Teresa Bandeira

Environmental tobacco smoke (ETS) exposure and respiratory morbidity in school age children

INTRODUCTION Tobacco smoke is a risk factor for Chronic Obstructive Pulmonary Disease and a major public health problem. Prenatal maternal smoking and post-natal environmental tobacco smoke (ETS) lead to dose-dependent decrease in lung function and respiratory morbidity. Influence of different socioeconomic indicators and ETS in the home has also been suggested. METHODS Data on 313 children (52 % male) from 4 public schools in Lisbon was analyzed [1st (46 %) and 4th graders]. ETS assessment and respiratory symptoms were based on a self-answered questionnaire. All children performed standard spirometry in the school setting and 54 % were acceptable according to ATS/ERS criteria. Descriptive and bivariate analysis of the most relevant variables was done, followed by multiple logistic regression analysis adjusted to the variables with clinical/statistical relevance. RESULTS ETS in the home was found in 41 % (maternal smoking during pregnancy 18 %, smoking mother 32 %, smoking father 38 %). Smoking fathers had lower education and less qualified occupation. Cough was more frequent in children with a smoking mother (adjusted OR = 2.1 95CI 1.1-4.0) and wheezing in children with maternal smoking during pregnancy and smoking parents. All differences were significant (p < 0.05). No association was found between parental education and cough/wheeze or ETS and respiratory infections/asthma/decreased spirometric values. CONCLUSIONS Children in Lisbon are frequently exposed to ETS which results in significant respiratory morbidity. Targeted interventions must have social conditions in consideration. In this study, field spirometry was not helpful in early detection of lung function disability in children associated with ETS.

Non-invasive ventilation in complex obstructive sleep apnea--a 15-year experience of a pediatric tertiary center.

INTRODUCTION Obstructive sleep apnea (OSA) affects approximately 1-3% of pediatric population and is associated with significant morbidity. As adenotonsillar hypertrophy (ATH) is its primary cause in children, elective adenotonsillectomy is the first treatment of choice. Noninvasive ventilation (NIV) has been increasingly considered as an option, mainly for children with complex diseases, ineligible or waiting for surgeries, or after surgery failure. OBJECTIVES To describe the experience in the management of children with complex OSA, and to evidence the feasibility and advantages of NIV. METHODS This was a retrospective cohort study of 68 children on NIV, in whom complex OSA was the main indication for ventilation, in a Pediatric Respiratory Unit at a University Hospital between January 1997 and March 2012. Demographic and clinical data were collected on the underlying diagnosis, therapeutic interventions prior to NIV, NIV related issues and outcome. RESULTS Forty (59%) children were male, median age at starting NIV was 6 years and 7 months, with interquartile range (IQR) of 15-171 months. Twenty-two (32%) were infants and 25 (37%) adolescents. The most common diagnosis was congenital malformations and genetic disorders in 34 (50%) patients. Nine patients had cerebral palsy, 8 were post treatment for central nervous system tumors and 6 had inborn errors of metabolism. Three children had ATH and three obesity. The majority of patients (76%) had exclusively obstructive OSA and started CPAP. Ten patients had minor complications. Twenty-two patients stopped NIV due to clinical improvement, 8 were non-compliant and 8 patients died. NIV median duration was 21.5 months (IQR: 7-72). CONCLUSIONS NIV is feasible and well tolerated by children with OSA associated with complex disorders, and has been shown to have few complications even in infants and toddlers.

Clinical, Radiological, and Physiological Differences Between Obliterative Bronchiolitis and Problematic Severe Asthma in Adolescents and Young Adults: The Early Origins of the Overlap Syndrome?

Few reports have compared chronic obstructive lung diseases (OLDs) starting in childhood.

Are there any differences in the community acquired pneumonias admitted to hospital over the past decade

The past few years have seen a decline in community acquired pneumonia (CAP) in children in the western world, although this has gone hand-in-hand with more serious cases needing hospital admission. Our study characterises cases of CAP admitted to hospital and compares this data with a 2001 study. We collected data on 63 admissions over a six-month period. The majority were aged 0-2 years old. Chest X-ray showed consolidation/atelectasy in 58 (92.1%) and pleural effusion (PE) in 17 (27.0%), of which 11 were empyema (17.4% of all admissions). The bacterial agent was isolated in five cases: Streptococcus pyogenes (two, pleural fluid), Streptococcus pneumoniae (two, blood culture) and Haemophilus influenzae (one, blood culture). Sixty-one children (96.8%) were prescribed antibiotherapy. The median length of hospital stay was five days. Patients with PE were older, had a longer course of fever, higher inflammatory parameters, longer hospital stay and longer course of iv antibiotics. Compared to the prior study we found greater severity of CAP, with higher prevalence of PE and empyema. Nevertheless there was a shorter course of fever during hospital stay and shorter hospital stay. We also noticed less antibiotic prescription prior to admission and greater prescription of ampicillin during hospital stay. In the literature, the higher severity of CAP has been partially attributed to the emergence of more aggressive serotypes of Stretococcus pneumoniae not included in the heptavalent vaccine. There is therefore a greater interest in new vaccines containing them. Complicated CAP should be referred to centres specialising in its diagnosis and management.

Acute viral bronchiolitis: Physician perspectives on definition and clinically important outcomes

Two key limitations hamper intervention research in bronchiolitis: the absence of a clear definition of disease, and the heterogeneous choice of outcome measures in current clinical trials. We assessed how paediatricians and general practitioners (GPs) perceived definition and clinically important outcomes in bronchiolitis.

Pycnodysostosis with novel gene mutation and severe obstructive sleep apnoea: management of a complex case

Pycnodysostosis is a rare genetic disease. Impaired osteoclastic function is the basis for typical phenotypic features and bone fragility. The main differential diagnosis is osteopetrosis, also associated with altered bone remodelling, but with a more severe prognosis. We describe the case of an 8-year-old boy who presented life-threatening obstructive sleep apnoea successfully managed with non-invasive ventilation. Haematological overlap phenotype included anaemia and altered bone marrow, more common in osteopetrosis. Molecular analysis of the CTSK gene revealed a mutation not previously described in the literature.

Traqueostomia: Indicações e complicações em doentes pediátricos

Resumo Apesar dos avancos nas tecnicas de ventilacao nao invasiva, a traqueostomia continua a ter indicacao em criancas com perturbacao grave da via aerea ou com necessidade de ventilacao prolongada. Sendo um procedimento de execucao facil, nao e isenta de riscos, pelo que se justifica sempre a ponderacao previa de alternativas a decisao de traqueostomizar. Foram objectivos deste estudo a identificacao das criancas traqueostomizadas com seguimento num servico de pediatria de hospital terciario, a caracterizacao da doenca primaria e indicacoes conducentes a decisao de traqueostomizar e a avaliacao das complicacoes registada neste grupo de doentes. Procedeu-se a revisao dos processos clinicos das dezasseis criancas traqueostomizadas, com uma mediana de idade a data da realizacao da traqueostomia de 4,5 meses, cinco com doenca neuromuscular, tres com paralisia cerebral e sete com doenca pulmonar ou das vias aereas. A indicacao para a traqueostomia foi a necessidade de ventilacao invasiva prolongada em doze casos, estenose subglotica ou traqueal em tres e laringomalacia num outro. As complicacoes mais frequentes foram a colonizacao bacteriana persistente, a descanulacao transitoria acidental e a obstrucao transitoria da cânula. Verificou-se um obito relacionado com a traqueostomia. Nove criancas mantem traqueostomia, cinco foram descanuladas (uma das quais veio a falecer) e outras duas faleceram ainda com traqueostomia. Tal como sublinhado na literatura, as criancas e adolescentes traqueostomizados tem habitualmente patologias multiplas que exigem apoio multidisciplinar. A complexidade das situacoes clinicas e a exigencia de recursos determinam a necessidade de acompanhamento em centro especializado de referencia. Rev Port Pneumol 2009; XV (2): 227-239

Tracheostomy: Indications and complications in paediatric patients

UNLABELLED Despite advances in non-invasive ventilation techniques, tracheostomy is still indicated in children with serious airway obstruction or with the need for long-term ventilation. Alternatives should be studied before deciding to tracheostomise as complications exist, despite the simple procedure. The aims of this study were the identification of tracheostomised children followed in a tertiary care paediatric department, the characterisation of primary disease, the indications leading to tracheostomy and any complications. We present a case review of tracheostomised children followed in our department. Sixteen tracheostomised children were followed, median age of 4.5 months, neuromuscular disease - 5, cerebral palsy - 3 and pulmonary or airway disease - 7. Indications were long-term invasive ventilation - 12, subglottic or tracheal stenosis - 3 and laryngomalacia - 1. The most frequent complications found were persistent bacterial colonisation, accidental decannulation and obstruction. There was a tracheostomy- related death in 1 child. OUTCOME 9 children maintained tracheostomy, 5 were successfully decannulated and 2 children died while on tracheostomy. Tracheostomised children usually have complex disease that requires a multidisciplinary team and should be followed-up at a specialised reference centre.

Rastreio de patologia respiratória em crianças em idade escolar com o uso de espirometria portátil

OBJECTIVES: To assess the prevalence of respiratory disease in school-aged children and to determine the value of field spirometry. METHODS: Data on 313 1st and 4th graders from four public schools in Lisbon were analyzed. A respiratory self-answered questionnaire and standard spirometry were performed. Descriptive and bivariate analysis was followed by multiple logistic regression. RESULTS: Thirty-five percent of the children presented at least one episode of wheezing (18% > 2 episodes), and 4% had asthma. Wheezing was more frequent with family history of atopy (adjusted OR = 2.7; 95%CI 1.4-5.1), maternal smoking during pregnancy, lower respiratory tract infection (LRTI) (adjusted OR = 2.8; 95%CI 1.2-6.2), bronchiolitis (adjusted OR = 3.3; 95%CI 1.3-8.2), and allergy to aeroallergens (adjusted OR = 3.2; 95%CI 1.4-7.2). Asthma was more frequent with previous history of LRTI (adjusted OR = 14.6; 95%CI 1.7-122.9) and allergy to aeroallergens (adjusted OR = 8.2; 95%CI 2.0-34.2). Fifty-five percent of spirometry measurements met the acceptability criteria of the American Thoracic Society and of the European Respiratory Society. Wheezers presented mean lower z scores for forced expiratory volume in 1 second (FEV1), ratio between FEV1 and forced vital capacity (FVC) (FEV1/FVC), and forced expiratory flow between 25 and 75% (FEF25-75) (p < 0.05), as well as higher percentage of abnormal FEV1, FEV1/FVC and FEF25-75 (FEF25-75, p < 0.05). CONCLUSIONS: This pilot study showed a high prevalence of obstructive airway symptoms in school-aged children in Lisbon. Symptoms assessed by the questionnaire showed good correlation with spirometric values. The small prevalence of asthma leads us to speculate that asthma is under-diagnosed in this population.

Estarão diferentes as pneumonias agudas adquiridas na comunidade com internamento hospitalar em idade pediátrica na última década

Resumo Nos ultimos anos tem sido descrita, no mundo ocidental, uma reducao da incidencia da pneumonia aguda da comunidade (PAC) nas criancas, parodoxalmente associada a maior gravidade dos casos internados. O presente estudo pretendeu caracterizar os casos de PAC internados e compara-los com um estudo anterior a 2001. Recolhemos dados referentes a 63 internamentos, durante seis meses. Houve predominio do grupo dos 0-2 anos. Na radiografia toracica, em 58 casos (92,1%) detectou-se condensacao/atelectasia e em 17 (27,0%) derrame pleu ral (DP). Onze dos DP corresponderam a empiema (17,4% dos internamentos). Isolou-se agente bacteriano em cinco casos: Streptococcus pyogenes (dois, liquido pleural), Streptococcus pneumoniae (dois, hemocultura) e Haemophilus influenzae (um, hemocultura). Foi prescrita antibioticoterapia em 61 (96,8%) criancas. A duracao mediana de internamento foi de cinco dias. Constatou-se, nos casos de DP, idade superior, maior duracao de febre, proteina C reactiva mais alta e maior duracao de internamento e de antibioticoterapia endovenosa. Comparativamente com o estudo anterior, constatou-se haver maior gravidade dos casos internados, traduzida por maior incidencia de DP e empiema; paradoxalmente, registou-se menor duracao da febre em meio hospitalar e menor duracao do internamento. No estudo actual houve menor prescricao antibiotica previa a admissao e maior prescricao de ampicilina durante o internamento. Na literatura, a maior gravidade das pneumonias internadas nos ultimos anos tem sido associada a emergencia de serotipos mais agressivos de Stretococcus pneumoniae nao integrados na vacina heptavalente, assumindo interesse crescente a introducao de vacinas que os incluam. As pneumonias complicadas devem ser orientadas para centros de referencia com experiencia no seu diagnostico e tratamento. Rev Port Pneumol 2010; XVI (2): 287-305