[Guidelines for the Management of Community Acquired Pneumonia in Children and Adolescents (Pediatric Community Acquired Pneumonia, pCAP) - Issued under the Responsibility of the German Society for Pediatric Infectious Diseases (DGPI) and the German Society for Pediatric Pulmonology (GPP)]. / S2k-Leitlinie Management der ambulant erworbenen Pneumonie bei Kindern und Jugendlichen (pädiatrische ambulant erworbene Pneumonie, pCAP).

The present guideline aims to improve the evidence-based management of children and adolescents with pediatric community-acquired pneumonia (pCAP). Despite a prevalence of approx. 300 cases per 100 000 children per year in Central Europe, mortality is very low. Prevention includes infection control measures and comprehensive immunization. The diagnosis can and should be established clinically by history, physical examination and pulse oximetry, with fever and tachypnea as cardinal features. Additional signs or symptoms such as severely compromised general condition, poor feeding, dehydration, altered consciousness or seizures discriminate subjects with severe pCAP from those with non-severe pCAP. Within an age-dependent spectrum of infectious agents, bacterial etiology cannot be reliably differentiated from viral or mixed infections by currently available biomarkers. Most children and adolescents with non-severe pCAP and oxygen saturation > 92 % can be managed as outpatients without laboratory/microbiology workup or imaging. Anti-infective agents are not generally indicated and can be safely withheld especially in children of young age, with wheeze or other indices suggesting a viral origin. For calculated antibiotic therapy, aminopenicillins are the preferred drug class with comparable efficacy of oral (amoxicillin) and intravenous administration (ampicillin). Follow-up evaluation after 48 - 72 hours is mandatory for the assessment of clinical course, treatment success and potential complications such as parapneumonic pleural effusion or empyema, which may necessitate alternative or add-on therapy.

Safety and tolerability of seasonal ultra-rush, high-dose sublingual-swallow immunotherapy in allergic rhinitis to grass and tree pollens: an observational study in 193 children and adolescents.

OBJECTIVE: We conducted a large observational study in 193 children and adolescents with allergic rhinitis due to grass or tree pollens to evaluate the safety and tolerability of an ultrarush high-dose sublingual immunotherapy (SLIT) regimen reaching a maintenance dose of 300 index of reactivity within 90 minutes. METHODS: Children and adolescents aged 5 to 17 years with at least a 1-year medical history of allergic rhinitis with or without mild to moderate asthma due to tree pollens (birch, alder, hazel) or grass pollens (cocksfoot, meadow grass, rye grass, sweet vernal grass, timothy) were recruited. Standardized grass and tree pollen allergen extracts were used for ultrarush titration and subsequent coseasonal maintenance. RESULTS: During ultrarush titration, 60 patients (31%) reported 117 predominantly mild and local adverse events, which resolved within 150 minutes. During the maintenance phase, 562 adverse events were reported; the most frequent local events were oral pruritus, burning sensation, lip or tongue swelling, and gastrointestinal symptoms, and the most frequent systemic events were rhinoconjunctivitis and asthma. There was 1 clinically significant asthma event in an 11-year old boy with known asthma in whom SLIT was resumed after an interval of 4 days. CONCLUSION: Ultrarush titration was safe and well tolerated. Pediatric patients with asthma should be carefully monitored and adequately trained to use their rescue medications.

Importance of inhaler devices in the management of airway disease.

The delivery of drugs by inhalation is an integral component of asthma and chronic obstructive pulmonary disease (COPD) management. However, even with effective inhaled pharmacological therapies, asthma, particularly, remains poorly controlled around the world. The reasons for this are manifold, but limitations of treatment guidelines in terms of content, implementation and relevance to everyday clinical life, including insufficient patient education, access to health care and cost of medication as well as poor inhaler technique are likely to contribute. Considering that inhalation therapy is a cornerstone in asthma and COPD management, little advice is provided in the guidelines regarding inhaler selection. The pressurised metered dose inhaler (pMDI) is still the most frequently prescribed device worldwide, but even after repeated tuition many patients fail to use it correctly. In addition, the correct technique can be lost over time. Although several improvements in pMDIs such as a change in the propellant and actuation have resulted in improvements in lung deposition, many dry powder inhalers (DPIs) are easier to use. However, these devices also have limitations such as dependency of drug particle size on flow rate and loss of the metered dose if the patient exhales through the device before inhaling. Improvements in using inhalation devices more efficiently, in inhaler design for supporting patient compliance, and advances in inhaler technology to assure drug delivery to the lungs, have the potential to improve asthma and COPD management and control. New and advanced devices are considered being helpful to minimise the most important problems patients have with current DPIs.

Small airway patency in infants with apparent life-threatening events.

UNLABELLED: A reduction in specific airway conductance has been reported in infants with a history of an apparent life-threatening event (ALTE). It is unclear, however, whether this reflects upper or lower airway narrowing. We performed a controlled study to determine small airway patency in infants with ALTE. Lung function tests were performed in 26 infants with a history of ALTE and 27 healthy controls. Partial expiratory flow-volume curves were obtained during quiet sleep using the rapid chest compression technique; thoracic gas volume (TGV) and expiratory airway resistance (RAW) were measured by whole body plethysmography. Compliance of the respiratory system (Crs) was measured using the single breath occlusion technique. The median maximal flow at functional residual capacity (VmaxFRC) was 85 ml/s (range 10-198 ml/s) in patients and 123 (range 47-316 ml/s) in controls (P = 0.003). VmaxFRC corrected for TGV was 0.5 s(-1) (range 0.06-1.3 s[-1]) and 0.9 s(-1) (range 0.4-1.8 s[-1]), respectively (P = 0.001). TGV, RAW and Crs were not significantly different between patients and controls. CONCLUSION: Reduced small airway patency may play a role in the pathogenesis of ALTE.

Determinants of lung volume in spontaneously breathing preterm infants.

To study the effects of apneic pauses, sighs, and breathing patterns on functional residual capacity (FRC), we measured FRC repeatedly in 48 healthy preterm infants (weight at study 2,042 +/- 316 g [mean +/- SD], postconceptional age 36.6 +/- 2.0 wk), during unsedated sleep using a modified heliox/nitrogen washout technique. Breathing movements and pulse oximeter saturation (SpO2) were recorded throughout and recordings analyzed for the presence of regular and nonregular breathing pattern, apneic pauses, sighs, and desaturations (SpO2 < 90%) during the last 2 min prior to each FRC measurement. FRC was lower during nonregular than during regular breathing pattern (23.3 +/- 7.2 ml/kg versus 26.9 +/- 7.8 ml/kg, p < 0.02); however, this apparent effect of breathing pattern disappeared after controlling the data for apneic pauses. Apneic pauses resulted in a significant decrease in FRC: mean FRC was 20.0 +/- 6.8 ml/kg if measured within 2 min of an apneic pause, 26.0 +/- 6.9 ml/kg if measured after a sigh (p < 0.001), and 24.0 +/- 7.7 ml/kg if there had been neither a sigh nor an apneic pause (p < 0.05). The interval between the apneic pause and the FRC measurement had no effect on FRC. There was an inverse correlation between FRC and the speed with which SpO2 fell during desaturation (r = -O.5, p < 0.03). Apneic pauses resulted in a persistent reduction in FRC in these preterm infants. Sighs appeared to restore FRC. The significant relationship between FRC and the speed of desaturation found in this study underscores the importance of endogenous or exogenous strategies that help to increase FRC, such as sighs or the application of continuous positive airway pressure, for the stability of oxygenation in preterm infants who have difficulty maintaining their oxygenation.

Comparison of heliox and oxygen as washing gases for the nitrogen washout technique in preterm infants.

The nitrogen washout technique usually involves exposure of the patient to 100% oxygen for several minutes. This may be dangerous in preterm infants who are at risk of retinopathy of prematurity (ROP). We wanted to know whether heliox (79% He, 21% O2) can be used instead of oxygen when determining functional residual capacity (FRC). FRC measurements were made in 14 preterm infants [median (range) gestational age at birth 34 wk (27-37 wk), and at time of study 36 wk (33-40 wk)] who were breathing room air. FRC was measured using a computerized infant pulmonary function system, beginning in random order with either 100% O2 followed by heliox or vice versa. There was no systematic difference between the two methods with regard to lung volume measurements: mean (SD) FRC values, corrected for body weight, were 22.9 (7.1) mL/kg for O2 and 23.4 (7.0) mL/kg for heliox. We did not observe a systematic influence of the type of washing gas used (heliox or oxygen) on FRC in these infants. Our results suggest that the use of heliox instead of pure oxygen may be a suitable and safer alternative for FRC measurements with the nitrogen washout technique in preterm infants who are breathing low concentrations of inspired oxygen and are still at risk of ROP.

Assessment of tidal breathing patterns for monitoring of bronchial obstruction in infants.

Two parameters of tidal breathing, the ratio of time to reach peak tidal expiratory flow to the total expiratory time (Tme/TE) and the ratio of volume exhaled at peak tidal expiratory flow to the total exhaled volume (dV/VT) were used to assess lung function in 21 sedated infants (aged 6-14 mo) with different degrees of airway obstruction. These parameters were compared with airway resistance as percentage predicted (Raw%) and maximum expiratory flow at functional residual capacity corrected for lung volume (VmaxFRC/TGV). VmaxFRC/TGV values correlated significantly with Tme/TE (r = 0.630, p = 0.002) as well as with dV/VT (r = 0.728, p = 0.001). Raw% values showed only a weak correlation with dV/VT (r = -0.435, p = 0.048). We conclude that Tme/Te and dV/VT are both able to detect airway obstruction in infants and that these parameters correlate much better with the forced expiratory flow values obtained by the rapid thoracic compression method than with airway resistance, determined by body plethysmography.

Pressure sensor plethysmography: a method for assessment of respiratory motion in children.

Noncalibrated respiratory inductance plethysmography has been used to measure respiratory function by calculation of the phase angle and, more recently, by determination of the ratio of each time to reach peak tidal expiratory flow to total expiratory time (TPEF/TE). Since TPEF/TE is known to be decreased in airway obstruction when derived from flow signals obtained by a pneumotachograph, we wanted to develop an alternative method to measure rib cage and abdominal respiratory movements. For this purpose, we used two pressure sensors attached to the skin above the umbilicus and in the right medioclavicular line at the fourth intercostal space: "pressure sensor plethysmography". We tested the ability of this method to assess thoracoabdominal asynchrony and TPEF/TE by comparison with respiratory inductance plethysmographic and pneumotachographic measurements in 30 children, aged 1-12 yrs, with airway obstruction. The mean difference (95% confidence interval (95% CI)) between phase angles obtained by respiratory inductance plethysmography and pressure sensor plethysmography was only -5.8 degrees (range -18.0 to +6.4 degrees). Similarly, all methods used to measure TPEF/TE agreed well: mean differences (95% CI) between pneumotachographic and respiratory inductance plethysmographic, pneumotachographic and pressure sensor plethysmographic, and respiratory inductance plethysmographic and pressure sensor plethysmographic measurements of TPEF/TE were +0.01 (range -0.05 to +0.06), -0.03 (-0.09 to +0.03) and -0.03 (-0.10 to +0.04), respectively. We conclude that pressure sensor plethysmography is a simple and noninvasive method, and suitable to measure thoracoabdominal asynchrony and TPEF/TE ratios as well as respiratory inductance plethysmography and pneumotachography.

Effect of endotracheal tube leakage on functional residual capacity determination by nitrogen washout method in a small-sized lung model.

The determination of functional residual capacity (FRC) would be extremely helpful for the controlled adjustment of mechanical ventilation in sick neonates and infants. However, these patients have small lung volumes and usually have been intubated by uncuffed endotracheal tubes (ETT). Therefore, the open-circuit nitrogen washout technique (N2wo) may give false FRC values if the inspired oxygen concentration (FIO2) is high and leakage around the ETT is present. We evaluated the N2wo as supplied by the Pediatric Pulmonary System 2600 (Sensor-Medics) in a small-sized lung model by 570 measurements using five different ventilator settings, an FIO2 increasing up to 0.9, different bypass flows between 0 and 12 L/min, and various patterns of leakage, either during inspiration or exhalation, or both. We found the most reliable results (error, 0.6%; CV, 0.7%) with a bypass flow of 6 L/min. Absolute N2 volumes as small as 14 mL could be measured using an FIO2 as high as 0.9 with only slight loss of accuracy (error, 4%; CV, 2.8%). During leakage, FRC had been underestimated with a very strong correlation to the total amount of leakage over the measurement period, which was irrespective of the ventilatory parameters (r = 0.9, P < 0.001). The regression equation could, therefore, be used for FRC correction in the lung model. However, most of the miscalculation was due to N2 loss during expiratory leakage, which quite simply and reliably can be excluded by an end-inspiratory occlusion test.(ABSTRACT TRUNCATED AT 250 WORDS)

[Life threatening pneumocystis carinii pneumonia in a 4-month-old boy with hyper-IgM syndrome]. / Lebensbedrohliche Pneumocystis-carinii-Pneumonie bei einem 4 Monate alten Jungen mit Hyper-IgM-Syndrom.

At the age of four months, a boy with a normal history and family history, suddenly fell ill with a life-threatening pneumocystis carinii-pneumonia. Surprisingly, this opportunistic infection was not brought about by a T-cell deficiency. However, the patient's diagnosis turned out to be the rare "Hyper-IgM-syndrome", confirmed by: serum levels of IgM always at least normal whereas IgG, IgA and IgE were markedly decreased or absent; the development of neutropenia and occasional diarrhea. Generally, infections with pneumocystis carinii are rare in isolated deficiencies of immunoglobulines, but relatively frequent in primary "Hyper-IgM-syndrome" (approx. 12% of the cases described). The boy finally recovered after receiving Cotrimoxacol (20 mg/kg bw/d) in an intensive care unit. Now, at the age of nearly two his condition is almost good under regular substitution of IgG. Cotrimoxacol (4 mg/kg bw/d) is recommended to prevent further pneumocystis carinii infections and most of the pathogenes which frequently appear in neutropenias.

[Accuracy of measurements of Kontrol 7840, Nellcor N200 and Radiometer OX13 pulse oximeters in infants and young children]. / Die Messgenauigkeit des Kontron 7840, Nellcor N200, und Radiometer OX13 Pulsoximeters bei Säuglingen und Kleinkindern.

Comparative validation studies of pulse oximeters from different manufacturers have predominantly been performed in adult patients. However, due to differences in the patient-sensor interface, the results from those studies may not be transferable to the paediatric population. We therefore performed 123 simultaneous measurements (37 patients) of transcutaneous O2-saturation (StcO2) from 3 pulse oximeters and compared these with the arterial O2-saturation (SaO2) from a co-oximeter (Radiometer OSM 3). The median age of the 37 patients at the time of study was 2.0 months (range 1 day-5 years), their weight 4.7 kg (0.8-15.0 kg). The mean difference between StcO2 and SaO2 was -0.6% (SD 5.2%) for the Kontron 7840 pulse oximeter, -0.9% (SD 2.3%) for the Nellcor N200, and -1.2% (SD 3.5%) for the Radiometer OXI3 pulse oximeter. The corresponding 95% intervals were -7.4(-) + 9.6%, -5.7(-) + 4.3% and -7.0(-) + 6.3% for the Kontron, Nellcor and Radiometer instrument, respectively. These results demonstrate that neither of the 3 instruments systematically under- or overestimated SaO2. However, there were differences in precision, particularly in the low range of SaO2.

Reliability of a pulse oximeter in the detection of hyperoxemia.

To evaluate the reliability of the Nellcor N200 pulse oximeter in the detection of hyperoxemia (oxygen tension > 80 mm Hg), we obtained 213 simultaneous recordings and measurements of transcutaneous oxygen saturation (SO2) and arterial oxygen tension (PaO2) in 50 patients. During 95% of measurements with PaO2 > 80 mm Hg, SO2 was > or = 96%; SO2 was also > or = 96% in 20% of measurements with PaO2 < or = 80 mm Hg (false-positive results for hyperoxemia). With the upper alarm limit set at 95%, the pulse oximeter identified 95% of hyperoxemic instances while allowing PaO2 to be kept to > 60 mm Hg.

Pulmonary artery sling with tracheal stenosis: primary one-stage repair in infancy.

Pulmonary artery sling is often associated with tracheal stenosis. In many cases repair of the vascular anomaly alone does not relieve dyspnea. Primary one-stage repair with long segment tracheal resection (2.4 cm) and relocation of the left pulmonary artery using cardiopulmonary bypass and deep hypothermic circulatory arrest is described in a 6.5-month-old girl weighing 6.5 kg. This technique resulted in normal ventilation and pulmonary flow distribution.

Hypoxemia in infants with biliary atresia: the role of airway obstruction.

Hypoxemia in liver cirrhosis has been attributed to increased pulmonary perfusion; lung function abnormalities have rarely been found in adults. In infants, however, smaller airways and the disproportion in size between the enlarged liver and abdominal cavity leading to lung compression by elevated diaphragms may well suggest that ventilation disturbances play an important role in the development of hypoxemia. We examined lung functions, ventilation-perfusion scans, chest radiographs, and blood gases in air and 80% oxygen in 19 infants with biliary atresia (mean age 14 months) and found maximum flows at functional residual capacity (VmaxFRC) markedly decreased [48% +/- 29% (mean +/- SD)] and thoracic gas volume (TGV) elevated (156% +/- 30.2%). PO2 was less than 9.3 kPa in seven of 19 patients, in whom TGV was higher compared with the other patients (182% vs. 141%, p less than 0.005). However, the decrease in PO2, was much more closely correlated to the amount of shunting (r = 0.62, p less than 0.05) than to the reduced airway patency (VmaxFRC/TGV, r = 0.41, p = 0.08). We conclude that airway narrowing probably by lung compression is present more frequently in infants than in adults with liver disease. We found some evidence that hyperinflation contributes to the observed low PO2 values, possibly aggravated by inadequate vasoconstriction to hypoxic stimuli. However, pulmonary shunting independent of ventilatory disturbances more readily explained hypoxemia already present in these infants.

[Neonatal variant of Bartter syndrome]. / Die neonatale Variante des Bartter-Syndroms.

A male preterm infant of 32 weeks of gestation with history of severe polyhydramnios during pregnancy presented soon after birth with polyuria with initial sodium chloride loss subsequently followed by increasing potassium loss. After manifestation of hypokalaemia, hypochloraemia, alkalosis and high urinary prostaglandin concentrations, the diagnosis of the neonatal variant of Bartter's syndrome was made. The treatment consisted of administered of large amounts of fluid with sodium chloride and potassium supplementation and indomethacin (1.5 to 2 mg/kg per day).

[Mucociliary clearance in childhood]. / Die mukoziliare Clearance im Kindesalter.

AIM OF THE STUDY: A new, nearly monodisperse human serum albumin particle produced by air-pressure-nebulization was inhaled by children and lung-transplant patients. METHOD: After inhalation of the particles obtained with an air-pressure nebulizer, the initial deposition pattern showed a marked tracheobronchial deposition which could be reproducibly obtained without a special breathing technique, the alveolar deposition being not higher than 10%. With the use of 99mTc, the radiation exposure is limited to a level which is low enough for children, but images can be taken up to 24 hrs later. Further parameters for in vivo characterization of the mucociliary function are the 24 h retention pattern and the velocity of particle motion in the trachea. RESULTS: Within the first 45 minutes, the global clearance rate was 51% in healthy children, which is rather high in comparison with the literature, most likely due to size of particles and the selection of patients with a mean age of 10.7 years. In ciliary dysfunction, the initial clearance rate was 16% and 46% within 24 h. CONCLUSIONS: With simplification of the preparation, application, and examination technique, this method is to be used in children, so that a wider use can be anticipated. The normally fast initial elimination of particles allows quick differentiation of normal and impaired ciliary function.

Inhaled frusemide against cold air induced bronchoconstriction in asthmatic children.

Inhaled frusemide prevents bronchoconstriction in asthmatic adults induced by various triggers. To determine if frusemide provides similar protection in children, whether this is age dependent and equally effective for central and peripheral airways, we performed a double blind, placebo controlled, randomised, crossover study on the effect of inhaled frusemide on lung function changes induced by cold air challenge in 21 asthmatic children. In addition, we measured diuresis before and after inhalation. Bronchodilatation after frusemide was not observed. However, deterioration in lung function after frusemide, compared with placebo, was significantly diminished: forced expiratory volume in one second (FEV1) was -5.7% v -11.5%, peak expiratory flow (PEF) -7.7% v -23.3%, maximum expiratory flow at 50% of vital capacity (MEF50VC) -16.0% v -35.2%, and at 60% of total lung capacity (MEF60TLC) -32.4% v -61.6%, and specific airways conduction -42.0% v -57.7%, respectively. This effect was not age dependent. Diuresis was significantly increased from a mean (SEM) of 198 (34) ml/3 hours before inhaled frusemide to 379 (62) ml/3 hours after nebulisation. We conclude that inhaled frusemide prevents cold air induced bronchoconstriction in asthmatic children and that increased diuresis can be expected with a dose as low as 28 mg of frusemide given by nebuliser.

[Juvenile laryngeal papillomatosis--a case report]. / Juvenile Larynxpapillomatose--ein Fallbericht.

Juvenile papillomatosis of the larynx is a disease of viral origin and is a rare cause of hoarseness and stridor in childhood. Although the tumours are basically benign, they may present problems in therapy due to their localisation and marked tendency to recur. According to the present state of knowledge, a combination of laser coagulation and alpha-interferon therapy is the treatment of choice. It can be applied on a long-term basis effectively and with few side effects due to individualised dosage determination. We report on a girl patient of 2 1/2 years of age with recurrent juvenile papillomatosis of the larynx. Long-term alpha-interferon therapy was so far successful in preventing progress of the pattern of findings. Treatment is well tolerated after the most suitable dose has been found for a particular patient. No side effects were seen that would have compelled us to discontinue the treatment. We are planning to continue interferon therapy for at least 1 to 2 years with regular endoscopic control.