Hemodynamic Responses to Recorded Maternal Voice Among Sedated Children in the Pediatric Intensive Care Unit: An Open-Label Randomized Controlled Trial

Objective: To assess the effect of maternal audiotaped voice on clinical parameters of sedated children. Methods: A randomized controlled trial was conducted on 25 sedated critically ill children admitted to the pediatric intensive care unit. An audiotaped maternal voice was played to the children in the experimental group (n=13) via a headphone for 15 minutes, twice a day for 3 days. Children in the control group (n=12) received routine care without any additional auditory stimulation. Clinical and hemodynamic variables were recorded at 5 minutes interval three times. Results: Significant changes were observed in the mean (SD) heart rate (per minute) at 10 minutes [129.83 (19.14) vs 124.29 (14.90), P=0.051], respiratory rate at 5 minutes [44.38 (17.79) vs 34.65 (7.64), P=<0.001] and 10 minutes [42.79 (13.89) vs 35.44 (7.65) P=<0.001], systolic blood pressure at 5 minutes [95.24 (15.01) vs 101.02 (19.83) P=0.045], and mean blood pressure at 15 minutes [68.66 (13.61) vs 73.61 (17.59) P=0.051] mmHg between the experimental and the control group, respectively. Conclusion: Listening to recorded maternal voice had a positive effect on clinical parameters of sedated critically ill children.

Initial Immunomodulation and Outcome of Children with Multisystem Inflammatory Syndrome Related to COVID-19: A Multisite Study from India

Objective To determine the outcomes in children with MIS-C receiving diferent immunomodulatory treatment. Methods In this multicentric, retrospective cohort study, data regarding treatment and outcomes of children meeting the WHO case defnition for MIS-C, were collected. The primary composite outcome was the requirement of vasoactive/inotropic support on day 2 or beyond or need of mechanical ventilation on day 2 or beyond after initiation of immunomodulatory treatment or death during hospitalization in the treatment groups. Logistic regression and propensity score matching analyses were used to compare the outcomes in diferent treatment arms based on the initial immunomodulation, i.e., IVIG alone, IVIG plus steroids, and steroids alone. Results The data of 368 children (diagnosed between April 2020 and June 2021) meeting the WHO case defnition for MIS-C, were analyzed. Of the 368 subjects, 28 received IVIG alone, 82 received steroids alone, 237 received IVIG and steroids, and 21 did not receive any immunomodulation. One hundred ffty-six (42.39%) children had the primary outcome. On logistic regression analysis, the treatment group was not associated with the primary outcome; only the children with shock at diagnosis had higher odds for the occurrence of the outcome [OR (95% CI): 11.4 (5.19–25.0), p<0.001]. On propensity score matching analysis, the primary outcome was comparable in steroid (n=45), and IVIG plus steroid (n=84) groups (p=0.515). Conclusion While no signifcant diference was observed in the frequency of occurrence of the primary outcome in diferent treatment groups, data from adequately powered RCTs are required for defnitive recommendations.

Geographic information system-based mapping of air pollution & emergency room visits of patients for acute respiratory symptoms in Delhi, India (March 2018-February 2019)

Background & objectives: Studies assessing the spatial and temporal association of ambient air pollution with emergency room visits of patients having acute respiratory symptoms in Delhi are lacking. Therefore, the present study explored the relationship between spatio-temporal variation of particulate matter (PM)2.5 concentrations and air quality index (AQI) with emergency room (ER) visits of patients having acute respiratory symptoms in Delhi using the geographic information system (GIS) approach. Methods: The daily number of ER visits of patients having acute respiratory symptoms (less than or equal to two weeks) was recorded from the ER of four hospitals of Delhi from March 2018 to February 2019. Daily outdoor PM2.5 concentrations and air quality index (AQI) were obtained from the Delhi Pollution Control Committee. Spatial distribution of patients with acute respiratory symptoms visiting ER, PM2.5 concentrations and AQI were mapped for three seasons of Delhi using ArcGIS software. Results: Of the 70,594 patients screened from ER, 18,063 eligible patients were enrolled in the study. Winter days had poor AQI compared to moderate and satisfactory AQI during summer and monsoon days, respectively. None of the days reported good AQI (<50). During winters, an increase in acute respiratory ER visits of patients was associated with higher PM2.5 concentrations in the highly polluted northwest region of Delhi. In contrast, a lower number of acute respiratory ER visits of patients were seen from the ‘moderately polluted’ south-west region of Delhi with relatively lower PM2.5 concentrations. Interpretation & conclusions: Acute respiratory ER visits of patients were related to regional PM2.5 concentrations and AQI that differed during the three seasons of Delhi. The present study providessupport for identifying the hotspots and implementation of focused, intensive decentralized strategies to control ambient air pollution in worst-affected areas, in addition to the general city-wise strategies.

Development of the India COVID-19 vaccine tracker

COVID-19 was declared a pandemic by the World Health Organization (WHO) on March 11, 2020. Since then, efforts were initiated to develop safe and effective vaccines. Till date, 11 vaccines have been included in the WHO’s emergency use list. The emergence and spread of variant strains of SARS-CoV-2 has altered the disease transmission dynamics, thus creating a need for continuously monitoring the real-world effectiveness of various vaccines and assessing their overall impact on disease control. To achieve this goal, the Indian Council of Medical Research (ICMR) along with the Ministry of Health and Family Welfare, Government of India, took the lead to develop the India COVID-19 Vaccination Tracker by synergizing three different public health databases: National COVID-19 testing database, CoWIN vaccination database and the COVID-19 India portal. A Vaccine Data Analytics Committee (VDAC) was constituted to advise on various modalities of the proposed tracker. The VDAC reviewed the data related to COVID-19 testing, vaccination and patient outcomes available in the three databases and selected relevant data points for inclusion in the tracker, following which databases were integrated, using common identifiers, wherever feasible. Multiple data filters were applied to retrieve information of all individuals ?18 yr who died after the acquisition of COVID-19 infection with or without vaccination, irrespective of the time between vaccination and test positivity. Vaccine effectiveness (VE) against the reduction of mortality and hospitalizations was initially assessed. As compared to the hospitalization data, mortality reporting was found to be much better in terms of correctness and completeness. Therefore, hospitalization data were not considered for analysis and presentation in the vaccine tracker. The vaccine tracker thus depicts VE against mortality, calculated by a cohort approach using person-time analysis. Incidence of COVID-19 deaths among one- and two-dose vaccine recipients was compared with that among unvaccinated groups, to estimate the rate ratios (RRs). VE was estimated as 96.6 and 97.5 per cent, with one and two doses of the vaccines, respectively, during the period of reporting. The India COVID-19 Vaccination Tracker was officially launched on September 9, 2021. The high VE against mortality, as demonstrated by the tracker, has helped aid in allaying vaccine hesitancy, augmenting and maintaining the momentum of India’s COVID-19 vaccination drive

Poor Respiratory Health Following Relapsing SARS-CoV-2 Infection in Children with Cystic Fibrosis

Children with cystic fbrosis (CF) constitute a high-risk group for COVID-19 with underlying chronic lung disease. COVID19 severity varying from mild infection to need of intensive care has been described in children with CF. Two children with signifcant underlying pulmonary morbidity are described here, who developed severe disease following SARS-CoV-2 infection. Case 1 (a 9-y-old boy) had pneumonia with respiratory failure requiring noninvasive ventilation support. He had delayed clearance of SARS-CoV-2, with recurrence of symptomatic disease with short asymptomatic period in between. He was also diagnosed with CF-related diabetes and allergic bronchopulmonary aspergillosis during the second episode. Case 2 (an 18-mo-old boy) had two episodes of SARS-CoV-2–related severe lower respiratory infection within a period of 2 mo, requiring high-fow nasal oxygen support. Both children had 3rd pulmonary exacerbation but SARS-CoV-2 was not detected in respiratory secretions. To conclude, children with CF with underlying pulmonary morbidity, can develop severe COVID-19 and prolonged SARS-CoV-2 shedding.

Study Designs: Diagnostic Studies

Diagnostic tests are evolving with betterment of technology, quest for patient safety with less invasive medicine, and evolution of new diseases. It is important to assess diagnostic accuracy of a new test, and clinical impact of introduction of new test on outcomes and cost. A diagnostic study is planned for the index test based on place of new test in diagnostic pathway (screening, triage, diagnostic or add-on test) and established information of the test. A reference standard is used to classify population into diseased and healthy, and the discriminating ability of index test is measured. A sample size is calculated for expected sensitivity/specificity, margin of error and prevalence of disease in population. For dichotomous outcomes, sensitivity, specificity, predictive values and likelihood ratio are used to describe diagnostic accuracy. Efforts should be made to avoid common forms of bias including spectrum bias and partial verification bias, and blinding of observers should preferably be done.

Clinical Profile of Children With Cystic Fibrosis Surviving Through Adolescence and Beyond

Objective: To document morbidities in adolescents with cystic fibrosis (CF) from India. Methods: Details of children with cystic fibrosis surviving beyond 15 years of age were extracted from hospital records, and analyzed. Results: 43 children [Median (IQR) age 18.7 (17, 20.6) years, were enrolled. Median (IQR) body mass index was 15.82 (13.5, 19.05) kg/m2. Pseudomonas species were isolated from respiratory specimens of 34 (79%) adolescents. Allergic bronchopulmonary aspergillosis (ABPA) and Cystic fibrosis-related diabetes (CFRD) were seen in 12 (28%) and 11 (26%) patients, respectively. Conjugated hyperbilirubinemia and distal intestinal obstruction syndrome (DIOS) were diagnosed in 15 (35%) and 6 (14%) children, respectively. Pseudomonas species colonization (P=0.04) and multiple pulmonary exacerbations in last one year (P<0.001) were significant predictors of FEV1% predicted. Conclusion: Malnutrition, chronic airway colonization, ABPA, CFRD, conjugated hyperbilirubinemia and DIOS are morbidities observed in adolescents with CF in India. The data support the need for early screening of CF-associated morbidities.

Wheezing in Preschool Children and Total IgE Levels: A Birth Cohort Study

Objectives: To evaluate association between total IgE levels and wheezing in preschoolchildren from India. Methods: Datawere collected in a prospective birth cohort study relatedto wheezing till three years of age. Total IgE was measured at enrolment, at one year and twoyears of age and correlated with wheezing episodes. Results: A total of310 (167 boys)children were enrolled. Total IgE levels increased with age (P<0.001). Overall, 101 (32.6%)children had 182 episodes of wheezing. The median (IQR) total IgE levels in children withwheezing and without wheezing were similar at one year [42.1 (12.7, 93.5) vs 41.9 (17.1,96.7) kU/L; P=0.39] and two years of age [62.8 (32.4, 212.0) vs 75 (25.8, 173.0) kU/L,P=0.92). Conclusion: Total IgE levels increased with age and were not different in preschoolchildren with and without wheezing.

Role of Impulse Oscillometry in Assessing Asthma Control in Children

Background: Impulse oscillometry is an effort-independenttechnique of assessment of airway resistance and reactance, andcan be performed in children unable to complete spirometry.Objective: To evaluate the utility of impulse oscillometry andspirometry for assessing asthma control in children.Study design: Prospective cohort study.Participants: Children aged 5-15 years, with mild to severepersistent asthma.Intervention: On each 3-monthly follow-up visit, clinicalassessment, classification of control of asthma, impulseoscillometry and spirometry were performed.Outcome: Utility of impulse oscillometry parameters [impedance(Z5), resistance (R5), reactance (X5) at 5 Hz, and R5-20(resistance at 20Hz -5Hz) (% predicted), and area of reactance(AX, actual values)] and FEV1 (% predicted) to discriminatebetween controlled and uncontrolled asthma was assessed byreceiver operating characteristic (ROC) curve. Association ofFEV1 and impulse oscillometry parameters over time withcontrolled asthma was evaluated by generalized estimatingequation model.Results: Number of visits in 256 children [mean (SD) age, 100(41.6) mo; boys: 198 (77.3%)], where both impulse oscillometryand spirometry were performed was 2616; symptoms werecontrolled in 48.9% visits. Area under the curve fordiscrimination between controlled and uncontrolled asthma byFEV1, AX, R5-20, Z5, R5, and X5 were 0.58, 0.55, 0.55, 0.52,0.52 and 0.52, respectively. FEV1 [OR (95% CI): 1.02 (1.01-1.03)]and AX [OR (95% CI): 0.88 (0.81-0.97)] measured over theduration of follow-up were significantly associated withcontrolled asthma.Conclusion: Spirometry and impulse oscillometry parametersare comparable in ascertaining controlled asthma. Impulseoscillometry being less effort-dependent may be performed formonitoring control of childhood asthma, especially in youngerchildren.

Normative Data of Infant Pulmonary Function Testing: A Prospective Birth Cohort Study from India

Objective: To develop a normal reference range of Infantpulmonary function test (IPFT) indices for Indian children.Design: Prospective birth cohort study.Setting: Division of Pediatric Pulmonology of a tertiary-careinstitute in India from August 2012 to March 2017.Participants: All neonates born at the institute during the studyperiod were screened for eligibility.Measurement: IPFT at baseline and every 6-month until 36-months of age.Main Outcome Measure(s): Tidal breathing flow-volume loop(TBFVL), Rapid thoracoabdominal compression (RTC), andRaised volume RTC (RVRTC) indices at baseline and follow-up.Results: 310 newborns were enrolled in the cohort; 281 of them(169 male) had completed 36-months of follow-up at the end ofthe study period. There was no influence of gender on thebaseline IPFT indices. Tidal volume per unit body weight (VT/kg)significantly increased from baseline to 36 months of age(P<0.001) while the peak ratio (tPTEF/tE) initially decreased in first18-months of age (P<0.001), after that returned to the baselinevalue by 36 months of age. RTC indices did not changesignificantly from baseline values. In RVRTC, the ratio of forcedexpiratory volume in 0.5s to forced vital capacity (FEV0.5/FVC)was significantly decreased from baseline to 36 months of age(P=0.002).Conclusions: Normal values for various IPFT indices for TBFVL,RTC, and RVRTC from neonates to the age of 36-month areprovided. These data may be used as normative data for healthyneonates and children of Indian origin

Propofol versus Fentanyl for Sedation in Pediatric Bronchoscopy: A Randomized Controlled Trial

Objectives: To compare propofol and fentanyl to induceconscious sedation in children undergoing flexiblebronchoscopy.Study design: Randomized controlled trial.Setting: Pediatric Pulmonology division at a tertiary care centerin Delhi, India.Participants: Children aged 3-15 years who underwentflexible bronchoscopy.Intervention: Children received either intravenous propofol 1mg/kg administered as a slow bolus over 1 minute followed by 2mg/kg/hour infusion, or intravenous Fentanyl 2 μg/kgadministered as a slow bolus over one minute.Outcomes: Primary outcome was time to achieve conscioussedation (Ramsay score 3). Secondary outcomes were need foradjuvant midazolam, physician satisfaction, level of cough,recovery features, and side-effects in the groups.Results: 53 children (propofol 27, fentanyl 26) were enrolled inthe study. The mean (SD) time taken to achieve Ramsay score 03was lower in propofol than fentanyl [15.7 (4.4) s vs 206 (55) s,P<0.001]. Propofol arm had significantly higher physiciansatisfaction, less requirement of adjuvant midazolam, lesscoughing and faster regain of full consciousness. There was nodifference in drug side-effects between the groups.Conclusion: Propofol has a shorter sedation induction time, lesscoughing during procedure, less recovery time, and betterphysician satisfaction compared to fentanyl for flexiblebronchoscopy in children.

Predictors of Malnutrition in Children with Cystic Fibrosis

Objective: To determine occurrence of malnutrition in childrenwith cystic fibrosis and identify predictors of malnutrition at time ofenrolment and after 2 years of follow up.Design: Retrospective chart review.Setting: Pediatric chest clinic at a tertiary-care center in northernIndia.Patients: Cystic fibrosis patients enrolled between 2009-2015with at least 3 years follow-up.Procedure: Weight and height were noted at enrolment, and after1 year and 2 years of follow-up. Clinical details, medications, andpulmonary exacerbations during second year were recorded.Main outcome measure: Occurrence of malnutrition i.e. weightfor age Z-score < -2.Results: 61 medical records were reviewed. Occurrence ofmalnutrition at baseline, and 1- and 2-year follow-up was 65.5%,54.1% and 57.3%, respectively. Weight for age Z-score atenrolment significantly correlated with time to diagnosis fromonset r=0.015, P=0.029). Weight for age Z-score at 2-year follow-up was significantly associated with steatorrhea (P=0.03),increased frequency of stools (P<0.01) and pulmonaryexacerbation (P=0.03) during second year. Linear regressionshowed significant association between weight for age Z-score at2 years with steatorrhea and pulmonary exacerbations [r=-0.795(-1.527, -0.062)] and [r=-0.261 (-0.493, -0.028)]. Pulmonaryexacerbations during second and third year had significantcorrelation with weight for age Z-score at the beginning ofrespective years (r = -0.219, P=0.015).Conclusion: Occurrence of malnutrition is high in children withcystic fibrosis in this region, with uncontrolled fat malabsorptionand recurrent respiratory infections being significant risk factors.

Aquagenic Wrinkling of Skin: A Screening Test for Cystic Fibrosis

Objectives: To study the utility of aquagenic wrinkling asscreening test for children with cystic fibrosis.Design: Evaluation of diagnostic test.Setting: Pediatric Chest Clinic, and Pediatric Wards of a tertiarycare hospital in New Delhi.Participants: Three groups (children with cystic fibrosis,carriers of cystic fibrosis, and controls).Method: Time taken to develop aquagenic wrinkling wasmeasured. The test was performed by asking the enrolled subjectto put their one hand in water and was checked for development ofwrinkling every minute, and a photograph was also taken everyminute.Results: A total of 64 children with cystic fibrosis, 64 controls and64 carriers were enrolled in the study. Median (IQR) time todevelop aquagenic wrinkling in the three groups was 2 (1.5,3)minutes, 4 (3,5) minutes and 8 (5,11) minutes, respectively. Theoptimal cut-off was calculated as 3 minutes by Receiveroperating characteristic curve with a sensitivity and specificityfor identification of children with cystic fibrosis as 81% and 57%,respectively. The area under curve was 76.5%. The 3 minutecut-off for development of aquagenic wrinkling was applied to 54children referred for sweat test. 20 children had sweat chloridevalues of ≥60 mEq/l and diagnosed as cystic fibrosis. 15 of thesedeveloped aquagenic wrinkling at ≤3 minutes, giving a sensitivityof 75%.Conclusion: In places with no facility for sweat test, childrenwith phenotype compatible with cystic fibrosis who developaquagenic wrinkling in 3 minutes may be diagnosed as probablecystic fibrosis and referred for confirmation by sweat tes

Clinical Profile and Outcome of Pediatric Sarcoidosis

Objectives: To document clinical features and outcome of children with sarcoidosis.Methods: Case records of 18 children (mean (SD) age 9 (2.2) years) diagnosed withsarcoidosis between 2006 and 2016 were reviewed. All children were followed up every 2-3months and monitored for clinical and laboratory parameters. Their treatment and outcomewere recorded. Results: Clinical features at the time of diagnosis were fever (83%), uveitis(50%), difficulty in breathing (44%), hepatosplenomegaly, weight loss, arthritis and peripheraladenopathy. Imaging findings included: hilar adenopathy (94%), abdominal nodes (50%) andpulmonary infiltrates (44%). All children were treated with steroids (range 6-12 months) andweekly low dose oral methotrexate. All patients showed significant improvement over a mean(SD) duration of follow-up of 3.1 (0.9) years, as assessed by resolution of clinical symptoms,and improvement in spirometry parameters, erythrocyte sedimentation rate, and serumangiotensin converting enzyme levels. Conclusions: Children with sarcoidosis seem torespond well to systemic steroids and low dose methotrexate. Delayed diagnosis and ocularinvolvement are probably associated with poor outcome.

Diagnostic Yield of Xpert MTB/RIF in Bronchoalveolar Lavage in Children with Probable Pulmonary Tuberculosis

Objective: To evaluate utility of XpertMTB/RIF in bronchoalveolar lavage fluid in childrenwith probable pulmonary tuberculosis. Methods: Children with probable pulmonarytuberculosis with negative smear and Xpert on induced sputum/gastric aspirate weresubjected to bronchoalveolar lavage (BAL) for Xpert assay and mycobacterial liquid culture.Data of children <14 y undergoing bronchoscopy for suspected MDR-TB (n=12) were alsoanalyzed. The sensitivity of Xpert in BAL fluid for diagnosis of probable and confirmedpulmonary tuberculosis was calculated with clinico-radiological diagnosis and culture as goldstandards, respectively. Results: Of 41 enrolled children, 24 (58.5%) had Xpert positive inBAL fluid and 11 (26.8%) had culture confirmed tuberculosis (BAL fluid;10; sputum,1). Thesensitivity of Xpert in BAL fluid among probable and culture confirmed tuberculosis caseswas 58.5% (24/41) and 81.8% (9/11), respectively. Conclusion: Xpert in bronchoalveolarlavage fluid has good sensitivity in both probable and confirmed pulmonary tuberculosis inchildren

Comparison of Outcomes using Pediatric Index of Mortality (PIM) -3 and PIM-2 Models in a Pediatric Intensive Care Unit

Objectives: To compare patient outcomes using the Pediatric Index of Mortality-3 (PIM-3)model with PIM-2 model for children admitted to the intensive care unit. Methods: Weprospectively recorded the baseline characteristics, variables of PIM-3 and PIM-2 atadmission, and outcomes of children ?17 years over a period of 11 months. We used AreaUnder Receiver Operating Characteristics (AU-ROC) curves and Goodness-of-fit (GOF)tests to determine which of the two models had better discrimination and calibration.Results: Out of 202 children enrolled, 69 (34%) died. Sepsis and pneumonia were thecommon admitting diagnoses. The AU-ROC was better for PIM-3 (0.75) as compared to PIM-2 (0.69; P=0.001). The GOF-P value was 0.001 for both models, that indicated poorcalibration of both (P<0.001). The AU-ROC curves were acceptable across different age anddiagnostic sub-groups. Conclusion: PIM-3 had better discrimination when compared toPIM-2 in our unit. Both models had poor calibration across deciles of risk.

Association of Fluid Overload with Mortality in Critically-ill Mechanically Ventilated Children

Objectives: To study the association of fluid overload withmortality and morbidity in critically-ill mechanically ventilatedchildren.Design: Prospective observational study.Setting: Pediatric Intensive Care Unit (PICU) of a tertiary carehospital, New Delhi, India.Participants: 118 children (age 1 mo - 15 y) requiring mechanicalventilation.Outcome measures: Primary: Association of fluid overload withmortality. Secondary: Association of fluid overload withoxygenation, organ dysfunction, duration of mechanicalventilation and PICU stay.Results: Cumulative fluid overload of ?15% was observed in 74(62.7%) children. About 50% of these children reachedcumulative fluid overload of ?15% within the first 5 days of PICUstay. The mortality was 40.5% in those with ?15% cumulative fluidcompared to 34% in the rest [OR (95% CI): 1.02 (0.97, 1.07)]. Onmultivariate analysis, after adjusting for confounders, cumulativefluid overload ?15% was associated with higher maximumPELOD (pediatric logistic organ dysfunction) score (Median: 21vs. 12; P = 0.03), longer median duration of mechanicalventilation (10 vs. 4 d; P <0.0001) and PICU stay (13.5 vs. 6 d; P<0.0001). There was no significant association of fluid overloadwith oxygenation index (P=0.32).Conclusion: There is no association of fluid overload withmortality. However, it is associated with poor organ function,longer duration of mechanical ventilation and PICU stay incritically-ill, mechanically ventilated children.

Target Oxygen Saturation Among Preterm Neonates on Supplemental Oxygen Therapy: A Quality Improvement Study

Objective: To avoid excessive oxygen exposure and achieve target oxygen saturation(SpO2) within intended range of 88%-95% among preterm neonates on oxygen therapy.Methods: 20 preterm neonates receiving supplemental oxygen in the first week of lifewere enrolled. The percentage of time per epoch (a consecutive time interval of 10 hours/day) spent by them within the target SpO2 range was measured in phase 1 followed byimplementation of a unit policy on oxygen administration and targeting in phase 2. In phase 3,oxygen saturation histograms constructed from pulse-oximeter data were used as dailyfeedback to nurses and compliance with oxygen-targeting was measured again. Results:48 epochs in phase 1 and 69 in phase 3 were analyzed. The mean (SD) percent time spentwithin target SpO2 range increased from 65.9% (21.4) to 76.5% (12.6) (P=0.001).Conclusion: Effectiveimplementation of oxygen targeting policy and feedback usingoxygen saturation histograms may improve compliance with oxygen targeting.

Nebulized N-Acetylcysteine for Management of Plastic Bronchitis

Background: Plastic bronchitis is characterized by formation of extensive obstructiveendobronchial casts and high recurrence rates. Case characteristics: Two children (1-year-old girl, 7-year-old boy) who had recurrent episodes of respiratory distress with acuteworsening. Bronchoscopy revealed membrane-like casts. Both children were managed withnebulized N-acetylcysteine in addition to management for asthma. Outcome: Symptom-free without recurrence for more than 9 months of follow-up. Message: Nebulized N-acetylcysteine may be helpful in prevention of recurrence of plastic bronchitis due to asthma.