Jürg Hammer

Effects of a multidisciplinary inpatient intervention on body composition, aerobic fitness, and quality of life in severely obese girls and boys

PURPOSE The last few decades have seen a major increase in the prevalence of juvenile obesity. Inpatient treatment programs are used mainly in children with severe obesity and related comorbidities. The aim of this study was to evaluate the gender differences of an 8-week multidisciplinary inpatient program on body weight, body composition, aerobic fitness, and quality of life of severely obese children and adolescents. METHODS Body weight was measured daily, and body composition, aerobic fitness, and quality of life were measured at the beginning and the end of an 8-week multidisciplinary inpatient program in 130 severely obese patients (52 girls, 78 boys), median (25th, 75th percentile) age of 13.8 (12.1, 15.0) years, median body weight of 89.4 kg (77.1, 100.1), and a body mass index of 33.4 (30.1, 36.6) kg/m(2), which is well above the 98th percentile. The inpatient program was based on a multidisciplinary treatment and education program that focused on daily physical activity, a 1200-1600 kcal/day balanced nutrition regimen, and a behavior modification therapy. RESULTS All results are expressed as medians (25th, 75th percentiles). At the end of the program all patients had lost a significant amount of body weight: 12.7 kg (10.8, 16.6), p < .001, girls 11.6 kg (9.7, 13.2), boys 13.7 kg (11.7, 17.3), p < .001, absolute body fat 8.0 kg (6.8, 10.0) p < 001, girls 7.0 kg (5.7, 8.1), boys 9.4 kg (7.6, 11.0) p < .001, % body fat per kg body weight: 4.9% (3.2, 6.6) p < .001, girls 3.7% (2.7, 4.9), boys 5.7% (4.0, 7.5) p < .001, and absolute fat free (or lean body) mass: 1.8 kg (0.64, 3.0) p < .001, girls 1.8 kg (0.87, 3.2), boys 1.7 kg (0.50, 2.9) p = .43. In addition, all measurements of aerobic fitness: VO(2)peak (mL/min.kg) and peak mechanical power (watts and watt/kg) and of quality of life increased significantly (p < .001, p < .001, p < .004 to p < .001). CONCLUSION A multidisciplinary inpatient treatment program including moderate calorie restriction, daily physical activity, and behavior modification induced a major weight loss, a decrease in body fat, and an increse in aerobic fitness as well as the quality fo life of severely obese children and adolescents. Weight loss and the decrease in body fat (absolute and percent) were significantly more pronounced in boys than girls.

Inhaled nitric oxide therapy in neonates and children: reaching a European consensus

Inhaled nitric oxide (iNO) was first used in neonatal practice in 1992 and has subsequently been used extensively in the management of neonates and children with cardiorespiratory failure. This paper assesses evidence for the use of iNO in this population as presented to a consensus meeting jointly organised by the European Society of Paediatric and Neonatal Intensive Care, the European Society of Paediatric Research and the European Society of Neonatology. Consensus Guidelines on the Use of iNO in Neonates and Children were produced following discussion of the evidence at the consensus meeting.

Albuterol responsiveness in infants with respiratory failure caused by respiratory syncytial virus infection

OBJECTIVE To assess the bronchodilator effect of inhaled albuterol in the acute stage of severe respiratory syncytial virus (RSV) infection. DESIGN Prospective, nonrandomized study of previously healthy infants who underwent intubation and whose lungs were ventilated because of respiratory failure caused by RSV infection. Ten infants with an endotracheal tube in place and without lung disease were matched for age and weight and served as normal control subjects. METHODS Lung function tests, including respiratory mechanics by single-breath occlusion, small airway function by forced deflation, and lung volumes by nitrogen washout, were performed before and after inhalation of 900 micrograms albuterol by metered dose inhaler. Bronchodilator response was defined as a change of more than twice the coefficient of variation of repeated baseline measurements. RESULTS Twenty-three infants (mean +/- SE age = 4.2 +/- 1.1 months) were studied, of whom 20 (87%) had obstructive small airway disease, and 3 (13%) had exclusively restrictive lung function profiles. Ten of the infants with obstructive disease (50%) did not benefit from albuterol, and 9 (45%) had small but significant improvements in lung function. Deterioration of lung function was documented in 1 patient after albuterol inhalation. CONCLUSION Inhaled albuterol is of limited value as a bronchodilator in infants with RSV-induced respiratory failure and should be discontinued if a beneficial response cannot be observed.

Decrease of functional residual capacity and ventilation homogeneity after neuromuscular blockade in anesthetized young infants and preschool children

Background: Based on age-dependent differences in pulmonary mechanics, the effect of neuromuscular blockade may differ in infants compared with older children. The aim of this study was to determine the impact of neuromuscular blockade and its reversal by positive end-expiratory pressure (PEEP) on functional residual capacity (FRC) and ventilation distribution in young infants and preschool children. Methods: The authors studied 14 infants (aged 0–6 months) and 25 preschool children (aged 2–6 yr). FRC and lung clearance index were calculated. Measurements were taken (1) after intubation, (2) during neuromuscular blockade, and (3) during neuromuscular blockade plus application of PEEP (3 cm H2O). Results: Functional residual capacity (mean ± SD) decreased from 21.3 ± 4.7 ml/kg to 12.2 ± 4.8 ml/kg (P < 0.001) during neuromuscular blockade in infants and from 25.6 ± 5.9 ml/kg to 23.0 ± 5.3 ml/kg (P < 0.001) in preschool children. With the application of PEEP, FRC increased to 22.3 ± 5.9 ml/kg (P = 0.4829, compared with baseline) in infants and 28.2 ± 5.8 ml/kg (P < 0.001) in children. The lung clearance index increased after neuromuscular blockade, whereas baseline values were regained after the application of PEEP. The changes induced by neuromuscular blockade were significantly greater in infants compared with preschool children (P < 0.001). Conclusions: Although the use of neuromuscular blockade decreased FRC and ventilation distribution substantially in both groups, the changes were more pronounced in young infants. With PEEP, FRC increased and ventilation homogeneity was restored. These results provide a rationale to use PEEP in anesthetized, paralyzed infants and children.

The impact of positive end-expiratory pressure on functional residual capacity and ventilation homogeneity impairment in anesthetized children exposed to high levels of inspired oxygen

BACKGROUND:High fractions of inspired oxygen (Fio2) result in resorption atelectasis shortly after their application. However, the impact of different levels of Fio2 and their interaction with positive end-expiratory pressure (PEEP) on functional residual capacity (FRC) and ventilation distribution is unknown in anesthetized children. We hypothesized that the use of a Fio2 of 1.0 results in a decrease of FRC and ventilation homogeneity compared with that of a Fio2 of 0.3, and that this decrease is prevented by PEEP of 6-cm H2O compared to a PEEP of 3-cm H2O. METHODS:Forty-six children (3–6 yr) without cardiopulmonary disease were randomly allocated to receive PEEP of 6-cm H2O (PEEP 6 group) during the entire study period or PEEP of 3-cm H2O (PEEP 3 group). The order of the Fio2 (0.3 or 1.0) was also randomized. A defined recruitment maneuver was performed after tracheal intubation and 5 min later the first measurement. This procedure was then repeated with the second Fio2 level. FRC and lung clearance index (LCI) were calculated by a blinded observer. RESULTS:While FRC (mean ± sd) was similar at both levels of Fio2 (0.3: 25.6 ± 2.9 mL/kg vs 1.0: 25.6 ± 2.8 mL/kg, P = 0.189) in the PEEP 6 group, FRC decreased in the PEEP 3 group (0.3: 24.9 ± 3.8 vs 1.0: 21.7 ± 4.1, P < 0.0001). Furthermore, with continuous PEEP of 6-cm H2O a similar LCI was observed at both levels of Fio2 (0.3: 6.45 ± 0.4 vs 6.43 ± 0.4, P = 0.668) while LCI increased at the higher Fio2 in the PEEP 3 group (0.3: 6.5 ± 0.5 vs 1.0: 7.7 ± 1.2, P < 0.0001). CONCLUSIONS:During the application of a very low PEEP of 3–cm H2O, FRC and ventilation distribution decreased significantly at an Fio2 of 1.0 compared with that at an Fio2 of 0.3. This decrease could be counterbalanced by the administration of PEEP of 6-cm H2O, indicating that a low level of PEEP is sufficient to maintain FRC and ventilation distribution regardless of the oxygen concentration.

Assessment of thoraco-abdominal asynchrony

Thoraco-abdominal asynchrony is often observed in many respiratory disorders and/or respiratory muscle dysfunctions and clinically assessed as a sign of respiratory distress and increased work of breathing. This review describes the assessment of thoraco-abdominal asynchrony by respiratory inductance plethysmography. Visual inspection of the Konno-Mead plot yields information about the relative contribution of the RC and the ABD to respiration and about respiratory muscle dysfunction in selected patients. The monitoring of thoraco-abdominal asynchrony is a useful, non-invasive indicator of respiratory muscle load or respiratory muscle dysfunction and can be used to determine response to therapy in individual patients. The technique is limited by the fact that it does not detect respiratory muscle fatigue and that the occurrence of TAA does not always correspond to a clinically relevant respiratory problem, especially in the neonatal period.

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.

Ultrastructural and molecular analysis in fatal neonatal interstitial pneumonia caused by a novel ABCA3 mutation

Pulmonary surfactant is essential to maintain alveolar patency, and invariably fatal neonatal lung disease has been recognized to involve mutations in the genes encoding surfactant protein-B or ATP-binding cassette transporter family member ABCA3. The lipid transporter ABCA3 targets surfactant phospholipids to lamellar bodies that are lysosomal-derived organelles of alveolar type II cells. ABCA3−/− mice have grossly reduced surfactant phosphatidyl glycerol levels and die of respiratory failure soon after birth. We studied lung biopsy samples of two siblings with a novel homozygous ABCA3 mutation at nucleotide position 578 (c.578C>G), leading to a Pro193Arg amino-acid exchange, who died at 55 and 105 days of age. Light microscopy revealed thickened alveolar septa with abundant myxoid interstitial matrix, marked hyperplasia of type II pneumocytes, desquamation of alveolar macrophages and focal alveolar proteinosis. Surfactant protein-B was detected by immunohistochemistry after antigen retrieval. Transmission electron microscopy showed rare cytoplasmic inclusions with concentric membranes and eccentrically placed electron-dense aggregates. These ‘fried-egg’-appearing lamellar bodies differed both from normal lamellar bodies and the larger, poorly formed composite bodies with multiple vesicular inclusions observed in surfactant protein-B deficiency. In conclusion, our findings underscore that the implications of interstitial lung disease in infant lungs differ from those in adults. In infants with a desquamative interstitial pneumonitis pattern, surfactant or ABCA3 mutations should be evaluated. Importantly, these findings support the notion that electron microscopy is useful in distinguishing between surfactant protein-B and ABCA3 deficiency, and has an important role in evaluating biopsies or autopsies of term infants with unexplained severe respiratory failure and interstitial lung disease.

A deeper level of ketamine anesthesia does not affect functional residual capacity and ventilation distribution in healthy preschool children

Background:  Ketamine is commonly used in children in the emergency setting and while undergoing diagnostic and therapeutic interventions because of its combination of hypnotic and analgesic properties. Although studies comparing various levels of ketamine anesthesia are lacking, previous work suggests that lung mechanics might only be minimally affected by ketamine.

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.