Assessment of Airway Bronchodilation by Spirometry Compared to Airway Obstruction in Young Children with Asthma

A reversibility test by an increase of greater than 12% in FEV1 can support a diagnosis of asthma and alter a patient's treatment plan but may not be applicable to the young ages. We retrospectively gathered spirometric data from 85/271 asthmatic children having mild obstruction (FEV1 > 80% predicted), age 2.6-6.9 years. Spirometry was performed before and 20 min after inhalation of 200 mcg Albuterol. We defined a deviation below -1.64 z scores from control as obstruction and an increased above 1.64 scores from control as a positive response to bronchodilators. Sensitivity of the index was considered significant if it captured >68% of the participants. The sensitivity of detecting airway obstruction in these children by FEV1 was 15.3% and 62.4% by FEF25-75. A positive response to Albuterol was an increase of 9.2% for FEV1 (12% for adults) and 18.5% for FEF25-75. The sensitivity for detecting a response to Albuterol in mild asthma was 64.7% by FEV1 and 91.8% by FEF25-75. Young children having normal spirometry can demonstrate airway reversibility. The response of spirometry parameters to bronchodilators may be more sensitive than obstruction detection and may help to support the diagnosis of asthma and adjust treatment plan.

The use of telehealth (text messaging and video communications) in patients with cystic fibrosis: A pilot study

Background Poor communications between cystic fibrosis (CF) patients and health-care providers may result in gaps in knowledge and misconceptions about medication usage, and can lead to poor adherence. We aimed to assess the feasibility of using WhatsApp and Skype to improve communications. Methods This single-centre pilot study included CF patients who were older than eight years of age assigned to two groups: one without intervention (control group), and one with intervention. Each patient from the intervention group received Skype-based online video chats and WhatsApp messages from members of the multidisciplinary CF team. CF questionnaires, revised (CFQ-R) scores, knowledge and adherence based on CF My Way and patients satisfaction were evaluated before and after three months. Feasibility was assessed by session attendance, acceptability and satisfaction survey. Descriptive analysis and paired and non-paired t-tests were used as applicable. Results Eighteen patients were recruited to this feasibility study (nine in each group). Each intervention group participant had between four and six Skype video chats and received 22-45 WhatsApp messages. In this small study, CFQ-R scores, knowledge, adherence and patient satisfaction were similar in both groups before and after the three-month intervention. Conclusions A telehealth-based approach, using Skype video chats and WhatsApp messages, was feasible and acceptable in this pilot study. A larger and longer multi-centre study is warranted to examine the efficacy of these interventions to improve knowledge, adherence and communication.

"I sit to sleep"-Spirometry as a clue to diagnosis

A 15-year-old patient presented with a 4-month history of choking while sleeping that necessitated sleeping in a sitting position. Flow-volume curve demonstrating fixed upper airway obstruction led to further workup and to the diagnosis of childhood achalasia as a cause of unusual symptoms and fixed upper airway obstruction. Pediatr Pulmonol. 2016;51:E13-E15. © 2015 Wiley Periodicals, Inc.

Systematic Analysis of CCNO Variants in a Defined Population: Implications for Clinical Phenotype and Differential Diagnosis

Reduced generation of multiple motile cilia (RGMC) is a novel chronic destructive airway disease within the group of mucociliary clearance disorders with only few cases reported. Mutations in two genes, CCNO and MCIDAS, have been identified as a cause of this disease, both leading to a greatly reduced number of cilia and causing impaired mucociliary clearance. This study was designed to identify the prevalence of CCNO mutations in Israel and further delineate the clinical characteristics of RGMC. We analyzed 170 families with mucociliary clearance disorders originating from Israel for mutations in CCNO and identified two novel mutations (c.165delC, p.Gly56Alafs*38; c.638T>C, p.Leu213Pro) and two known mutations in 15 individuals from 10 families (6% prevalence). Pathogenicity of the missense mutation (c.638T>C, p.Leu213Pro) was demonstrated by functional analyses in Xenopus. Combining these 15 patients with the previously reported CCNO case reports revealed rapid deterioration in lung function, an increased prevalence of hydrocephalus (10%) as well as increased female infertility (22%). Consistent with these findings, we demonstrate that CCNO expression is present in murine ependyma and fallopian tubes. CCNO is mutated more frequently than expected from the rare previous clinical case reports, leads to severe clinical manifestations, and should therefore be considered an important differential diagnosis of mucociliary clearance disorders.

The impact of a national population carrier screening program on cystic fibrosis birth rate and age at diagnosis: Implications for newborn screening

BACKGROUND

Population carrier screening (PCS) has been available in Israel since 1999 and universally subsidized since 2008. We sought to evaluate its impact.

METHODS

A retrospective review of governmental databanks, the national CF registry and CF centers.

RESULTS

CF rate per 100,000 live births has decreased from 14.5 in 1990 to 6 in 2011. From 2004-2011 there were 95 CF births: 22 utilized PCS; 68 (72%) had 2 known CFTR mutations; 37% were pancreatic sufficient. At diagnosis, age was 6 (0-98) months; 53/95 had respiratory symptoms, 41/95 failure to thrive and 19/95 pseudomonas. Thirty-four (36%) were Arabs and 19 (20%) orthodox Jews, compared to 20% and 8% respectively, in the general population.

CONCLUSIONS

PCS markedly reduced CF birth rates with a shift towards milder mutations, but was often avoided for cultural reasons. As children regularly have significant disease at diagnosis, we suggest a balanced approach, utilizing both PCS and newborn screening.

The effect of vitamin D on airway reactivity and inflammation in asthmatic children: A double-blind placebo-controlled trial

BACKGROUND

Cross-sectional studies have reported an association of vitamin D deficiency with increased asthma prevalence and severity, and with allergies. The effect of vitamin D as sole therapy on airway hyper-reactivity (AHR) and airway inflammation has not been reported.

AIM

To evaluate the effect of vitamin D therapy on AHR as assessed by methacholine concentration, causing a 20% reduction in FEV1 (PC20 -FEV1 ) and fractional exhaled nitric oxide (FeNO), systemic markers of allergy and inflammation, and exhaled breath condensate cytokines.

PATIENTS AND METHODS

Children aged 6-18 years with a clinical diagnosis of mild asthma currently not receiving anti-inflammatory therapy and with low vitamin D levels were included in this randomized, double-blind, placebo-controlled study assessing the effect of 6 weeks of treatment with oral vitamin D 14,000 units once weekly or placebo.

RESULTS

Of the 39 patients included, 20 received vitamin D treatment and 19 received a placebo. Vitamin D replacement resulted in a significant increase in vitamin levels, which remained unchanged in the placebo group (P < 0.0001). There was no change in IgE, eosinophil count, high sensitivity C-reactive protein, FeNO levels or PC20 -FEV1 following treatment. Similar values of exhaled breath condensate cytokines (IL4, IL5, IL10, IL17, and γ interferon) were observed in both groups.

CONCLUSIONS

In our small group of children with mild asthma, no difference could be demonstrated between the effect of vitamin D and placebo, despite significant increases in vitamin D blood levels. Larger interventional studies are needed to fully explore the possible effect of vitamin D in asthma.

Maximal flow at functional residual capacity in asthmatic preschool children

BACKGROUND

Many preschool children will perform correct peak-flow but will not exhale to residual volume, thus limiting the determination of airways obstruction. The maximal flow measured at function residual capacity (V'maxFRC) is independent of lung empting and could potentially serve as a parameter for describing flow at low lung volumes. The study determines the detection of airway obstruction/dilation in asthmatic preschool children by V'maxFRC, compared to FEV1 and FEF25-75.

METHODS

Children performed bronchial provocation test (BPT; n = 26) or received bronchodilators (Post-BD; n = 31). V'maxFRC was extracted at inspiratory capacity point of flow/volume maneuvers. The %change of V'maxFRC from baseline was compared with changes in various spirometry indices and to values obtained from our previously studied healthy control children.

RESULTS

FEV1, FEF25-75, and V'maxFRC decreased by 30.9 ± 12.2%, 46.2 ± 10.9%, and 36.6 ± 8.0%, respectively, while FRC increased by 37.0 ± 24.9% at end of the BPT. Post-BD spirometry values increased by 17.1 ± 16.1%, 47.0 ± 42.2, and 45 ± 24%, respectively (p < 0.0001). A positive response to bronchodilators was observed in 15/31 (48%) children by FEV1, in 22/31 (71%) children by V'maxFRC, and in 21/31 children by FEF25-75.

CONCLUSION

V'maxFRC detects airway obstruction/dilation in young asthmatic children similar to FEF25-75 and FEV1. V'maxFRC may be a valuable index in preschool children who cease exhalation prematurely. Digitally measured V'maxFRC should confirm the actual values in a wider age range in healthy and disease states.

Bronchial Reactivity, Inflammatory and Allergic Parameters, and Vitamin D Levels in Children With Asthma

BACKGROUND

A low serum vitamin D level may represent a marker of other perplexing factors that may lead to increased asthma prevalence and severity. Our aim was to assess the correlation between vitamin D levels and asthma and allergy markers in a subgroup of children with fewer confounding factors.

METHODS

Non-obese children (6-18 y old) with asthma who were not receiving anti-inflammatory treatment were recruited. Subjects underwent spirometry with a methacholine challenge test, and fractional exhaled nitric oxide (FENO), serum vitamin D levels, total immunoglobulin E (IgE) levels, blood eosinophil counts, and high-sensitivity C-reactive protein levels were determined. The primary end point was the correlation between vitamin D level and airway hyper-responsiveness as assessed by a methacholine challenge test. The secondary end point was the correlation between vitamin D level and FENO, systemic inflammatory markers, and allergy.

RESULTS

Seventy-one children with asthma (25 females, 35%; 12.5 ± 3.6 y of age) were included. The median vitamin D level was 23 ng/mL (range of 6-48.5, mean of 23.02 ± 7.74), the median IgE level was 305 IU/mL (range of 4.3-4,240), the median provocational concentration of methacholine that produced a 20% decrease in FEV1 was 1.1 mg/mL (range of 0-13.9), and the median FENO was 26.5 ppb (range of 3.6-285). No correlation was found between vitamin D level and response to the methacholine challenge test, FENO, high-sensitivity C-reactive protein levels, IgE levels, eosinophil counts, and frequency of allergic rhinitis or atopic dermatitis.

CONCLUSIONS

In our group of children with asthma, no correlation was found between the level of vitamin D and the degree of airway reactivity, airway inflammation, and allergy. The cause-and-effect relationship between vitamin D, asthma, and allergy should be further clarified. (ClinicalTrials.gov registration NCT01287455).

A mutated vitamin D receptor in hereditary vitamin D-resistant rickets prevents induction of bronchial hyperreactivity and inflammation

CONTEXT

Previous studies have reported an association between vitamin D deficiency and asthma. Hereditary 1,25-dihydroxyvitamin D-resistant rickets (HVDRR) patients provide a natural model to assess the role of the vitamin D receptor (VDR) in regulating human lung immune responses and airway hyperreactivity.

OBJECTIVES

The aim of the study was to determine the role of the VDR on lung functions, airways, and systemic markers of inflammation and allergy in HVDRR patients.

DESIGN AND METHODS

Thirteen HVDRR patients (aged 6-37 y) and 17 normal controls (aged 6-38 y) underwent spirometry, a methacholine challenge test (MCT), blood tests, allergy skin tests, determination of fractional exhaled nitric oxide, and measurement of serum and exhaled breath condensate cytokines, including IL-4, IL-5, IL-10, IL-17, and interferon-γ levels.

RESULTS

All HVDRR patients had negative MCT results, whereas six controls (35.3%) had positive MCT results (P < .014). Serum IgE levels, eosinophil counts, and fractional exhaled nitric oxide and allergy skin test results were similar for the HVDRR patients and controls, as were the serum cytokine concentrations. The HVDRR patients had different cytokine levels in their exhaled breath condensate (increased IL-4 and IL-17 and decreased IL-5, IL-10, and interferon-γ levels) compared to the controls (P < .005).

CONCLUSIONS

HVDRR patients show diverse exhaled cytokine profiles but seem to be protected against provoked bronchial hyperreactivity and clinical asthma. These findings suggest that an intact VDR has an important role in asthma pathophysiology.

Salivary and serum analysis in children diagnosed with pneumonia

The aim of the current study was to evaluate specific markers for pneumonia by using a non-invasive assessment of inflammatory/oxidative biomarkers in saliva accompanying a routine serum analysis. No study evaluating saliva of children with pneumonia has been published previously. Salivary analysis was performed in 15 children diagnosed with lobar pneumonia and in a parallel group of 16 children matching in age and gender in whom there was no respiratory illness, and compared to the serum analysis obtained routinely in both groups of children. Salivary flow rate was lower in the patients' group as was uric acid concentration (by 60%). Increase in salivary concentrations of almost all parameters analyzed was found: Ca, P, and Mg concentrations were higher in the patients' group by 23%, 55%, and 33%, respectively, while LDH, total protein amylase and albumin concentrations were higher by 275%, 79%, and 42%, respectively. In the serum, white cell counts and neutrophils were significantly higher, and sodium level significantly lower in the patients' group. Compositional changes were in the range of 3-80% while the saliva alterations were more profound, in the range of 42-275%. The results demonstrated in the current study indicate salivary analysis as a potentially novel tool for children with pneumonia. Human salivary collection and analysis is a non-invasive tool that could provide additional information for diagnosis and follow-up of pneumonia, especially in children. This is especially beneficial for pediatric patients, as salivary collection is simple, non-invasive, and patient-friendly.

Propranolol as a treatment option in Gorham-Stout syndrome: a case report

Gorham-Stout syndrome is a very rare syndrome characterized by progressive angiomatosis and lymphangiomas involving multiple organs. We describe herein a girl with progressive Gorham-Stout syndrome since the age of 13 years. Her disease involved the mediastinum, pericardium, vertebrae, ribs, and skull and did not respond to interferon and bisphosphonates. Propranolol administration was initiated at the age of 18 years and was associated with improvement in pulmonary function tests and involution of the mediastinal and hilar hemangiomatous lesions. The possible beneficial effect of propranolol in Gorham-Stout syndrome should be further investigated.

Duplication in CHIT1 gene and the risk for Aspergillus lung disease in CF patients

BACKGROUND

Aspergillus often persists in the respiratory tract of patients with Cystic Fibrosis (CF) and may cause allergic broncho-pulmonary aspergillosis (ABPA). Chitinases are enzymes that digest the chitin polymer. Plants use chitinase as a defense mechanism against fungi. Chitotriosidase (CHIT1) is the major chitinase in human airways. Variation in the coding region with 24-bp duplication allele results in reduced CHIT1 activity. Recently, CHIT1 duplication heterozygocity was found in 6/6 patients with severe asthma and fungal sensitization (SAFS).

AIM

Our aim was to evaluate the link between CHIT1 duplication in CF patients and the predisposition to Allergic broncho-pulmonary mycosis (ABPM) or persistent Aspergillus positive sputum (APS).

PATIENTS AND METHODS

CHIT1 duplication was assessed in three CF groups. Group 1: patients who had neither ABPM nor APS in the past (control group). Group 2: patients with persistent APS (≥2/year), without ABPA. Group 3: patients with current or past ABPM.

RESULTS

Forty patients with CF were included in the analysis, CHIT1 duplication heterozygocity was found in 3/6 (50%) of the patients in the ABPM group, 3/12 (25%) in the APS group, and 7/22 (31.8%) in the control group (P > 0.05). Eleven patients carried W1282X mutation, 90.9% were negative for CHIT1 duplication, five of them were homozygous for W1282X; none of them had CHIT1 duplication or ABPM.

CONCLUSIONS

CHIT1 duplication is not found in all CF patients with ABPM in contrast to patients with SAFS. These results suggest that CHIT1 duplication cannot be the sole explanation for Aspergillus positive sputum in CF patients.

Forced expiratory decay in asthmatic preschool children--is it adult type?

BACKGROUND

The forced expiratory decay in healthy preschool children portrays a convex shape that differs from the linear decay in the older healthy population. The "adult-type" expiratory decay during airway obstruction is concave. The study objective was to determine if the expiratory decay in young asthmatic children is "adult-type".

METHODS

Among 245 children (age 3-7 yrs), 178 had asthma (asthmatics) and 67 were non-asthmatic (controls). The expiratory flow decay was inspected by FEF25-75/FVC ratio (=1.0 when linear). Values were compared to those of our formerly studied (n = 108) healthy children. A meaningful obstruction in FEF25-75/FVC ratio was defined as 2-zScores from healthy. A meaningful response to bronchodilators was related to non-asthmatics.

RESULTS

In healthy subjects FEF25-75/FVC ratio declined with age from 1.73 ± 0.17 to 1.28 ± 0.11. Non-asthmatics portrayed ratio values similar to those of healthy subjects. In asthmatics, 118/178 displayed a convex to linear expiratory decay (FEF25-75/FVC = 1.33 ± 0.22). Sixty/178 asthmatics portrayed concavity (FEF25-75/FVC-0.79 ± 0.16) that appeared when FEF50 was 43.4 ± 12%healthy. Concavity appearance was also age-dependent (30.4% of 3-4 y old and 59.1% of 6-7 y). Vital-Capacity decreased in either decays, forming a visually petit curve. Most asthmatic children respond to bronchodilators by a meaningful elevation in FEF25-75/FVC values and by a visual change in the shape of the curve. Other common spirometry indices also increased meaningfully.

CONCLUSION

Most asthmatic preschool children portray convex to linear expiratory decay with diminished vital-capacity, resulting in a visually smaller than healthy curve, with seemingly normal expiratory decay. These curves may be misinterpreted as "normal" or as "no-cooperation" and may lead to misinterpretation. In response to bronchodilators, FEF25-75/FVC value increases in asthmatics and the curve changes from concave to linear or from linear to convex contour.

Intractable cough in a preterm infant with ventriculoperitoneal shunt

We describe the case of an 8-month-old preterm female with a ventriculoperitoneal (VP) shunt who had an intractable resistant cough of three months duration without any identifiable cause. Reposition of the abdominal part of the VP shunt resulted in an immediate and lasting resolution of the cough. This is the first case report describing an infradiaphragmatic irritation as an etiology for persistent cough with ultimate resolution upon reposition of the shunt.