Care of the child with a chronic tracheostomy. This official statement of the American Thoracic Society was adopted by the ATS Board of Directors, July 1999.
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Airway Obstruction↗
Biomedical subjects
R Zinman
Publications and source records attributed to R Zinman.
An observational asthma study alters emergency department use: the Hawthorne effect.
The objective of this study was to document that an observational study decreases the use of the emergency department (ED) for asthma. Comparison of rates between an audit and prospective period were used at a regional referral pediatric hospital ED. A total of 526 asthma visits from February 12, 1992, to April 10, 1992, were examined in an initial audit and compared to 725 visits during a prospective study from May 16, 1993, to September 29, 1993. A physician check list for medications and follow-up plans was utilized during the prospective study. The rate of repeat visits and admissions was compared between the audit and the prospective periods. In the audit, 422 asthma patients were seen, and there were 68 repeat visits within one week of the initial visit and 153 admissions. For 29 of the 68 repeat visits there was no documentation that medication had been increased after the initial visit. No follow-up plans were recorded in 275 of the 526 visits. During the prospective period 668 children presented to the ED with asthma, and 346 were enrolled into the study on risks for repeat visits. There were 57 repeat visits and 89 admissions. The repeat visit rate during the prospective period was 9 and 8%, respectively, in the enrolled and nonenrolled subjects. The repeat visit and admission rate decreased during the prospective period as compared to during the audit by 39% (P = 0.004) and 58% (P < 0.0001), respectively. A possible explanation for the difference in admission and repeat visit rates between the audit and prospective study is that physicians' behavior may have been altered by the awareness that their behavior was being closely monitored during the study.
Asthma↗
How to modify a volume-cycled home ventilator to satisfy a child's need for pressure-limiting and continuous positive airway pressure during spontaneous breathing.
Piston driven volume-cycled home ventilators increase work of breathing in the synchronized intermittent mandatory ventilation mode. A 2-year-old trisomy 21 patient with chronic lung disease due to recurrent aspiration pneumonia required a ventilator rate of 6-8 breaths per minute awake and 15 asleep, with peak pressure of 32 cm H2O and positive end-expiratory pressure (PEEP) of 10 cm H2O. Two circuits were designed to facilitate breathing and respiratory mechanics of his spontaneous breaths on both were compared. A spring valve on the inspiratory line pressure-limited ventilation and at the end of the expiratory line provided PEEP in both systems. The reservoir system had a 2-liter bag on the inspiratory limb of the circuit, and two one-way valves at the patient connector to direct inspiratory and expiratory flow. The continuous positive airway pressure (CPAP) system provided continuous flow with a CPAP device set to deliver a pressure 2 cmH2O higher than the PEEP valve. On the CPAP system, compared to the reservoir system, dynamic compliance was greater [1.52 (0.14 SD) ml/cm H2O/kg vs. 0.39 (0.02), p < 0.001] and resistance less [8.15 (1.26) cm H2O/l/s vs. 45.86 (0.87), p < 0.001] as measured with a PeDS machine. This is an innovative use of a CPAP device.
Child, Preschool↗
Transvenous closure of patent ductus arteriosus in a sick 2780g infant.
A three-and-a-half-month-old 2780 g critically ill infant had successful transvenous coil occlusion of a ductus arteriosus. At six-and-a-half months of age the infant died, and autopsy showed coverage of the coil on the aortic aspect and no lumenal narrowing. It was concluded that transvenous coil occlusion of the patent ductus arteriosus in small infants is possible and that th venous route is preferred to be arterial route.
Amniocentesis↗
Predictors of sunscreen use in childhood.
OBJECTIVE: To identify risk factors predictive of sunscreen use in children. DESIGN: Cross-sectional review of convenience sample. SETTING: Emergency department of a regional referral pediatric hospital. SUBJECTS: Nine hundred twenty-five parents of children presenting to the emergency department in August 1993. MAIN OUTCOME MEASURES: Parental risk factors assessed were use of sunscreen, tanning behaviors, previous blistering sunburn, knowledge of cancer risk related to sunburn and sun protection factor definition, education level, and other health-promoting behaviors. The parents were asked about perceived risk for their child's being sunburned in the next month or development of skin cancer in their lifetime, as well as an estimation of safe sun exposure time for their child. Child risk factors included a history of previous painful sunburn and parental assessment of their child's skin type based on susceptibility to sunburn. RESULTS: Eighty-four percent of parents reported that their children had used sunscreen at least once in the previous 2 months. The use of sunscreen in children younger than 1 year was 54%, from 1 to 12 years of age was 91%, and older than 12 years was 68%. Factors associated with increased likelihood of sunscreen use were age of 1 to 12 years, parental use of sunscreen, estimation of safe sun exposure of less than 30 minutes, description of child skin type as burns "sometimes," "easily," or "always," and correct definition of sun protection factor. Application of a multivariate model yielded a sensitivity of 96%, specificity of 36%, and positive predictive value of sunscreen use of 89%. CONCLUSIONS: Sunscreen use in parents is predictive of use in their children and relates more to experience with sunburn than with concerns about future skin cancer risk.
Adolescent↗
Tracheal stenting improves airway mechanics in infants with tracheobronchomalacia.
The compliance and expiratory resistance of the tracheobronchial tree is increased in infants with tracheobronchomalacia because of a weakness in cartilaginous support of the airway. Life threatening episodes may occur in these patients due to airway collapse. The goals of this study were to compare the effects on respiratory system mechanics of stenting the airway with either continuous positive airway pressure (CPAP) or a long tracheostomy tube. Five infants were studied: two had bronchopulmonary dysplasia (BPD), 2 had associated congenital anomalies, and one had tracheomalacia and polydactyly; none had a tracheoesophageal fistula. All patients required tracheostomy and were treated with CPAP. Lung mechanics were evaluated by measuring transpulmonary pressure, obtained by subtracting airway opening pressure from pleural pressure measured with an esophageal balloon, and flow measured with a pneumotachometer placed in series with the tracheostomy. Dynamic compliance (Cdyn) and total respiratory system resistance (Rt) were calculated by two-factor, least-mean-squares analysis, solving for the equation of motion of the lung with the PeDS system (MAS, Hatfield). In all subjects Cdyn increased and Rt decreased with increasing CPAP. In 4 subjects the airway was stented with a specially designed, long tracheostomy tube which reached to just above the carina; the special tube improved dynamic mechanics sufficiently to permit the discontinuation of CPAP. Speech was improved by fenestrating the tube and the use of a one-way inspiratory valve, placed over the tracheostomy. Inspiration occurred via the tracheostomy and expiration was directed to the larynx.
Airway Resistance↗
Home monitoring impact in CF.
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Adolescent↗
Oxygen saturation during sleep in patients with bronchopulmonary dysplasia.
We hypothesized that significant sleep desaturation might occur in infants with bronchopulmonary dysplasia whose awake saturations were between 90 and 92%. Supplemental oxygen was continued until the awake saturation on room air was 90% or greater. Sleep saturations were monitored by oximetry sampling for a 3-min period every hour overnight. Significant desaturation was considered to be present if the saturation fell repeatedly below 88%. There were 39 studies performed in room air, and 14 studies in supplemental oxygen. We demonstrated that patients with acceptable awake saturation may desaturate while sleeping. However, only 1 of 25 patients whose saturation in room air was 92% or more repeatedly desaturated during sleep.
Bronchopulmonary Dysplasia↗
Nonhomogeneous lung emptying in cystic fibrosis patients. Volume history and bronchodilator effects.
In spontaneous asthma after a deep inhalation (DI) obstruction occurs in direct proportion to disease severity. Since this has been associated with peripheral inflammation, which is present in cystic fibrosis (CF), we tested whether worsening obstruction after DI also occurs in CF in 12 patients. We assessed volume history effects by comparing isovolumic expiratory flows (Vmax) during forced exhalation begun at the end of tidal inspiration (partial P) with those begun at TLC (maximal M) to obtain M/P. As in asthma there was a correlation between M/P and FEV1 (% predicted; r = 0.64, p less than or equal to 0.03, n = 12). To control for a time dependency effect due to preferential emptying of fast compartments early in both the P and M maneuvers, we compared Vmax obtained from a first partial (P1) with a second (P2) obtained after inspiration to TLC and slow exhalation to the same starting volume as P1 (P2/P1). In contrast to asthma the P2/P1 was greater than the M/P and not related to disease severity. A further index of nonhomogeneous lung emptying was the relationship between M/P and the slope ratio at 70% TLC (r = -0.67, p less than or equal to 0.03). After isoetharine inhalation the M/P decreased (-0.12 +/- 0.12, p less than or equal to 0.01) but no change was apparent in P2/P1, indicating further increases in the degree of nonhomogeneity. We conclude that although volume history effects on M/P are similar in asthma and CF, this is due to a predominance of parenchymal hysteresis in the former and nonhomogeneity in the latter, which worsens with bronchodilator use.
Bronchodilator Agents↗
Nocturnal home oxygen in the treatment of hypoxemic cystic fibrosis patients.
The effect of nocturnal oxygen therapy on mortality and morbidity rates and on progression of disease was tested in a double-blind, randomized trial of 28 subjects with advanced cystic fibrosis. Patients were selected on the basis that their awake arterial oxygen tension was less than 65 mm Hg when they were clinically stable. Oxygen was prescribed in 1 L/min increments to obtain an awake arterial oxygen tension of greater than or equal to 70 mm Hg. Subjects received humidified oxygen or room air from modified concentrators. They were enrolled over a 3-year period and followed for an average (+/- SD) of 26 +/- 9 months. The average number of hours per night of concentrator use was 5.3 +/- 3.2 hours in the air group and 7.0 +/- 1.9 hours in the oxygen group. Over the follow-up period there were four deaths in each group, and oxygen therapy had no significant effect on the frequency of hospitalizations. Progression of disease was ascertained from nutritional status, pulmonary function, blood gas values, exercise ability, and right ventricular ejection fraction response to exercise (as measured by equilibrium-gated radionuclide angiocardiography), and psychologic status was measured by standardized tests of mood, self-esteem, and cognitive function; group comparisons for the first year revealed no significant differences; however, school or work attendance was maintained in the oxygen group but deteriorated in the air group. Clinical signs of cor pulmonale were documented during follow-up in 10 patients in toto, and all lived at least 9 months from the onset of these signs. The lack of association between the onset of these signs and imminent death, or the usefulness of measurements of the maximal oxygen uptake during progressive exercise and the right ventricular ejection fraction response to exercise as prognostic indicators, suggest that death may not be the result of cor pulmonale. We conclude that nocturnal oxygen treatment in patients with cystic fibrosis did not appear to affect mortality rates, the frequency of hospitalizations, or the progression of disease; oxygen use should be instituted only after the development of symptoms related to hypoxemia.
Adult↗
Effect of changes in lung volume on respiratory system compliance in newborn infants.
Total respiratory system compliance (Crs) at volumes above the tidal volume (VT) was studied by use of the expiratory volume clamping (EVC) technique in 10 healthy sleeping unsedated newborn infants. Flow was measured with a pneumotachograph attached to a face mask and integrated to yield volume. Volume changes were confirmed by respiratory inductance plethysmography. Crs measured by EVC was compared with Crs during tidal breathing determined by the passive flow-volume (PFV) technique. Volume increases of approximately 75% VT were achieved with three to eight inspiratory efforts during expiratory occlusions. Crs above VT was consistently greater than during tidal breathing (P less than 0.0005). This increase in Crs likely reflects recruitment of lung units that are closed or atelectatic in the VT range. Within the VT range, Crs measured by PFV was compared with that obtained by the multiple-occlusion method (MO). PFV yielded greater values of Crs than MO (P less than 0.01). This may be due to braking of expiratory airflow after the release of an occlusion or nonlinearity of Crs. Thus both volume recruitment and airflow retardation may affect the measurement of Crs in unsedated newborn infants.
Humans↗
A new technique to demonstrate flow limitation in partial expiratory flow-volume curves in infants.
Partial expiratory flow-volume (PEFV) curves in infants are generated by applying a compressive pressure over the chest wall with an inflatable jacket. This study addresses two issues: pressure transmission to and across the chest wall and whether flow limitation can be identified. Eleven infants sedated with chloral hydrate were studied. Pressure transmission to the chest wall, measured with neonatal blood pressure cuffs placed on the infant's body surface, was 72 +/- 4% of jacket pressure during compression maneuvers. The pressure transmission to the air spaces, determined by measuring airway pressure during a compression maneuver against an occluded airway, was 56 +/- 6% of jacket pressure. A significant amount of the applied pressure is therefore lost across both the jacket and chest wall. Rapid pressure oscillations (RPO) were superimposed on static jacket pressures while expiratory flow was measured. Absence of associated oscillations of flow measured at the mouth was taken to indicate that flow was independent of driving pressure and therefore limited. Flow limitation was demonstrable with the RPO technique in all infants for jacket pressures greater than 50 cmH2O; however, it was evident at jacket pressures less than 30 cmH2O jacket pressure in four infants with obstructive airway disease. The RPO technique is a useful adjunct to the compression maneuver utilized to generate PEFV curves in infants because it facilitates the recognition of expiratory flow limitation.
Humans↗
Use of caffeine in the treatment of apnea associated with the Arnold-Chiari malformation.
The occurrence of significant apnea has been reported in infants with Arnold-Chiari malformation (ACM). We report 1 infant with ACM and severe apnea treated with caffeine therapy. There was a marked decrease in apnea frequency, less variability in breathing patterns, and a shift to the left of the CO2 response curve with caffeine. Our findings in 1 infant suggest that caffeine may be an effective adjunct in the treatment of apnea associated with ACM.
Arnold-Chiari Malformation↗
Disclosure of psychosocial concerns of young adults with advanced cystic fibrosis (CF) by a nurse home visiting program.
Twelve patients with advanced cystic fibrosis were enrolled over a 36 month interval in a trial to assess the effect of nocturnal home oxygen therapy. As part of this study, there were repeated home visits by the nurse. Immediately following a visit, the nurse encoded all spontaneous expressions of concern into three general categories: CF management, growth and development and family relations. During the first 6 months, the concerns focused on CF management and over the subsequent year were followed by concerns related to growth and development and, finally to family interactions. This pattern suggests a sequence to the types of interventions accepted by this population.
Adolescent↗
The effects of chronic airflow limitation, increased dead space, and the pattern of ventilation on gas exchange during maximal exercise in advanced cystic fibrosis.
Although exertional hypercapnea has been observed in patients with advanced cystic fibrosis (CF), the causes have not been fully elucidated. In 14 patients aged 15 to 35 yr of age with advanced CF, the effects of chronic airflow limitation (CAL), increased physiologic dead space (VD), and the timing components of ventilation (VE) on gas exchange during maximal exercise were assessed. The patients were divided into those who retained CO2 during exercise, the CO2R group, and those who did not, the CO2NR group. CO2 retention was defined as a rise in end-tidal CO2 tension of 5 mm Hg or more or to a value greater than 50 mm Hg during a progressive exercise test on a cycle ergometer. CO2 retention occurred in half the subjects, usually by the halfway mark of the test, and did not rise progressively as exercise continued. It was associated with a low VE caused by a low tidal volume (VT) that was the result of a short inspiratory time to total respiratory time ratio (0.33 +/- 0.03 versus 0.38 +/- 0.04, p less than 0.02), whereas there was no difference in mean inspiratory flow or respiratory rate. Although the CO2R group had the worst CAL, with a FEV1 of 28 +/- 7 versus 41 +/- 12% predicted (p less than 0.5) and a FVC of 42 +/- 12 versus 61 +/- 9% predicted (p less than 0.01), the VT at maximal work expressed as a percentage of FVC was lower (45 +/- 13 versus 60 +/- 11, p less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)
Adolescent↗
Histamine challenge test in children using forced oscillation to measure total respiratory resistance.
This study analyzed the relationship between total respiratory resistance (Rrs) measured by forced oscillation technique and FEV1 during histamine provocation test in 31 children between seven and 17 years of age. Rrs was measured at frequencies between 6 (R6) and 26 Hz (R26). (R6-R26)/R26 was used as an index of frequency dependency of Rrs. A positive histamine test was defined as PC20 less than 8 mg/ml. Seventeen subjects had a positive test, and all of these had increases from baseline of R6 greater than 50 percent and (R6-R26)/R26 greater than 0.45. Of the 14 subjects whose PC20 was greater than 8 mg/ml, only two had changes in R6 and (R6-R26)/R26 of this magnitude. These two subjects had changes in FEV1 of 16 and 18 percent. There was a strong linear relationship between the changes in FEV1 and both R6 and (R6-R26)/R26 from baseline to the final value at the end of the test (r = 0.87 and 0.91 respectively). In conclusion, this study demonstrated that the evaluation of airway reactivity by histamine challenge may be done by forced oscillation technique. It is easy to administer and may allow testing of children unable to perform spirometry.
Adolescent↗
Nursing care plan for adolescents and young adults with advanced cystic fibrosis.
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Activities of Daily Living↗
Maximal static pressures and lung volumes in young female swimmers.
The postulate that lung volumes are increased in swimmers because of a training effect that increases maximal static pressures (Pmax) thus augmenting the ability to inflate and deflate the lung was examined by comparing 38 competitively trained female swimmers to 59 controls between 7 and 13 years of age. Maximal static pressures on inspiration and expiration were generated near residual volume (RV), at functional residual capacity (FRC) and near total lung capacity (TLC). Lung volumes were measured by body plethysmography. The expected increase in lung volumes was present in the swimmers and was most marked in the oldest subjects. However, training did not have the anticipated effect on Pmax. In the younger swimmers training was associated with an increase in Pmax, but in the older swimmers Pmax was actually decreased in comparison to controls. These findings suggest that training may directly enhance lung growth, since the changes in lung volume cannot be accounted for by increases in respiratory muscle strength.
Child↗