Mutasim Abu-Hasan

Pseudo-asthma: When Cough, Wheezing, and Dyspnea Are Not Asthma

Although asthma is the most common cause of cough, wheeze, and dyspnea in children and adults, asthma is often attributed inappropriately to symptoms from other causes. Cough that is misdiagnosed as asthma can occur with pertussis, cystic fibrosis, primary ciliary dyskinesia, airway abnormalities such as tracheomalacia and bronchomalacia, chronic purulent or suppurative bronchitis in young children, and habit-cough syndrome. The respiratory sounds that occur with the upper airway obstruction caused by the various manifestations of the vocal cord dysfunction syndrome or the less common exercise-induced laryngomalacia are often mischaracterized as wheezing and attributed to asthma. The perception of dyspnea is a prominent symptom of hyperventilation attacks. This can occur in those with or without asthma, and patients with asthma may not readily distinguish the perceived dyspnea of a hyperventilation attack from the acute airway obstruction of asthma. Dyspnea on exertion, in the absence of other symptoms of asthma or an unequivocal response to albuterol, is most likely a result of other causes. Most common is the dyspnea associated with normal exercise limitation, but causes of dyspnea on exertion can include other physiologic abnormalities including exercise-induced vocal cord dysfunction, exercise-induced laryngomalacia, exercise-induced hyperventilation, and exercise-induced supraventricular tachycardia. A careful history, attention to the nature of the respiratory sounds that are present, spirometry, exercise testing, and blood-gas measurement provide useful data to sort out the various causes and avoid inappropriate treatment of these pseudo-asthma clinical manifestations.

An examination of comorbid asthma and obesity: assessing differences in physical activity, sleep duration, health-related quality of life and parental distress

Abstract Objective: Compare youth with comorbid asthma and obesity to youth with obesity only to determine if differences exist in body mass index, dietary intake, levels of physical activity, sleep duration and health-related quality of life. Levels of parent distress were also compared. Methods: Participants included 248 children (nu2009=u2009175 in Obesity group; nu2009=u200973 in Asthmau2009+u2009Obesity group) with a BMIu2009≥u200985th percentile for age and gender, and their participating parent(s) or legal guardian(s). Measures of child height and weight were obtained by study personnel and Z-scores for child body mass index were calculated using age- and gender-specific norms. Child physical activity and sleep duration were measured via accelerometers. Dietary intake, health-related quality of life and parent distress were assessed via self-report. Results: The Asthmau2009+u2009Obesity group evidenced significantly higher body mass index scores, and had lower sleep duration. There was a non-statistically significant trend for lower levels of physical activity among children in the Asthmau2009+u2009Obesity group. Dietary intake, health-related quality of life and parent distress did not differ between groups. Conclusions: Youth with comorbid asthma and obesity are at increased risk for negative health and psychosocial difficulties compared to youth who are overweight or obese only. Professionals providing treatment for youth with asthma are encouraged to assess the implications of weight status on health behaviors and family psychosocial adjustment.

Omalizumab therapy for asthma patients with poor adherence to inhaled corticosteroid therapy

BACKGROUNDnOmalizumab, an anti-IgE monoclonal antibody, is administered by injection once or twice monthly in offices and clinics. It offers a potential alternative intervention for patients with allergic asthma that is not well controlled because of recalcitrant poor adherence to inhaled corticosteroid therapy.nnnOBJECTIVEnTo assess the effect of omalizumab therapy by measuring airway responsiveness to adenosine, a marker of allergic airway inflammation, and resource use.nnnMETHODSnPatients (N = 17) aged 6 to 26 years (mean age, 16.4 years) with poorly controlled persistent allergic asthma, less than 50% adherence to inhaled corticosteroid therapy, a forced expiratory volume in 1 second (FEV1) of 60% predicted or higher, and adenosine provocation concentration that caused a decrease in FEV1 of 20% (PC20) of 60 mg/mL or less were randomized to receive 4 months of omalizumab or placebo in a double-blind, crossover trial with a 3- to 4-month washout between treatments. Patients were instructed to continue taking inhaled corticosteroids throughout the study. The PC20 was measured before and after each period.nnnRESULTSnFifteen patients completed the study. The mean baseline PC20 was 14.1 mg/mL (95% CI, 10.8-18.4 mg/mL). The fold change PC20 was 0.9 (95% CI, 0.5-1.7) during placebo and 3.1 (95% CI, 1.6-6.2) during omalizumab treatment; the estimated ratio was 3.4 (95% CI, 1.2-9.3; P = .02). Six patients required one or more short courses of oral corticosteroids for asthma exacerbations during placebo, but none required this intervention during omalizumab. During the study, the median prescription refills for inhaled corticosteroids was 0.15 (95% CI, 0.00-0.33) canisters per month.nnnCONCLUSIONnOmalizumab therapy is an alternative for patients with more severe poorly controlled asthma in whom adherence does not improve with conventional interventions.nnnTRIAL REGISTRATIONnclinicaltrials.gov Identifier: NCT00133042.

Successful use of bronchoscopic lung insufflation to treat left lung atelectasis

We report first use of bronchoscopic lung insufflation in a child to treat acute left lung collapse. The patient is a 6‐year old male asthmatic who was hospitalized with a 2‐day history of cough, chest pain, and abdominal pain. He was tachypneic and hypoxemic on room air. Chest exam revealed diminished breath sounds on the left side. Chest X‐ray and Chest CT showed complete left lung collapse. He underwent bronchoscopic lung insufflation procedure by injecting total of 200u2009ml air via flexible bronchoscope in the left upper lobe using 50cc syringe aliquots followed by similar injection of 200u2009ml of air in left lower lobe. After air insufflations, 6u2009ml of bovine surfactant (calfactant) were instilled in each lobe. Chest fluoroscopy was done immediately after procedure and showed expansion of entire left lung with no pneumothorax. The procedure was well tolerated. The patients symptoms and hypoxemia resolved soon after procedure. However, left lower lobe atelectasis recurred next day and persisted for 6 days despite treatments with chest physical therapy, systemic steroids, oral azithromycin, nebulized dornase alpha, and endoscopic removal of secretions from left lower lobe. Bronchoscopic insufflation of left lower lobe was repeated resulting in immediate expansion of that lobe as demonstrated by intraoperative fluoroscopy. The patient was discharged home next day. This case suggests that brochoscopic lung insufflation can be safe and effective in treating acute lung collapse and in treating atelectasis which is refractory to conventional therapy. Pediatr Pulmonol. 2013; 48:306–309.

Exercise in Children during Health and Sickness.

Because of the rapidly increasing prevalence of obesity among children worldwide and the realization that this global epidemic is closely related to changing life style, especially relating to diet and exercise, research in the effects of exercise on childrens health and the effects of childrens health on their ability to exercise becomes timely and imperative. Promoting scientific researching in the field of exercise medicine in children has therefore been the primary motive behind this special issue of the International Journal of Pediatrics which is dedicated to publishing important works in the field. n nTo the great satisfaction of our team of editors, a great number of good quality research results were submitted to the issue from all four corners of the world which indicates a strong interest in this very important field of medicine worldwide. n nThe first section of this issue contains cross-sectional population studies that provide evidence confirming the strong correlation between obesity and lack of activity in children of different populations and different age groups (the first, second, and third papers). Furthermore, a 12-month interventional study from Sweden showed that longer exercise periods performed by school age boys resulted in more muscle mass and increased muscle strength (the fourth paper). n nThe second section of the issue contains several articles studying the different genetic, environmental, parental, and other psychosocial factors that can potentially affect childrens level of exercise activity. These articles collectively provide evidence for the variety and complexity of factors that affect childrens predilection or exercise (the fifth, sixth, seventh, and eighth papers). They also identify potential areas for future intervention to promote exercise early in life (the ninth paper). One example of such opportunities involves the use of video gaming. Even though the overuse of video gaming has been largely blamed for the decreasing level of physical activity in children, the case might be completely reversed with the recent advent of interactive video gaming which tends to be preferred by children over conventional video gaming and is associated with higher level of physical activity (the tenth paper). n nThe third section deals with research relating to exercise in children with known chronic illness such as diabetes, cystic fibrosis, neuromuscular diseases, arthritis, and congenital heart diseases with emphasis not only concerning the limitations these illnesses impose on childrens ability to exercise and become physically fit but also on how increased fitness in these patients can modulate their disease process and therefore on ways exercise can be performed and promoted (the eleventh, twelfth, thirteenth, fourteenth, fifteenth, and sixteenth papers). n nThe fourth section discusses hemodynamic responses to exercise in children as compared to adults (the seventeenth paper) and explores the hormonal and inflammatory profile of overweight and normal weight children and relates them to cardiovascular fitness (the eighteenth paper). n nThe fifth and final section has one article which evaluates the validity of different accelerometeric measurements used in exercise research to objectively grade level of physical activity as compared to the gold standard of directly measuring energy expenditure (the nineteenth paper). n nWe hope that this special issue will contribute substantially to the existing body of knowledge of this new and growing field of exercise medicine in children and to stimulate further needed research. n n nMutasim Abu-Hasan n nNeil Armstrong n nLars B. Andersen n nMiles Weinberger n nPatricia A. Nixon

Benzalkonium chloride; a bronchoconstricting preservative in continuous albuterol nebulizer solutions

For convenience, many pediatric hospitals are preparing solutions for continuous nebulized albuterol using the 0.5% 20‐ml multidose albuterol dropper bottle. This product contains benzalkonium chloride (BAC) that, by itself, produces bronchospasm that is dose dependent and cumulative. The bronchoconstrictive effects of BAC are greater in patients with more severe airway obstruction and increased airway responsiveness. Use of BAC‐containing albuterol during severe acute asthma exacerbations may antagonize the bronchodilator response to albuterol, prolong treatment, and increase the risk of albuterol‐related systemic adverse effects. Such a deleterious effect of BAC is difficult to detect because some patients improve slowly or may even worsen during treatment. We recommend that only preservative‐free albuterol products be used.

Applying Interactive Mobile health to Asthma Care in Teens (AIM2ACT): Development and design of a randomized controlled trial

Early adolescents have difficulties performing asthma self-management behaviors, placing them at-risk for poor asthma control and reduced quality of life. This paper describes the development and plans for testing an interactive mobile health (mHealth) tool for early adolescents, ages 12-15years, and their caregivers to help improve asthma management. Applying Interactive Mobile health to Asthma Care in Teens (AIM2ACT) is informed by the Pediatric Self-management model, which posits that helpful caregiver support is facilitated by elucidating disease management behaviors and allocating treatment responsibility in the family system, and subsequently engaging in collaborative caregiver-adolescent asthma management. The AIM2ACT intervention was developed through iterative feedback from an advisory board composed of adolescent-caregiver dyads. A pilot randomized controlled trial of AIM2ACT will be conducted with 50 early adolescents with poorly controlled asthma and a caregiver. Adolescent-caregiver dyads will be randomized to receive the AIM2ACT smartphone application (AIM2ACT app) or a self-guided asthma control condition for a 4-month period. Feasibility and acceptability data will be collected throughout the trial. Efficacy outcomes, including family asthma management, lung function, adolescent asthma control, asthma-related quality of life, and self-efficacy for asthma management, will be collected at baseline, post-treatment, and 4-month follow-up. Results from the current study will inform the utility of mHealth to foster the development of asthma self-management skills among early adolescents.

Effect of laparotomy on respiratory muscle activation pattern

Muscular tone of the abdominal wall is important in maintaining transdiaphragmatic pressures and its loss can lead to decreased lung volumes. Patients who are status postlaparotomy are at risk of developing atelectasis. The compensatory role of respiratory muscle activity in postlaparotomy is not well studied. Normally, inspiratory muscles are active during inspiration and passive during expiration to allow for lung recoil. However, electrical activities of the inspiratory muscles continue during early expiratory phase to prevent rapid loss of lung volume. This activity is known as post‐inspiratory inspiratory activity (PIIA). In this study, we hypothesized that laparotomy will elicit an increase in PIIA, which is enhanced by respiratory chemical loading. Experiments were conducted in cats under three different conditions: intact abdomen (n = 3), open abdomen (n = 10), and post abdominal closure (n = 10) during eupnea and hypercapnia (10% CO2). Electromyography (EMG) activities of the diaphragm and parasternal muscles were recorded and peak EMG amplitude, PIIA time, and area under the curve were measured. Intraesophageal pressure was also obtained. PIIA was significantly higher under open abdominal conditions in comparison to intact abdomen during eupnea. Our data indicates that PIIA is increased during open abdomen and may be an important compensatory mechanism for altered respiratory mechanics induced by laparotomy. Also, PIIA remained elevated after abdominal closure. However, under hypercapnia, PIIA was significantly higher during intact abdomen in comparison to open abdomen, which is thought to be due to respiratory muscle compensation under chemical loading.

Radiological Case of the Month

A 7-DAY-OLD boy presented with a 1-day history of poor breast-feeding. He was alert, with cold extremities, reduced skin turgor (Figure 1), dry mucous membranes, and a sunken anterior fontanelle. His weight was 2.66 kg, representing a loss of 25% from birth. The plasma sodium level was 174 mmol/L; urea nitrogen, 40 mmol/L (112 mg/dL); creatinine 111 μmol/L (1.25 mg/dL); leukocyte count, 12.3 310/L; and fibrinogen, 0.98 g/L (reference range, 1.5-4.5 g/L). A blood culture was performed prior to administration of intravenous broad spectrum antibiotics. He was treated with intravenous fluids containing 40-mmol/L sodium, at 275 mL/kg per day. Ten hours after admission, his plasma sodium level had fallen to 156 mmol/L and 4 hours later the neonate had 2 brief generalized seizures. Rectal diazepam, intravenous mannitol, and phenytoin were given. He became apneic and required tracheal intubation, mechanical ventilation, and was transferred to the pediatric intensive care unit. Renal diagnostic ultrasound showed no abnormalities. A cranial sonogram showed effacement of the subarachnoid spaces indicating moderate cerebral edema. An unenhanced computed tomogram (CT) of the brain also demonstrated cerebral edema, and high density and enlargement of the superior sagittal sinus with sparing of the anterior portion (Figure 2). A diagnosis of acute sagittal sinus thrombosis was made. A subsequent color Doppler sonogram also demonstrated absence of flow in the superior sagittal sinus, except in the anterior portion. The sagittal sinus with color flow signal in adjacent cortical arteries is shown (Figure 3). Intravenous fluids with 140-mmol/L sodium were given during a 72-hour period to correct dehydration. He was treated with ventilatory support and intravenous antibiotics for 2 days. One day after admission, the urinary sodium level was 50 mmol/L and urinary osmolality was 723 mmol/kg. His mother expressed very small volumes of breast milk, with a sodium content of 16 mmol/L. The plasma sodium approached more normal levels during the next 4 days, as progressively more hypotonic fluids and enteral feedings were given.

The association of nocturnal hypoxia and an echocardiographic measure of pulmonary hypertension in children with sickle cell disease

BackgroundPulmonary hypertension (PH) is multifactorial in origin and may develop early in children with sickle cell disease (C-SCD). Potential etiologies are hemolysis-induced endothelial dysfunction, left ventricular (LV) dysfunction, and chronic hypoxia. Nocturnal hypoxia (NH) in C-SCD is known to be a sequela of obstructive sleep apnea (OSA). The primary objective of this study is to correlate polysomnographic evidence NH with echocardiographic measures of PH in C-SCD.MethodsWe performed a retrospective chart review of 20 C-SCD (Hemoglobin SS), who had polysomnography and echocardiogram performed within a narrow time interval, and 31% of them had pre-existing cardiac conditions. Tricuspid regurgitant jet velocity (TRJV)u2009≥u20092.5u2009m/s was considered as an indicator of PH.ResultsTwenty-five percent of the subjects had NH. Forty percent of C-SCD, predominantly male, had evidence of PH based on an elevated TRJV. Children with NH compared to non-NH had significantly worse baseline hypoxemia (pu2009<u20090.001), higher TRJV (pu2009=u20090.005), and higher LV end-diastolic diameters (pu2009=u20090.009). The severity of NH was influenced by OSA. However, PH was not associated with OSA or duration of hydroxyurea therapy.ConclusionOur study indicates that NH is associated with PH in C-SCD, and that screening for NH may help to identify C-SCD with higher morbidity risk.