P. D. Phelan

Lower respiratory infection and inflammation in infants with newly diagnosed cystic fibrosis

The nature and timing of lower respiratory infections in infants with cystic fibrosis is largely unknown1 because infants do not produce sputum and throat cultures may not predict lower respiratory pathogens.2 We performed a prospective cross sectional study of an unselected cohort of infants with cystic fibrosis in which bronchoalveolar lavage was used to determine lower respiratory infection and inflammation during the first three months of life. The state of Victoria, Australia (66000 births per year) has a cystic fibrosis screening programme, all patients being managed by one centre. Between February 1992 and September 1994 we recruited 45 (27 boys) of the 52 infants with newly diagnosed disease; 32 were identified by screening, 12 from meconium ileus, and one by failure to thrive, and all cases were confirmed by sweat testing. Sixteen infants had respiratory symptoms, and seven of them were receiving oral antibiotics when bronchoalveolar lavage was performed at a mean age of 2.6 (SD 1.6) months. Nine otherwise healthy infants (five boys) aged …

Bronchoalveolar lavage or oropharyngeal cultures to identify lower respiratory pathogens in infants with cystic fibrosis

As collections of lower respiratory tract specimens from young children with cystic fibrosis (CF) are difficult, we determined whether oropharyngeal cultures predicted lower airway pathogens. During 1992–1994, 75 of 90 (83%) infants with CF diagnosed by neonatal screening had 150 simultaneous bronchoalveolar lavage (BAL) and oropharyngeal specimens collected for quantitative bacterial culture at a mean age of 17 months (range, 1–52). Ten children undergoing bronchoscopy for stridor served as controls. Total and differential cell counts and interleukin‐8 concentrations were measured in BAL fluid. A subset of bacterial pathogens were typed by pulsed field gel electrophoresis. A non‐linear relationship with inflammatory markers supported a diagnosis of lower airway infection when ≥105 colony‐forming units/ml were detected. This criterion was met in 47 (31%) BAL cultures from 37 (49%) children. Staphylococcus aureus (19%), Pseudomonas aeruginosa (11%), and Hemophilus influenzae (8%) were the major lower airway pathogens. In oropharyngeal cultures, S. aureus (47%), Escherichia coli (23%), H. influenzae (15%), and P. aeruginosa (13%) predominated. The sensitivity, specificity, and positive and negative predictive values of oropharyngeal cultures for pathogens causing lower respiratory infections were 82%, 83%, 41%, and 97%, respectively. When there was agreement between paired oropharyngeal and BAL cultures, genetic fingerprinting showed some strains of the same organism were unrelated. We conclude that oropharyngeal cultures do not reliably predict the presence of bacterial pathogens in the lower airways of young CF children. Pediatr Pulmonol. 1996; 21:267–275.

Subjective scoring of cough in children: parent-completed vs child-completed diary cards vs an objective method

Cough is often used as an outcome measure, although the reporting of cough is unreliable. Using a 24 h ambulatory cough meter to measure cough frequency, the aim of this study was to compare: 1) the correlation of child-completed diary cards to the objective measurement, with that of parent-completed diary cards; and 2) the visual analogue scale (VAS) to the verbal category descriptive (VCD) score. The cough meter consisted of a previously validated Holter monitor and a cough processor. Eighty four children (39 with recurrent cough and 45 controls, aged 6-17 yrs) used a cough meter at least once. Thirty three subjects used the cough meter twice. Parents and children completed separate diary cards using the VAS and VCD scores. The strength of the relationship between the subjective scores and the objective recordings was analysed by spearmans rank correlation coefficient. For daytime cough, child-completed diary cards and the VCD correlated better to the objective measurement than parent-completed diary cards and the VAS, respectively. In subjects that used the cough meter twice, the difference between the cough frequency correlated to the difference in the subjective scores. The confidence intervals for the correlation coefficients were wide. The agreement between the objective and subjective presence of daytime cough was good but that for night-time cough was poor. We conclude that the severity of cough defined on diary cards may not represent cough frequency. Objective readings are first choice but currently not yet practical. The verbal category descriptive diary card completed by children and assisted by parents has the highest correlation to cough frequency measured objectively.

Childhood asthma in adult life: a further study at 28 years of age.

A group of 323 subjects who had wheezed in childhood and 48 control subjects of the same age were studied prospectively from 7 to 28 years of age. A classification system based on wheezing frequency was found to correlate well with clinical and spirometric features of airway obstruction. The amount of wheezing in early adolescence seemed to be a guide for severity in later life with 73% of those with few symptoms at 14 continuing to have little or no asthma at 28 years. Similarly 68% of those with frequent wheezing at 14 still suffered from recurrent asthma at 28 years. Most subjects with frequent wheezing at 21 continued to have comparable asthma at 28 years. Of those with infrequent wheezing at 21, 44% had worsened at 28 years. Women fared better than men between 21 and 28 with 19% having worse symptoms compared with 28% of men. Treatment at all ages was generally inadequate. The number of smokers among those with asthma was of concern.

Asthma from childhood at age 21: the patient and his disease.

Information was obtained from 336 21-year-olds who had begun wheezing before the age of 7 about their knowledge of asthma and its effect on their current life style. Two-thirds of the subjects were still symptomatic. A control group of 62 subjects was available for comparison. Knowledge about asthma was poor, particularly among those with less troublesome symptoms. Half of those with frequent episodic asthma and one-third with persistent asthma did not regard excess use of bronchodilator aerosols as potentially dangerous. Over three-quarters of those with persistent asthma were not receiving adequate treatment. One-third of third of those with persistent asthma were missing substantial time from work because of respiratory illness, and a similar proportion were restricting sporting activities. The incidence of smoking was disturbingly high in all asthma groups. The higher the number of cigarettes ever smoked and the higher the current tobacco consumption the less satisfactory was the progress of asthma. Both cigarette smoking and severity of asthma contributed to chronic production of sputum. Children and teenagers with asthma should be educated to seek more appropriate medical help and thereby reduce morbidity.

THE EFFECT ON GROWTH OF CHILDHOOD ASTHMA

ABSTRACT. Martin, A. J., Landau, L. I. and Phelan, P. D. (Department of Thoracic Medicine, Royal Childrens Hospital, Melbourne, Australia). The effect on growth of childhood asthma. Acta Paediatr Scand, 70:683,.–The effect on growth of asthma has been documented in a prospective study from age 7 to 21 years in a randomly selected group of 342 subjects. These subjects covered the whole spectrum of childhood wheezing. Growth suppression was first noted at 10 years of age in the more severely affected groups and was most marked at 14 years of age. By 21 years of age, all groups had achieved a height and weight not significantly different from control subjects. Growth delay occurred in children with more persistent asthma even if they had never received oral corticosteroid therapy but growth was more delayed in those receiving oral steroids. The effect of steroids was most significant in those with frequent episodic asthma whose asthma alone was probably not sufficiently severe to retard growth.

Atopy in subjects with asthma followed to the age of 28 years

The relationship between markers of asthma and atopy was examined in 323 subjects at the age of 28 years who have been followed since the age of 7 years. Hay fever was common in all groups with severe asthma, increasing from 25% of the control group to 67% of the group with the most severe asthma, class V. Eczema was uncommon at this age in all groups. IgE levels, peripheral blood eosinophil counts, and skin reactions were significantly (p less than 0.05) higher in class V than in the control group. Increasing age was associated with a progressive fall in eosinophil counts and an increase in skin reactivity to common allergens. No change in IgE levels was observed from 21 to 28 years. A general relationship between bronchial hyperreactivity and atopic markers was found. However, only the occurrence of hay fever was significantly related to reactivity when account was taken of severity of asthma. The results indicate that the relationship between asthma and atopy observed at earlier reviews continues into adult life and that bronchial hyperreactivity and atopy are not directly linked.

Cough sensitivity in children with asthma, recurrent cough, and cystic fibrosis

In adults, cough sensitivity is influenced by gender and is heightened in those with non-productive cough. This study examined if cough sensitivity is (i) altered in children with asthma, recurrent cough, and cystic fibrosis and (ii) influenced by age, gender, or forced expiratory volume in one second (FEV1).  Cough sensitivity to capsaicin and spirometry were performed on 209 children grouped by the diagnosis of asthma, recurrent dry cough, cystic fibrosis, and controls. Cough sensitivity was increased in children with recurrent cough, and lower in children with cystic fibrosis when compared with children with asthma and controls. Age influenced cough sensitivity in the controls. In the asthmatics, FEV1 (% predicted) correlated to cough sensitivity measures. There was no gender difference in cough sensitivity. It is concluded that cough sensitivity is different among children with recurrent dry cough, asthma, and cystic fibrosis. In children, age, but not gender, influences cough sensitivity measures and when cough sensitivity is used in comparative studies, children should be matched for age and FEV1.

Nebulized gentamicin in children and adolescents with cystic fibrosis

A study of 29 children and adolescents with cystic fibrosis over 2 years showed some evidence of benefit from the twice daily inhalation of 20 mg nebulized gentamicin when compared to the inhalation of a nebulized saline mixture. Clinical symptoms, deterioration in pulmonary function, antibiotic usage, days in hospital and development of Pseudomonas aeruginosa in the sputum were recorded. There was no significant difference in antibiotic usage, days in hospital or clinical symptoms between the two regimes. Those subjects with P. aeruginosa in sputum showed significantly less deterioration in lung function over 2 years while using gentamicin aerosol. There was no difference in progress between the two treatment regimes for those subjects with P.aeruginosa in sputum at the beginning of the study, nor was there any difference in the number developing P. aeruginosa in sputum.

A new use for an old Holter monitor: An ambulatory cough meter

Cough is commonly used as an outcome measure in clinical studies, although the subjective reporting of cough is unreliable when compared to objective measures. We describe an inexpensive new ambulatory cough meter that is based on a disused Holter monitor. The cough meter consists of a Holter monitor and a cough processor, designed on a computer to select the most appropriate filters. The cough meter was then validated against the overnight tape recorder on 21 occasions in 18 children (aged 6-15 yrs). The agreement between the cough meter and the tape recorder was good (mean difference of -0.3 coughs x h(-1); limits of agreement -2.2 to 1.7 coughs x h(-1)). We conclude that our newly described ambulatory cough meter provides a valid and inexpensive method of objectively monitoring cough for up to 24 h.