Warren Richards

Prolonged Morbidity Due to Delays in the Diagnosis and Treatment of Obstructive Sleep Apnea in Children

The inclusion of a query concerning the presence of snoring in a questionnaire used by the Allergy Service of Childrens Hospital Los Angeles (CHLA) uncovered a significant number of patients who were experiencing prolonged and discomforting symptoms owing to previously undiagnosed obstructive sleep apnea (OSA) caused by adenotonsillar hypertrophy. Of 352 patients who were discharged with a diagnosis of OSA and tonsillectomy and/or adenoidectomy at CHLA in 1996-1997, a retrospective study of the first 45 randomly selected patients who agreed to participate in a telephone interview was performed. Analysis revealed that all patients experienced severe and discomforting symptoms with all describing severe or moderate snoring. Other symptoms included chronic mouth breathing (84%), frequent otitis media (64%), sinusitis (56%), sore throat (51%), choking (47%), and daytime drowsiness (42%). Other symptoms included poor school performnce, enuresis, poor appetite and/orxweight gain, dysphagia, and vomiting. Symptoms began at a mean age of approximately 2 years (”birth“-9 years), and the mean period of time between the development of significant symptoms and OSA was 3.3 years (6 months-1 3 years). Delay between onset of significant symptoms and surgery was>1 year in 82% of the patients,>2 years in 51% of the patients,>4 years in 31% of the patients, and>6 years in 13% of the patients. Forty percent of patients were self-referred to an otolaryngologist for treatment despite their primary care physician being aware of the symptoms. These results indicate that patient with OSA experienced prolonged morbidity and delays in treatment, which is probably widespread. Physican, parent, and third-party factors were found to have contributed to the delays in treatment.

Sinusitis in Status Asthmaticus

The relationship between sinusitis and status asthmaticus (SA) remains obscure. The purposes of this study were to determine the prevalence of abnormal sinus radiographs (SXRs) and investigate possible risk factors among unselected children admitted with SA. Eighty-eight patients over 2 years of age (range 2 to 16 years) consecutively admitted with SA were studied. The principal investigator, blinded to SXR findings, interviewed and examined the patients with respect to 10 physical parameters and 14 historical parameters. Two staff radiologists, blinded to the clinical findings, interpreted the SXRs. Relationship of historical and physical findings with positive SXRs was determined by statistical analysis. Twenty-seven percent of patients were found to have abnormal SXRs, manifesting two thirds or greater opacification of the sinuses. The mean age, sex, and race of patients with abnormal SXRs was not significantly different from those with normal films. A history of two or more admissions per year for SA, and, in children under 5 years of age, a history of chronic otitis media, and the physical finding of otitis media were significantly more frequent among patients with abnormal SXRs. Although not found to be statistically significant, a history of sinusitis and cough occurred more frequently in association with abnormal SXRs.

A Self-Help Program for Childhood Asthma in a Residential Treatment Center

A structured program designed to enhance self-treatment was successfully implemented in a residential center for asthmatic children. The ultimate objective of the program was to improve compliance with therapeutic regimens, which was felt to be a factor that had necessitated placement of many of the patients. The program was designed to educate the patient and the patients family regarding the nature of asthma, its treatment and the importance of self-help. Efforts were also made to enhance the emotional maturity of the child. Patients remembered to take their medication over 90% of the time within 1 month of implementation of the program. A similar program was instituted for outpatient use.

Review of Intensive Care Unit Admissions for Asthma

A review of ICU admissions for asthma to the Childrens Hospital of Los Angeles was conducted for the period January 1969 through July 1977. The admission rate remained relatively constant during this period. Patients requiring ICU admission tended to be young, intractable severe asthmatics whose asthma started at a very young age. There were three patients who had no previous history of asthma. The incidence of pneumomitis/atelectasis was somewhat greater than has been reported for patients hospitalized for status asthmaticus. A significant number of children received neither intravenous corticosteroids, sympathomimetics nor oxygen therapy while hospitalized prior to transfer to the ICU. Those children receiving mechanical ventilation or intravenous isoproterenol tended to be somewhat younger and had a higher incidence of pneumonitis/atelectasis and more abnormal blood gas determina tions than their counterparts who were not similarly treated. Mechanical ventilation was administered to 15 patients and 19 patients received intra venous isoproterenol. Intravenous isoproterenol resulted in prompt improve ment in most patients; except for one patient who experienced cardiac arrhyth mia (reversed when the dosage was decreased), this medication was well-tolerated.