Pablo Bertrand

Influence of asthma on sleep disordered breathing in children: A systematic review

UNLABELLED The objective of this study was to perform a systematic review for the association between asthma and sleep disordered breathing (SDB) in children. We performed an electronic search in Medline, Embase, CINAHL, LILACS and Cochrane databases. Study selection criteria: children <18 y of age with diagnosis of asthma and SDB. PRIMARY OUTCOMES odds ratios (OR) and 95% confidence intervals [95%CI] of asthma for SDB were calculated. There were n = 968 citations identified, of them n = 17 studies were selected, which included n = 45 155 (53% males) children. All included studies defined asthma and SDB based on questionnaires, and only two performed a sleep study for diagnosing obstructive sleep apnea. Mean age was 8.6 ± 2.5 y. SDB was significantly more frequent in children with asthma compared with non-asthmatics: 23.9% vs 16.7% respectively, p < 0.0001. Children with asthma had a significantly higher risk for SDB: OR 1.9 [1.7; 2.2]. This systematic review showed evidence of a significant association between asthma and SDB in children. Asthma seems to be a significant risk factor for developing SDB. However, the minority of the studies based the diagnosis of SDB on polysomnography, considered the current gold standard for SDB. The physiological and temporal relationships between both conditions should be addressed in future cohort studies.

Prevalence of habitual snoring and associated neurocognitive consequences among Chilean school aged children.

OBJECTIVE To assess the prevalence of habitual snoring and symptoms of sleep disordered breathing (SDB) and their association with neurocognitive consequences in school-aged children. METHODS A population based cross-sectional study was carried out in a low income urban setting in Santiago, Chile. A parental SDB-questionnaire was adapted and applied to a community based sample of children aged 7-17 years. Hyperactive/inattentive behavior was assessed using the Conners rating scale. School grades were obtained and the associations between questionnaires results and risks for poor academic performance were investigated. RESULTS Of 700 questionnaires sent; 523 (75%) returned correctly filled in. Mean age of the subjects was 11.0±2.5 years; 246 (47%) were boys. Prevalence of habitual snoring was 18%. The Conners rating scale correlated significantly with the SDB-questionnaires score (r(s)=0.47). Children with habitual snoring showed significantly lower (mean±standard deviation) school grades in Spanish language (5.6±1.2 vs. 5.4±0.9, p-value=0.04) and general average school grades (5.9±0.6 vs. 5.7±0.6, p-value=0.05). After adjustment for possible confounding factors, children with an abnormal SDB questionnaire score had significantly higher risk for poor academic performance in Spanish language, odds ratio (95% confidence interval): 1.82 (1.01-3.27) and physical education 1.85 (1.05-3.26). DISCUSSION There was a high prevalence of habitual snoring and symptoms of SDB in this survey of Chilean children, being among the highest reported. The presence of habitual snoring and an abnormal SDB questionnaire were associated with poor academic performance and hyperactive behavior.

Asistencia ventilatoria domiciliaria en niños chilenos: 12 años de experiencia

Objetivo Los sistemas de apoyo ventilatorio domiciliario son una alternativa para el tratamiento de los pacientes con insuficiencia respiratoria cronica grave. El objetivo del presente estudio ha sido caracterizar a los ninos ingresados en el Servicio de Asistencia Ventilatoria en Domicilio (SAVED). Pacientes y metodo El SAVED es un programa de nuestro hospital que coordina el apoyo profesional y tecnologico para ninos con dependencia de asistencia ventilatoria (AV) cronica. Se revisaron y actualizaron datos demograficos, tipo de AV, morbilidad respiratoria y fallos de equipo entre 1993 y 2004. Resultados Se realizo seguimiento en nuestro centro a 35 ninos (varones: 18). La mediana de edad al entrar en el programa fue de 12 meses (rango: 5 meses a 14 anos). El tiempo de permanencia fue de 21 meses y la retirada del soporte se logro en el 40% del total. Fallecieron 6 pacientes. Las principales indicaciones de AV fueron: enfermedad neuromuscular en 12 casos, alteracion de la via aerea en 11, enfermedad cardiopulmonar en 7 y sindrome de hipoventilacion en 5. Los tipos de AV utilizados fueron presion positiva continua de la via aerea en 17 casos, presion positiva en 2 niveles (BiPAP) en 8 y ventilacion mecanica intermitente sincronizada en 10. Se administro ventilacion invasiva a 26 pacientes a traves de traqueotomia. En los ultimos 4 anos se produjo un aumento de la utilizacion de la ventilacion no invasiva. La morbilidad respiratoria (neumonia y traqueitis bacteriana) fue la causa mas frecuente de hospitalizacion y alcanzo 1,6 evento/nino/ano. Los fallos de sistema fueron causa de hospitalizacion en 0,1 evento/nino/ano. Conclusion El SAVED es un programa seguro y necesario para ninos con insuficiencia respiratoria cronica de caracter grave. El apoyo profesional que proporciona la hospitalizacion domiciliaria ha beneficiado la evolucion de estos ninos. Es importante considerar esta experiencia para laformacion de un programa nacional de AV domiciliaria.

Home Ventilatory Assistance in Chilean Children: 12 Years' Experience

OBJECTIVE Home ventilatory support systems are a treatment option for patients with severe chronic respiratory failure. The objective of the present study was to characterize the children admitted to a home ventilatory assistance program. PATIENTS AND METHOD The home ventilation program was created by our hospital to coordinate professional and technological support for chronic ventilator-dependent children. We revised and updated information on patient characteristics, type of assisted ventilation, respiratory morbidity, and equipment failures between 1993 and 2004. RESULTS Follow-up of 35 children (18 male) was carried out by our hospital staff. Median age upon admission to the program was 12 months (range, 5 months to 14 years). Median length of time in the program was 21 months and we were able to wean 40% of patients from ventilators. Six patients died. The main indications for assisted ventilation were neuromuscular disease (12 cases), airway abnormality (11 cases), cardiopulmonary disease (7 cases), and hypoventilation syndrome (5 cases). The types of assisted ventilation used were continuous positive airway pressure (in 17 cases), bilevel positive pressure (in 8 cases), and synchronized intermittent mandatory ventilation (in 10 cases). Invasive ventilation via a tracheostomy was used in 26 cases. The use of noninvasive ventilation increased in the last 4 years. Respiratory morbidity (pneumonia and bacterial tracheitis) was the most frequent cause of hospitalization and the annual rate of such episodes was 1.6 per child. The annual rate of hospitalization due to equipment failures was 0.1 per child. CONCLUSION The program provides safe and necessary home ventilatory assistance for children with severe chronic respiratory failure. The professional support that home hospitalization offers had a positive effect on outcome in these children. It is important to take our experience into account in creating a Chilean national home ventilatory assistance program.

Utilidad del lavado broncoalveolar en niños inmunodeprimidos: rendimiento y complicaciones

Objetivo Los ninos inmunodeprimidos presentan el riesgo de desarrollar neumonia por germenes oportunistas. El papel del lavado broncoalveolar (LBA) en la evaluacion de estos pacientes es aun controvertido. Material Y Metodo Se revisaron las fichas de pacientes con inmunodepresion y sintomas respiratorios a los que se les habia practicado un LBA en el Servicio de Pediatria del Hospital Clinico de la Pontificia Universidad Catolica de Chile. Resultados Se practicaron 68 LBA en 54 ninos inmunodeprimidos (edad media: 7,5 anos). Los sintomas respiratorios mas frecuentes fueron fiebre (90%) y tos y dificultad respiratoria (81%); el 18% tenia neutropenia y el 43%, trombocitopenia. Todos los pacientes estaban en tratamiento antibiotico de amplio espectro. Las muestras del LBA proporcionaron un germen especifico en 25 pacientes (37%). Los patogenos aislados fueron: bacterias en 21 casos, virus en 6, Pneumocystis carinii en 5, hongos en 4 y Mycobacterium tuberculosis en uno. Catorce (19%) LBA se realizaron a ninos que recibian ventilacion mecanica. La evolucion fue satisfactoria en todos los casos. Se registraron 21 complicaciones, 17 menores (hipoxemia leve o fiebre) y 4 mayores que requirieron intubacion traqueal. No se registraron muertes. Conclusiones La evaluacion fibrobroncoscopica asociada a un LBA fue un metodo seguro, con un adecuado rendimiento, que permitio evaluar la etiologia de los infiltrados pulmonares en la radiografia de torax. Tanto los resultados positivos como los negativos del LBA contribuyeron al tratamiento de estos pacientes.

Elevated IL-3 and IL-12p40 levels in the lower airway of infants with RSV-induced bronchiolitis correlate with recurrent wheezing.

Respiratory Syncytial Virus (RSV) is the first cause of hospitalization due to bronchiolitis in infants. RSV bronchiolitis has been linked to asthma and recurrent wheezing, however the mechanisms behind this association have not been elucidated. Here, we evaluated the cytokine and chemokine profiles in the airways in infants with RSV bronchiolitis. Nasopharyngeal Aspirates (NPA) and Bronchoalveolar Lavage Fluids (BALF) from infants hospitalized due to RSV bronchiolitis and healthy controls were analyzed for cytokine and chemokine production. We observed elevated levels of Th2 cytokines (IL-3, IL-4, IL-10 and IL-13), pro-inflammatory cytokines and chemokines (IL-1β, IL-6, TNF-β, MCP-1/CCL2, MIP-1α/CCL3 and IL-8/CXCL8) in BALF from infants with RSV bronchiolitis, as compared to controls. We found a direct correlation of IL-3 and IL-12p40 levels with the development of recurrent wheezing later in life. These results suggest that IL-3 and IL-12p40 could be considered as molecular predictors for recurrent wheezing due to RSV infection.

Infección respiratoria por virus influenza en niños: ¿Qué aprendimos durante el año 2004?

BACKGROUND Infants and toddlers have the highest influenza hospitalization rate in pediatrics. Although the impact of this virus in children has been recognized, there is no defined statement related to vaccination in this population. AIM To describe clinical and epidemiological characteristics of complicated influenza infections in hospitalized children. MATERIAL AND METHODS All hospitalizations due to influenza virus were recorded prospectively between March and June 2004. RESULTS We registered 40 laboratory-confirmed influenza admissions. Median age was 24 months (range: 15 days-14.5 years), 52% males, 18 younger than 2 years. Most of them had an underlying medical condition. The most common conditions were recurrent wheeze in 17, a neurological disease in 7 and asthma in 6. Twenty had more than one condition and 15 were previously healthy. The average days of respiratory symptoms and fever prior to admission were 5 and 3, respectively. The most common discharge diagnoses were concomitant viral-bacterial pneumonia in 53%, viral pneumonia in 38% and laryngitis in 8%. Influenza virus A was identified in 34/40 children. Oxygen supplementation was required by 34 cases; 20% of which required an O2 inspired fraction over 40%. The average days of hospitalization and oxygen were 4 and 3, respectively. Eleven children were treated with amantadine and 21 with antimicrobials. Four children were admitted to pediatric intensive care units and two cases required non-invasive ventilatory support. No deaths were recorded. CONCLUSIONS Our data confirms the importance of influenza virus infection in children, as measured by admission rates, complications and length of hospital stay. Young children are a risk group for which immunization is recognized as protective.

Utility of Bronchoalveolar Lavage in Immunocompromised Children: Diagnostic Yield and Complications

OBJECTIVE Immunocompromised children are at high risk for developing pneumonia due to opportunistic pathogens. The role of bronchoalveolar lavage (BAL) in the evaluation of such patients is still controversial. MATERIAL AND METHOD We reviewed the hospital records of immunosuppressed patients with respiratory symptoms who had undergone BAL in the pediatric department of the Hospital Clinico de la Pontificia Universidad Católica of Chile. RESULTS Sixty-eight BAL were performed on 54 children (mean age: 7.5 years) receiving wide-spectrum antibiotic treatment. The most frequent respiratory signs and symptoms were fever (90%) and cough and respiratory distress (81%); 18% had neutropenia and 43% thrombocytopenia. A specific pathogen was identified in BAL samples for 25 patients (37%). The pathogens isolated were bacteria in 21 cases, viruses in 6, Pneumocystis carinii in 5, fungi in 4, and Mycobacterium tuberculosis in one. Fourteen (19%) of the children who underwent BAL were on mechanical ventilation. Outcome was satisfactory in all cases. Twenty-one complications were recorded, 17 of which were minor (mild hypoxemia or fever) and 4 major, requiring tracheal intubation. No deaths were recorded. CONCLUSIONS Evaluation by fiberoptic bronchoscopy together with BAL proved to be a safe procedure with an adequate diagnostic yield that made it possible to determine the etiology of the pulmonary infiltrates seen in chest x-rays. Both positive and negative results of BAL were useful for treating the patients.

Síndrome de muerte súbita del lactante: prevalencia y cambios en los últimos años en Chile

BACKGROUND The sudden infants death syndrome (SD) is the leading cause of death in children under one year. Despite advances in its study, the pathogenesis has not been yet fully elucidated. AIM To assess the prevalence of SD in Chilean infants and its changes in recent years. MATERIAL AND METHODS Review of birth and death databases of the Ministry of Health from 1997 to 2009. All cases diagnosed as SD, according to the lnternational Classification of Diseases, 10th edition, were selected. A demographic analysis was performed and mortality rates for each year were calculated. RESULTS We identified 1442 cases of SD (847 males, 517 deaths at home). The median age of death was 2 months (0 to 11.0 months). Ninety six percent of deaths occurred in children aged <6 months. Mortality rate for SD was 0.45/1000 live births. There was a 23% reduction between 1997 and 2009. When analyzing geographic distribution, more cases were found in the Southern latitudes of the country. CONCLUSIONS The overall rate of SD in Chile is higher than in European countries and in North America. The observed decrease in cases over the years is still far from optimal.

Many respiratory viruses have temporal association with meningococcal disease

BACKGROUND Previous ecological studies have shown a temporal and spatial association between influenza epidemics and meningococcal disease (MNG); however, none have examined more than two respiratory viruses. METHODS Data were obtained in Chile between 2000 and 2005 on confirmed cases of MNG and all confirmed cases of respiratory viruses (influenza A and B; parainfluenza; adenovirus; and respiratory syncytial virus [RSV]). Both variables were divided by epidemiological weeks, age range, and regions. Models of transference functions were run for rates of MNG. RESULTS In this period, 1022 reported cases of MNG and 34,737 cases of respiratory virus were identified (25,137 RSV; 4300 parainfluenza; 2527 influenza-A; 356 influenza-B; and 2417 adenovirus). RSV was the major independent virus temporally associated to MNG (it appears one week before MNG), followed by parainfluenza, influenza-B, adenovirus, and influenza-A. CONCLUSIONS The rate of MNG in Chile is temporally associated to all of the respiratory viruses studied, but with variability according age range, and regions.