Elif Dagli

Non-Cystic-Fibrosis Bronchiectasis in Children: A Persisting Problem in Developing Countries

Background: Non-cystic-fibrosis (non-CF) bronchiectasis in childhood is still one of the most common causes of childhood morbidity in developing countries. The management of these patients remains problematic, and there are few studies of long-term outcome. Objective: The aim of this retrospective study was to define the general characteristics, underlying causative factors and long-term follow-up results of non-CF bronchiectasis patients. Methods: One hundred and eleven consecutive children, diagnosed with non-CF bronchiectasis were included in the study. General characteristics and underlying causes were recorded from the medical records. Clinical outcomes were evaluated in terms of lung function tests, annual exacerbation rates and patient/parent perception of health status. Results: Mean age of the patients was 7.4 ± 3.7 years at presentation, and patients had been followed 4.7 ± 2.7 years on average. In 62.2% of the patients, an underlying etiology was identified, whereas postinfectious bronchiectasis was the most common (29.7%). In spite of intensive medical treatment, 23.4% of the patients required surgery. The annual lower respiratory infection rate has decreased from a mean of 6.6 ± 4.0 to 2.9 ± 2.9 during follow-up (p < 0.0001). Lung function tests were also found to be improved (mean FEV1% 63.3 ± 21.0 vs. 73.9 ± 27.9; p = 0.01; mean FVC% 68.1 ± 22.2 vs. 74.0 ± 24.8; p = 0.04). There was clinical improvement in both the surgical (73%) and medical (70.1%) groups (p > 0.05). Conclusion: In conclusion, bronchiectasis remains a disease of concern to pediatricians, particularly in developing countries. Infections are still important causes of bronchiectasis, and clinical improvement can be achieved by appropriate treatment. Although medical treatment is the mainstay of management, surgery should be considered in selected patients.

The effect of passive smoking on the development of respiratory syncytial virus bronchiolitis.

In spite of the increasing evidence that passive smoking increases the incidence of respiratory infections and bronchial hyper-responsiveness, the information about whether exposure to sudden heavy smoke enhances the development of acute respiratory infections in children remains inadequate. In this study, to quantitate the level of exposure to environmental tobacco smoke, in 28 children (age ranging 2–18 months) with respiratory syncytial virus (RSV) bronchiolitis and in 30 children (age ranging between 2–15 months) with non-respiratory symptoms, the serum levels of cotinine, the major metabolite of nicotine, were measured at admission to the emergency department. Parents were asked to fill in a questionnaire about the housing conditions and their smoking habits. Serum samples were taken again from the children with RSV bronchiolitis at their second visit at 1 month after discharge from the hospital. The children with RSV bronchiolitis had higher levels of serum cotinine (mean of 10.8 ng/ml) in the acute stage, compared with post-bronchiolitis stage (mean of 7.4 ng/ml). Moreover, patients admitted with non-respiratory symptoms had significantly lower levels of serum cotinine (mean of 3.9 ng/ml) than both phases of patients with RSV bronchiolitis. Children with RSV bronchiolitis were found to have higher levels of cotinine when either the mother or both of the parents smoked, than the children with non-smoker parents. In conclusion, children admitted to the hospital with RSV bronchiolitis were shown to be acutely exposed to more cigarette smoke after 1 month and much more than the children admitted for non-respiratory diseases. These findings may imply that sudden heavy cigarette smoke exposure may predispose to an acute respiratory infection.

Foreign body aspiration in children: The value of diagnostic criteria

OBJECTIVE Foreign body aspiration (FBA) is a serious problem in children. While bronchoscopy should be performed in all patients with aspiration; patients without aspiration should be carefully excluded to avoid an unnecessary bronchoscopy. In this study we analyzed the details of our series, complication rates and compared the diagnostic findings between patients with an aspirated FB and those without. We also calculated the sensitivities, specificities, positive predictive values and negative predictive values of clinical history, symptoms, physical examination findings and radiological findings in patients with suspected FBA (sFBA). Finally, we evaluated the validity of our bronchoscopy indications in these patients. METHODS We reviewed the data of 207 patients who underwent rigid bronchoscopy for sFBA. We used clinical history, symptoms, physical examination and radiological findings as diagnostic findings. Complication rates in addition to these four diagnostic criteria constitute our indications for performing a rigid bronchoscopy. RESULTS After excluding 15 patients with radiopaque FB or previous fiberoptic bronchoscopy, 138 of 192 patients had an aspirated foreign body. The sensitivity and specificity of clinical history, symptoms, physical examination findings and radiological findings were 90.5% and 24.1%, 97.8% and 7.4%, 96.4% and 46.3, and 71.7% and 74.1% respectively. There was only one major complication which caused moderate neurological sequelae. There was no mortality and no thoracotomy or tracheotomy requirement in this group. CONCLUSIONS While symptoms, physical examination findings and clinical history had high sensitivities, radiological findings had the highest specificity. Low specificities of clinical history, symptoms and physical examination findings were due to our expanded bronchoscopy indication, which aimed to include all patients with foreign body aspiration. Our low complication rate facilitated the expansion of bronchoscopy indications, even for patients with slight clinical suspicion.

Flexible bronchoscopy for diagnosis and follow up of childhood endobronchial tuberculosis.

Background: In this study, our aim was to determine the clinical and bronchoscopic outcome of the endobronchial tuberculosis (ETB). Methods: Patients with suspected tuberculosis (TB) or TB patients with an inadequate response to 8 weeks of antituberculosis treatment were enrolled in the study. Results: Seventy patients were included to the study and 118 flexible bronchoscopies were performed. ETB was present in 33 (47%) patients. There was isolated compression in 14 cases, caseous lesions in 13, granuloma formation in 6, polypoid lesions in 2, adenopathy protrusion in 1, and mucosal erosion in 1 case. The mean duration of bronchoscopic resolution of endobronchial lesions was 5.50 ± 2.74 months. Mycobacterium tuberculosis was isolated from gastric lavage in 10% and from bronchoalveolar lavage in 12.8% of 70 cases. When both of the procedures were performed concurrently, the isolation rate increased to 20%. Transient hypoxia resolving with nasal O2 was observed in 3 patients as a complication of bronchoscopy. Conclusions: Bronchoscopy offered a safe and rapid means of confirming the diagnosis of ETB.

Home Ventilation for Children with Chronic Respiratory Failure in Istanbul

Background: The number of children on home mechanical ventilation (HMV) has increased markedly in Europe and North America but little is known about the HMV use and outcomes in children in Turkey. Objective: To review clinical conditions and outcome of children who were discharged from the hospital on respiratory support. Methods: Thirty-four patients assessed at the Marmara University Hospital in Istanbul who had been receiving ventilatory support at home for more than 3 months were included in the study. Results: Thirty-four patients with a median age of 5.1 years were discharged home with ventilatory support. HMV was started in 2001 at our institution and the number of children treated has increased substantially since then (2001: n = 1, 2002: n = 3, 2003: n = 3, 2004: n = 2, 2005: n = 14, 2006: n = 11).Ventilatory support was started at a median age of 1.8 years and continued for 13 months. Eleven (32.4%) patients received invasive mechanical ventilation via tracheostomy and 23 (67.6%) patients received noninvasive mechanical ventilation. Sixteen children (47.1%) were on noninvasive mechanical ventilation via nasal mask while 7 (20.6%) used a face mask. Seven (20.6%) patients received ventilatory support for 24 h and 27 (79.4%) patients were supported only during sleep. Twenty-four (70.6%) children received supplemental oxygen in addition to ventilatory support. Three patients successfully came off ventilatory support; 11 patients died during follow-up. None of the patients had home nursing and there were no life-threatening complications. Conclusions: A rapidly rising trend of HMV use in chronic respiratory failure (CRF) has been observed in this study. HMV can be safely applied in selected children with CRF with close monitoring and proper follow-up in developing countries despite the lack of home nursing.

The Prevalence of Headache and Its Association With Socioeconomic Status Among Schoolchildren in Istanbul, Turkey

Objective.— The etiology and pathogenesis of migraine and other types of headache are still under discussion. An interaction of organic, psychological, and psychosocial factors is operative. In this study, we aimed to determine the prevalence of headache and its association with socioeconomic status among schoolchildren.

Tobacco Control in Turkey

This report was prepared by WHO within the framework of the Bloomberg Global Tobacco Control Initiative in collaboration with the Ministry of Health and the Tobacco and Alcohol Market Regulatory Authority in Turkey. It outlines the current state of tobacco-smoking in Turkey, including the health and social aspects, epidemiological data and economic, legal and political issues. Turkey, until recently one of the major tobacco-producing countries of the world, has made substantial progress in tobacco control in a short time. The initial efforts of the Ministry of Health in the late 1980s received an impetus when Turkey ratified the WHO Framework Convention for Tobacco Control in 2004. Law No. 4207 of 1996 was substantially amended in 2008 and thus became one of the most advanced tobacco control laws in the world. Even so, smoking is still a serious health problem in the country, with one tenth of all the disabilityadjusted life-years lost due to smoking. About one third of the population smokes, despite a slight decrease over the last 15 years.

Withdrawal of inhaled steroids in children with non‐cystic fibrosis bronchiectasis

Background:  To study the effects of inhaled steroid withdrawal on bronchial hyperreactivity, sputum inflammatory markers and neutrophilic apoptosis in children with non‐cystic fibrosis (non‐CF) bronchiectasis.

Effect of night symptoms and disease severity on subjective sleep quality in children with non-cystic-fibrosis bronchiectasis.

Night‐time symptoms and hypoxemia during sleep may affect sleep quality in children with chronic lung disease such as bronchiectasis. Poor sleep quality may impair growth, learning, and emotional development of children. Our aim was to assess the sleep quality and associated factors in children with non‐cystic fibrosis bronchiectasis.

Flexible bronchoscopy as a valuable tool in the evaluation of persistent wheezing in children

BACKGROUND Persistent wheezing is a common problem in early childhood and leads to a diagnostic dilemma, excessive investigations, drug administration and additional cost. OBJECTIVE To determine the efficacy and the safety of FOB in children with persistent wheezing despite bronchodilator and inhaled steroid therapy. METHODS Patients with persistent wheezing that lasted at least 6 weeks and did not respond to bronchodilator and inhaled steroid therapy and to whom flexible bronchoscopy was performed were included to the study. RESULTS Between 1997 and 2009; 113 patients were enrolled to the study. Sixty-three percent of the children were male. Median age was 14 months at presentation and median duration of symptoms was 5 months. Bronchoscopy revealed pathological findings in 48% of the patients. Thirty-eight patients had malacia disorders, 14 had foreign body aspiration and two had external compression of airways which were later diagnosed as vascular ring. Major and minor complications were not seen in 92% of the patients while transient hypoxia was seen in 6%, stridor in 1% and tachycardia in 1% of the patients. CONCLUSION Flexible bronchoscopy provided rapid and definitive diagnosis for our patients with persistent wheezing without any major complications. This study is one of the largest studies concerning persistent wheezing. Early bronchoscopic evaluation can reduce cost by providing rapid and accurate diagnosis and preventing unnecessary investigations and drug administration. Flexible bronchoscopy is a safe procedure and should be considered in the evaluation of children with persistent wheezing.