Chest wall constriction after too extensive and too early operations for pectus excavatum.

BACKGROUND AND METHODS: Since 1990 we have evaluated 12 children and teenagers in whom severe cardiorespiratory symptoms have developed due to failure of chest wall growth after very extensive pectus excavatum operations (removal of five or more ribs) at very early ages (< 4 years). RESULTS: Apparently these extensive procedures have removed or prevented growth center activity, which resulted in restriction of chest wall growth with marked limitation of ventilatory function. The forced vital capacity ranged from 30% to 50% of predicted and the forced expiratory volume in 1 second from 30% to 60%. All patients are symptomatic with mild exercise and cannot compete in running games. Our protocol for critical evaluation includes exercise pulmonary function studies and axial computed tomographic reconstruction. CONCLUSIONS: This report is an alert to recognize such patients and also to recommend delay in operative repair in small children until at least 6 to 8 years of age. The younger the patient the more limited the chest wall resection for pectus excavatum should be. Five of these patients have had a chest cavity expansion operation with encouraging early results.

Chronic cough in childhood: approach to diagnosis and treatment.

Chronic cough in childhood has many possible causes. The two most common are asthma and viral upper respiratory infection. Although usually associated with wheezing, dyspnea, or both, cough may be the sole manifestation of asthma ("cough-variant asthma"). Most important to initial evaluation are physical examination, patient history, and chest radiograph. Bronchial provocation testing may also prove helpful but is usually unnecessary. A trial of antiasthma therapy is appropriate when the pattern of symptoms is typical of asthma (excepting the lack of wheezing) and when nothing incompatible with asthma is present in the clinical picture. Drug therapy for cough-variant asthma is the same as that for more typical asthma. A vigorous trial of antiasthma therapy should not be considered complete unless a short course of high oral doses of corticosteroids has been included. The presence of clinical signs or symptoms atypical or incompatible with asthma and the failure of symptoms to respond to aggressive antiasthma therapy both warrant a more aggressive and complete diagnostic study.

Fatal prolonged foreign body aspiration following an asymptomatic interval.

Patients with nondiagnosed foreign body aspiration usually have persistent symptoms and occasionally die. We are reporting two patients with histories suggestive of foreign body aspiration who were not definitively studied because of resolving symptoms. Both children became asymptomatic but subsequently developed acute, total airway obstruction and died. These cases demonstrate the difficulty of diagnosing aspiration and the necessity of timely intervention.