Maximilian S. Zach

EFFECT OF SWIMMING ON FORCED EXPIRATION AND SPUTUM CLEARANCE IN CYSTIC FIBROSIS

Ten children with cystic fibrosis participated in swimming training over 7 weeks. Ventilatory status, assessed by spirometry, had improved significantly after the course. 10 weeks after the end of the training most measurements had returned to their preswimming levels. In the majority of the children sputum production on swimming days was higher than on nonswimming days. Regular swimming can assist in mucus clearance and improve ventilatory function in children with cystic fibrosis.

Cystic fibrosis: physical exercise versus chest physiotherapy.

Twelve children with cystic fibrosis were admitted to a paediatric rehabilitation hospital for 17 days to take part in a training programme of vigorous physical exercise and sport. The daily inhalation-physiotherapy routine was stopped. Ventilatory status was assessed by spirometry and measurement of lung volumes one day before admission, one day after the end of the hospital stay, and 8 weeks later. Flow measurements of forced expiration had improved appreciably by the end of the course, but most of them returned to pretraining levels 8 weeks later. Lung volumes did not change significantly. Daily recordings of peak flow indicated improvement of airways function plus some ventilatory muscle training. Regular physical exercise could replace the inhalation-physiotherapy routine in some children with cystic fibrosis.

Adult outcome of congenital lower respiratory tract malformations

Congenital malformations of the lower respiratory tract are usually diagnosed and managed in the newborn period, in infancy, or in childhood. To what extent should the adult pulmonologist be experienced in this predominantly paediatric field? There are three ways in which an adult physician may be confronted with this spectrum of disorders. The most frequent type of encounter will be a former paediatric patient, now reaching adulthood, with the history of a surgically treated respiratory malformation; in some of these patients the early loss of lung tissue raises questions of residual damage and compensatory growth. Secondly, there is an increasing number of children in whom paediatric pulmonologists treat respiratory malformations expectantly; these patients eventually become adults with their malformation still in place. Thirdly, there is a small group of patients in whom the malformation goes unrecognised throughout childhood; in these a late complication or the coincidental discovery of a radiographic anomaly may demand a late diagnosis and management in adulthood. All three of these adult presentations will require some expertise on the part of the managing physician. The subsequent text reviews the most common “classical” congenital malformations of the lower respiratory tract from the above three perspectives. ### PAEDIATRIC PRESENTATION TOF usually occurs in association with oesophageal atresia; thus, the outcome is invariably fatal unless the anomaly is surgically repaired in the first days of life. The rare “H type” TOF without oesophageal atresia is an exception to this rule and may persist into later childhood or even adulthood before the diagnosis is established.1 The malformation is explained by the defective progression of a complex system of folds that separate the foregut into trachea and oesophagus.2 Approximately 50% of infants with TOF have associated anomalies, most often involving the urinary, gastrointestinal, and cardiac systems.3 4 The first successful repair of …

Self-administered chest physiotherapy in cystic fibrosis: A comparative study of high-pressure pep and autogenic drainage

Fourteen patients with cystic fibrosis were trained in 2 self-administered chest physiotherapy (PT) techniques: high-pressure PEP-mask physiotherapy (PEP), and autogenic drainage (AD). They then visited the clinic on 5 consecutive days, and, in a random order, performed 1 of the following: PEP, AD, PEP followed by AD (PEP-AD), AD followed by PEP (AD-PEP), and, no PT except for spontaneous coughing. Lung function was measured repeatedly before, during, and after PT; time needed for and sputum produced by each form of PT was recorded. PEP produced the highest amount of sputum, followed by PEP-AD, AD-PEP, and AD; all 4 forms of PT produced significantly more sputum than coughing. Lung function improved significantly after PEP, AD, and PEP-AD, but PEP-induced changes did not exceed those after AD. Within the investigated group, the PEP-induced lung function improvement per milliliter of sputum produced was significantly lower for those patients with airway hyperreactivity. The fact that the highest sputum yield with PEP was not reflected in higher PEP-effected lung function changes might thus be explained by PEP-induced bronchospasm in patients with airway hyperreactivity. PEP clears more sputum than AD or combined techniques; patients with airway hyperreactivity, however, should either prefer AD or should take a bronchodilator premedication before PEP.

Laser acupuncture in children and adolescents with exercise induced asthma

Background: Laser acupuncture, a painless technique, is a widely used alternative treatment method for childhood asthma, although its efficacy has not been proved in controlled clinical studies. Methods: A double blind, placebo controlled, crossover study was performed to investigate the possible protective effect of a single laser acupuncture treatment on cold dry air hyperventilation induced bronchoconstriction in 44 children and adolescents of mean age 11.9 years (range 7.5–16.7) with exercise induced asthma. Laser acupuncture was performed on real and placebo points in random order on two consecutive days. Lung function was measured before laser acupuncture, immediately after laser acupuncture (just before cold dry air challenge (CACh)), and 3 and 15 minutes after CACh. CACh consisted of a 4 minute isocapnic hyperventilation of –10°C absolute dry air. Results: Comparison of real acupuncture with placebo acupuncture showed no significant differences in the mean maximum CACh induced decrease in forced expiratory volume in 1 second (27.2 (18.2)% v 23.8 (16.2)%) and maximal expiratory flow at 25% remaining vital capacity (51.6 (20.8)% v 44.4 (22.3)%). Conclusions: A single laser acupuncture treatment offers no protection against exercise induced bronchoconstriction in paediatric and adolescent patients.

Sudden death in asthma.

Two girls with asthma died suddenly in autumn-winter 1985. On clinical criteria, both had been classified as moderately severe asthmatics, had shown a stabilised disease course, and had complied with antiasthmatic medication. By chance, lung function, bronchial reactivity, and subjective perception of lung function impairment had been assessed five and a half months and one month before death, respectively. For comparative purposes, we measured lung function and bronchial reactivity in a reference group of 37 children who had asthma of the same clinical severity and who were taking the same medication. In comparison with this reference group the index subjects showed a high degree of bronchial reactivity, incomplete recovery of function after bronchodilation, and appreciably reduced perception of severe lung function impairment. Regular assessment of lung function, bronchial reactivity, and perception of breathlessness might help to identify the patient who is prone to a fatal attack of asthma.

Chest physiotherapy: the mechanical approach to antiinfective therapy in cystic fibrosis

SummaryChest physiotherapy is a treatment program that attempts to compensate for impaired mucociliary clearance. By removing mucopurulent secretions, it reduces airway obstruction and its consequences, such as atelectasis and hyperinflation; furthermore, physiotherapy can decrease the rate of proteolytic tissue damage by removing infected secretions. Conventional physiotherapy (clapping, vibration and compression, together with postural drainage and assisted coughing) is the most efficient physiotherapy for sick infants and young children. Later, mechanical chest percussion can reduce the patients dependency on others. The forced expiration technique is another method of self-treatment, employing expiratory techniques to blow secretions out of the bronchi. Autogenic drainage, a special breathing technique, aims at avoiding airway compression by reducing positive expiratory transthoracic pressure. PEP-mask-physiotherapy achieves the same goal by expiring against an external airflow obstruction. Last but not least, physical exercise can clear the lungs of some CF patients and thus offers an attractive adjunct to physiotherapy.ZusammenfassungDie Thoraxphysiotherapie versucht die Auswirkungen der gestörten mukoziliären Reinigung zu reduzieren. Durch die Entfernung mukopurulenter Sekretmassen werden einerseits die mechanischen Folgen der Sekretobstruktion (Atelektase, Überblähung) hintangehalten, andererseits die proteolytische Bronchialwanddestruktion verzögert. Die „konventionelle“ Thoraxphysiotherapie (Thoraxperkussion, -vibration, -kompression mit Drainagelagerung und assistiertem Husten) ist noch immer die wirksamste Behandlungsmethode im Säuglings- und Kleinkindesalter. Später kann dann die maschinelle Thoraxperkussion zur Selbstbehandlung überleiten und dem Patienten größere Unabhängigkeit ermöglichen. Die forcierte Exspirationstechnik ist eine weitere Selbstbehandlungsmethode, die mit besonderen Exspirationsmanövern das Sekret aus den Bronchien „bläst“. Die Autogene Drainage, eine spezielle Atemtechnik, versucht diesen Effekt bei gleichzeitiger Vermeidung eines exspiratorischen Bronchialkollaps zu erreichen. Die PEP-Masken-Physiotherapie entleert die Lunge bei Luftwegsdehnung durch Expiration gegen eine externe Stenose. Nicht zuletzt kann Sport die Lungen mancher Patienten gut säubern und wird damit zu einer wertvollen Ergänzung der Thoraxphysiotherapie.

Atopy, lung function and bronchial responsiveness in symptom-free paediatric asthma patients

In adolescence, some paediatric asthma patients will become symptom-free and require no further treatment. There is little information on the atopic status, lung function and bronchial responsiveness of these patients. Symptom-free asthma patients (n=118) aged 7.7-19.2 yrs, were evaluated 1 year after termination of therapy. Bronchial asthma had previously been diagnosed on the basis of recurrent wheezing episodes. Atopic status was assessed by skin-prick testing. Baseline lung function was measured by spirometry, flow-volume curve and plethysmography. Bronchial responsiveness was assessed nonpharmacologically by cold dry air challenge. Eighty one patients had at least one positive skin test result, and the remaining 37 were defined as nonatopic. In atopic subjects, the prevalence of bronchial hyperresponsiveness was significantly higher than in nonatopic patients (41 out of 81 versus 7 out of 37; p=0.001). Atopic subjects showed a significantly lower maximal expiratory flow at 25% remaining vital capacity (p<0.05) and a higher residual volume (p<0.05) than nonatopic subjects. Nonatopic subjects were significantly younger than atopic patients (p<0.01). These symptom- and medication-free paediatric and adolescent asthma patients could, thus, be divided into two groups: 1) atopic subjects with a tendency towards bronchial hyperresponsiveness; and 2) nonatopic subjects with better lung function and normal bronchial responsiveness In view of the increased understanding of the epidemiology of early childhood wheezing, these findings support the concept of different pathogenic mechanisms underlying wheezing episodes in early childhood.

Clinical and histopathological findings in two Turkish children with follicular bronchiolitis

Abstract We report on two Turkish children who presented with progressive airway obstruction. Open lung biopsy revealed follicular bronchiolitis. The children were treated with systemic steroids and various topical medications. Whereas the respiratory situation of patient 1 required immunosuppressive therapy, the condition of patient 2 stabilised without systemic medication. Conclusion Diagnosis of follicular bronchiolitis should be considered when children present with recurrent respiratory tract infections, progressive dyspnoea, and chronic bronchial obstruction. Children in whom follicular bronchiolitis is suspected should undergo open lung biopsy for confirmation of diagnosis.

Reproducibility of forced expiratory flow and volume measurements in infants with bronchiolitis.

The end‐tidal rapid thoracoabdominal compression (ETRTC) technique is an established method for lung function testing in infancy. Previous work in healthy infants, however, has shown that measurements with the newly developed raised volume rapid thoracoabdominal compression (RVRTC) technique are more reproducible than those with the ETRTC technique. So far, reproducibility of the two techniques has not been compared in infants with acute airway disease. Twenty‐three infants with acute viral bronchiolitis underwent lung function assessment with both the ETRTC and the RVRTC technique. A series of 8–10 measurements with each technique was done in randomized order. Forced expired volumes at 0.5, 0.75, and 1 sec after chest compression (FEV0.5, FEV0.75, and FEV1.0) were measured with the RVRTC technique; maximum expiratory flow at functional residual capacity (V′maxFRC) was measured with the ETRTC technique. Group mean intrasubject coefficients of variation (CV) were 4.84% for FEV0.5, 5.01% for FEV0.75, 5.43% for FEV1.0, and 13.79% for V′maxFRC, respectively.