João Antônio Bonfadini Lima

Foreign body aspiration in children

Foreign body aspiration is a common accident in children and represents an important cause of morbidity and mortality. Diagnosis of this condition demands a high degree of suspicion since physical examination and basic radiology exams have low sensitivity. It is more frequent in children younger than 3 years of age, predominantly boys. Food materials are most commonly involved, particularly peanuts, although this could change according to regional feeding habits. The right main bronchus is the site where foreign bodies are most commonly found. Radiographical findings are not diagnostic, but the presence of unilateral obstructive emphysema or atelectasis are important clues. A rigid endoscopy is indicated whenever there is a suggestive history, since delays in removing foreign bodies can lead to severe bronchial sequelae. In developing countries this type of accident may be more relevant due to the lack of resources and awareness, which can lead to late diagnosis and treatment. Routine preventive measures must be taught to caregivers in order to reduce the incidence. Health care professionals should also be made more aware of the prevalence of this condition.

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).

Respiratory syncytial virus (RSV) bronchiolitis: comparative study of RSV groups A and B infected children

The grouping characteristics of 29 respiratory syncytial virus (RSV) present in nasopharyngeal cells collected from hospitalized children with bronchiolitis during the 1990 RSV season in Porto Alegre, RS, were analysed. Twenty-two were grouped as belonging to group A and 7 to group B. Cyanosis, oxygen therapy, cough, length of hospitalization and atelectasis were observed to be more frequently found within group B infected children. Other clinical signs and symptoms were similarly found in both groups.

Prevalência e fatores de risco para sibilância no primeiro ano de vida

OBJECTIVE To determine the prevalence of and the risk factors for wheezing in infants under one year of age and residing in the city of Porto Alegre, Brazil. METHODS This was a cross-sectional study and is part of a multicenter, multinational project. The parents or legal guardians of the infants were interviewed at primary health care clinics or during home visits. We used a standardized questionnaire, validated for use in Brazil. Potential risk factors were assessed by means of a Poisson regression model with robust variance estimation, using the Wald test to determine the significance of each variable in the model. RESULTS The sample comprised 1,013 infants. The majority of those were male (53%), and the mean age was 13.5 ± 1.2 months. In 61% of the infants, there had been at least one episode of wheezing, which had recurred at least three times in one third of those infants. The mean age at the first episode of wheezing was 5.16 months (median, 5 months). Over 40% of the infants with wheezing visited emergency rooms due to wheezing, and 17% of those were hospitalized at least once in the first year of life because of this symptom. In the multivariate analysis, the risk factors for wheezing were as follows: male gender; history of pneumonia; maternal smoking during pregnancy; day care center attendance; low maternal level of education; early weaning; multiple episodes of cold; first viral infection prior to 3 months of age; existence of siblings; and history of asthma in the nuclear family. CONCLUSIONS The prevalence of wheezing is high among infants in the city of Porto Alegre. We identified various risk factors for wheezing in infants.

Aspiração de corpo estranho na árvore traqueobrônquica em crianças: avaliação de seqüelas através de exame cintilográfico

Objective: The aim of this study was to detect late sequelae of foreign body aspiration in the respiratory tract of children. Methods: This study included children admitted from 1987 to 1999 to Hospital da Crianca Santo Antonio, of Porto Alegre, with clinical symptoms of foreign body aspiration to the respiratory tract confirmed by chest X-ray and bronchoscopy. Thirty days after the extraction of the foreign body a perfusion lung scan with technetium was performed. Results: 77% of the foreign bodies were organic materials. In 65% of children the aspiration event occurred at least 7 days before referral. The main location of foreign body was in the right lower lobe bronchus. Perfusion lung scans were performed in 24 patients. In 67% of them reduction in lung perfusion was detected. A chance of sequelae was 3.8 times greater in those patients who had the foreign body removed after 7 days from the aspiration event. Conclusion: This study showed that children that have had foreign body aspiration may have perfusion sequelae in their lungs even after removal of the foreign body. These sequelae were more frequent if the removal was delayed in 7 days of aspiration. Pediatricians must keep this in mind at the follow-up of children that have had foreign body aspiration.

Pleural Tuberculosis in Children

Pleural tuberculosis effusion (PTE) in children is a diagnosis which must be considered in isolated pleural effusions in non-toxemic children. It is more common in children over 5 years of age. A history of close contact with an adult with pulmonary tuberculosis reinforces the suspicion for its diagnosis. Pleural effusion without any parenchymal lesion is the characteristic finding on the chest x-ray. However, in 20% to 40% of patients, intrathoracic disease may also occur. Adenosine deaminase, interferon-gamma, analysis of pleural fluid and pleural biopsy are the main tools for diagnostic confirmation. Tuberculin skin test may provide supporting evidence of tuberculous infection. PTE has a good prognosis in children and no long term sequelae are expected.

Características clínicas e epidemiológicas do adulto contagiante da criança com tuberculose

BACKGROUND: Tuberculosis in children generally occurs as a direct result of cohabitation with a contagious adult. OBJECTIVE: To create a profile of a typical adult with contagious tuberculosis (as identified through the public health system) living with a child who has been diagnosed with tuberculosis. METHOD: Case study. Children younger than 14 years of age who were diagnosed with tuberculosis were included. Parents were interviewed using structured questionnaires. Means and standard deviations were analyzed using the Students t-test. Fishers exact test or the C² test was used for comparisons. RESULTS: Fifty children, representing 96% of those diagnosed with tuberculosis in the Porto Alegre health care system between July 20, 2001 and August 10, 2002, were included. The mean age was 76 months, and 60% were girls. The classic forms of pulmonary presentation (consolidation or cavitation) were seen in 38%. The majority of the children were diagnosed in the hospital and came from homes in which there were (a mean of) 6 cohabitants and a total family income less than 2 times the local minimum wage. Using ELISA, HIV co-infection was identified in 25% (although not all were tested). The children regularly visited places other than their homes. In 78% of cases, the contagious adult was identified. These contagious adults were mostly males (56%), and the mean age was 32. In most cases (79%), the contagious adult was a relative, usually a parent. Within this group of adults with contagious tuberculosis, HIV co-infection was identified in 43% of those tested. CONCLUSIONS: Adults with contagious tuberculosis living in the home continue to be the most likely source of tuberculosis infection in children. Co-infection with HIV in these pediatric patients, as well as in the cohabiting adults with contagious tuberculosis, is a significant finding. It must be emphasized that the possibility of contact with contagious individuals in the home should be explored in every diagnosed case of pediatric tuberculosis.

A workshop on asthma management programs and centers in Brazil: reviewing and explaining concepts

Objective: To report the results of a workshop regarding asthma management programs and centers (AMPCs) in Brazil, so that they can be used as a tool for the improvement and advancement of current and future AMPCs. Methods: The workshop consisted of five presentations and the corresponding group discussions. The working groups discussed the following themes: implementation of asthma management strategies; human resources needed for AMPCs; financial resources needed for AMPCs; and operational maintenance of AMPCs. Results: The workshop involved 39 participants, from all regions of the country, representing associations of asthma patients (n = 3), universities (n = 7), and AMPCs (n = 29). We found a direct relationship between a lack of planning and the failure of AMPCs. Based on the experiences reported during the workshop, the common assumptions about AMPCs in Brazil were the importance of raising awareness of managers; greater community participation; interdependence between primary care and specialized care; awareness of regionalization; and use of medications available in the public health system. Conclusions: Brazil already has a core of experience in the area of asthma management programs. The implementation of strategies for the management of chronic respiratory disease and their incorporation into health care system protocols would seem to be a natural progression. However, there is minimal experience in this area. Joint efforts by individuals with expertise in AMPCs could promote the implementation of asthma management strategies, thus speeding the creation of treatment networks, which might have a multiplier effect, precluding the need for isolated centers to start from zero.