Are we adequately managing children with wheeze using the standard case management guidelines?

INTRODUCTION: Prevalence of wheezing is increasing, bronchodilators are sub-optimally utilized and antibiotics are over-prescribed. In Thailand, current case management guidelines based on WHO guidelines, recommend two doses of rapid-acting bronchodilator for children with audible wheeze and fast breathing (FB) and/or lower chest indrawing (LCI). OBJECTIVE: To document the response of children with wheeze with FB and/or LCI to up to three doses of bronchodilator therapy and followed children whose FB and LCI disappeared for 7 days. MATERIAL AND METHOD: We documented response to up to three dose of inhaled salbutamol in consecutively assessed eligible children 1-59 months of age presenting with auscultatory/audible wheeze and FB [WHO defined non-severe pneumonia (NSP)] and/or LCI [WHO defined severe pneumonia (SP)] at the outpatient department of a referral hospital. Data were collected for up to 7 days in responders to bronchodilator therapy. RESULTS: Of 534 children were screened from November 2001 to February 2003, 263 (49.3%) had wheeze and NSP and 271 (50.7%) had wheeze and SP Forty-eight children (9%) had audible wheeze. At screening, 224/263 (85.2%) children in the NSP group and 195/271 (72.0%) in the SP group responded to inhaled salbutamol. 86/419 (20.5%) responded to the third dose of bronchodilator Four hundred and nineteen responders were enrolled and followed up. On follow-up, 14/217 (6.5%) responders among the NSP group and 24/190 (12.6%) among the SP group showed deterioration. Age 1-11 months at screening was identified as an independent predictor of subsequent deterioration. Two seasonal peaks from December to March and from August to October were documented. CONCLUSION: A third dose of bronchodilator therapy at screening will improve the specificity of case management guidelines and reduce antibiotic use. Physicians should use auscultation for management of wheeze.

Factors effecting the outcome of acute respiratory distress syndrome in pediatric patients treated with high frequency oscillatory ventilation.

OBJECTIVES: To evaluate the survival rate and factors affecting the outcome of pediatric patients treated with high-frequency oscillatory ventilation (HFOV) for diffuse alveolar disease (DAD) compatible with acute respiratory distress syndrome (ARDS). METHOD: A cohort study was conducted at the pediatric intensive care unit of Queen Siritkit National Institute of Child Health from 1st January 1999 to 31st December 2001. Children who suffered from DAD compatible with ARDS were enrolled. Inclusion criteria were PaO2/FiO2 < 200 and oxygenation index (OI) > 10. High-frequency oscillatory ventilator (3100A Sensor Medics Corp, Yorba Linda, Calif) was used applying high volume strategy of treatment. Patients were weaned to conventional ventilation (CV) once clinical improvement occurred. Demographic data, duration of CV mode before changing to HFOV, duration of HFOV, ventilator parameters and gas exchange variables from beginning and during the course of HFOV were recorded, so patient data could be compared between surviving and non-surviving groups. RESULTS: A total of 21 children were enrolled during the 3 year period. There were 4 patients with simultaneous air leak syndrome and a total of 10 male patients. The average age was 3.58 +/- 3.9 years. There were 11 surviving patients (52.4%). Data of ventilator parameters and gas exchange variables after changing to HFOV for 4-6 hours for the two groups, FiO2 was higher (0.99 +/- 0.32 vs 0.84 +/- 0.18; p = 0.02) and alveolar arterial oxygen gradient [P(A-a)O2] was lower (448.5 +/- 140.8 vs 562.7 +/- 99.9 mmHg; p = 0.047) in the surviving group than in the non-surviving group. Concerning mean airway pressure (Paw), oxygenation index (OI), P(A-a)O2 and PaO2/FiO2 at initiation and during the course of HFOV with comparison of the surviving and non-surviving groups: Paw and OI decreased in the surviving group and was significantly different at 36 and 24 hours respectively. P(A-a)O2 was statistically significantly lower at 6 hours after HFOV initiation in the surviving group. PaO2/FiO2 was statistically significantly increased at 24 hours in the surviving group. CONCLUSION: Implement of HFOV is useful in patients with DAD, ARDS and air leak syndrome from the initial phase of illness which fulfill criteria for decreasing ventilator induced lung injury and thus decrease the mortality rate from ARDS. Predisposing survival factor showing statistically significant differences was lower Paw during CV before changing to HFOV, lower Paw at 36 hours, lower OI at 24 hours, lower P(A-a)O2 at 6 hours and higher PaO2/FiO2 at 24 hours. These parameters are good indicators for the prognosis of ARDS for patients responding or not responding to HFOV.