Mutación S1455X del CFTR y colonización de vías aéreas altas por Pseudomonas aeruginosa / S1455X CFTR Mutation and Upper Airway Colonization With Pseudomonas aeruginosa

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Viral croup: diagnosis and a treatment algorithm.

Viral croup is a frequent disease in early childhood. Although it is usually self-limited, it may occasionally become life-threatening. Mild croup is characterized by the presence of stridor without intercostal retractions, whereas moderate-to-severe croup is accompanied by increased work of breathing. A single dose of orally administered dexamethasone (0.15-0.6 mg/kg) is the mainstay of treatment with addition of nebulized epinephrine only in cases of moderate-to-severe croup. Nebulized budesonide (2 mg) can be given alternatively to children who do not tolerate oral dexamethasone. Exposure to cold air or administration of cool mist are treatment interventions for viral croup that are not supported by published evidence, but breathing heliox can potentially reduce the work of breathing related to upper airway obstruction. In summary, corticosteroids may decrease the intensity of viral croup symptoms irrespective to their severity on presentation to the emergency department.

Family history of adenotonsillectomy as a risk factor for tonsillar hypertrophy and snoring in childhood.

OBJECTIVE: Accumulating evidence supports a role for familial predisposition in the pathogenesis of OSA. In this study, it was hypothesized that parental history of adenoidectomy and/or tonsillectomy (AT), which is the standard treatment for pediatric OSA is a risk factor for tonsillar hypertrophy and habitual snoring (>3 nights/week) in the offspring. METHODS: Children were recruited from the emergency department and the pediatric pulmonology clinic. Paternal or maternal history of AT (explanatory variables) and habitual snoring (outcome) were recorded and presence of tonsillar hypertrophy (outcome) was assessed. RESULTS: Two hundred ninety-two children (2-14 y.o.) were recruited; 37 (12.7%) of them had paternal history of AT, 39 (13.4%) maternal history of AT, 60 (20.5%) tonsillar hypertrophy, and 48 (16.4%) habitual snoring. Maternal and paternal history of AT were significantly associated with the presence of tonsillar hypertrophy even after adjustment for age, gender, obesity, passive smoking, and physician-diagnosed wheezing requiring treatment with inhaled medications over the past year [odds ratios (95% confidence interval): 3.52 (1.54-8.06); P < 0.01 and 4.70 (2.13-10.36); P < 0.01, respectively]. Only maternal history of AT predicted history of snoring [4.12 (1.86-9.12); P < 0.01]. When entered in the same multivariate logistic regression analysis model, tonsillar hypertrophy was a stronger predictor of habitual snoring than maternal history of AT [4.00 (1.97-8.14) vs. 2.73 (1.20-6.20)]. CONCLUSIONS: Children with parental history of AT have more frequently tonsillar hypertrophy than those without such history. Tonsillar hypertrophy mediates at least in part the association between maternal history of AT and habitual snoring in childhood.

Associations of tonsillar hypertrophy and snoring with history of wheezing in childhood.

BACKGROUND: Reports in adults and children have correlated history of wheezing or asthma with the presence of obstructive sleep-disordered breathing but the mechanism of this epidemiologic association is unknown. The goal of the present study was to examine whether tonsillar hypertophy can explain this association. METHODS: Children were recruited from the Emergency Department and the Pediatric Pulmonology Clinic. History of wheezing requiring treatment (explanatory variable) and snoring > or = 1 night/week (outcome) were recorded and presence of tonsillar hypertrophy (outcome) was assessed. RESULTS: Four hundred forty-two children were recruited (mean age: 7.6 + or - 3.6 years) and 210 of them had history of wheezing. History of wheezing was significantly associated with the presence of tonsillar hypertrophy and snoring even after adjustment for age, gender, obesity, and passive smoking [odds ratio (95% confidence interval): 2.23 (1.37-3.63); P = 0.001 and 1.73 (1.12-2.67); P = 0.013, respectively]. When only children with tonsillar hypertrophy were considered (n = 92), history of wheezing was significantly related to the presence of snoring, whereas in subjects without tonsillar hypertrophy (n = 350) wheezing did not affect snoring [odds ratio: 2.76 (1.10-6.93); P = 0.031 and 1.49 (0.92-2.43); P = 0.107, respectively]. CONCLUSIONS: Children with history of wheezing have more frequently tonsillar hypertrophy than those without wheezing. Tonsillar hypertrophy may mediate at least in part the reported association between asthma and obstructive sleep-disordered breathing in childhood.

Tonsillar size in 2- to 14-year-old children with and without snoring.

BACKGROUND: Few investigations have assessed tonsillar size in children of variable age, sleep-disordered breathing (SDB) status and degree of adiposity. This study evaluated the size of tonsils in young and older, lean and obese children, without or with snoring. METHODS: Children attending the Emergency Department or Pulmonology Clinic were recruited and tonsillar size was scored 1-4. Snoring >or=1 night/week was considered diagnostic of SDB and body mass index z-score >or=1.645 was defined as obesity. Age was analyzed as dichotomous variable (7 years old). RESULTS: 362 children (2-14 years old) were recruited; 78 (21.5%) were obese and 108 (29.8%) had SDB. SDB-but not age or obesity-was significantly related to tonsillar size (P = 0.001). There was not enough evidence to support the presence of interactions between SDB and age or obesity regarding the size of tonsils (P = 0.157 and P = 0.978, respectively). Young subjects without SDB had larger tonsils than older subjects without SDB (1.9 +/- 0.7 vs. 1.7 +/- 0.8; P = 0.017), whereas age did not affect tonsillar size in children with SDB (P = 0.78). CONCLUSIONS: Young and older children with SDB have similar tonsillar size. In contrast, older subjects without snoring have smaller tonsils than young subjects without snoring. Tonsillar enlargement in children with SDB probably occurs in early childhood without change in older age.

Nocturnal change of circulating intercellular adhesion molecule 1 levels in children with snoring.

Hypoxia promotes adherence of leukocytes to endothelial cells by inducing expression of adhesion molecules like intercellular adhesion molecule 1 (ICAM-1). Increased serum levels of circulating ICAM-1 (cICAM-1) have been reported in adults with sleep apnea and associated hypoxemia. This investigation assessed the hypothesis that the overnight change of cICAM-1 levels in children with snoring is correlated with the severity of obstructive sleep-disordered breathing. Evening and morning serum levels of cICAM-1 were measured in children with snoring referred for polysomnography. Twenty-five children with an apnea-hypopnea index greater than or equal to 5 episodes/h (5.5 +/- 1.8 years), 30 subjects with an index less than 5 and greater than 1 (6.3 +/- 2 years), and 19 children with an index less than or equal to 1 (7.1 +/- 3 years) were recruited. Overnight change in cICAM-1 (log-transformed ratio of morning-to-evening levels) was similar in subjects with an apnea-hypopnea index greater than or equal to 5 episodes/h compared to those with an index less than 5 and greater than 1 or to children with an index less than or equal to 1 (-0.001 +/- 0.08 vs -0.03 +/- 0.09 vs -0.06 +/- 0.1; p > 0.05). When multiple regression analysis was applied, apnea-hypopnea index, respiratory arousal index, and oxygen saturation of hemoglobin nadir were not significant predictors of overnight change in cICAM-1 levels. Thus, in children with snoring, overnight change in cICAM-1 levels is not related to severity of obstructive sleep-disordered breathing.

Morning levels of C-reactive protein in children with obstructive sleep-disordered breathing.

Obstructive sleep-disordered breathing is associated with cardiovascular disease in adults, and elevated C-reactive protein (CRP) has been proposed as a link between the two disorders. We hypothesized that children with sleep-disordered breathing have higher CRP values than do control subjects. CRP was measured in 39 children (mean age +/- SD: 6.9 +/- 3.2 years) without snoring (controls) and in 102 children (6.2 +/- 2.2 years) with habitual snoring who underwent polysomnography. No significant differences were found in mean CRP values between control subjects (0.12 +/- 0.16 mg/dl; n = 39) and snorers with an apnea-hypopnea index of less than 1 episode/hour (0.15 +/- 0.26; n = 18), snorers with an index of 1 or more and less than 5 (0.15 +/- 0.26; n = 54), and snorers with an index of 5 or more (0.22 +/- 0.43; n = 30; p > 0.05). There was no correlation between CRP or log-transformed CRP values and apnea-hypopnea index, respiratory movement/arousal index, Sa(O(2)) nadir, oxygen desaturation (>/= 4%) of hemoglobin index, or percentage of sleep time with saturation less than 95% (p > 0.05). Thus, findings of higher CRP values in adults with sleep-disordered breathing and correlations of these values with polysomnography indices were not confirmed in children.

Nasal corticosteroids for children with snoring.

Nasal corticosteroids improve polysomnography indices but not symptoms in children with mild to moderate sleep-disordered breathing. We hypothesized that administration of nasal corticosteroids for 4 weeks to snoring children with only mild elevation in their apnea-hypopnea index would improve both polysomnography findings and symptoms of sleep-disordered breathing. Budesonide 50 mcg per nostril twice daily was administered for 4 weeks to children (2-14 years old) with habitual snoring and an apnea-hypopnea index of 1-10 episodes/hr. Subjects were evaluated before treatment and at 2 weeks and 9 months after its completion. Primary outcome variables were changes in apnea-hypopnea index and symptom score. Twenty-seven children were studied. At 2 weeks, the mean apnea-hypopnea index decreased from 5.2 (+/-2.2) episodes/hr to 3.2 (+/-1.5) episodes/hr, and median oxygen desaturation of hemoglobin index fell from 3.1 (0.4-8.2) to 1.9 (0.2-5.4) (P < 0.0001). Mean symptom score was 1.33 (+/-2.11) at baseline, and decreased to -0.008 (+/-2.24) at 2 weeks after treatment and to -1.08 (+/-1.75) at 9 months after treatment (P < 0.05). Four weeks of nasal budesonide improved both polysomnography findings and symptoms in children with mild sleep-disordered breathing. The clinical effect is maintained for several months after treatment.