Noninvasive treatment of bronchomalacia, successful ventilation of a severely ill infant.

UNLABELLED: Noninvasive treatment of bronchomalacia. Successful ventilation of a severely ill infant. AIM: To describe an effective treatment of a boy with bronchomalacia by noninvasive mechanical ventilation support. METHODS: We describe a case of a severely ill patient with bronchomalacia from the time he was born and until the age of five. Bi-level positive airway pressure given through a specially adapted full face mask was used to treat his respiratory condition. RESULT: Our patient responded well to the noninvasive treatment of bronchomalacia. CONCLUSION: We found that noninvasive mechanical ventilation support is a low risk and highly effective treatment of infants and children with respiratory distress caused by bronchomalacia.

Pulmonary outcome in adolescents of extreme preterm birth: a regional cohort study.

AIMS: The pulmonary outcome of extreme prematurity remains to be established in adults. We determined respiratory health and lung function status in a population-based, complete cohort of young preterms approaching adulthood. METHODS: Forty-six preterms with gestational age < or = 28 wk or birthweight < or = 1000 g, born between 1982 and 1985, were compared to the temporally nearest term-born subject of equal gender. Spirometry, plethysmography, reversibility test to salbutamol and methacholine bronchial provocation test were performed. Neonatal data were obtained from hospital records and current symptoms from validated questionnaires. RESULTS: When entering the study at a mean age of 17.7 (SD: 1.2) y, a doctor's diagnosis of asthma and use of asthma inhalers were significantly more prevalent among preterms than controls (one asthmatic control compared to nine preterms, all but one using asthma inhalers). Peak expiratory flow (PEF) and forced expiratory volume in 1 s (FEV1) were decreased and the discrepancies relative to controls increased parallel to increased severity of neonatal lung disease. Parameters of increased neonatal oxygen exposure significantly predicted FEV1. Adjusted for height, gender and age, FEV1 was reduced by a mean of 580 ml/s in subjects with a history of bronchopulmonary dysplasia. Fifty-six percent of preterms had a positive methacholine provocation test compared to 26% of controls. CONCLUSION: A substantially decreased FEV1, increased bronchial hyperresponsiveness and a number of established risk factors for steeper age-related decline in lung function were observed in preterms. A potential for early onset chronic obstructive pulmonary disease is present in subsets of this group.

Abandoning prone sleeping: Effect on the risk of sudden infant death syndrome.

OBJECTIVE: This study was designed to evaluate the long-term effect of a campaign to avoid prone sleeping on the sudden infant death syndrome (SIDS) mortality rate and on parents' choice of sleeping position for young infants. Before the campaign, 64% of infants usually slept prone and the SIDS rate was 3.5 (95% CI, 2.64 to 4.36) per 1000 live births. STUDY DESIGN: Population-based case reference study of infants dying suddenly and unexpectedly at the ages of 1 week to 1 year, and of 493 healthy infants between 2 and 6 months of age, starting 4 years after an intervention program to avoid prone sleeping. RESULTS: The SIDS rate was 0.3 per 1000 live births (95% CI, 0.05 to 0.54). One of five (20%) SIDS victims usually slept prone, three of five (60%) were placed prone for their last sleep, and five of six were found dead in the prone position. Of the reference infants, 1.4% were usually placed prone to sleep, although all had previously accepted a non-prone position. Nearly half of the infants (49.1%) were usually placed supine, 22.7% usually on the side, and 26.8% in variable positions of which 2.0% occasionally included prone. The side position was the least stable position. After the age of 1 week, 59.4% of infants had been found with their heads covered on at least one occasion. CONCLUSIONS: SIDS is rare when prone sleeping is avoided. Infants at the age of particular risk for SIDS may spontaneously turn from the side to the prone position, and they commonly slip under the bedding during sleep.

Consequences of getting the head covered during sleep in infancy.

OBJECTIVE: To study the consequences of getting the head covered by bedding (fiber quilt) on carbon dioxide (CO2) accumulation around the face, behavior, and physiologic responses during prone and supine sleep in infants to add understanding to why victims of sudden infant death syndrome are often found under the bedding. METHPDOLOGY: Of 33 healthy term, usually nonprone sleeping infants, behavior and computerized polysomnography were successfully recorded for 30 during prone and supine sleep at 21/2 months and for 23 prone and 25 supine at 5 months. RESULTS: For both ages and body positions, covering the head resulted in significant CO2 accumulation around the face, fewer apneas (3 to 10 seconds), shorter duration of apneas after sighs, higher heart and respiratory rates, and peripheral skin temperature. Differences were generally greater at 21/2 than at 5 months. While covered, the prone position was associated with higher CO2 levels close to the face, slightly higher transcutaneous PCO2, and higher heart rates and peripheral skin temperatures than the supine position. In the supine position 23% were able to remove the cover from the head at 21/2 and 60% at 5 months, whereas only 1 infant of 5 months managed to remove the cover when prone. CONCLUSIONS: The observed responses are consistent with a potential for distress when the head is covered, particularly when placed prone. Probably most important with respect to sudden infant death syndrome is the infants' inability to remove the bedding from the head upon awakening from prone sleep.

Behaviour and physiological responses during prone and supine sleep in early infancy.

AIMS: To study the effect of prone and supine sleep on infant behaviour, peripheral skin temperature, and cardiorespiratory parameters to aid understanding of why prone sleeping is associated with an increased risk of sudden infant death syndrome. METHODS: Of 33 enrolled infants, 32 were studied at 2.5 and 28 at 5 months of age. A computer aided multichannel system was used for polysomnographic recordings. Behaviour was charted separately. RESULTS: Prone REM (active) sleep was associated with lower frequencies of short arousals, body movements and sighs, and a shorter duration of apnoeas than supine REM sleep at both ages. At 2.5 months there were less frequent episodes of periodic breathing during prone sleep in non-REM (quiet) and REM sleep. Heart rate and peripheral skin temperature were higher in the prone position during both sleep states at both ages. CONCLUSIONS: The observation of decreased variation in behaviour and respiratory pattern, increased heart rate, and increased peripheral skin temperature during prone compared with supine sleep may indicate that young infants are less able to maintain adequate respiratory and metabolic homoeostasis during prone sleep.

Infant behaviour in response to a change in body position from side to prone during sleep.

UNLABELLED: The consequences of provoking a change in the sleeping position from side to prone during quiet (non-REM) and active (REM) sleep in young infants were studied in terms of ability to turn the face away from the mattress within 3 min, and in terms of ventilatory and heart rate responses in those who remained face down. Twenty-six infants were exposed to repeated tilts from the side to prone at 2.5 months, and 20 at 5 months of age. Eighteen infants were tested on both occasions. A computer-aided multichannel system was used for polysomnographic recordings. Approximately 66% of the infants did not rotate the face away from the mattress on at least one occasion. There were no significant differences in the rate of face down outcome between sleep states or ages, and no consistent pattern of final face position following repeated tilts. The face to side position was commonly accomplished after considerable difficulties involving vigorous body movements, particularly if the arm became positioned between the body and the mattress or alongside the trunk after the tilt. Apnoeas of 3-14 s in immediate response to the tilt were observed in 75% of the infants monitored electronically. In 13% of the infants, all in a face down position, the test was terminated because of increases in heart and respiratory rates, drop in oxygen saturation, or marked pallor. CONCLUSIONS: The observed difficulties of obtaining a face to side position when suddenly exposed to the prone position during sleep, may render some young infants at risk of sudden infant death (SID).

CO2 rebreathing: a possible contributory factor to some cases of sudden infant death?

Physical and geometrical conditions influencing carbon dioxide (CO2) accumulation near the face of a sleeping infant positioned deep in a cot or pram (open cot shaft) or underneath bedding (closed cot shaft) were investigated. By means of mathematical and data-based simulation, and an experimental rebreathing model, both hypothetical (dry, exhaled air +20 degrees C) and more physiological conditions (heated, humidified exhaled air, room temperature +20 degrees C; with and without pooling of cold air within the shaft) were tested. With exhaled air at +20 degrees C, the CO2 concentration increased to about 10% within 5 min. The increase was faster the smaller the volume, and the smaller the opening of the cot shaft. When expiratory air was heated, the CO2 concentration increased with the same speed as when the shaft was closed, but to only 0.1-0.3% when the shaft was open. Pooling of cold air in the shaft increased CO2 accumulation 70-200 times the concentration in air (to <5.5%) when the shaft was open. Turbulence of the air outside the open shaft reduced the increase in CO2 concentration. The experiments imply that CO2 may accumulate around an infant's head when placed deep in a cot or pram with the bedding and walls creating a narrow, vertical, shaft-like tunnel to the surrounding air. Although the CO2 concentration may theoretically attain dangerous levels in such circumstances, a rapid equilibrium between the air within and outside the cot usually occurs due to convection of the expiratory air and turbulence from drafts, the infant's body movements and breathing. Such factors will largely eliminated any significant rebreathing with the exception of the extreme situation when expired air is contained within a closed space.

[Intermittent bradyarrhythmia in infants and small children treated with permanent pacemaker]. / Intermitterende bradyarytmi i sped- og småbarnsalderen behandlet med permanent pacemaker.

Four children aged two, two and four months and five years respectively, with intermittent cardiac bradyarrhythmias and otherwise normal hearts are described. The diagnoses were based upon findings by telemetry and 24-hour ECG-recordings. Two patients had sinus node disease, one patient had intermittent complete atrioventricular block, and the fourth had a permanent first degree atrioventricular block and intermittent high grade second degree atrioventricular block. All patients presented serious symptoms with apparent life-threatening events before admission. They were given a permanent cardiac pacemaker. One patient experienced recurrent excessive increase in the myocardial stimulation threshold, leading to further syncopal episodes. All patients are developing adequately with normally functioning pacemakers.

The influence of supine relaxation on blood pressure, heart rate and atrial natriuretic peptide in normal subjects.

The effect of recumbent rest on plasma atrial natriuretic peptide (ANP) concentration, mean blood pressure (MBP) and heart rate was studied in 26 normal human volunteers. Plasma ANP concentration, MBP and heart rate were determined after 10 min sitting and after 2, 5, 8, 15 and 30 min of recumbency. During the first 5 min of recumbency there were significant decreases in both MBP (p less than 0.001) and heart rate (p less than 0.001) compared with sitting. There was a small but significant fall in plasma ANP concentration (p = 0.02) after 30 min of recumbency compared with sitting. No further reduction in MBP or heart rate occurred after 5 min supine. The level of MBP following 5 min supine correlated significantly (r = 0.44; p = 0.02) with the plasma ANP concentration 25 min later. Blood pressure and heart rate are highly dependent on posture and relaxation, and plasma ANP concentration in lesser degree. It is necessary to wait for stable baseline values to develop before any comparisons between blood pressure and plasma ANP are done. If it is assumed that a causative relation exists between blood pressure and plasma ANP level, it appears there may be a delay of 20-30 min between a change in blood pressure and the physiological response of plasma ANP level. This observation may have implications for the interpretation of the relation between blood pressure and plasma ANP concentration in healthy individuals.

Combined intoxication with digitoxin and verapamil. The possible inhibition of sensitisation to digitalis-specific antiserum by toxic drug concentrations.

The clinical course in a patient with a combined intoxication with digitoxin (maximal serum level 357 nmol/l) and verapamil is described. The patient received two injections of digitalis-specific antiserum. No adverse reactions to the therapy was seen, and the antiserum markedly shortened the plasma half-life of digitoxin. In vitro studies indicate that digitoxin in concentrations seen during the intoxication may have an immunosuppressive effect, thereby reducing the risk of sensitisation to the antiserum.

Sudden death caused by heart block in a patient with multiple myeloma and cardiac amyloidosis.

A patient with multiple myeloma and amyloidosis was admitted to hospital following successful cardiopulmonary resuscitation at home. No disturbances in heart rhythm were seen during the first 48 hours of continuous telemetric ECG recording. The patient died from ventricular asystole due to complete atrioventricular block, while he was on a 24-hour Holter monitoring the fifth night in hospital. Patients with known cardiac amyloidosis and syncope should undergo long-term ECG recordings, preferably by telemetry. Repeated registrations may be necessary to discover disturbances in heart rhythm.