Lea Bentur

Effectiveness and safety of inhaled corticosteroids in controlling acute asthma attacks in children who were treated in the emergency department: A controlled comparative study with oral prednisolone

BACKGROUNDnInhaled corticosteroids have a greater antiinflammatory potency and fewer systemic effects than intravenous, intramuscular, or oral corticosteroids. However, their role in acute asthma has not been established. We prospectively investigated the efficacy and safety of inhaled corticosteroids in controlling moderately severe acute asthma attacks in children who were treated in the emergency department.nnnMETHODSnChildren who were treated in the emergency department with moderately severe asthma attacks after receiving treatment with inhaled terbutaline were allocated by double-blind design to receive 1 dose of either 1600 micro(g) budesonide turbohaler or 2 mg/kg prednisolone. The pulmonary index score and peak expiratory flow rate were measured hourly for the first 4 hours. After discharge the children were treated with the same initial doses given 4 times daily, followed by a 25% reduction in dose every second day for 1 week. Parents recorded asthma symptoms and use of beta-2 agonists on a daily diary card. Serum cortisol concentration was measured at the end of weeks 1 and 3.nnnRESULTSnTwenty-two children (11 in each group) with similar baseline parameters completed the study. There was a similar improvement in pulmonary index score and peak expiratory flow rate in the 2 groups. Children treated with budesonide showed an earlier clinical response than those given prednisolone, who also showed a decrease in serum cortisol concentration.nnnCONCLUSIONnIn children with moderately severe asthma attacks who were treated in the emergency department, a short-term dose schedule of inhaled budesonide turbohaler, starting with a high dose and followed by a decrease over 1 week, is at least as effective as oral prednisolone, without suppressing serum cortisol concentration.

The acute effects of water-pipe smoking on the cardiorespiratory system.

OBJECTIVEnThere are limited data on the acute effects of water-pipe tobacco smoking, commonly known as water-pipe smoking (WPS), on cardiopulmonary parameters. This study evaluated the acute effects of a single 30-min session of WPS on carboxyhemoglobin (COHb) levels, pulmonary function test results, vital signs, fractional exhaled nitric oxide (Feno) levels, and exhaled breath condensate (EBC) cytokine levels in volunteers in a domestic, open-air, group smoking setting.nnnMETHODSnThis prospective study evaluated the above-noted outcome parameters before and after 30 min of WPS. The primary outcome parameter was the change in COHb levels.nnnRESULTSnForty-five volunteers (30 men, 15 women), aged 32.35 ± 15.33 years, were recruited. After one session of WPS, the COHb levels rose significantly, from 1.47% ± 0.57% (median 1.4) to 9.47% ± 5.52% (median 7.4), P < .001. Systolic and diastolic BP levels significantly increased after smoking (systolic, 119.52 ± 12.07 mm Hg vs 131.98 ± 17.8 mm Hg; diastolic, 74.84 ± 7.89 mm Hg vs 82.98 ± 12.52 mm Hg, respectively; P < .001). Heart rates increased from 80.39 ± 9.92 beats/min to 95.59 ± 17.41 beats/min, P < .001; and respiratory rates increased from 14.36 ± 1.63 breaths/min to 16.68 ± 2.24 breaths/min, P < .001. There were decreases in forced expiratory flow between 25% and 75% of FVC, peak expiratory flow rate, Feno levels, percentage of eosinophils in peripheral blood, and 8-isoprostane levels in EBC.nnnCONCLUSIONSnThis study shows that one session of WPS causes acute biologic changes that might result in marked health problems. It adds to the limited evidence that WPS is harmful and supports interventions to control the continuing global spread of WPS, especially among youth.nnnTRIAL REGISTRYnClinicalTrials.gov; No.: NCT01157832; URL: www.clinicaltrials.gov.

Wheeze monitoring in children for assessment of nocturnal asthma and response to therapy.

The utilisation of nocturnal wheeze monitoring and quantification for assessment of asthma activity was studied in symptomatic school-aged children before and during treatment. Twelve children 6–14u2005yrs of age with mild or moderate untreated asthma were studied at home three times: before, 48u2005h and 6 weeks into treatment with 5u2005mg montelukast daily. Lung sounds were recorded overnight by an automatic wheeze detection device (PulmoTrack®). Per cent wheezing within each respiratory cycle was calculated every 30u2005s throughout the night and a Nocturnal Wheeze Index (NWI) was calculated for the total night. The results were compared with spirometric indices (forced expiratory volume in one second (FEV1), forced vital capacity), bronchial reactivity (provocative concentration causing a 20% fall in FEV1 by adenosine 5′-monophosphate (PC20)) and daily symptom scores, performed in parallel at each stage of the study. The pretreatment NWI was 814±898 (mean±sd), which declined to 318±199 2 days after onset, and to 137±101 after 6 weeks of treatment. The NWI in seven healthy children was 47±43. The FEV1, PC20 and symptom scores improved in parallel. Wheeze monitoring provides quantitative and noninvasive information about the extent of nocturnal wheezing in children, correlates well with conventional indices of asthma activity and can assist in assessing efficacy of treatment.

Dexamethasone inhalations in RSV bronchiolitis: A double‐blind, placebo‐controlled study

OBJECTIVEnTo evaluate the effect of inhaled dexamethasone on hospitalization for respiratory syncytial virus (RSV) bronchiolitis.nnnSTUDY DESIGNnA double-blind, placebo-controlled study compared nebulization of dexamethasone versus nebulization of 0.9% saline. Both groups were treated with epinephrine nebulizations. Follow-up continued for 3 mo.nnnPATIENTS AND METHODSnSixty-one infants with bronchiolitis aged 3 to 12 mo were included. They were randomly allocated to nebulizations with 0.25 mg dexamethasone every 6 h (group 1) or an equivalent amount of normal saline (group 2).nnnRESULTSnNo statistically significant differences with respect to clinical score, oxygen saturation, or IV fluid requirement between the groups were noted. Using Kaplan-Meyers method, the cumulative proportion of in-hospital stay was significantly lower in group 1 compared with group 2, mainly in days 5 and 6 post-hospitalization (p<0.038). A subgroup of prematurely born children in group 1 had a shorter hospitalization period (6.5+/-1.7 d) compared with group 2 children (9.1+/-1.9) (p<0.018). Follow-up revealed similar wheeze and hospitalization rates in the two groups.nnnCONCLUSIONnInhaled dexamethasone may reduce the length of hospitalization among infants with acute viral bronchiolitis, especially among those born prematurely.

Laboratory and Clinical Acute Effects of Active and Passive Indoor Group Water-Pipe (Narghile) Smoking

BACKGROUNDnIndoor group water-pipe tobacco smoking, commonly referred to as water-pipe smoking (WPS), especially in coffee shops, has gained worldwide popularity. We performed a comprehensive laboratory and clinical evaluation of the acute effects of active and passive indoor group WPS.nnnMETHODSnThis comparative study evaluated pre- and post-30-min active and passive indoor group WPS. The outcome parameters were carboxyhemoglobin (COHb), nicotine, and cotinine levels; CBC count; and cardiorespiratory parameters. Exhaled breath condensate (EBC) cytokines and endothelial function (using the EndoPat device [Itamar Medical Ltd]) were measured only in active smokers. Statistical methods used were Student t test, Wilcoxon signed rank test, Fisher exact test, analysis of variance, and Newman-Keuls post hoc test where relevant.nnnRESULTSnSixty-two volunteers aged 24.9±6.2 years were included; 47 were active smokers, and 15 were passive smokers. COHb level increased postactive WPS (active smokers, 2.0%±2.9% vs 17.6%±8.8%; P<.00001); six subjects (12.7%) had a >25% increase, and two subjects (4.2%) had a >40% increase. Plasma nicotine level increased postactive WPS (active smokers, 1.2±4.3 ng/mL vs 18.8±13.9 ng/mL; P<.0001); plasma cotinine and urinary nicotine and cotinine levels also increased significantly. EBC IL-4, IL-5, IL-10, IL-17, and γ-interferon decreased significantly with postactive smoking; endothelial function did not change. WPS was associated with adverse cardiorespiratory changes. In passive smokers, COHb level increased (0.8%±0.25% vs 1.2%±0.8%, respectively, P=.003) as did respiratory rate.nnnCONCLUSIONSnOne session of active indoor group WPS resulted in significant increases in COHb and serum nicotine levels (eightfold and 18-fold, respectively) and was associated with adverse cardiorespiratory health effects. The minor effects found in passive smokers suggest that they too may be affected adversely by exposure to WPS. The results call for action to limit the continuing global spread of WPS in coffee shops.nnnTRIAL REGISTRYnClinicalTrials.gov; No.: NCT1237548; URL: www.clinicaltrials.gov.

SEVERE PULMONARY DISEASE IN ASSOCIATION WITH CROHN’S DISEASE IN A 13-YEAR-OLD GIRL

Pulmonary manifestations of Crohns disease are infrequent in adults and even less common in children. Our literature search found only a few cases of Crohns disease causing pulmonary manifestations in children. We report on the case of a 13‐year‐old girl in whom severe pulmonary disease was found four years after the onset of Crohns disease. Open lung biopsy uncovered bronchiolitis obliterans and granulomatous lung disease. Aggressive treatment has yielded gradual improvement. This case emphasizes the importance of recognizing the association, the differential diagnosis, and treatment implications. Pediatr Pulmonol. 2000; 29:151–154.

Nitric Oxide Inhalation for Paraquat-Induced Lung Injury

BACKGROUNDnWhen ingested, concentrated paraquat can cause either rapid death from multisystem failure and cardiovascular shock or delayed death from progressive pulmonary fibrosis. Diquat ingestion does not usually cause pulmonary fibrosis, but produces early onset acute renal failure.nnnCASE REPORTnA 52-year-old male ingested approximately 50 mL of a solution containing 13% paraquat and 7% diquat (about 6650 mg of paraquat and 3500 mg of diquat), and subsequently developed adult respiratory distress syndrome and pulmonary fibrosis. Survival prediction employing the criteria of Hart et al. for paraquat plasma levels was 30%. From the probable amount of paraquat ingested, severe toxicity was expected. The clinical course was not consistent with significant diquat toxicity. Treatment included oral Fullers earth, forced diuresis, hemofiltration, N-acetylcysteine, methylprednisolone, cyclophosphamide, vitamin E, colchicine, and delayed continuous nitric oxide inhalation. The patient recovered and pulmonary function was subsequently normal.nnnCONCLUSIONnIt is unclear which, if any, of the above treatments contributed to recovery, but the encouraging outcome suggests a possible benefit of nitric oxide inhalation in paraquat poisoning which deserves further study.

The effect of vitamin D on airway reactivity and inflammation in asthmatic children: A double-blind placebo-controlled trial.

Cross‐sectional studies have reported an association of vitamin D deficiency with increased asthma prevalence and severity, and with allergies. The effect of vitamin D as sole therapy on airway hyper‐reactivity (AHR) and airway inflammation has not been reported.

Evaluation of the intestinal current measurement method as a diagnostic test for cystic fibrosis

The sweat test and nasal potential difference measurement are now established tools in the diagnostic work up of cystic fibrosis (CF). Intestinal current measurement (ICM) is under consideration as an aid in the diagnosis of CF especially in young children. The aim of this study is to evaluate the diagnostic reliability of ICM.

CT diagnosis of traumatic bronchial rupture in children.

Abstract. Bronchial rupture is a rare and serious complication of blunt chest trauma in children. The diagnosis of this injury is challenging and requires a high degree of clinical suspicion. It is frequently associated with other severe injuries that may draw the focus of attention away from this potentially catastrophic but treatable injury. The radiographic findings of bronchial rupture have been reported in very few series. We report the findings in two children with bronchial rupture diagnosed by CT, in whom CT resulted in a significant change in patient management.