Drug therapy approaches in the treatment of acute severe asthma in hospitalised children.

Acute severe paediatric asthma remains a serious and debilitating disease throughout the world. The incidence and mortality from asthma continue to increase. Early, effective and aggressive outpatient therapy is essential in reducing symptoms and preventing life-threatening progression. When complications occur or when the disease progresses to incipient respiratory failure, these children need to be managed in a continuous care facility where aggressive and potentially dangerous interventions can be safely instituted to reverse persistent bronchospasm. The primary drugs for acute severe asthma include oxygen, corticosteroids, salbutamol (albuterol) and anticholinergics. Second-line drugs include heliox, magnesium sulfate, ketamine and inhalational anaesthetics. Future therapies may include furosemide, leukotriene modifiers, antihistamines and phosphodiesterase inhibitors. This review attempts to explore the multitude of medications available with emphasis on pharmacology and pathophysiology.

Noninvasive monitoring in the pediatric intensive care unit.

The best ICU monitors are physicians and nurses, who integrate all of the physiologic parameters of patients with the known pathophysiology of the disease process. Over-reliance on raw electronic data, with their inherent errors, jeopardizes the safe and efficient care of patients. Data must be interpreted in the context of the history, repetitive physical examinations, response to therapy, and a background of experience. New modalities and the application of artificial intelligence may facilitate the interpretation of data, but the role of the bedside medical practitioner remains as the heart of pediatric critical care.

Exhaled nitric oxide as an indicator of severity of asthmatic inflammation.

Traditional assessment of severity of asthma relies on an evaluation of signs and symptoms and pulmonary function tests. These pulmonary function tests, such as peak expiratory flow rates, forced vital capacity, and forced expiratory flow rates, are indirect measures of airway caliber only, and not inflammation. Since asthma is an inflammatory disease, a measure of the degree of inflammation would be helpful in quantitating severity and titrating of anti-inflammatory therapy. A noninvasive method for measuring pulmonary inflammation would therefore be helpful to assist the emergency physician in initial treatment and assist in titration of anti-inflammatory therapy during repeat visits. Exhaled nitric oxide (NO) assays are convenient and practical and may fulfill this role. In this review, we discuss the role of NO in asthmatic inflammation and the role that exhaled NO values may play in the emergency management of asthma.

Intrarenal determinants of sodium retention in mild heart failure: effects of angiotensin-converting enzyme inhibition.

The onset and the mechanisms leading to Na+ retention in incipient congestive heart failure (CHF) have not been systematically investigated. To investigate renal Na+ handling in the early or mild stages of CHF, Na+ balance and renal clearances were assessed in 10 asymptomatic patients with idiopathic or ischemic dilated cardiomyopathy and mild heart failure (HF) off treatment (left ventricular ejection fraction, 29.7+/-2%) and in 10 matched normal subjects during a diet containing 100 mmol/d of NaCl and after 8 days of high salt intake (250 mmol/d). Six patients were studied again after 6 weeks of treatment with enalapril (5 mg/d P.O.). At the end of the high salt diet, in patients with mild HF the cumulative Na+ balance exceeded by 110 mmol that of normal subjects (F=3.86, P<.001). During high salt intake, renal plasma flow and glomerular filtration rate were similarly increased in both normal subjects and mild HF patients. In spite of comparable increases of filtered Na+ in the two groups, fractional excretion of Na+, fractional clearance of free water, and fractional excretion of K+ (indexes of distal delivery of Na+) increased in normal subjects and were reduced in patients with mild HF. During enalapril treatment, in the mild HF patients the cumulative Na+ balance was restored to normal; furthermore, enalapril significantly attenuated the abnormalities in the distal delivery of Na+. Our results indicate that a defective adaptation of Na+ reabsorption in the proximal nephron is associated with Na+ retention in response to increased salt intake in the early or mild stages of HF. These abnormalities of renal Na+ handling are largely reversed by enalapril.

Submersion injuries in children and adults.

Drowning and near drowning remain a common cause of childhood death and disability. Toddlers aged one through four drown in private swimming pools. Submersions greater than 10 minutes and lack of CPR at the scene or the need for greater than 20 minutes of resuscitation portends a poor prognosis. Management of respiratory failure without neurologic impairment has the most successful outcome. Prevention of drowning morbidity is dependent on constant parental supervision, and immediate and expert CPR.

Treatment of critical status asthmaticus in children.

Status asthmaticus is complex in its etiology and pathophysiology and may be associated with significant morbidity and mortality. Although there are many therapeutic options, specific inhaled beta 2-agonists, corticosteroids, and oxygen remain the mainstay of therapy. Several new drugs and some older drugs are being used in management; their exact role in treatment at present, however, relies largely on personal preferences. Innovative methods of providing ventilatory support are also emerging. What is quite clear is the fact that involvement of specialists (pulmonologists and intensivists) early in the course of severe status asthmaticus is needed to ensure optimal management and possibly favorable outcomes.

Use of pediatric physician extenders in pediatric and neonatal intensive care units.

OBJECTIVES: To determine present and future use of pediatric physician extenders in neonatal and pediatric intensive care units (ICUs). DESIGN: Descriptive, prospective, questionnaire survey. PARTICIPANTS: One hundred thirty hospitals represented by members of the Pediatric Section of the Society of Critical Care Medicine and 18 randomly selected hospitals identified as having no pediatric intensivist. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: One hundred one (68.2%) of 148 responding institutions employed physician extenders and 69 (46.7%) employed pediatric physician extenders. Eighty percent of the hospitals using pediatric physician extenders employed pediatric nurse practitioners and 25% employed physician assistants. Of the 69 hospitals that employed pediatric physician extenders, 51 (73.9%) hospitals utilized them in neonatal ICUs and 12 (17.4%) hospitals used them in the pediatric ICUs. Institutions that did or did not employ pediatric physician extenders in pediatric ICUs were comparable in all factors studied, except for the perception of childcare physician staffing shortages. Duties competently performed by pediatric physician extenders did not differ between pediatric nurse practitioners and physician assistants and were similar to those duties of a second-year pediatric resident. More than 40% of institutions expected to increase the use of pediatric physician extenders in neonatal and pediatric ICUs and they expected to provide the majority of the specialty training required. CONCLUSIONS: Pediatric physician extenders are extensively employed in pediatric and neonatal ICUs. They are perceived to perform at the level of second-year pediatric residents and are strongly supported by staff physicians and residents. It appears that more pediatric physician extenders will be employed in pediatric and neonatal ICUs in the future.

Multi-institutional approach to regionalization of pediatric critical care. Seven year experience.

A multi-institutional, pediatric intensive care program initiated in Jacksonville, Florida, is a systematic approach to critical care which avoids costly duplication and provides efficient clinical services and an academic fellowship program. A total of 6,876 consecutive admissions to the two units over a seven-year period are discussed and compared to national data. A coordinated system may provide a model for other communities; however, the ability to expand services in a market where public and private third party funding is being reduced may become a problem.

Resistant status asthmaticus in children.

Use of halothane anesthesia for treating respiratory failure caused by status asthmaticus in children is highly controversial. Previous reports suggest that bronchodilation occurs within minutes of administration. This report describes the case of a child who received five and a half hours of halothane in conjunction with isoproterenol and theophylline to reverse respiratory failure. Halothane did not significantly improve ventilation, and it was associated with significant hemodynamic complications. The use of newer beta-2-agonists and anticholinergics is discussed.

Epstein-Barr virus infections in the X-linked recessive lymphoproliferative syndrome.

Prospective studies demonstrated variable phenotypic expression of the X-linked recessive lymphoproliferative syndrome (X.L.R.L.S.) in three brothers: (1) hypogammaglobulinaemia and subclinical Epstein-Barr-virus (E.B.V.) infection with antibody response to E.B.V.; (2) E.B.V. infection with defective immune response to E.B.V., fatal infectious mononucleosis (I.M.), and immunoblastic lymphoma; and (3) histiocytic lymphoma. Hypogammaglobulinaemia and measles pneumonitis had preceded infection with E.B.V. The diverse phenotypic expressions probably resulted from the varied immune response to E.B.V. Recombination of X chromosomes was documented by Xg-blood-group studies in a survivor. E.B.V. can induce fatal I.M. and malignant lymphoma in X.L.R.L.S., but an immune response to E.B.V. can be protective.