring, barium esophagram, and esophagoscopy; group 2 included 41 children with chronic respiratory tract disorders without GER. LLAM were present in 63 (85%) and eight (19%) children from groups 1 and 2, respectively (P less than 0.0001). Thus a strong association between the presence of LLAM and GER in children with chronic respiratory tract disorders was established. We suggest that LLAM from bronchial lavage may be a useful marker for tracheal aspiration in children with GER in whom chronic lung disease may subsequently develop.

Pediatric fiberoptic bronchoscopy: Clinical experience with 2,836 bronchoscopies.

Objective To report 21 yrs of experience with pediatric flexible fiberoptic bronchoscopy in infants and children, explore newer applications, delineate potential complications, and make recommendations for its future application. Design Retrospective review. Setting A 20-bed pediatric critical care unit in a tertiary care, university-based children’s hospital. Patients A total of 2,836 pediatric and infant fiberoptic bronchoscopies, performed over a course of 21 yrs, were reviewed. Measurement and Main Results A total of 2,836 children (1,536 girls) were subjected to flexible fiberoptic bronchoscopy. Of those, laryngeal mask airway was incorporated in 92 procedures (3.2%) and general anesthesia was applied in 198 cases (7%). The youngest subject was a 1-wk-old, 600-g, premature infant. The procedure resulted in diagnoses that modified patient care, particularly in tracheostomized infants and those with upper airway obstruction, plastic bronchitis of acute chest syndrome, dyskinetic cilia syndrome, immunocompromised individuals, and those with unexplained chronic cough and recurrent pulmonary infiltrates. Microbiologic and cytologic data from bronchoalveolar lavage helped confirm the diagnoses of pulmonary hemosiderosis and gastroesophageal reflux and validated the presence, or lack of, bacterial or viral pathogens. A total of 21 patients (<1%) experienced life-threatening hypoxemia, prompting termination of the procedure. Laryngospasm or bronchospasm was observed in 17 individuals (<1%) undergoing bronchoalveolar lavage, and 4% of the total population experienced mild nasopharyngeal bleeding. No fatalities were encountered. Conclusions Pediatric flexible fiberoptic bronchoscopy is a safe diagnostic and interventional tool, even in young or extremely premature infants. Although the rate of serious complications in this report is low, general anesthetic agents and incorporation of laryngeal mask airway is advocated for severe mucoid impaction, transbronchial biopsy, and chronic pulmonary infiltrates, which may necessitate extensive bronchoalveolar lavage.

Risk factors for near-fatal asthma.

BACKGROUND There is a paucity of lung function data in patients, both before and after episodes of near-fatal asthma (NFA), requiring transient endotracheal intubation and mechanical ventilation. METHODS Lung function was initially measured in 43 asthmatic patients (age range, 16 to 49 years), who were observed and treated in a tertiary referral asthma clinic and were clinically stable at the time of study. Subsequently, clinical and physiologic follow-up studies were obtained over > 5 years. The primary outcomes were to determine (1) the integrity of lung elastic recoil and (2) the severity of expiratory airflow limitation, and (3) to correlate these outcomes with adverse clinical complications. RESULTS Fourteen of 26 asthmatic patients (54%) [age range, 30 to 49 years] had significantly reduced lung elastic recoil pressures at all lung volumes compared to 3 of 17 asthmatic patients (18%); p = 0.02 [chi(2) test and Fisher exact test] [age range, 16 to 26 years]. In asthmatic patients between the ages of 30 and 49 years, significant loss of lung elastic recoil was noted in 4 of 10 patients with mild reduction in FEV(1) (FEV(1), > 79% predicted), 6 of 12 patients with moderate reduction in FEV(1) (FEV(1), 61 to 79% predicted), and all 4 patients with severe reduction in FEV(1) (FEV(1), < 61% predicted). In asthmatic patients between the ages of 16 and 26 years, significant loss of lung elastic recoil was noted in 0 of 11 patients with mild reduction in FEV(1), 2 of 5 patients with moderate reduction in FEV(1), and 1 of 1 patient with severe reduction in FEV(1). A subgroup of 10 asthmatic patients (7 men) [mean (+/- SD) age, 37 +/- 11 years] were studied when clinically stable, both before and after an episode of NFA in 8 cases and only after an episode of NFA in 2 additional cases. In 1 of 10 cases, the FEV(1) was mildly reduced, in 4 cases it was moderately reduced, and in 5 cases it was severely reduced, both before and after an episode of NFA. The sensitivity was 90%, the specificity was 61%, the positive predictive value was 41%, and the negative predictive value was 95% for NFA with an FEV(1) < or = 79% predicted or FEV(1)/FVC ratio of < 75%. Prior to an episode of NFA, all 8 asthmatic patients had significant loss of lung elastic recoil pressure, and afterward all 10 had significant loss of lung elastic recoil pressure (ie, less than the predicted normal mean minus 1.64 SD at a total lung capacity [TLC] of 100 to 70% predicted). The sensitivity was 100%, the specificity was 79%, the positive predictive value was 59%, and the negative predictive value was 100% for NFA with the loss of lung elastic recoil. The mean TLC measured with a plethysmograph in 10 patients with NFA was 7.2 +/- 1.41 (124 +/- 16% predicted). The sensitivity for TLC of > 115% predicted was 70%, the specificity was 70%, the positive predictive value was 88%, and the negative predictive value was 41% for NFA. CONCLUSION A persistent reduction in FEV(1) of < or = 79% predicted or an FEV(1)/FVC ratio of < 75%, and, especially, the loss of lung elastic recoil and hyperinflation at TLC are risk factors for NFA. The loss of lung elastic recoil in asthmatic patients was associated with increased age, duration of disease, and progressive expiratory airflow limitation.

Intracranial pressure monitoring as a guide to prognosis in the nearly drowned, severely comatose child

During a 34-month-period, 55 nearly drowned, comatose children who were admitted to our pediatric intensive care unit were divided into C1 (decorticate), C2 (decerebrate), and C3 (flaccid) subgroups. Patients in subgroup C3 were selected for intracranial pressure (ICP) measurements by the subarachnoid bolt, and were reclassified according to clinical outcome into recovered (group A), fatality (group B), and brain damaged (group C) categories. Six children (29%) had complete recovery, 10 died (48%), and five (23%) demonstrated residual brain damage. There was a highly significant difference between the ICP in group A and group B (P less than 0.001), and between group B and group C (P less than 0.001). Both group A and group C had highly significant differences in mean cerebral perfusion pressure (CPP) values compared with group B (P less than 0.001). There were no significant differences in ICP or CPP between groups A and C. Finally, using a combination of ICP and CPP, we found that ICP less than or equal to 20 mm Hg and CPP greater than or equal to 50 mm Hg were associated with survival in 11 of 12 patients (92%), whereas ICP greater than 20 mm Hg and CPP less than 50 mm Hg were associated with death in seven patients cases (100%). The two other patients who died had either CPP less than 50 mm Hg or ICP greater than 20 mm Hg, but not both. We find that intracranial pressure monitoring is a safe, useful tool in predicting death or survival, but not residual brain damage, in the nearly drowned, severely comatose child.

Immunosuppressive and cytotoxic effects of furosemide on human peripheral blood mononuclear cells

BACKGROUND We have previously shown that children with mild asthma have a modest improvement in their pulmonary function tests after aerosolized furosemide. The mechanism of action is not known. The observation that furosemide possesses a similar profile of protection as sodium cromoglycate and nedocromil sodium suggests that furosemide may inhibit mediator production and release. OBJECTIVE We studied the in vitro effects of furosemide on cytokine release from normal human peripheral blood mononuclear cells (PBMC) induced by E. coli lipopolysaccharide (LPS). METHODS Peripheral blood mononuclear cells were isolated by density gradient centrifugation, stimulated with LPS and incubated at 37 degrees C with varying concentrations of furosemide, hydrocortisone, sodium cromoglycate, and nedocromil sodium for 24 hours. Supernatants were extracted and study for levels of tumor necrosis factor-alpha (TNF-alpha), interleukin-6 (IL-6), and interleukin-8 (IL-8). Intracellular IL-6 and TNF-alpha concentrations were also measured by cell cytometry. Cell viability was examined using XTT cell proliferation test and-measuring the release of lactate dehydrogenase (LDH). RESULTS There was a significant reduction in levels of TNF-alpha and IL-6 at a furosemide concentration of 0.5 x 10(-2) M and a reduction in IL-8 levels at 10(-2) M. This inhibition was comparable to that found with equivalent molar concentrations of hydrocortisone. These findings were also confirmed with measurements of intracellular IL-6 and TNF-alpha by cell cytometry. High concentration of furosemide at 10(-2) M caused significant cellular cytotoxicity. CONCLUSION These data suggest that furosemide may exhibit an anti-inflammatory effect. Specifically, the addition of furosemide resulted in decreased production of cytokines. This effect may be due to an immunosuppressive activity on monocytes as well as a direct cytotoxic effect at high furosemide concentrations.

Flexible fiberoptic bronchoscopy and laryngoscopy in children under 2 years of age: diagnostic and therapeutic applications of a new pediatric flexible fiberoptic bronchoscope.

The new flexible fiberoptic bronchoscope (Olympus BF Type 3C4, Tokyo, Japan) was employed for diagnostic and therapeutic purposes in 96 children below 2 yr of age. Sixty-two laryngoscopies and 34 bronchoscopies were performed without any mortality or significant morbidity. The bronchoscope was helpful in establishing diagnosis and also served as a tool for aspirating secretions and resolving atelectasis. It is concluded that flexible fiberoptic bronchoscopy and laryngoscopy in children 2 yr or younger is a safe procedure and may aid in the diagnosis and therapy of disorders of the respiratory tract in this age group.

Adult-type Respiratory Distress Syndrome in Children Experience with Seven Cases

Adult respiratory distress syndrome (ARDS) is not well recognized in children. We report seven individuals, ranging in age from 1.5 to 16 years. The clinical picture of ARDS reached a peak in 72 hours from admission and was associated with a 28.5 per cent death rate (2/7). In no case was an organism isolated, either from bronchial washings via a flexible bronchoscope or from open lung biopsy specimen. ARDS is characterized by severe damage to the alveolar- capillary unit and probably inadequate production of lung surfactant, resulting in severe hy poxia, hypoxemia, intrapulmonary shunting, and marked decline in pulmonary compliance. The prognosis remains poor in the pediatric age group. The pathophysiology of this entity is outlined, with guidance for monitoring and therapy.

Early echocardiographic and pulmonary function findings in idiopathic scoliosis.

Thirty-six children and adolescents with early stages of idiopathic scoliosis underwent evaluation by echocardiography and pulmonary function testing. Mildly increased pulmonary vascular resistance was inferred from an elevated ratio of right preejection period to right ventricular ejection time, an increased right ventricular dimension, and a decreased left ventricular dimension. Since neither decreased arterial oxygen saturation nor increased end-tidal expired carbon dioxide partial pressure was seen, desaturation and hypoventilation should not account for these abnormalities. Pulmonary function parameters showed no distinct patterns of abnormality. Even though the patients were divided into two groups by severity of spinal curvature, the cardiopulmonary measures did not correlate with thoracic deformity. Billowing of the mitral leaflets, termed mitral valve prolapse, was demonstrated in 25% of the subjects. Our findings suggest that cardiopulmonary and thoracic changes in idiopathic scoliosis may develop in parallel and may be expressions of a common collagen defect. However, study of sleep and exercise arterial saturation may be required to rule out intermittent hypoxemia as a precipitating factor of cor pulmonale in scoliosis.

Femoral artery cannulation for monitoring in critically ill children: prospective study.

Seventy-seven attempted percutaneous femoral artery cannulations were prospectively evaluated in 74 children. Artery cannulation was successfully accomplished in 73 (95%) cases and lasted for a mean of 6 days. Sixty percent of the catheters were inserted on the first attempt. Fifty-two (71%) patients weighed <10 kg and 55 (75%) patients were <12 months old. Fifty-one (70%) patients received inotropic support at the time of cannulation, and 27 (37%) eventually died from causes unrelated to catheter insertion. There was one episode each of line-associated infection and transient distal ischemia not resulting in tissue loss, and two episodes of catheter malfunction. In eight (11%) patients, signs of distal vascular insufficiency developed shortly after catheter placement and resolved after catheter removal. The development of this complication correlated significantly (p < .05) with younger age (5.5 vs. 22.3 months).We conclude that femoral artery cannulation has a high degree of success in very small, critically ill children. It should be considered an acceptable alternative to small-vessel cannulation when the latter is not technically achievable, or in the unstable patient where rapid establishment of reliable arterial access is necessary.

Fiberoptic laryngoscopy as a guide to tracheal extubation in acute epiglottitis.

atrophic skin changes? There are no diagnostic laboratory features of eosinophilic fasciitis, although peripheral blood eosinophilia is usually present, and most patients have modest elevations of the serum immunoglobulin concentrations and erythrocyte sedimentation rates. 7-8 Histologically, eosinophilic fasciitis is characterized by inflammation and thickening of the collagen bundles of the deep fascia, with some extension into the muscle and subcutaneous tissue. Eosinophils are rarely prominent in the tissue infiltrate; the major infiltrative cells are lymphocytes and plasma cells. 7~9 However, biopsy during the acute stage of eosinophilic fasciitis may show prominent eosinophilic infiltrate of the dermis and subcutis, 9 thus blurring the histologic distinction between it and eosinophilie eellulitis. Signs and symptoms in our patient would most closely fit the syndrome of eosinophilic cellulitis. Exact categorization of difficult, however, because eosinophilic cellulitis and eosinophilic fasciitis share a number of features in common. Further characterization will await precise definition of the cause(s) of these two conditions. REFERENCES 1. Wells GC: Recurrent granulomatous dermatitis with eosinophilia. Trans St Johns Hosp Dermatol Soc 57:46, 1971. 2. Shulman LE: Diffuse fasciitis with hypergammaglobulinemia and eosinophilia: A new syndrome? (abst). J Rheumatol (SuppI) 1:82, 1974. 3. WeIIs GC, Smith NP: Eosinophilic ceIlulitis. Br J Dermatol 100:10t, 1979. 4. Nielsen T, Schmidt H, Sogaard H: Eosinophilic cellulitis (Wells syndrome) in a child. Arch Dermatol 117:427, 1981. 5. Spigel GT, Winkelmann RK: Wells syndrome: Recurrent granulomatous dermatitis with eosinophilia. Arch Dermatol 115:611, 1979. 6. Rosenthal J, Benson MD: Diffuse fasciitis and eosinophilia with symmetric polyarthritis. Ann Intern Med 92:507, 1980. 7. Michet C J, Doyle JA, Ginsburg WW: Eosinophilic fasciitis: Report of 15 cases. Mayo Clin Proc 56:27, I981. 8. Moutsopoulos HM, Webber BL, Pavlidis NA, Fostiropoulos G, Goules D, Shulman LE: Diffuse fasciitis with eosinophilia: A clinicopathologic study. Am J Med 68:701, 1980. 9. Barnes L, Rodman GP, Medsger TA, Short D: Eosinophilic fasciitis: A pathologic study of twenty cases. Am J Pathol 96:493, 1979.