Etiology of Hemoptysis in Children and Adolescents – Multicentric Retrospective Data (2012-2021) From Chennai

Objective: To analyze the etiology of hemoptysis in children and to correlate the severity of bleed with the etiology. Methods: This retrospective multicentre study reviewed data from inpatient units of four tertiary care public and private sector pediatric hospitals in Tamil Nadu. Methods: Inpatient case records of children (aged 2 month-15 years) treated for hemoptysis at the four institutions between April, 2012 and March, 2021 were identified, after ethical clearance from respective institutions. Data of children with underlying known bleeding disorders like hemophilia or platelet abnormality were excluded from the study. Hemoptysis was categorized as mild, moderate and severe Results: Of the 73 children who had presented with hemoptysis during the study period, 60 (82.2%) children had mild, 9 (12.3%) had moderate and rest had severe hemoptysis. Idiopathic pulmonary hemorrhage was the most common cause of hemoptysis. The common causes of mild hemoptysis in children were idiopathic pulmonary hemorrhage (n=15, 25%), pulmonary tuberculosis (n=12, 20%) and pneumonia (n=8, 13.3%). Congenital airway anomalies and vascular anomalies were more likely to present with moderate to severe bleed. Conclusion: Etiology of hemoptysis is broad and categorizing them into mild, moderate and severe may give a clue about the possible etiology, there by restricting to the required investigations.

Laser Treatment of a Tracheal Inflammatory Myofibroblastic Tumor

Background: Inflammatory myofibroblastic tumors of the trachea are rare childhoodquasi-neoplastic lesions. Case characteristics: 7-year-old boy with recurrent episodesof cough, breathing difficulty and wheeze, initially treated as asthma. Intervention: CTchest and flexible bronchoscopy revealed a mass lesion of the trachea, which wasexcised by diode laser through the ventilating bronchoscope. Histopathology confirmed itas the inflammatory myofibroblastic tumor. Message: Use of laser ensured completeendotracheal excision of the tumor.

Clinical Characteristics and Associated Congenital Lesions with Tracheomalacia in Infants

Objective: To describe clinical presentation, bronchoscopy findings and associatedanomalies in cases of congenital tracheomalacia in infants (age <1y). Methods: Hospitalrecord review of 88 infants (mean age 8 mo, 57 males) diagnosed as having tracheomalaciaby flexible bronchoscopy between 2012 and 2015. Results: The predominant features werewheeze (57.9%), stridor (42.1%), cough (38.6%), pneumonia (29.5%) and collapse (12.5%).On bronchoscopy, malacia was observed in lower half of trachea in 51 (57.9%) infants.Synchronized airway lesions observed were laryngomalacia (30.7%) and bronchomalacia(3.4%). 15 (17%) infants had associated congenital heart disease and 21 (23.8%) requiredcare in intensive care unit. Conclusion: Wheeze,stridor and cough are the main symptomsin tracheomalacia. Laryngomalacia and congenital heart diseases are the most commonother anomalies associated in these infants.

Airway Diseases Education and Expertise (ADEX ) in Pediatrics: Adaptation for Clinical Practice in India.

Justification: Asthma and allergic rhinitis together are part of the concept of ‘one airway, one disease’ or ‘united airway disease’. The management of allergic airway diseases should address this united concept and manage the issue by educating the patients and their parents and health care providers, along with environmental control measures, pharmacotherapy and immunotherapy. Here, we present recommendations from the module of ‘Airway Diseases Education and Expertise’ (ADEX) that focused on allergic rhinitis, asthma and sleep disorder breathing as a single entity or Allergic Airway Disease. Process: A working committee was formed by the collaboration of Pediatric Allergy Association of India (PAAI) and Indian Academy of Pediatrics (IAP) Allergy and Applied Immunology chapter to develop a training module on united airway disease. Objectives: To increase awareness, understanding and acceptance of the concept of "United Airway disease" and to educate the primary health care providers for children and public health officials, in the management of united airway diseases. Recommendations: Recommendations for diagnosis, management and follow-up of Allergic airway disease are presented in this document. A better compliance by linking education of child, parent, grandparents and other health care providers, and scientific progress by collaboration between practitioners, academicians, researchers and pharmaceutical companies is suggested.

Tracheobronchomalacia Presenting as Infantile Wheeze.

We report six months old infant with a history of recurrent wheeze, admitted for foreign body aspiration like presentation, where fibreoptic bronchoscopy revealed the diagnosis of tracheobronchomalacia.

Fiberoptic Bronchoscopy in Unresolved Atelectasis in Infants.

This retrospective analysis documents the usefulness of fiberoptic bronchoscopy in finding the etiology of 56 cases of unresolved atelectasis in infancy, over a two year period (June 2005 to May 2007). Fiberoptic bronchoscopy identified the etiology leading to a revised diagnosis and change in management strategy in 38 (67.8%) cases, which included congenital airway anomalies (46.4%), inflammatory changes (10.7%), mucus plugs (28.5%), hypoplasia (4%), endobronchial granulation tissue (3.5%) and foreign body (3.5%). Fiberoptic bronchoscopy plays an important role in diagnostic work up of infants with unresolved atelectasis.

Lower airway anomalies in infants with laryngomalacia.

Objective. To study the prevalence of associated airway anomalies in infants presenting with moderate to severe laryngomalacia. Methods. Eighty three symptomatic infants with recurrent respiratory symptoms including wheeze and cough diagnosed as moderate to severe laryngomalacia based on their clinical and direct laryngoscopic findings were subjected to fiberoptic bronchoscopy (FOB) during the period March 2007 to February 2009 in the Department of Pulmonology, Institute of Child Health and Hospital for Children, Chennai, India. Analysis of the clinical features, radiological findings and associated lower airway anomalies by FOB was done. Results. Lower airway anomalies were demonstrated in 40 (48%) infants of the study population. Tracheomalacia was the most common lower airway anomaly 24(29%) followed by bronchomalacia 8(10%) and tracheobronchomalacia 6 (7%). (4:1:1). Conclusion. Infants with moderate and severe laryngomalacia should be evaluated with flexible fibreoptic bronchoscopy to rule out associated lower airway lesions.

Mantoux and contact positivity in tuberculosis.

OBJECTIVE: To study the role of Mantoux and contact history in various forms of Childhood tuberculosis. METHODS: 605 children registered with TB clinic of Institute of Child Health and Hospital for Children, Chennai over a 5 year period from January 2000 to October 2005 with various forms of tuberculosis were recruited in the study. Clinical examination findings, basic investigations, chest skiagrams, computerized tomography (CT) wherever warranted, sputum or gastric aspirates for AFB smear, histopathology wherever possible were analyzed. RESULTS: The study showed that Mantoux positivity in various forms of tuberculosis studied is 34.7%. The positivity of Mantoux was highest in lymph node tuberculosis (53%) and the lowest with CNS tuberculosis (21.2%). Among the other forms, Mantoux positivity was 36.4% in TB abdomen, 44.4% in Skeletal TB, 30.3% in pulmonary tuberculosis. The contact positivity was 30.4% in the sample studied. CONCLUSION: The study also reflects that the extra pulmonary forms of tuberculosis seems to be more common in the pediatric population which constituted 79.8% of the cases included in the study.

Pediatric interstitial lung disease.

This study was done to ascertain the symptomatology, clinical features and investigations pertaining to interstitial lung diseases (ILD) in children. The medical records of 16 children admitted over a 4-year period from June 2000 to May 2004 with progressive cough, dyspnea, and chest X-ray/High Resolution Computerized Tomography (HRCT) abnormalities suggesting ILD were retrospectively evaluated. Clinical findings, investigations, chest skiagrams, HRCT, bronchoalveolar lavage (BAL) and lung biopsy reports were analyzed. An acute presentation of symptoms was seen in 4 cases (25%). Velcro crackles were the commonest clinical finding, present in 15 cases (93.8%). Serial X-rays revealed findings suggestive of ILD in 12 cases (75%) and HRCT was diagnostic in 13 cases (86.6%). Spirometry done in 5 cases showed a restrictive ventilatory defect, BAL analysis done in 8 cases demonstrated increased neutrophils and lung biopsy done in 5 cases was consistent with idiopathic pulmonary fibrosis. Mean survival duration of 2 years and 7 months after initial diagnosis was observed.

Acute plastic bronchitis.

Plastic bronchitis is a rare disorder characterized by the formation of bronchial cast. The etiology is obscure, though usually associated with conditions like asthma, aspergillosis, pneumonia, cystic fibrosis and cardiac problems.

Bronchoscopist talks to you.

Fiberoptic bronchoscopy (FBS) is an important entry in the armamentarium of procedures listed in management of respiratory problems. It is a simple and a safe procedure. FBS has a great scope for diagnosis as well as therapy in pediatric respiratory illnesses. This article gives a practical overview of FBS in pediatric practice.

Empyema thoracis.

Parapneumonic effusion and empyema thoracis remains a significant source of morbidity in children, though the overall incidence of empyema thoracis has decreased in the past two decades. These conditions pose a dilemma regarding evaluation and treatment for the treating physician. This article discusses the practical strategies in the management of empyema thoracis in children.

Bronchoalveolar lavage in pediatrics.

Bronchoalveolar lavage is a relatively new technique that is used to study the local cellular, biochemical and immunological changes occurring in the lower respiratory tract. The procedure involves instilling a fixed volume of saline into a lung segment after the flexible fibreoptic bronchoscope is wedged into a distal bronchus. The saline is aspirated back and can be used for microbiological and other studies. Recently, attempts have been made to standardise the procedure in children and obtain data on BAL cellular profile in healthy children. The main indications for BAL are diagnostic, particularly to diagnose unusual infections in immunocompromised children. It is also helpful in the diagnosis of a number on non infectious conditions, based on the cellular profile and other constituents. With the availability of new techniques like flow cytometry, analysis of lymphocyte and other cell subsets has become possible leading to a better understanding of the immunopathogenesis of various respiratory diseases.

Flexible fiberoptic bronchoscopy.

The value of flexible fiberoptic bronchoscopy in children are increasing day by day, but still underutilized even in many advanced institutions. 630 Fiberoptic bronchoscopy procedures under local anaesthesia were performed for various clinical conditions for diagnosis and therapy. Nasal route is preferred than oral route. Therapeutic indications are more in children than adults. Nearly one third of children with collapse, consolidation have shown radiological clearance after repeated bronchoscopy.

Childhood asthma--advances in pathogenesis.

Increase in morbidity and mortality of asthmatics in the world is a cause of concern. Many researchers have described various aspects of etiopathogenesis which has thrown light on the better understanding of asthma. Our experience with nearly 3 lakhs of asthmatic children, over a period of twenty-five years and our studies in Asthma clinic of ICH & HC, Madras generated new ideas to propose a hypothesis on etiopathogenesis of asthma. "Asthma is a disease caused by a specific infective agent in a genetically predisposed individual resulting in altered cellular response initially leading to hyperactive bronchial tree which on exposure to various aggravating factors manifest clinically as recurrent cough, dyspnoea and wheeze". Category of wheezers who manifest asthma is also discussed.

Value of antibiotic therapy in tuberculin-positive children with parenchymal lung lesions.

BACKGROUND. A tuberculin-positive child with radiological evidence of a parenchymal lung lesion is likely to be treated for tuberculosis by a physician. However, non-tuberculous microbial infections may also cause parenchymal lung lesions. We tried to distinguish tuberculous from non-tuberculous lung lesions by administering a course of antibiotics. METHODS. Three hundred and five tuberculin-positive children with parenchymal lung lesions due to pneumonia, bronchiectasis (cylindrical and reversible) and minor fissure opacification were studied at the Tuberculosis Clinic, Institute of Child Health, Madras. Those with more serious forms of tuberculosis like miliary, cavitary and segmental lesions and with grade III and IV undernutrition were excluded. Three weeks of oral antibiotic therapy, with erythromycin (30 mg/kg/day) and chloramphenicol (50 mg/kg/day) for the first two weeks followed by co-trimoxazole (trimethoprim 6 mg/kg/day and sulphamethoxazole 25 mg/kg/day) for the third week, was given. Chest X-rays were taken before and after antibiotic therapy. RESULTS. Sixty per cent of the children with pneumonia, 57% with bronchiectasis and 62% with minor fissure opacification showed complete radiological clearance. CONCLUSION. In tuberculin-positive children with parenchymal lung lesions radiological clearance was seen in 60% after three weeks of antibiotic therapy indicating that the parenchymal lung lesions were caused by non-tuberculous organisms. Hence a course of antibiotic therapy in these children may have diagnostic value as well as considerable financial, social and therapeutic implications.