Effective treatment of post-intubation subglottic stenosis in children with holmium laser therapy and cryotherapy via flexible bronchoscopy.

IMPORTANCE: Post-intubation subglottic stenosis (SGS) in children can be life threatening. Definitive treatment varies and lacks a universally accepted approach. OBJECTIVE: We performed a prospective study to assess the safety and feasibility of holmium laser combined with cryotherapy delivered via flexible bronchoscopy for the treatment of post-intubation SGS in children. METHODS: This study involved all patients with post-intubation SGS seen at the Interventional Pulmonology Department of Beijing Children's Hospital between July 2014 and December 2016. Holmium laser treatment and cryotherapy was then performed under flexible bronchoscopy, whose parents refused to accept the alternative standard treatment of tracheotomy and balloon dilation under direct laryngoscopy. RESULTS: Sixteen patients with post-intubation SGS were included in this study. Ages ranged from 2 months to 12.25 years old. According to the Cotton-Myer grading system, three cases were Grade II, 12 cases were Grade III, and one case was Grade IV. According to the McCaffrey system, eight cases were Stage 1, two cases were Stage 2, and six cases were Stage 3. The average number of procedures was 4.88. Fifteen of the 16 patients achieved clinical cure. One patient achieved clinical improvement. The average treatment course duration was 55.31 days. No severe complications were seen. Post-treatment clinical symptoms, endoscopic findings and quality of life showed marked improvement. INTERPRETATION: Our study supports the conclusion that holmium laser treatment combined with cryotherapy via flexible bronchoscopy appears to be a safe and feasible treatment for post-intubation SGS in children.

Characteristics and clinical role of bronchoscopy in diagnosis of childhood endobronchial tuberculosis.

BACKGROUND: Endobronchial tuberculosis (EBTB) is the most frequent complication of primary pulmonary tuberculosis (PTB) in children. The aim of the study was to analyze characteristics and clinical role of bronchoscopy in diagnosis of childhood EBTB. METHODS: A retrospective, descriptive study was undertaken in 157 children with EBTB undergone flexible bronchoscopy (FB) between January 2006 and June 2014. RESULTS: The median age of the enrolled patients was 3.4 years, with 73.2% of patients under five years old. The most common subtype was tumorous type (145/157, 92.4%). If only involved bronchus were considered, the common affected sites were right middle lobe bronchus (49/228, 21.5%), left upper lobe bronchus (41/228, 18.0%), right upper lobe bronchus (41/228, 18.0%), right main bronchus (35/228, 15.4%), respectively. Children younger than five years old were at higher risk to have multiple endobronchial lesions (P=0.044), with an odds ratio of 2.313 (95% confidence interval: 1.009-5.299). Before the bronchoscopy, only 16 (10.2%) patients were highly suspected of EBTB, while the others were diagnosed as PTB without EBTB (69.4%), or misdiagnosed as pneumonia or foreign body aspiration (20.4%) on admission. CONCLUSIONS: The patients under five years old are at high risk to progress to EBTB and have multiple endobronchial lesions. The most frequent subtype of EBTB in children is tumorous type. The lesions are seen in the right bronchial system more frequently. FB should be performed to detect the endobronchial lesions in suspected patients as soon as possible.

Rapid diagnosis of childhood pulmonary tuberculosis by Xpert MTB/RIF assay using bronchoalveolar lavage fluid.

In order to evaluate the diagnostic accuracy of the Xpert MTB/RIF assay on childhood pulmonary tuberculosis (PTB) using bronchoalveolar lavage fluid (BALF), we evaluated the sensitivity, specificity, positive predictive value, and negative predictive value of Xpert MTB/RIF assay using BALF in comparison with acid-fast bacilli (AFB) microscopy and Mycobacterium tuberculosis (MTB) culture for diagnosing childhood PTB using Chinese "composite clinical reference standard" (CCRS) as reference standard. Two hundred fifty-five children with suspected PTB were enrolled at Beijing Children's Hospital from September 2010 to July 2013. Compared with Chinese CCRS, the sensitivity of AFB microscopy, MTB culture, and Xpert MTB/RIF assay was 8.4%, 28.9%, and 53.0%, respectively. The specificity of three assays was all 100%. Xpert MTB/RIF assay could detect 33.9% of cases with negative MTB culture, and 48.7% of cases with negative AFB microscopy. Younger age (<3 years), absence of BCG scar, and contact with TB patient were found significantly associated with a positive result of Xpert MTB/RIF assay. In conclusion, Xpert MTB/RIF assay using BALF can assist in diagnosing childhood PTB much faster when fiberoptic bronchoscopy is necessary according to the chest radiograph.

[Value of fractional nitric oxide concentration in exhaled breath in assessing level of asthma control in children].

OBJECTIVE: To investigate the value of fractional nitric oxide concentration in exhaled breath (FeNO) in assessing the level of asthma control in children. METHODS: A total of 226 asthmatic children were divided into controlled asthma (n= 86), partially controlled asthma (n=63), and uncontrolled asthma groups (n=77). Ninety healthy children were enrolled as controls. FeNO was measured for both asthmatic and healthy children using the Swedish-designed NIOX system. RESULTS: The control group had an FeNO of 14±6 ppb, the controlled asthma group had an FeNO of 29±26 ppb, the partially controlled asthma group had an FeNO of 32±30 ppb, and the uncontrolled asthma group had an FeNO of 40±32 ppb. The three asthma groups showed significantly higher FeNO than the control group (P<0.05). The uncontrolled asthma group showed significantly higher FeNO than the controlled asthma group (P<0.05), but there were no significant differences in FeNO between the partially controlled and uncontrolled asthma groups and between the partially controlled and controlled asthma groups (P>0.05). CONCLUSIONS: Asthmatic children have significantly higher FeNO than healthy children, and FeNO is correlated with the level of asthma control.

[Clinical analysis of bronchial foreign bodies in 246 children].

OBJECTIVE: To analyze the characters of bronchial foreign bodies in children and the utilization of bronchoscope in the treatment of bronchial foreign bodies. METHODS: A total of 246 children were diagnosed with bronchial foreign bodies at our hospital during January 2000 until August 2009. Under local mucosal anesthesia, a bronchoscope was inserted through nasal cavity into bronchi. After identifying the site of foreign body, grasping forceps was guided through bronchoscope to remove the foreign body from airway. RESULTS: Among 246 cases, hard nut and skin of melon seed were found (n = 230, 93.5%). The most common site of foreign body was in right lower lobe bronchi (n = 98, 38.9%). The average operative frequency was 1.9 +/- 1.3 and one-time extraction ratio 58.5% (n = 144). The one-time extraction ratio of patients with foreign body obstructed in main bronchi (91.1%), right middle lobe (60.0%) and right lower lobe (55.1%) was higher than others. The operation frequency of using basket grasping forceps (1.4 +/- 0.9) was lower than those using tooth type forceps (2.1 +/- 1.4). And the difference was significant (P = 0.000). CONCLUSION: For bronchial foreign body in pediatric patients, hard nut and skin of melon seed are the most common foreign bodies. The right and left lower lobe bronchi are the predilection site. Foreign body in main bronchus is the easiest to be removed by grasping forceps. For massive foreign bodies, basket grasping forceps fares better than tooth grasping forceps.

[Measurement of pulmonary function with body plethysmograph in infants].

OBJECTIVE: To observe the alterations of pulmonary function in infants with respiratory diseases. METHODS: A total of 900 infants with respiratory diseases were recruited and pulmonary function measured in 30 healthy infants. The tests were performed in the sleeping infants with sedation. Tidal breathing flow-volume (TBFV) loops were recorded when infants were breathing quietly. Passive flow-volume technique was used to obtain static respiratory system compliance and resistance. Functional residual capacity was measured by body plethysmograph. RESULTS: The TBFV loop showed proximate round or oval curve in healthy infants. The shape and parameters of TBFV loop had significant differences in infants with respiratory diseases as compared with healthy controls. The TBFV loop displayed a concave expiratory curve and ratio of time to reach tidal peak flow to total expiratory time, the expiratory volume till peak flow divided by the total expiratory volume significantly decreased in infants with small airway obstruction. The expiratory or inspiratory curve showed a plateau and the ratio of mid-expiratory to mid-inspiratory flow was less than 60% or over 150% in infants with upper airway obstruction. The TBFV loop turned narrow and lung volume decreased in infants with restrictive diseases. CONCLUSION: The TBFV loop show proximate round or oval curve in healthy infants. Pulmonary function has significant differences between healthy controls and infants with respiratory diseases. Pulmonary function test is useful in the assessment of respiratory diseases.

Brief report: An epidemiologic survey of the prevalence of sleep disorders among children 2 to 12 years old in Beijing, China.

OBJECTIVE: This survey was conducted to examine the prevalence of sleep disorders in 2- to 12-year-old children in the Beijing area of China. METHODS: From October 2001 to June 2002, 5979 children 2 to 12 years old in 6 randomly selected counties in Beijing were investigated with questionnaires. RESULTS: The average total sleep time per day ranged from 11.38 hours among 2-year-olds down to 9.34 hours among 12-year-olds. The overall prevalence of sleep disorders was 21.2% and included parasomnia symptoms (bruxism [6.5%], sleep talking [4.9%], enuresis [1.0%], sleepwalking [0.6%], restless sleep [5.0%], and leg movements [1.9%]) and symptoms of sleep-disordered breathing (frequent snoring [5.6%], mouth breathing [4.1%], choking/gasping [0.9%], and breathing pauses [0.2%]). CONCLUSION: The overall prevalence of parent-reported symptoms of sleep disorders in a large sample of children in Beijing, China, was comparable to that reported in other countries, although the prevalence of some specific symptoms differed somewhat.

[Pulmonary function in infants with respiratory syncytial virus bronchiolitis].

OBJECTIVE: To observe the dynamics of pulmonary function in infants with respiratory syncytial virus (RSV) bronchiolitis. METHODS: The to test the pulmonary function of 31 infants with RSV bronchiolitis during acute phase at admission was tested. Pulmonary fuction test was performed for the second time among 17 out of the 31 infants during the clinical recovery phase, and performed for the third time among 10 out of the 17 infants one week after discharge. In the meantime pulmonary function test was performed in 74 healthy infants as controls. RESULTS: During the acute phase of RSV bronchiolitis, the respiratory rate (RR), peak tidal expiratory flow (PTEF), peak tidal flow/tidal volume (PF/Ve), respiratory system resistance (Rrs), and functional residual capacity per kilogram (FRC/kg) were significantly increased, while the inspiratory tidal volume (Vi), inspiratory volume per kilogram (Vi/kg), expiratory tidal volume (Ve), percent of tidal volume to peak tidal expiratory flow (%V-PF), terminal flows/peak expiratory flow (25/PF), respiratory system compliance (Crs), and respiratory system compliance per kilogram (Crs/kg) were significantly decreased as compared with those in healthy infants. Ratio of mid-expiratory to mid-inspiratory flow (ME/MI) and respiratory system time constant (Trs) showed no statistically significant differences. The tidal breathing flow-volume (TBFV) loop displayed a concave expiratory curve. During the clinical recovery phase, the above abnormal indexes showed significant improvement, except for the %V-PF, 25/PF and Crs/kg which were still lower as compared with those in healthy infants, most indexes had returned to normal. The TBFV loop showed mild decelerating expiratory limb. One week after discharge all of the indexes returned to normal. CONCLUSION: In the acute phase of RSV bronchiolitis higher resistance in small airway and obstructive ventilatory disturbance can be seen. Some of the indexes remain abnormal during the clinical recovery phase. However, the abnormalities disappear in a short time. Pulmonary function test is a valuable way for surveillance of the course and prognosis of RSV bronchiolitis. %V-PF, 25/PF, and FRC/kg are sensitive indexes.