Continuous end-tidal CO2 in pediatric bronchoscopy.

In recent years flexible fiberoptic bronchoscopy (FFB) has been applied to children for diagnostic and therapeutic purposes. Sedation during FFB, along with introduction of the bronchoscope into the pediatric airway, may cause hypoventilation, leading to hypoxia and desaturation, even in the presence of oxygen supplementation. Arterial oxygen saturation is usually monitored by pulse oximetry (SpO2) during FFB. End-tidal PCO2 (P(etCO2)) monitoring is not routinely used. Twenty-two pediatric patients (15 days to 18 years old) undergoing FFB and receiving supplemental oxygen were studied prospectively and had continuous P(etCO2) and SpO2 measured before and during the procedure (bronchoscope at the carina or either main bronchus). Mean P(etCO2) (+/- SD) decreased from 33.9 (+/- 6.0) mmHg before to 27.1 (+/- 12.1) mmHg during the procedure (P < 0.024). Concomitantly, mean SpO2 (+/- SD) also decreased from 99.9 (+/- 0.4)% before to 95.7 (+/- 11.1)% during the procedure (P < 0.015). P(etCO2) changes seemed to precede the variations in SpO2, especially in young patients who experienced significant desaturation and decompensation during FFB. We conclude that PetCO2 and SpO2 decrease during FFB in children, even with supplemental oxygen. We speculate that this reflects airway obstruction by the instrument. Further studies are needed to assess the utility of PetCO2 monitoring in pediatric FFB.

Femoral artery cannulation for monitoring in critically ill children: prospective study.

Seventy-seven attempted percutaneous femoral artery cannulations were prospectively evaluated in 74 children. Artery cannulation was successfully accomplished in 73 (95%) cases and lasted for a mean of 6 days. Sixty percent of the catheters were inserted on the first attempt. Fifty-two (71%) patients weighed less than 10 kg and 55 (75%) patients were less than 12 months old. Fifty-one (70%) patients received inotropic support at the time of cannulation, and 27 (37%) eventually died from causes unrelated to catheter insertion. There was one episode each of line-associated infection and transient distal ischemia not resulting in tissue loss, and two episodes of catheter malfunction. In eight (11%) patients, signs of distal vascular insufficiency developed shortly catheter placement and resolved after catheter removal. The development of this complication correlated significantly (p less than .05) with younger age (5.5 vs. 22.3 months). We conclude that femoral artery cannulation has a high degree of success in very small, critically ill children. It should be considered an acceptable alternative to small-vessel cannulation when the latter is not technically achievable, or in the unstable patient where rapid establishment of reliable arterial access is necessary.

Laryngomalacia in children.

Two hundred three (68 percent) of 297 children with laryngomalacia had associated respiratory disorders by flexible fiberoptic bronchoscopy (FFB). Associated disorders included congenital respiratory anomalies, a variety of anatomic obstructions of the upper and lower airways, and aspiration disorders. Mean age for isolated laryngomalacia (type 1) was 11.5 weeks (range, 5 weeks to 4 months) while children with laryngomalacia and associated respiratory disorders (type 2) had a mean age of 9.06 years (range, 6 weeks to 18 years). We conclude the following: (1) complete evaluation of the pediatric airways (bronchoscopy) is recommended in every symptomatic child with diagnosis of laryngomalacia confirmed by laryngoscopy; (2) type 1 laryngomalacia was more common in early infancy while type 2 laryngomalacia was associated with older age; (3) although type 2 laryngomalacia is the most common endoscopic diagnosis in our experience, the majority of cases were associated with lower airway dysfunction.

Pentobarbital therapy does not improve neurologic outcome in nearly drowned, flaccid-comatose children.

The effect of pentobarbital therapy was studied prospectively in 31 nearly drowned children in a flaccid state of coma. Each child was assigned to one of two sequential treatment groups. Group A: 16 children were treated with hypothermia and IV pentobarbital, achieving serum levels greater than 25 mu/mL within 48 hours of admission. Group B: 15 children were treated with hypothermia but no pentobarbital. All patients received "conventional therapy" (ie, PaCO2 20 to 25 mm Hg, PaO2 90 to 100 mm Hg, fluid restriction, pancuronium bromide, and furosemide or mannitol). Analysis of variance failed to detect differences for age, estimated time of submersion, arterial pH, core temperature, and mean intracranial pressure between the patients prior to treatment with pentobarbital. In Group A, six patients (37%) recovered completely and were neurologically intact, six patients (37%) had severe brain damage and four patients (26%) died. In Group B, six patients (40%) recovered completely, six patients (40%) survived with brain damage, and three patients (20%) died. There were no statistical differences between the two groups (P greater than .05, chi 2 analysis) for the mortality rate, survival with brain damage, and complete recovery. The results suggest that: (1) pentobarbital therapy does not improve neurologic outcome for nearly drowned, flaccid-comatose children; (2) previous claims implying better outcome with hypothermia combined with pentobarbital therapy may be attributed to the effect of hypothermia alone; and (3) pentobarbital therapy may not be justified in nearly drowned, flaccid-comatose victims.

Association of lipid-laden alveolar macrophages and gastroesophageal reflux in children.

The association of lipid-laden alveolar macrophages (LLAM) and gastroesophageal reflux (GER) was investigated prospectively in 115 patients in two groups. Group 1 included 74 children with chronic respiratory tract disorders and documented GER by prolonged esophageal pH monitoring, barium esophagram, and esophagoscopy; group 2 included 41 children with chronic respiratory tract disorders without GER. LLAM were present in 63 (85%) and eight (19%) children from groups 1 and 2, respectively (P less than 0.0001). Thus a strong association between the presence of LLAM and GER in children with chronic respiratory tract disorders was established. We suggest that LLAM from bronchial lavage may be a useful marker for tracheal aspiration in children with GER in whom chronic lung disease may subsequently develop.

Intracranial pressure monitoring by subarachnoid bolt in comatose children.

The safety of intracranial pressure (ICP) monitoring by the subarachnoid bolt was studied in 124 comatose children with global (103 patients) and focal (21 patients) cerebral lesions. None of the children developed cerebral hematoma, diffuse bleeding, epileptical focus, or local or systemic infection. Based on our experience, we advocate the use of the subarachnoid bolt for the purpose of ICP monitoring as a simple and safe modality.

Evaluation of neonatal neutrophil function using the combined immunobead/NBT dye reduction assay.

An improved assay for the simultaneous assessment of phagocytic uptake (via Immunobeads) and metabolic integrity (via NBT dye reduction) was used to evaluate the neutrophil function in neonates, one year olds, and adults. The unique advantage of this assay is that it evaluates both phagocytic and killing function simultaneously which appears to make the assay more reliable in the detection of neutrophil dysfunction. This assay allowed us to establish a subtle but significant neutrophil dysfunction in full term unstressed neonates which proved to be more pronounced in both the stressed and the preterm neonates. The one year olds, however, were found to have neutrophil function comparable to that of an adult.