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REVIEW ARTICLES
Primary spontaneous pneumothorax in children: A literature review
Ping-Yang Kuo, Bao-Ren Nong, Yung-Feng Huang, Yee-Husan Chiou
April-June 2018, 2(2):25-31
DOI:10.4103/prcm.prcm_3_18  
Studies about primary spontaneous pneumothorax (PSP) in pediatric patients are not as many as in adult patients since the incidence of PSP is lower in children than in adults. There are evidence-based guidelines for the management of PSP in adults, whereas, in children, the approach of PSP is mainly extrapolated from the adult guideline. In this article, aspects of incidence rate, epidemiology, and pathophysiology, diagnosis, management, and recurrence rate about pediatric PSP are discussed.
  2,770 488 -
REVIEW ARTICLE
Nasal high-flow therapy in infants and children
Donna Franklin, Andreas Schibler
January-March 2018, 2(1):2-6
DOI:10.4103/prcm.prcm_22_17  
This review highlights and summarizes the current evidence and knowledge of nasal high flow therapy management in infants and children. This review outlines the distinct differences in the use of NHF therapy between children and adults. A comprehensive literature review has been performed reviewing the relevant physiological studies and current evidence of support measures in these children. Despite the quick uptake of nasal high flow therapy in the clinical area there has been limited high-grade evidence, with new studies showing beneficial results with the use of nasal high flow therapy in acute respiratory disease and children.
  2,599 556 1
Pediatric obstructive sleep apnea: A short review of clinical aspects
Christian Guilleminault, Yu-Shu Huang
April-June 2017, 1(2):39-45
DOI:10.4103/prcm.prcm_7_17  
This report reviews the historical developments leading to recognition of pediatric obstructive sleep apnea. It briefly summarized the rationale why the upper airway becomes at risk of collapsibility during sleep. It also reviews the complaints that vary with age. It emphasizes points of the examination that must be systematically look for. The report reviews the variables to monitor, to look for, and to be analyzed, and patterns not often looked at but that disturb sleep and lead to complaints and symptoms in sleep polysomnography.
  2,651 395 1
ORIGINAL ARTICLES
Focal chest wall protuberance due to forked ribs or cartilages: An analysis of 12 cases
Kin-Sun Wong, Yen-Chun Huang, Shen-Hao Lai, Chih-Yung Chiu
January-March 2017, 1(1):22-24
DOI:10.4103/prcm.prcm_13_16  
Objective: The purpose of this article is to describe and summarize the clinical manifestations and radiographic features of focal bulging of chest walls in children using plain chest radiography and computed tomography (CT) scans. Methods: From 2008 to 2014, we identified 12 patients with forked ribs younger than 18 years of age. These patients received plain chest radiography and computed tomographic scans of the chest for focal anterior chest wall protrusion at the outpatient chest clinic of a children's facility. Results: A total of 12 patients (5 girls and 7 boys; age range, 2–12 years; median, 5 years) were enrolled in this study. Six patients had right-sided costal lesions, four had left-sided lesions, and two had anomalies on both sides. The most common rib involved was the 4th rib. Two patients with forked cartilages and one patient with forked rib were not detected in frontal radiograph but seen by CT scans only. Up to the time of this writing, the follow-up of patients revealed no progression of focal bulging. Conclusion: In otherwise healthy children with asymptomatic focal anterior chest wall bulging, forked ribs is a common cause of variation. The chest radiographs may be normal. Chest CT scans demonstrated forked ribs/cartilage as the cause of focal bulging of the chest wall unequivocally in such instances.
  2,532 195 -
REVIEW ARTICLE
The Asian Paediatric Pulmonology Society (APPS) position statement on childhood obstructive sleep apnea syndrome
Daniel Kwok-Keung Ng, Yu-Shu Huang, Oon-Hoe Teoh, Aroonwan Preutthipan, Zhi-Fei Xu, Takeshi Sugiyama, Kin-Sun Wong, Ka-Li Kwok, Brigitte Kim-Yook Fung, Rachel Shui-Ping Lee, Jonathan Pak-Heng Ng, Shuk-Yu Leung, Da-Tian Che, Albert Martin Li, Tat-Kong Wong, Indu Khosla, Anna M Nathan, Mary Therese M Leopando, Hussein Al Kindy
April-June 2017, 1(2):26-38
DOI:10.4103/prcm.prcm_13_17  
With recognition of the importance of obstructive sleep apnea syndrome (OSAS) in children, practice guidelines have been developed for the management of OSAS in the USA and Europe. A panel of experts in pediatric OSAS in Asia were appointed by the Asian Paediatric Pulmonology Society (APPS) to prepare a position statement for management of childhood OSAS in Asia. The purpose of this statement is to provide a reference standard in the diagnosis and management of childhood OSAS for doctors working in Asia. The expert panel determined the scope of this statement. Focused literature search related to the key topics was conducted by panel members. The final content of this statement was agreed on by all panel members and approved by the council of APPS. The current statement covered diagnostic approach, diagnostic criteria, management algorithm, drug-induced sleep endoscopy, medical treatment including medications and positive pressure ventilation, surgical treatment including adenotonsillectomy, orthodontic treatment, and orofacial myofunctional therapy (OMT). Diagnostic criteria of childhood OSAS from 1 year to 18 years were presented that include both clinical (criteria A) and polysomnography findings (criteria B) in the diagnosis of childhood OSAS. The use of nocturnal pulse oximetry as a screening tool was suggested using the McGill oximetry score. Management of OSAS with medical treatment, tonsillectomy and adenoidectomy (TandA), positive airway pressure, orthodontic devices, nasal valves, and OMT were reviewed. Management of persistent OSAS after TandA was addressed, and the importance of weight control was emphasized. The position statement provides a guideline to the management of childhood OSAS in Asia.
  2,278 362 3
A review of treatment options in paediatric sleep-disordered breathing
Yu-Shu Huang, Christian Guilleminault
July-September 2017, 1(3):54-58
DOI:10.4103/prcm.prcm_5_17  
The clinical presentation of paediatric obstructive sleep apnoea (OSA) is different from that reported in adults. Children with paediatric OSA have more disturbed nocturnal sleep than excessive daytime sleepiness and present with more behavioural problems such as hyperactivity. They have sleep-related issues such as nocturnal enuresis and sleep-terrors and psychiatric problems such as depression and insomnia. Adenotonsillectomy has been the recommended treatment for paediatric OSA, but this practice as the initial treatment for all children has been questioned. The orthodontic approaches have been studied in children. Preliminary studies have suggested that rapid maxillary expansion and mandibular advancement with functional appliances may be effective even in children. Mandibular advancement devices, however, are not recommended for pre-pubertal children. These devices have been used in children in the late-teens, but long-term follow-up data are still lacking. Another non-invasive treatment is myofunctional therapy that has not been widely investigated. In syndromic children and where hypoventilation during sleep is present, positive airway pressure ventilation can be given. Nasal allergies are common in children. Increased nasal resistance impacts on breathing during sleep. Therefore, the treatment of nasal allergies with anti-inflammatory agents is an integral part of the management of paediatric OSA. Another important aspect of paediatric OSA is the presence of a short lingual frenulum and less frequently, a short nasal frenulum. They have been shown to cause abnormal growth of oral-facial region leading to OSA. Gastroesophageal reflux is both a cause and consequence of OSA and should be treated if present. The recent advance in the understanding of the pathogenesis of paediatric OSA lends hope that early recognition and management of factors that lead to the development of OSA may reduce the frequency of this disease and its sequelae. However, these factors are mostly unknown or ignored by specialists and general paediatricians during the early childhood orofacial development.
  2,125 312 1
Asthma: What's new, and what should be old but is not!
Andrew Bush
January-March 2017, 1(1):2-10
DOI:10.4103/prcm.prcm_11_16  
Asthma is a common condition, which is commonly, badly diagnosed and badly treated, leading to unnecessary morbidity and even death in childhood, despite which complacency about management at all levels of care persists. Asthma is an umbrella term like anaemia and arthritis and should not be used as an unqualified diagnosis. It is suggested that airway disease should be deconstructed into treatable and untreatable components, such as fixed and variable airflow obstruction and airway inflammation and infection. Every effort should be made to make an objective diagnosis, and treatment should be individualised accordingly. Objective testing for airway inflammation may include determination of atopic status, blood eosinophil count and exhaled nitric oxide; physiological testing includes peak flow measurement, comprising response to exercise and short-acting μ-2 agonists. Most school-age atopic children with recurrent wheeze respond well to low-dose inhaled corticosteroids if these are regularly and correctly administered. The provision of an asthma plan is mandatory. If response is poor, rather than uncritically escalating therapies, a review of adherence and any adverse environmental factor should be considered. Asthma attacks are a red flag sign of a bad prognosis, and should prompt a full review, and changes in the asthma plan as necessary. Also, regular reviews of progress and treatment need are mandatory, even in the well child with asthma. In all contexts, the importance of getting the basic rights cannot be overemphasised; still, asthma deaths are attributed to neglect of this principle. Other issues discussed in this review include the approach to the child who is breathless on exercise and the diagnosis of exercise-induced laryngeal obstruction; the so-called habit/honk cough; the problem of breathlessness and airway disease in the obese child, including the airway as the target of systemic inflammation; and the problem of 'asthma' complicating other airways diseases such as cystic fibrosis and extrapulmonary diseases such as sickle-cell anaemia. Overall, the main message of this review is that it should never be forgotten that asthma is a disease which kills children and should always be taken seriously.
  2,002 413 3
ORIGINAL ARTICLES
The correlation of exhaled nitric oxide, atopy, and severity of allergic rhinitis in taiwanese children with moderate persistent asthma
Yu-Ting Yu, Shyh-Dar Shyur, Szu-Hung Chu, Yu-Hsuan Kao, Hou-Ling Lung, Wei-Te Lei, Li-Ching Fang, Chien-Hui Yang
January-March 2017, 1(1):17-21
DOI:10.4103/prcm.prcm_12_16  
Background: Allergic rhinitis (AR) is characterized by eosinophilic infiltration and immunoglobulin E (IgE)-mediated reaction after exposure to an allergen. Its severity may be correlated to fractional exhaled nitric oxide (FeNO). This study aimed to evaluate the correlation of FeNO and various parameters with severity of AR in Taiwanese children with moderate persistent asthma. Materials and Methods: The study enrolled 103 children aged 5–18 years with AR and moderate persistent asthma from the Outpatient Department, Mackay Memorial Hospital, Taipei. Based on Total Nasal Symptom Score (TNSS), the patients were divided into high-score group (TNSS ≥5) and low-score group (TNSS <5). Both groups were assessed and compared by FeNO, blood eosinophil percentage, serum total IgE level, specific IgE levels to 8 allergens, and pulmonary function tests. Results: The low-score group showed significantly lower FeNO (18.57 ± 14.47 vs. 26.83 ± 17.84 ppb; P < 0.05), lower blood eosinophil percentage (3.08 ± 3.43 vs. 4.53 ± 3.37%; P < 0.05), lower level of serum total IgE (232.64 ± 438.88 vs. 510.63 ± 732.64 IU/mL; P < 0.05), and lower specific IgE to Dermatophagoides pteronyssinus (Der p), Dermatophagoides farinae (Der f), and dog (1.80 ± 2.35 vs. 3.66 ± 2.23, P < 0.05; 1.78 ± 2.36 vs. 3.56 ± 2.31, P < 0.05; and 0.00 ± 0.00 vs. 0.29 ± 0.81, P < 0.05). There are no significant differences between two groups about forced expiratory volume in 1 s (FEV1) (96.95 ± 13.39 vs. 97.85 ± 14.98% predicted; P = 0.75), FEV1/forced vital capacity percentage (89.00 ± 9.78 vs. 90.20 ± 5.85%; P = 0.47), and forced expiratory flow 25%–75% (55.16 ± 18.48 vs. 56.75 ± 20.15% predicted; P = 0.68). Conclusions: Taiwanese children with moderate persistent asthma with more severe symptoms of AR are significantly associated with higher levels of FeNO, total IgE, specific IgE to Der p, Der f, and dog, and higher blood eosinophil percentage.
  2,023 171 -
The predictive factors in preschool wheezers for subsequent asthma hospitalization after the age of 6 years
Pui-Tak Yu, Johnny Yick-Chun Chan, Freddie Poon, Rachel Shui-Ping Lee, Shuk-Yu Leung, Jonathan Pak-Heng Ng, Ka-Ka Siu, Ada Yuen-Fong Yip, Ka-Li Kwok, Eric Yat-Tung Chan, Jeff Chin-Pang Wong, Daniel Kwok-Keung Ng
January-March 2017, 1(1):11-16
DOI:10.4103/prcm.prcm_15_16  
Background: Preschool children with wheeze may develop asthma later at school age. Positive skin prick test (SPT) to common aeroallergens in preschool wheezers may be associated with a higher chance of developing asthma at school age. Methods: All patients with SPT performed for the indication of preschool wheeze, i.e., before the age of 6 years, were included in the study from 1999 to 2011. Outcome measures including asthmatic attack requiring emergency hospitalization and the need for asthma controller prescription after the age of 6 years were retrieved from the hospital database. Potential risk factors including gender, family history of asthma, blood eosinophilia, environmental tobacco exposure, personal eczema, and allergic rhinitis were also retrieved for analysis. Multiple logistic regression was performed to identify independent risk factors. Results: Altogether, 463 children were included for analysis with mean age at SPT of 3.1 ± 1.36 years and 64.6% were male. Positive SPT results were obtained in 60.5% of patients. For preschool children with wheeze, female gender (odds ratio [OR] = 1.90, 95% confidence interval [CI]: 1.04–3.46, P = 0.036), positive SPT (OR = 2.96, 95% CI: 1.40–6.24, P = 0.004), and late-onset preschool wheeze hospitalization (OR = 2.82, 95% CI: 1.42–5.61, P = 0.003) were associated with a higher chance of asthmatic hospitalization after the age of 6 years. Allergic rhinitis (OR = 4.58, 95% CI: 2.16–9.71, P < 0.001) and family history of asthma (OR = 1.82, 95% CI: 1.09–3.02, P = 0.022) were associated with higher chance for asthma controller prescription. Conclusion: For preschool wheeze, female gender, positive SPT, and late-onset preschool wheeze index are associated with a higher chance of asthmatic hospitalization after the age of 6 years while allergic rhinitis and family history of asthma are associated with a higher chance for asthma controller prescription after the age of 6 years.
  1,835 306 2
ORIGINAL ARTICLE
Correlation between 6-min walk test and cardiopulmonary exercise test in Chinese patients
Pik-Fung Wong, Eric Yat-Tung Chan, Daniel Kwok-Keung Ng, Ka-Li Kwok, Ada Yuen-Fong Yip, Shuk-Yu Leung
April-June 2018, 2(2):32-35
DOI:10.4103/prcm.prcm_24_17  
Aim: The aim of the study was to evaluate the correlation between the 6-min walk test (6MWT) and the cardiopulmonary exercise test (CPET) in Chinese pediatric patients. Methods: A retrospective review was undertaken for Chinese patients with exercise intolerance who had undergone both 6MWT and CPET on the same day over 21 months. Pearson's correlation analysis was used to examine the correlation between the 6-min walk distance (6MWD) and the maximum oxygen uptake (VO2 max). The 6MWD was defined as abnormal if <10th percentile of height-matched reference, and the VO2 maxwas defined as abnormal if <80% predicted. Results: Twenty-nine patients with a mean age of 14.3 ± 3.6 years were included in the study. The correlation coefficient (r) between the 6MWD and the VO2 maxwas 0.457 with P = 0.013. Twenty-six (three excluded as no reference for VO2 maxwas available for age <10 years) patients were analyzed. Using CPET as the gold standard for functional exercise capacity, 6MWT had a positive predictive value (PPV) of 92%, negative predictive value of 29%, sensitivity of 52%, specificity of 80%, and accuracy of 58% for assessing exercise capacity. Conclusion: 6MWT had a high PPV for abnormal CPET. It could still be used as a simple tool to evaluate patients with exercise intolerance.
  1,720 250 -
ORIGINAL ARTICLES
Utilization of vibrating mesh nebulizer in the treatment of infants with acute bronchiolitis: A randomized, controlled trial
I-Ping Wu, Ming-Yi Chien, Hsiu-Feng Hsiao, Eric YT Chen, Yun-Yueh Liu, Chang-Wei Chou, Shen-Hao Lai
July-September 2017, 1(3):63-68
DOI:10.4103/prcm.prcm_17_17  
Background: Bronchiolitis is a disease that is predominantly caused by the infection of peripheral airway due to respiratory syncytial virus (RSV). The occurrence is highly prevalent among childhood stage with seasonal outbreak peak during fall and spring. Treatment of bronchiolitis invariably involves lengthy hospitalization, which places significant socio-economic burden on family caregivers and healthcare system. Aerosolizing hypertonic saline using small-volume jet nebulizer (SVN) remains as one of the effective therapies to alleviate symptoms in infants with acute bronchiolitis. However, such approach not only restraints treatment to hospitalization and can irritate patients with loud noise. It is unclear whether an alternative aerosol therapy that offers similar efficacy yet enhances portability, convenience and quiet operation is available. Materials and Methods: Herein we showed that a vibrating mesh nebulizer (VMN) offered quiet delivery and undisturbed nebulization yet harnessed similar improvement in clinical symptoms in contrast with SVN when treating hospitalized infants with acute bronchiolitis. Results: A total of 64 hospitalized infants (<12 months of age) with acute bronchiolitis were enrolled. Subjects were randomly assigned to SVN (n=32) and VMN (n=32) groups and had received the same aerosol treatment protocol during hospitalization. Besides respiratory rate, the initial overall severity score; hospital stay duration; and intravascular-line day for both groups (SVN vs VMN) were similar. The data were 4.30±1.44 vs 4.92±1.3; 3.97±1.88 vs 3.94±1.66 days; 2.31±1.47 vs 2.16±1.46 days correspondingly. However, a higher satisfaction score (4.8/5) was shown in a corresponding questionnaire indicating user preference in VMN due to enhanced portability, ease of clean and operation, and less-noise. These advantages could potentially facilitate bronchiolitis treatment and follow-up maintenance at home. Conclusion: In sum, the treatment outcome for infants with acute bronchiolitis was equivalent between SVN and VMN. Easy portability and simple operation features of VMN may present a much favored therapeutic option for home care users.
  1,700 261 -
REVIEW ARTICLES
'Suppurative lung disease' in children
Mark Lloyd Everard
April-June 2018, 2(2):18-24
DOI:10.4103/prcm.prcm_6_18  
A chronic neutrophil dominated bronchitis also known variously as PBB and CSLD is relatively common in childhood. There are numerous risk factors that may contribute to the development of a chronic bronchitis [inc viral LRTIs, malacia, aspiration, poorly controlled asthma etc.]. In most cases a specific significant on-going risk factor such as CF is not identified. It is under-diagnosed due to lack of awareness (if you do not know something exists you will never diagnose it). It is commonly mis-diagnosed as 'asthma' or 'recurrent chest infections'. Diagnosis is based on pattern recognition and response to treatment analogous to accurate diagnosis of asthma. Response to treatment must be dramatic and unequivocal to make a definite diagnosis. Beware regression to the mean PBB is a biofilm disease leading to challenges in treatment. A PBB is the cause of most cases of 'bronchiectasis'. Bronchiectasis is a radiological or pathological appearance, not a disease. Most cases are curable in the absence of a major underlying risk factor such as cystic fibrosis, PCD or significant immunodeficiency. Hence bronchiectasis is a largely preventable radiological appearance.
  1,631 265 -
ORIGINAL ARTICLES
Air pollution as a risk factor for increasing hospitalizations of preschool wheeze in Hong Kong
Ka-Ka Siu, Chin-Pang Wong, Rachel Shui-Ping Lee, Jack Pak-Yeung Chan, Shuk-Yu Leung, Eric Yat-Tung Chan, Ka-Li Kwok, Ada Yuen-Fong Yip, Rupert Phillips, Daniel Kwok-Keung Ng
January-March 2018, 2(1):11-15
DOI:10.4103/prcm.prcm_23_17  
Background: Wheeze has been reported to affect one-third of preschoolchildren. While different wheeze patterns have been shown to predict future asthma risk, limited data are available on the risk factors for preschool wheeze in Asia. Methods: Preschool children admitted to hospitals through emergency departments for wheeze, from 2004 to 2015 in Hong Kong, were retrospectively identified. Potential risk factors for admissions over the same period were retrieved (i.e., air pollutants, preterm delivery, and maternal age). Results: A total of 46,258 patients meeting the inclusion criteria were identified during the 12-year period. The preschool wheeze admission rate increased by 34% over the past 12 years, with an average year-on-year rise of 4.2%. Environmental nitrogen dioxide (NO2) concentration was significantly associated with an increase in admission for preschool wheeze (r = 0.63, P = 0.028). Univariate regression analysis was performed on potential risk factors. Annual average NO2concentration (P = 0.007) and maternal age more than 40 years (P = 0.012) were significant risk factors. For multivariable regression analysis, annual average NO2concentration (β = 0.18, 95% confidence interval = 0.06–0.30) was the only independent factor associated with preschool wheeze admission. Conclusions: The increase of NO2concentration is a significant risk factor for the increase in hospitalizations for preschool wheeze in Hong Kong.
  1,560 204 -
Role of biocard Mycoplasma immunoglobulin M rapid test in the diagnosis of Mycoplasma pneumoniae infection
Ta-Yu Liu, Hong-Ren Yu, Wei-Ju Lee, Chih-Min Tsai, Kuang-Che Kuo, Chih-Hao Chang, Yu-Tsun Su, Sui-Ching Wang, Chen-Kuang Niu, Kai-Sheng Hsieh
January-March 2018, 2(1):7-10
DOI:10.4103/prcm.prcm_30_17  
Background: Mycoplasma pneumoniae is an important pathogenic bacterium that causes community-acquired pneumonia in children. Rapid and dependable laboratory diagnosis of M. pneumoniae infection is important for starting an appropriate antibiotic treatment. Currently, the serological testing for detection of M. pneumoniae immunoglobulin M (IgM) has been used to determine the presence of an acute infection, the results of which, depending on the laboratory facility, are not available immediately. Therefore, an optimal and instant detection method is needed to facilitate a more accurate diagnosis, which leads to the appropriate treatment of patients with M. pneumoniae-related pneumonia and reduces rates of resistance to antibiotics because of their misuse. Aims: Here, we investigated the clinical diagnostic value of a rapid detection kit for M. pneumoniae-specific IgM antibody, the BioCard Mycoplasma IgM rapid test, in the detection of a Mycoplasma infection in children. Material and Method: 44 pediatric patients with clinically suspected Mycoplasma infection were enrolled for study. Result: Among 82 Mycoplasma IgM-positive samples, 51 samples were detected to be positive using the BioCard rapid test. The sensitivity and specifi city of the kit were 62.20% (51/82) and 100% (16/16), respectively. The positive and negative predictive values were 100% (51/51) and 34.04% (16/47), respectively. Conslusion: In conclusion, the BioCard Mycoplasma IgM rapid test provides an accurate point-of-care diagnosis for M. pneumonia infection.
  1,410 211 -
Prevalence and risk factors for symptoms of attention deficit and hyperactivity in primary snoring children
Mei-Ching Chan, Sharon Wan-Wah Cherk, Ka-Li Kwok, Shuk-Yu Leung, Jonathan Pak-Heng Ng, Rachel Shui-Ping Lee, Tracy Man-Kiu Ma
July-September 2017, 1(3):59-62
DOI:10.4103/prcm.prcm_15_17  
Aim: Primary snoring was reported to affect 7.2% of school children in Hong Kong, and emerging evidence suggested that neurobehavioural symptoms were more frequently found among this group of children. The current study investigated the prevalence of symptoms of attention deficit hyperactivity disorder (ADHD) i.e., attention deficit, hyperactivity and impulsivity (ADHI), in Chinese children with primary snoring. Materials and Methods: Polysomnography results and relevant clinical notes for all Chinese children aged 4–18-year performed from January 2009 to December 2010 in our sleep laboratory were retrospectively reviewed. Data of the Chinese version of modified Epworth Sleepiness Scale and C-domain of Paediatric Sleep Questionnaire were analysed. Results: In primary snorers, the presence of excessive daytime sleepiness (EDS) and higher apnoea–hypopnea index (AHI) were risk factors for symptoms of AD with adjusted odds ratio of 3.2 (95% confidence interval [CI] = 1.2–8.1) and 4.7 (95% CI = 1.1–20.7), respectively. Primary snorer with AD symptoms had higher AHI, 0.32 ± 0.31 compared those without symptoms, 0.21 ± 0.29, P = 0.038. EDS was an independent risk factor for ADHI with odds ratio of 4.7 (95% CI = 1.1–20.0). Conclusion: Early screening for symptoms of ADHD should be performed in children with primary snoring.
  1,415 199 1
Viruses and hospitalization for childhood lower respiratory tract infection in Malaysia: A prospective study
Anna Marie Nathan, Yun Lee Qiao, Faizatul Lela Jafar, Yoke-Fun Chan, Kah Peng Eg, Surendran Thavagnanam, Sazaly Abu Bakar, I-Ching Sam, Jessie Anne deBruyne
April-June 2017, 1(2):46-51
DOI:10.4103/prcm.prcm_2_17  
Context: Viruses are the main causes of acute lower respiratory tract infections (ALRIs) in childhood and its impact on hospital admission is largely unknown. Aims: The aim of this study is to determine (a) virus detection, (b) risk factors for admission, particularly virus detection, and (c) differential clinical responses to viral infections, in children attending pediatric emergency department (PED) with an ALRI in Malaysia. Subjects and Methods: This prospective study included children ≤2 years who presented to PED between September 1, 2010, and March 6, 2012, with features of lower respiratory tract infection. Nasopharyngeal aspirates (NPAs) were tested using a multiplex polymerase chain reaction (PCR) for 11 respiratory viruses. Results: Two hundred children were recruited in the study. Two-thirds (65.5%) of them were admitted. NPA-PCR was positive in 54% of all patients: 50.4% of those admitted and 60.9% of those discharged. The most common viruses detected were respiratory syncytial virus (RSV) (49.1%), rhinovirus (30.6%), and parainfluenza viruses (12.0%). Five patients had mixed infections. RSV detection was associated with previous history of wheeze (odds ratio, 2.05 [95% confidence interval 1.06, 4.00]). Viruses were detected in all severely ill patients and patients with apnea. Multivariate analysis showed that virus detection was not associated with the need for admission, but female sex, lack of breastfeeding and, attending nursery were associated with hospitalization. Conclusions: Half of the children who presented to the emergency room with ALRI had viruses detected in their NPA. There was no association between virus detection and hospitalization. RSV was associated with history of wheeze. Female gender, lack of breastfeeding, and nursery attendance were associated with hospitalization.
  1,377 231 3
Modified high-flow nasal cannula in young children with pneumonia: A 3-year retrospective study
Issaranee Vareesunthorn, Aroonwan Preutthipan
July-September 2018, 2(3):45-50
DOI:10.4103/prcm.prcm_2_18  
Objectives: We aimed to report our 3-year experience in modified HFNC (MHFNC) usage in young children with community-acquired pneumonia in infectious diseases ward and to identify factors associated with MHFNC failure. Materials and Methods: A retrospective, cross-sectional study of pediatric patients, aged <5 years, with community-acquired pneumonia, who were treated with MHFNC at infectious diseases from August 2012 to December 2015 were recruited. MHFNC failure was defined as a need for further respiratory support within 48 h after initiating MHFNC. Patients: Ninety-nine patients with community-acquired pneumonia were included in this study. Setting: A tertiary care hospital. Measurements and Results: Ninety-nine children (median age of 14 months, body weight 8.6 + 3.1 kg) were included. Ninety-two children (93%) were successfully treated with MHFNC and only seven (7%) were in the failure group. The maximal flow was 3 L/kg/min. Lower oxygen saturation (SpO2)/fraction of inspired oxygen (FiO2) ratio (<264) and higher FiO2 requirement were found to be associated with failure. Maximum FiO2 requirement >0.5 had high odds ratios (22.25) to develop MHFNC failure. No serious complication from MHFNC was found. Conclusions: MHFNC is a practical respiratory support in young children with pneumonia. SpO2/FiO2 ratio (<264) and FiO2 requirement >0.5 is a risk factor for MHFNC failure.
  1,200 211 1
Validation of a modified pediatric risk of mortality III model in a pediatric intensive care unit in Thailand
Kanokpan Ruangnapa, Sittikiat Sucheewakul, Tippawan Liabsuetrakul, Edward McNeil, Kantara Lim, Wanaporn Anantaseree
October-December 2018, 2(4):65-72
DOI:10.4103/prcm.prcm_11_18  
Objective: The objective of this study is to compare the performance of a modified Pediatric Risk of Mortality (PRISM) III model with the original PRISM III in prediction of mortality risk in a Thailand pediatric intensive care unit (PICU). Subjects and Methods: Children aged 1 month to 18 years who stayed in the PICU for more than 8 h during November 2013 to December 2016 were included in the study. Results: The medical records of 1175 PICU patients were included in the analysis. The patients were randomly split into two equal groups: a development (n = 588) and a validation (n = 587) sample. A modified PRISM III model was derived from the original PRISM III by omitting arterial blood gas parameters and adding selected clinical variables. The model was developed using a multiple logistic regression model on the development sample and assessed using the area under the curve (AUC) obtained from a receiver operating characteristic curve. The modified PRISM III scores were significantly higher in nonsurvivors (median = 9, interquartile range [IQR] = 4 − 13) compared to survivors (median = 2, IQR = 0 − 5). The modified PRISM III model had similar discriminative performances compared to the original PRISM III in predicting 2-day mortality (AUC: 0.874 vs. 0.873), 7-day mortality (AUC: 0.851 vs. 0.851) and overall mortality (AUC: 0.845 vs. 0.956). The modified PRISM III model was calibrated in the validation sample, and the standardized mortality ratios (SMRs) were similar. Conclusions: The performance of a modified PRISM III model in predicting mortality risk was comparable to the original PRISM III. Both had similar discriminative performance and SMR for overall mortality prediction in a PICU.
  1,194 197 1
Comparison of ventilator-associated pneumonia in children using disposable and nondisposable ventilator circuits
Panida Srisan, Kallayanee Meechaijaroenying
October-December 2017, 1(4):77-80
DOI:10.4103/prcm.prcm_21_17  
Aims: The aim of the study was to compare the incidence of ventilator-associated pneumonia (VAP), mortality, and ventilator circuit-related cost associated with patients using disposable ventilator circuit to those associated with patients using nondisposable ventilator circuit. Setting and Design: A prospective randomized controlled study in a 10-bed Pediatric Intensive Care Unit at Queen Sirikit National Institute of Child Health between November 2011 and October 2012. Subjects and Methods: Children aged 1 month to 18 years who were ventilated >48 h were enrolled. Patients were randomized to be ventilated with a disposable or nondisposable heated wire ventilator circuit. Statistical Analysis Used: Statistical analysis was performed using SPSS version 17.0. The P < 0.05 was considered statistically significant. Results: Ninety-eight patients were enrolled. Of these, 48 were administered the disposable ventilator circuit, whereas 50 were administered the nondisposable ventilator circuit. The VAP rate was 20.53/1000 ventilator days for the former (n = 7) compared to 30.77/1000 ventilator days (n = 12) for the latter (odds ratio: 1.85; 95% confidence interval: 0.66–5.19, P = 0.24). The mortality rates were 2.1% in the disposable and 12% in the nondisposable circuit groups (P = 0.06). The unit cost of the disposable circuit (US dollar [USD] 51.60) was higher than that of the nondisposable circuit (USD 37.90). However, the total cost for the nondisposable group was higher due to the required use of more units (63 circuits for the disposable group vs. 95 circuits for the nondisposable group). Conclusions: The type of ventilator circuit is not likely to affect the VAP rate and mortality in children. The unit cost of a disposable circuit is higher than that of a nondisposable circuit. The total cost depends on the number of circuits used in each patient.
  1,158 220 1
REVIEW ARTICLE
Pediatric interventional flexible bronchoscopy
Wen-Jue Soong
July-September 2018, 2(3):38-44
DOI:10.4103/prcm.prcm_12_18  
Pediatric interventional flexible bronchoscopy (IFB) procedures are difficult to standardize because of a lack of consensus across different countries. The current literature are scant with retrospective case series or case reports in single center only. The main aim of IFB is to keep an enough and patent central airway lumen. The prerequisites are secure environment, skillful technique, appropriate instruments, clear airway vision, and maintenance of cardiopulmonary status of patients. Noninvasive ventilation (NIV) with pharyngeal oxygen with intermittent nose-closure and abdomen-compression or Soong's ventilation is the preferred method in the author's center as it provides a simple and reliable ventilation support during IFB. Pulmonologists should be trained in basic IFB procedures such as tracheobronchial intubation, bronchoalveolar lavage, balloon dilatation, laser ablation, cryotherapy, or even stent placement and maintenance. Pulmonologists should achieve and maintain high skill levels during their career. There is a rapidly evolving IFB role for in the intensive care units (ICUs) because of critical and cardiopulmonary compromised patients. IFB procedures require intense training and a multidisciplinary approach for patient care. With developing technology, the role of IFB is destined to grow. The IFB modality of using short-length bronchoscopes, supported with a NIV and ICU facilities is a viable, instant, and effective management in pediatric patients. Successful IFB could result in rapid weaning of respiratory supports in ICU without the need for transport to the operation theater and more invasive procedure.
  1,162 201 1
Obstructive sleep-disordered breathing in children: Impact on the developing brain
Lisa M Walter, Rosemary S C Horne
October-December 2018, 2(4):58-64
DOI:10.4103/prcm.prcm_16_18  
Obstructive sleep-disordered breathing (SDB) affects up to 11% of children and forms a continuum of severity ranging from primary snoring to obstructive sleep apnea. Children with SDB exhibit significant neurocognitive and cardiovascular dysfunction, which is associated with repetitive hypoxia and sleep fragmentation that characterize the condition. We reviewed the recent literature pertaining to the effect of SDB on the brain in children. These include studies that utilized near-infrared spectroscopy to determine cerebral oxygenation and structural and functional magnetic resonance imaging (MRI) of the brain. Studies have identified that the effect of SDB on cerebral oxygenation in children is minimal and not clinically significant. There are conflicting reports on the association between the measures of cerebral oxygenation and peripheral arterial oxygen saturation (SpO2), and further research needs to be conducted to elucidate the relationship between peripheral SpO2, cerebral oxygenation, and SDB in children. MRI studies have reported significant structural and functional changes to the brains of children with SDB, in brain regions associated with neurocognition, behavior, and autonomic function. These include reduced white and gray matter and structural changes to a multitude of brain areas including, but not limited to, the hippocampus, cortex, amygdala, insula, thalamus, cerebellum, and basal ganglia. These studies utilize a variety of MRI techniques to address different research questions, but contribute to the gradually developing picture of the adverse effects of SDB on the brain in children.
  1,146 205 -
ORIGINAL ARTICLES
Airway disease and environmental aeroallergens in eczematics approaching adulthood
Ellis Kam Lun Hon, Meiruo Liu, Benny Zee
October-December 2017, 1(4):81-85
DOI:10.4103/prcm.prcm_18_17  
Background: Atopic eczema (AE) is one of the most common skin diseases affecting children and adults worldwide. The “Atopic March” paradigm suggests AE is part of a complex condition with related airway disease. Objective: This study aimed to evaluate the prevalence of airway disease, environmental aeroallergens, and review factors associated with eczema severity and quality of life (QoL) when AE patients approached adulthood. Methods: Patients who were diagnosed with AE at a young age were included in the study and followed up till their adolescence at pediatric dermatology clinics from 2000 to 2017. Demographic characteristics, clinical laboratory parameters, treatment history, personal atopic history, as well as disease outcomes assessed by Nottingham Eczema Severity Score (NESS) and Children Dermatology Quality Life Index (CDLQI) were reviewed. Results: Three hundred and eighty-three patients (55.4% males) with latest NESS at mean (standard deviation) age 16.23 (2.50) years were reviewed. Personal history of asthma (45%), allergic rhinitis (74%), and family history of atopy were prevalent. Seventy-two percent of the patients were skin prick testing positive for house dust mite, 27% for cockroach, 33% for cat fur, and 13% for dog fur. Fourteen percent reported “smokers in family”. Multiple logistic regression showed “food avoidance ever” (adjusted odds ratio [OR] =3.00, 95% confidence interval [CI] =1.08–8.32; P = 0.035) and log-transformed immunoglobulin E (IgE) (adjusted OR = 1.45, 95% CI = 1.09–1.92; P = 0.011) were significantly associated with more severe AE. Linear regression showed “food avoidance ever” (β = 1.79, 95% CI = 0.34–3.24; P = 0.016), higher log-transformed IgE (β = 0.62; 95% CI = 0.22–1.03; P = 0.003), dog dander sensitization (β = 2.07, 95% CI = 0.24–3.89; P = 0.027), and severe disease (β = 2.97, 95% CI = 2.26–3.68; P < 0.001) were significantly associated with QoL impairment. Conclusions: A number of patients do not grow out of their eczema, and many of them have allergic rhinitis and asthma co-morbidities. Toward adulthood, AE severity and QoL are associated with food avoidance and high IgE, but generally independent of family or personal history of airway disease and allergen sensitization. Blood IgE measurement may help assess the risk for more severe eczema when patients are becoming adults.
  1,171 176 2
EDITORIAL
Habitual snoring is probably pathological in children
Daniel Kwok-Keung Ng
July-September 2017, 1(3):53-53
DOI:10.4103/prcm.prcm_19_17  
  1,184 161 -
ERRATUM
The Asian Paediatric Pulmonology Society (APPS) position statement on childhood obstructive sleep apnea syndrome

July-September 2017, 1(3):69-69
DOI:10.4103/WKMP-0132.216541  
  1,164 176 -
EDITORIAL
The challenges for paediatric respirologists
Daniel Kwok-Keung Ng
October-December 2017, 1(4):71-71
DOI:10.4103/prcm.prcm_1_18  
  1,062 238 -