Helena Teresinha Mocelin

Função pulmonar de crianças e adolescentes com bronquiolite obliterante pós-infecciosa

OBJECTIVE: To describe the pulmonary function in children and adolescents with postinfectious bronchiolitis obliterans (PIBO), as well as to evaluate potential risk factors for severe impairment of pulmonary function. METHODS: The pulmonary function of 77 participants, aged 8-18 years, was assessed by spirometry and plethysmography. The following parameters were analyzed: FVC; FEV1; FEF25-75%; FEV1/FVC; RV; TLC; RV/TLC; intrathoracic gas volume; and specific airway resistance (sRaw). We used Poisson regression to investigate the following potential risk factors for severe impairment of pulmonary function: gender; age at first wheeze; age at diagnosis; family history of asthma; tobacco smoke exposure; length of hospital stay; and duration of mechanical ventilation. RESULTS: The mean age was 13.5 years. There were pronounced decreases in FEV1 and FEF25-75%, as well as increases in RV and sRaw. These alterations are characteristic of obstructive airway disease. For the parameters that were the most affected, the mean values (percentage of predicted) were as follows: FEV1 = 45.9%; FEF25-75% = 21.5%; RV = 281.1%; RV/TLC = 236.2%; and sRaw = 665.3%. None of the potential risk factors studied showed a significant association with severely impaired pulmonary function. CONCLUSIONS: The patients with PIBO had a common pattern of severe pulmonary function impairment, characterized by marked airway obstruction and pronounced increases in RV and sRaw. The combination of spirometric and plethysmographic measurements can be more useful for assessing functional damage, as well as in the follow-up of these patients, than are either of these techniques used in isolation. Known risk factors for respiratory diseases do not seem to be associated with severely impaired pulmonary function in PIBO.OBJECTIVE To describe the pulmonary function in children and adolescents with postinfectious bronchiolitis obliterans (PIBO), as well as to evaluate potential risk factors for severe impairment of pulmonary function. METHODS The pulmonary function of 77 participants, aged 8-18 years, was assessed by spirometry and plethysmography. The following parameters were analyzed: FVC; FEV1; FEF25-75%; FEV1/FVC; RV; TLC; RV/TLC; intrathoracic gas volume; and specific airway resistance (sRaw). We used Poisson regression to investigate the following potential risk factors for severe impairment of pulmonary function: gender; age at first wheeze; age at diagnosis; family history of asthma; tobacco smoke exposure; length of hospital stay; and duration of mechanical ventilation. RESULTS The mean age was 13.5 years. There were pronounced decreases in FEV1 and FEF25-75%, as well as increases in RV and sRaw. These alterations are characteristic of obstructive airway disease. For the parameters that were the most affected, the mean values (percentage of predicted) were as follows: FEV1 = 45.9%; FEF25-75% = 21.5%; RV = 281.1%; RV/TLC = 236.2%; and sRaw = 665.3%. None of the potential risk factors studied showed a significant association with severely impaired pulmonary function. CONCLUSIONS The patients with PIBO had a common pattern of severe pulmonary function impairment, characterized by marked airway obstruction and pronounced increases in RV and sRaw. The combination of spirometric and plethysmographic measurements can be more useful for assessing functional damage, as well as in the follow-up of these patients, than are either of these techniques used in isolation. Known risk factors for respiratory diseases do not seem to be associated with severely impaired pulmonary function in PIBO.

Functional capacity assessment in children and adolescents with post-infectious bronchiolitis obliterans.

OBJECTIVE To assess functional capacity during exercise in children and adolescents with post-infectious bronchiolitis obliterans (PIBO). METHODS 20 children with PIBO, aged 8-16 years old, and in follow-up at an outpatient clinic carried out cardiopulmonary exercise testing (CPET), a 6-minute walk test (6MWT) and pulmonary function tests (PFT), according to American Thoracic Society (ATS), European Respiratory Society (ERS) and American College of Chest Physicians (ACCP) guidelines. Results were expressed as percentages of predicted reference values: Armstrongs for CPET, Geigers for 6MWT, Knudsons for spirometry, and Zapletals for plethysmography. RESULTS Mean age (+/- SD) was 11.4+/-2.2 years; 70% were boys; mean weight: 36.8+/-12.3 kg; mean height: 143.8+/-15.2 cm. When compared to reference values, PFT detected lower airflows (spirometry) and higher volumes (plethysmography). Eleven patients had reduced peak VO2 values in CPET (< 84% predicted). The mean distance walked (6MWT) was 77.0+/-15.7% of predicted (512+/-102 m). Peak VO2 was not correlated with 6MWT, but it was correlated with FVC (L) (r = 0.90/p = 0.00), with FEV1 (L) (r = 0.86/p = 0.00) and with RV/TLC, both in absolute values (r = -0.71/p = 0.02) and as percentages of predicted values (r = -0.63/p = 0.00). CONCLUSIONS The majority of these post-infectious bronchiolitis obliterans patients exhibited reduced functional capacity, exhibited during both CPET and the 6MWT. Due to its greater feasibility, 6MWT could be an alternative where CPET is not available.

Avaliação funcional durante o exercício em crianças e adolescentes com bronquiolite obliterante pós-infecciosa

Objective: To assess functional capacity during exercise in children and adolescents with post-infectious bronchiolitis obliterans (PIBO).

Post-infectious bronchiolitis obliterans: can CT scan findings at early age anticipate lung function?

The image findings of post‐infectious bronchiolitis obliterans (PIBO) have been described, however, we do not know if such findings can predict lung function (LF) deterioration with increasing patient age. Aim: To assess whether computed tomography (CT) abnormalities detected at an early stage of the disease can anticipate abnormal LF a decade later in children with PIBO.

Epidemiology, presentation and treatment of pleural effusion

Pleural effusion (PE) is the most common manifestation of pleural disorders. In children a PE is usually secondary to an underlying disorder. In developing countries PE most frequently results as a complication of a bacterial pneumonia. A high index of suspicion is required in order to avoid delays in diagnosis that may influence treatment and outcome. The diagnosis of PE in children is based on chest radiographs, thoracentesis and pleural fluid analysis. This review discusses the usefulness of diagnostic methods and treatment in children with parapneumonic pleural effusion.

Histoplasmosis in children

Histoplamosis is the most common primary systemic mycosis in the USA and is becoming more common as an opportunistic infection in HIV patients worldwide. In children the rate of asymptomatic infection is high. However, in infants with an immature immunological system, disseminated disease may occur. The clinical picture is variable depending on the immunological status. At the onset of the infection clinical manifestations are non specific (headache, fever, cough and nausea). Usually, these symptoms are self-limited and improve without treatment. However, patients with disseminated diseases present with prolonged fever, malaise, cough and weight loss. Hepatosplenomegaly is frequent in infants. Chest radiographs may be normal in 40 to 50% of patients with disseminated disease but findings such as lobar or diffuse infiltrates, cavitations, hilar adenopathy, or any combination of these may be found. Frequently, the clinical presentation is misdiagnosed as tuberculosis. Skin tests, serological reaction and specific cultures are used for diagnosis confirmation. Treatment indications and regimens are similar to those for adults, except that amphotericin B deoxycholate is usually well tolerated in children.

Post-infectious bronchiolitis obliterans in children

OBJECTIVE To review publications about the main features of post-infectious bronchiolitis obliterans and its history, etiology, epidemiology, risk factors, pathogenesis, histological findings, clinical presentation, complementary tests, diagnostic criteria, differential diagnosis, treatment and prognosis. SOURCES Non-systematic review of MEDLINE and LILACS databases and selection of 66 most relevant studies. SUMMARY OF THE FINDINGS In the post-infectious bronchiolitis obliterans there is an insult to respiratory epithelial cells, and its clinical severity is associated with the degree of lesion and inflammation. Diagnosis is made according to clinical signs and symptoms, by exclusion of main differential diagnoses and with the aid of complementary tests. High resolution CT, particularly images obtained during inspiration and expiration, provide information for the evaluation of the small airways. Pulmonary function tests show fixed airway obstructions and marked decrease of FEF25-75%. Treatment has not been definitely established, and corticoids have been administered as pulse therapy or by inhalation of high doses of steroids. However, data about its efficacy are scarce in the literature. Long-term prognosis is variable, and there might be either clinical improvement or deterioration into respiratory insufficiency and death. CONCLUSION Post-infectious bronchiolitis obliterans is a disease with a high morbidity rate; it should be treated by a multidisciplinary team, and patients should be followed up for a long period of time.

Assessment of nutritional status in children and adolescents with post-infectious bronchiolitis obliterans

OBJECTIVE To assess the nutritional status of children and adolescents with bronchiolitis obliterans and to analyze associations with clinical and nutritional factors. METHODS The study included 57 patients. Nutritional status was assessed using z scores for weight/age, stature/age, weight/stature in children, and stature/age and body mass index percentiles in adolescents. Body composition was assessed via tricipital skin folds, subscapular skin folds, and the sum of both plus the muscular circumference of the arm; pulmonary function was also investigated in subjects over 8 years old. RESULTS The high percentages of malnutrition and risk for malnutrition are noteworthy: 21.7 and 17.5%, respectively. Among children, weight/age and stature/age detected higher percentages of malnutrition (21.6 and 16.2%), while weight/stature underestimated this diagnosis. Among adolescents, body mass index detected a high percentage of malnutrition (25%) and of risk for malnutrition (20%). Body composition analysis detected 51% of patients with low muscle reserves, and the majority of patients had normal fat reserves. Compromised pulmonary function was associated with poor performance at exercise (r = 0.434; p = 0.024). Malnutrition and/or nutritional risk and low muscle reserves were significantly associated with the 6-minute walk test (p = 0.032; p = 0.030). There was no association between spirometry and the nutritional variables (p > 0.05). CONCLUSION These results emphasize the need for nutritional intervention, and suggest that, in addition to using weight and height indices for nutritional assessment, it is necessary to combine these with an analysis of body composition, so that a larger number of patients with malnutrition and/or at an increased risk for developing malnutrition may be identified and correctly managed.

Bronquiolite obliterante pós-infecciosa em crianças

OBJECTIVES: To review publications about the main features of post-infectious bronchiolitis obliterans and its history, etiology, epidemiology, risk factors, pathogenesis, histological findings, clinical presentation, complementary tests, diagnostic criteria, differential diagnosis, treatment and prognosis. SOURCES: Non-systematic review of MEDLINE and LILACS databases and selection of 66 most relevant studies. SUMMARY OF THE FINDINGS: In the post-infectious bronchiolitis obliterans there is an insult to respiratory epithelial cells, and its clinical severity is associated with the degree of lesion and inflammation. Diagnosis is made according to clinical signs and symptoms, by exclusion of main differential diagnoses and with the aid of complementary tests. High resolution CT, particularly images obtained during inspiration and expiration, provide information for the evaluation of the small airways. Pulmonary function tests show fixed airway obstructions and marked decrease of FEF25-75%. Treatment has not been definitely established, and corticoids have been administered as pulse therapy or by inhalation of high doses of steroids. However, data about its efficacy are scarce in the literature. Long-term prognosis is variable, and there might be either clinical improvement or deterioration into respiratory insufficiency and death. CONCLUSION: Post-infectious bronchiolitis obliterans is a disease with a high morbidity rate; it should be treated by a multidisciplinary team, and patients should be followed up for a long period of time.

Oxigenoterapia domiciliar em crianças: relato de sete anos de experiência

Objective: To describe the results of a seven years experience using home oxygen therapy in children with hypoxemia and chronic lung disease. Patients and methods: This is a retrospective and descriptive study carried out at Hospital da Crianca Santo Antonio ¾ Porto Alegre-RS, Southern Brazil. The characteristics of the children on home oxygen therapy from January/93 to January/00 were analyzed. Results: Out of the 40 patients studied, 29 (72.5%) were males. At the beginning of home oxygen therapy, the age of the patients ranged from two months to 13 years and six months (mean: 24.8; median: 13), and 18 of them (45%) were less than one year old. The most frequent diseases were: obliterative bronchiolitis (31 cases; 77.5%); chronic obstructive lung disease with aspiration pneumonia (three cases); hypogammaglobulinaemia (two cases); suppurative lung disease (two cases), alveolar proteinosis (one case) and tuberculosis (one case). The length of the last hospitalization before home oxygen therapy was started ranged from nine to 240 days (mean: 63.7 days; median: 50 days). Most of the patients (30; 75%) received oxygen from a concentrator and the remainder from a cylinder. Mean oxygen therapy length ranged from 27 to 1,620 days (median: 392.5 days). There were five deaths from complications of the basic disease and one from accidental removal of the tracheostomy tube. Oxygen use could be discontinued in 19 patients ¾ 15 with obliterative bronchiolitis, two with chronic aspiration pneumonia, one with tuberculosis and one with alveolar proteinosis. Conclusion: Although oxygen was needed for long periods, evolution was satisfactory in most children. Home oxygen for oxygen-dependent is an alternative treatment that allows an early discharge and a quick return to home life.