M.R. Benoist

Value of bronchoalveolar lavage in the management of severe acute pneumonia and interstitial pneumonitis in the immunocompromised child.

The diagnostic value of 73 bronchoalveolar lavages was assessed in 67 immunocompromised children (aged 3 months to 16 years) with pulmonary infiltrates. Thirty one children had primary and 19 secondary immune deficiency, 14 acquired immunodeficiency syndrome (AIDS), and three AIDS related complex. Bronchoalveolar lavage was performed during fibreoptic bronchoscopy, under local anaesthesia in all but two. One or more infective agents was found in eight of 11 patients with severe acute pneumonia and in 26 of 62 patients with interstitial pneumonitis. In interstitial pneumonitis, the most frequently encountered agents were Pneumocystis carinii (12), cytomegalovirus (8), and Aspergillus fumigatus (3). The yield was related to the severity of interstitial pneumonitis. The mean cellular count and cytological profile in lavage returns from patients with varying infective agents or underlying pathological conditions showed no significant difference, except in those children with AIDS and AIDS related complex who had appreciable lymphocytosis (mean percentage of lymphocytes 28 (SD 17]. In children with AIDS and chronic interstitial pneumonitis lymphocytosis without pneumocystis infection was observed in eight of nine bronchoalveolar lavage returns and was suggestive of pulmonary lymphoid hyperplasia. Finally, bronchoalveolar lavage produced a specific diagnosis from the microbiological or cytological findings in 44 instances (60%). Transient exacerbation of tachypnoea was observed in the most severely ill children but there was no case of respiratory decompensation attributable to the bronchoscopy. Bronchoalveolar lavage is a safe and rapid examination for the investigation of pulmonary infiltrates in immunocompromised children. It should be performed as a first line investigation and should reduce the use of open lung biopsy techniques.

Chest computed tomography findings in bronchopulmonary dysplasia and correlation with lung function

Objective: With changes in the predominant pathogenic factors in the new form of bronchopulmonary dysplasia (BPD), a different pattern of CT findings may be expected. This study aimed to (1) describe CT findings in infants with BPD and (2) correlate the CT findings with lung function abnormalities. Study design and method: Retrospective review of 41 very low birthweight infants with BPD, who were referred for pulmonary investigations at between 10 and 20 months after birth because of persistent respiratory symptoms, and underwent CT and lung function tests. Results: None of the infants had normal CT findings. The most frequent abnormalities were hyperlucent areas (n = 36; 88%), linear opacities (n = 39; 95%), and triangular subpleural opacities (n = 26; 63%). Bronchiectasis was not seen. None of the CT abnormalities correlated with the maximum expiratory flow at functional residual capacity (VmaxFRC). In contrast, increased number of subpleural opacities and limited linear opacities were associated with low FRC and longer duration of neonatal oxygen exposure. The numbers of triangular subpleural opacities also correlated with duration of mechanical ventilation. Conclusions: Despite advances in neonatal care, many CT findings in infants with BPD are similar to those observed in the pre-surfactant era, and are still associated with duration of supplemental oxygen and mechanical ventilation. The absence of bronchial involvement in the present study was the most striking difference from previous studies.

Relationship between Bronchial Hyperresponsiveness and Impaired Lung Function after Infantile Asthma

Wheezing during infancy has been linked to early loss of pulmonary function. We prospectively investigated the relation between bronchial hyperresponsiveness (BHR) and progressive impairment of pulmonary function in a cohort of asthmatic infants followed until age 9 years. We studied 129 infants who had had at least three episodes of wheezing. Physical examinations, baseline lung function tests and methacholine challenge tests were scheduled at ages 16 months and 5, 7 and 9 years. Eighty-three children completed follow-up. Twenty-four (29%) infants had wheezing that persisted at 9 years of age. Clinical outcome at age 9 years was significantly predicted by symptoms at 5 years of age and by parental atopy. Specific airway resistance (sRaw) was altered in persistent wheezers as early as 5 years of age, and did not change thereafter. Ninety-five per cent of the children still responded to methacholine at the end of follow-up. The degree of BHR at 9 years was significantly related to current clinical status, baseline lung function, and parental atopy. BHR at 16 months and 5 years of age did not predict persistent wheezing between 5 and 9 years of age, or the final degree of BHR, but it did predict altered lung function. Wheezing that persists from infancy to 9 years of age is associated with BHR and to impaired lung function. BHR itself is predictive of impaired lung function in children, strongly pointing to early airway remodeling in infantile asthma.

Repeatability of lung function tests during methacholine challenge in wheezy infants

BACKGROUND The repeatability of lung function tests and methacholine inhalation tests was evaluated in recurrently wheezy infants over a one month period using the rapid thoracic compression technique. METHODS Eighty one wheezy, symptom free infants had pairs of methacholine challenge tests performed one month apart. Maximal flow at functional residual capacity (V˙maxfrc) and transcutaneous oxygen tension (Ptco 2) were measured at baseline and after methacholine inhalation. Provocative doses of methacholine causing a 15% fall in Ptco 2(PD15Ptco 2) or a 30% fall inV˙maxfrc (PD30V˙maxfrc) were determined. RESULTS Large changes in V˙maxfrcwere measured from T1 to T2 with a mean difference between measurements (T2—T1) of 7 (113) ml/s and a 95% range for a single determination forV˙maxfrc of 160 ml/s. The mean (SD) difference between pairs of PD30V˙maxfrc measurements was 0.33 (1.89) doubling doses with a 95% range for a single determination of 2.7 doubling doses. Repeatability of PD15Ptco 2 was similar. A change of 3.7 doubling doses of methacholine measured on successive occasions represents a significant change. CONCLUSIONS Baseline V˙maxfrcvalues are highly variable in wheezy, symptom free infants. Using either V˙maxfrc or Ptco 2 as the outcome measure for methacholine challenges provided similar repeatability. A change of more than 3.7 doubling doses of methacholine is required for clinical significance.

A study on the reproducibility of specific bronchial provocation testing in children

Bronchial provocation tests with housedust were carried out on thirty‐five asthmatic children aged 4‐13. Each patient was tested twice. Subjects were studied with two different doses of allergen: 1200 and 3600/μg.

Nebuhaler in young asthmatic children.

We thank Dr Bell and her colleagues for their comments. We were unaware of their paper when we submitted ours. There may well be differences in plasma amino acids depending on the type of preterm formula used, just as there will be differences if one formula is fed at different volumes. The purpose of our paper was not to compare formulasonly two infants were fed on formulas other than SMA Low Birthweight-but to examine the effects of a relatively high protein intake (in comparison with, for example, banked breast milk) in verv low birthweight infants. The infants in our study were appreciably smaller than those studied by Bell and her colleagues. but even so no potentially hazardous amino acid concentrations were detected.

Nebulized salbutamol in the treatment of severe asthmatic attacks in children

Summary Fifteen children who were admitted to hospital with a severe asthmatic attack, refractory to oral bronchodilators, were treated initially with an oxygen-propelled nebulized 0,5 % solution of salbutamol. Significant clinical improvement occurred rapidly in fourteen of these children. There was a significant decrease in their specific airway resistance (SRaw) 1 min after the end of the nebulization and this decrease was still present 1 hour later. Significant improvement of forced expiratory volume (FEV1), forced vital capacity (FVC) and peak expiratory flow rate (PEFR) paralleled the decrease in SRaw. Increased heart rate occured but was not perceived by the children. Transcutaneous arterial O2 tension (TcPaO2) was increased in thirteen children and unchanged in two of them 10 min after the nebulization. These results demonstrate that nebulized salbutamol is safe and highly effective in the treatment of severe asthmatic attacks in children.

Relationship between gastro esophageal reflux and airway response to acid infusion test in asthmatic children

Summary Gastro esophageal reflux (GER) was investigated in 15 children with asthma by esophageal pH monitoring and manometry. Bronchial response to Acid Infusion Test (AIT) was also evaluated by comparing specific baseline airway resistance (sRAW) and carbachol bronchial responsiveness before and after AIT. The response of the children in this study to AIT was considerably less than that reported in adults. AIT did not change baseline sRAW or bronchial sensitivity to carbachol (p = NS), but did significantly increase the bronchial reactivity (p