Pediatric tracheotomies: changing indications and outcomes.

OBJECTIVE/HYPOTHESIS: To study the outcomes and complications associated with pediatric tracheotomy, as well as the changing trend in indications and outcomes since 1970. STUDY DESIGN: Retrospective chart review at a major tertiary care children's hospital. METHODS: On children who underwent tracheotomy at Children's Hospital of the King's Daughters (Norfolk, VA) between 1988 and 1998, inpatient and outpatient records were reviewed. Of 218 tracheotomies, sufficient data were available on 204. Indications for tracheotomy were placed into the following six groups: craniofacial abnormalities (13%), upper airway obstruction (19%), prolonged intubation (26%), neurological impairment (27%), trauma (7%), and vocal fold paralysis (7%). RESULTS: The average age at tracheotomy was 3.2 +/- 0.6 years. Although the prolonged intubation group was significantly younger than all others, the neurological impairment and trauma groups were significantly older. Decannulation was accomplished in 41%. Time to decannulation was significantly higher in the neurological impairment and prolonged intubation groups, but was significantly shorter in the craniofacial group. Complications occurred in 44%. Overall mortality was 19%, with a 3.6% tracheotomy-related death rate. Comparison of our series to other published series of pediatric tracheotomies since 1970 shows fewer being performed for airway infections and more for chronic diseases, with a corresponding increase in duration of tracheotomy and decreased decannulation rates. CONCLUSIONS: Tracheotomy is a procedure performed with relative frequency at tertiary care children's hospitals. While children receiving a tracheotomy have a high overall mortality, deaths are usually related to the underlying disease, not the tracheotomy itself.

Improved outcomes for hospitalized asthmatic children using a clinical pathway.

BACKGROUND: Although asthma clinical pathways are used with increasing frequency, few controlled studies have evaluated the clinical and cost effectiveness of these pathways. OBJECTIVE: To evaluate the effect of an inpatient asthma clinical pathway on cost and quality of care for children with asthma. METHODS: One hundred forty-nine children were treated for status asthmaticus using an asthma clinical pathway in a children's hospital between September and December 1997. Thirty-four of 149 children treated with the clinical pathway were randomly selected. A retrospective cohort control group of non-pathway patients (N = 34) was matched with each pathway patient by age, race, gender, co-morbidities, asthma severity score, ICU admission, and time of year admitted. Differences between the two groups in length of stay, total costs, readmission rate, inpatient management, and discharge medications were compared. RESULTS: Length of stay was significantly lower in the clinical pathway group compared with the control group (36 hours versus 71 hours, P < .001) and total costs decreased significantly ($1685 versus $2829, P < .001) as a result of the pathway. Asthmatic children on the clinical pathway were significantly more likely than the control group to complete asthma teaching while hospitalized (65% versus 18%, P < .001), to be discharged with a prescription for a controller medication (88% versus 53%, P < .01), and to have a peak flow meter (57% versus 23%, P < .05) and a spacer device (100% versus 71%, P < .001) for home use. CONCLUSION: Implementation of this inpatient clinical pathway led to a decrease in length of stay and a reduction in total cost while improving quality of care for hospitalized asthmatic children.

Outcomes evaluation of a comprehensive intervention program for asthmatic children enrolled in medicaid.

OBJECTIVES: To evaluate health care and financial outcomes in a population of Medicaid-insured asthmatic children after a comprehensive asthma intervention program. DESIGN: Controlled clinical trial. SETTING: Pediatric allergy clinic in an urban, tertiary care children's hospital. SUBJECTS: Eighty children, 2 to 16 years old, with a history of frequent use of emergent health care services for asthma. Intervention. Children in the intervention group received asthma education and medical treatment in the setting of a tertiary care pediatric allergy clinic. An asthma outreach nurse maintained monthly contact with the families enrolled in the intervention group. OUTCOME MEASURES: Emergency department (ED) visits, hospitalizations, and health care charges per patient in the year after enrollment. RESULTS: Baseline demographics did not differ significantly between the 2 groups. In the year before the study, there were no significant differences between intervention and control children in ED visits (mean, 3.5 per patient), hospitalizations (mean,.6 per patient) or health care charges ($2969 per patient). During the study year, ED visits decreased to a mean of 1.7 per patient in the intervention group and 2.4 in controls, while hospitalizations decreased to a mean of.2 per patient in the intervention group and.5 in the controls. Average asthma health care charges decreased by $721/child/year in the intervention group and by $178/patient/year in the control group. CONCLUSIONS: A comprehensive asthma intervention program for Medicaid-insured asthmatic children can significantly improve health outcomes while reducing health care costs.asthma education, health care outcomes, Medicaid, asthma outreach, utilization.

Outcomes analysis of a summer asthma camp.

Forty children with moderate to severe asthma were enrolled in an asthma camp. Changes in peak flow meter (PFM) and metered-dose inhaler (MDI) technique, health care utilization, and school absenteeism were evaluated. The mean post-PFM score at the end of camp (8.9 +/- 0.3) was significantly higher (p < .0001) than the pre PFM score (6.0 +/- 3.4). The mean post-MDI score (6.5 +/- 1.5) was significantly higher (p < 0.0001) than the pre-MDI score (4.1 +/- 1.8). Emergency room visits decreased by 59%, hospitalizations decreased by 83%, and school absenteeism decreased from 266 to 188 days. Health care savings totaled $2014 per child enrolled.

Respiratory allergy and the relationship between early childhood lower respiratory illness and subsequent lung function.

In a study of 159 school-age children whose histories of outpatient visits for lower respiratory illness (LRI) had been documented from early infancy, we observed lower mean levels of small airway function in boys who had experienced two or more episodes of wheezing-associated LRI before 6 yr of age. To determine whether allergy was an important factor influencing this result, we examined relationships among the results of RAST tests for seven common inhalant allergens and concurrent lung function in 126 subjects who consented to venipuncture. Increasing values for the sum of scores for the seven RAST tests were associated with progressively lower mean levels of small airways function in boys with histories of recurrent wheezing LRI during the preschool years. The association of allergy with lower levels of lung function was largely accounted for by dust mite allergy. RAST results were not correlated with lung function in boys who had experienced zero or 1 wheezing LRI before 6 yr of age or in girls. A history of recurrent wheezing LRI during the preschool years was also associated with significantly lower mean levels of small airways function in boys who had negative RAST tests. A subset of 49 boys was reevaluated after an average interval of 4 yr with RAST tests, spirometry, and methacholine challenge. Dust mite allergy was associated with an increased prevalence of bronchial hyperreactivity independent of early childhood wheezing LRI history.(ABSTRACT TRUNCATED AT 250 WORDS)

Lung function in school-age children who had mild lower respiratory illnesses in early childhood.

We examined the relationship between patterns of mild lower respiratory illness (LRI) experienced in early childhood and lung function in 89 boys and 70 girls 6 to 18 yr of age. The children's histories of outpatient visits for wheezing and nonwheezing LRI during the first 6 yr of life had been documented by physicians in a single pediatric practice. Most children were reported by their parents to have been free of recurrent respiratory symptoms during the 2 yr prior to lung function testing. In sex-specific analyses, average lung function assessed by spirometry was similar in children who had made zero or one physician visit for wheezing LRI during the preschool years. Boys who had experienced two or more episodes of wheezing LRI during the preschool years had lower average FEV1, FEV1/FVC, FEF25-75, Vmax50, and Vmax75 than did boys who had zero or one preschool wheezing illness. The association between recurrent preschool wheezing LRI and later lung function remained after exclusion of data from seven boys who were reported to have wheezed in the 2 yr prior to study. Girls who had experienced two or more preschool wheezing LRI had lower average FEF25-75 and Vmax50 than girls with a history of zero or one such illness, but differences were not statistically significant. Recurrent nonwheezing LRI during the preschool years was not significantly associated with subsequent lung function in either sex, regardless of preschool wheezing LRI history. Detailed information concerning early childhood LRI experience is valuable in epidemiologic studies of factors influencing lung function in children.

Noncomparability of cross-sectional and longitudinal estimates of lung growth in children.

Results from longitudinal and cross-sectional studies of pulmonary function are often compared. However, previous studies in adults suggest that results from longitudinal and cross-sectional studies are different and may not be comparable. In order to evaluate these differences further, prospectively collected data in a group of children were analyzed by both longitudinal and cross-sectional methods. Spirometry was performed longitudinally over a period of 8 years on 58 healthy children. Straight-line regressions of expiratory flow-volume parameters on height were computed by averaging the individual regression lines for each child. A cross-sectional sample from these same children was analyzed and compared to the longitudinal analysis. For all expiratory flow-volume parameters, the cross-sectional analysis resulted in a significantly greater increase in growth with increasing height than the longitudinal analysis (P less than 0.005 for slope for all parameters except PEFR, P less than 0.05 and Vmax75, P less than 0.01). These differences cannot be explained by learning or horse-racing effects, loss to follow-up, or regression to the mean; however, they could be explained by cohort changes, time trends of pulmonary function, differences in the weighted averages used in the two analyses, or incorrect modeling. These observations indicate that comparisons between cross-sectional and longitudinal investigations must be made cautiously. These data do not support many of the reasons suggested for the differences in previous reports. It is recommended that studies of pulmonary function use a control group and investigate the groups at the same time and in the same manner.

Presentation and management of postcricoid hemangiomata in infancy.

Phillips and Ruh (1912) were the first to describe a congenital hemangioma of the larynx. Sweetser subsequently classified laryngeal hemangiomata into infantile and adult types and noted differences in incidence, location, and symptoms. According to Sweetser, the infantile form is less common, is almost always subglottic, and presents with stridor which may be intermittent. The adult form is somewhat more common, is generally supraglottic, and often presents with hoarseness or dysphagia. We present what we believe is the first reported case of a postcricoid hemangioma in an infant. A review of hemangiomata of the aerodigestive tract is presented and treatment is discussed.

A study of spirometry in children from Mexico City.

A study was conducted in two elementary schools in Mexico City to determine values for pulmonary function tests in school-aged residents of Mexico City. The schools were located in Xalostoc, a highly industrialized area of Mexico City, and San Lorenzo, a suburban area of the city. Although data regarding atmospheric pollution were not available, there is an acknowledged higher level of macroenvironmental air pollution in Xalostoc. Pulmonary function tests were performed on 468 children in San Lorenzo and 405 children in Xalostoc. No differences between residents of the two communities for acute or chronic respiratory conditions were detected by questionnaire. The pulmonary function data demonstrate that boys have larger forced vital capacities (FVC) and forced expiratory flows over the middle half of the FVC (FEF25-75) than girls. Slopes of regression lines for FVC but not for FEF25-75 are greater in boys and girls from Xalostoc than in boys and girls from San Lorenzo. This suggests that young children from Xalostoc may experience ill effects of air pollution but develop catch-up growth later. There were no important community or gender effects on slopes of regression lines for height and weight on age. In general, the regression lines for FVC and FEF25-75 were below regression lines reported for children of Mexican ancestry living at sea level.

Pulmonary function in children with sarcoidosis.

To document pulmonary function abnormalities in children with sarcoidosis, we reviewed the records of all children with this disease at the North Carolina Memorial Hospital. Spirometry was performed by 34 of 60 children at initial presentation and was repeated by 16 at least 1 yr after presentation (mean, 3.9 yr). Those with and without pulmonary function data available were similar in age, sex, race, and clinical manifestations at presentation. Results indicate that at presentation, 50% of children had the characteristic functional changes of restrictive lung disease (mean % predicted FVC, 79.8 +/- 16.0). Fifteen percent had a FVC of 70 to 80% predicted, 32% had a FVC of 50 to 70% predicted, and 3% had a FVC less than 50% predicted. The TLC and FRC supported the diagnosis of restrictive lung disease. There were 15% who had obstructive changes. Children with auscultatory abnormalities and parenchymal changes on chest radiograph had more severe decrements in pulmonary function; however, specific symptoms did not predict decrements in pulmonary function. There was significant improvement in lung function at the last pulmonary function test performed (mean % predicted FVC, 97.1 +/- 18.8).

Serum cotinine as a measure of tobacco smoke exposure in children.

To document passive smoke exposure, we measured concentrations of serum cotinine, a major metabolite of nicotine, in 38 young children and compared the results with the smoking histories of home residents. Cotinine was detected in 26 children (68%), of which ten had no household exposure according to a questionnaire. The serum cotinine concentration was significantly elevated in blacks compared with whites after controlling for the number of smokers in the home. After stratifying by race, there was a significant direct correlation between the serum cotinine concentration and the number of smokers in the home, the amount smoked by the mother, and the amount smoked by others in the home. We conclude that the serum cotinine concentration is a useful indicator of the actual exposure of young children to tobacco smoke and that unexplained racial differences in cotinine levels exist.

Respiratory responses of vigorously exercising children to 0.12 ppm ozone exposure.

Changes in respiratory function have been suggested for children exposed to less than 0.12 ppm ozone (O3) while engaged in normal activities. Because the results of these studies have been confounded by other variables, such as temperature or the presence of other pollutants or have been questioned as to the adequacy of exposure measurements, we determined the acute response of children exposed to 0.12 ppm O3 in a controlled chamber environment. Twenty-three white males 8 to 11 yr of age were exposed once to clean air and once to 0.12 ppm O3 in random order. Exposures were for 2.5 h and included 2 h of intermittent heavy exercise. Measures of forced expiratory volume in one second (FEV1) and the symptom cough were determined prior to and after each exposure. A significant decline in FEV1 was found after the O3 exposure compared to the air exposure, and it appeared to persist for 16 to 20 h. No significant increase in cough was found due to O3 exposure. Forced vital capacity, specific airways resistance, respiratory frequency, tidal volume, and other symptoms were measured in a secondary exploratory analysis of this study.

A longitudinal study of spirometry in young black and young white children.

Spirometry was performed longitudinally over a period of 8 yr on 72 children (29 black females, 26 black males, 9 white females, and 8 white males) starting as early as 3 yr of age. Weighted straight-line regressions of 6 maximal expiratory flow-volume parameters--forced vital capacity (FVC), forced expiratory volume in one second (FEV1), peak expiratory flow (PEF), forced expiratory flow during the middle half of the FVC (FEF25-75), and maximal expiratory flows after 50 and 75% of the FVC had been exhaled (Vmax50 and Vmax75, respectively) - on height were computed and were found to describe adequately the data over a height range of 100 to 150 cm. Statistical comparisons of regression lines revealed significant differences for FVC and FEV1 when white females were compared with white males, white females with black females, and white males with black males, but not for black females with black males. Regressions of FEF25-75 and Vmax50 for black females were significantly lower than for white females, and those for white males were lower than those for white females, but no differences were detected when black females and white males were compared with black males. Only white females compared with black females revealed significant differences for Vmax75. There were no significant differences for any of the comparisons for PEF. The data presented expand the age range for evaluating lung function in children, indicate the feasibility of testing pre-school-age subjects, and provide new approaches to analysis of longitudinally collected information.

Risk factors associated with the development of chronic lung disease in children.

By better understanding the intrinsic and extrinsic factors that predispose children to chronic lung disease, strategies to prevent its development can be proposed. This article addresses conditions, such as bronchiolitis, croup, hyaline membrane disease, hydrocarbon ingestion, and near-drowning, that have been found to result in long-term changes in lung physiology. Also considered are the possible relationships of common respiratory infection, asthma, smoking, and air pollution to the development of chronic respiratory infection.

Postoperative pulmonary function in children. Comparison of scoliosis with peripheral surgery.

We measured lung volumes, forced expirograms, and arterial blood gases in 2 groups of elective pediatric surgical patients (mean age, 11.4 +/- SD 2.8; n = 11, 12 operations) the day prior to surgery (control) and between the first and eighth postoperative days. The patients were Group I: peripheral surgery (n = 6) and Group II: reconstructive surgery for scoliosis (n = 5). The preoperative lung volumes and forced expiratory volume in one second were within the predicted normal range in both groups, except for a reduction in total lung capacity (TLC) and vital capacity (VC) in Group II. The postoperative lung volumes in Group I were not significantly different from the preoperative volumes. In group II, on postoperative Days 2 and 3, the lung volumes as a percent of preoperative volumes (mean +/- SEM) were VC, 44 +/- 11; functional residual capacity (FRC), 81 +/- 6; residual volume, 124 +/- 10; TLC, 61 +/- 10. Although the mean FRC returned to the preoperative volume by postoperative Days 5 and 6, the VC and its components remained reduced on postoperative Days 5, 6, and 8. We conclude that postoperative lung volume abnormalities are related to the site and magnitude of surgery and associated phenomena, such as pain, and preoperative respiratory function abnormalities.

Effect of allergic bronchoconstriction on airways epithelial permeability to large polar solutes in the guinea pig.

The effect of allergic bronchoconstriction on the permeability of the airway mucosa to large hydrophilic polar solutes was investigated in the guinea pig. After specific antigen (ovalbumin) challenge, there was a significant increase in the plasma levels of horseradish peroxidase (HRP) (molecular weight, approximately 40,000 daltons), 3H-dextran (approximately 10,000 daltons), and 14C-mannitol (approximately 182 daltons) compared with that in control animals aerosol-challenged with a nonspecific protein, lactoglobulin. The morphologic correlates of this enhanced transepithelial permeability after ovalbumin challenge appeared to be (1) increased HRP penetration of the epithelial tight junctions (p less than 0.001), and (2) increased mucus discharge from surface lining goblet cells. We conclude that antigen-induced bronchoconstriction leads to an increase in tracheobronchial permeability to macromolecules, and this effect is likely to be mediated by an increased paracellular as well as transcellular vesicular movement of large polar solutes across the airway epithelial barrier.

Dynamic respiratory mechanics in intact anesthetized hamsters.

A system for measuring parameters of ventilation and respiratory mechanics in intact anesthetized hamsters was developed. Means +/- SD of five weekly measurements in eight hamsters were 0.68 +/- 0.09 ml for tidal volume, 45 +/- 14 breaths.min-1 for respiratory frequency, 29.3 +/- 10.4 ml.min-1 for minute ventilation, 0.301 +/- 0.080 ml.cmH2O-1 for dynamic compliance, 0.435 +/- 0.151 cmH2O.ml-1.s for inspiratory resistance, 0.311 +/- 0.101 cmH2O.ml-1.s for expiratory resistance, and 0.334 +/- 0.096 cmH2O.ml-1.s for average resistance. The standard deviations of five consecutive measurements of these parameters on the same day were typically 10% of the corresponding mean values suggesting that acute changes as small as 10% can be detected in a study of similar size. The corresponding value for five single measurements on different days at weekly intervals was 30%. We believe that this system yields reasonable and repeatable measurements, and, because it is atraumatic, it can be used in chronic studies of diseases in hamsters and other small animals.