Nebulized N-Acetylcysteine for Management of Plastic Bronchitis

Analysis of the Risk Factors for Plastic Bronchitis in Children with Severe Adenovirus Pneumonia: A Retrospective Study

Purpose

Plastic bronchitis (PB), a rare complication of respiratory infection characterized by the formation of casts in the tracheobronchial tree, can lead to airway obstruction and severe condition. Adenovirus is one of the common pathogens of PB caused by infection. This study aimed to evaluate the clinical features and risk factors for PB in children with severe adenovirus pneumonia.

Methods

A retrospective study of children with severe adenovirus pneumonia with bronchoscopy results at Guangzhou Women and Children's Hospital between January 2018 and January 2020 was performed. Based on bronchoscopy, we divided children with severe adenovirus pneumonia into two groups: PB and non-PB. Binary logistic regression analysis was used to identify independent risk factors for PB in patients with severe adenovirus pneumonia after univariate analysis.

Results

Our study examined 156 patients with severe adenovirus pneumonia with bronchoscopy results in hospital. Among them, 18 developed PB and 138 did not. On multivariate analysis, the independent risk factors of PB in children with severe adenovirus pneumonia were history of allergies (OR 10.147, 95% CI 1.727-59.612; P=0.010), diminished breath sounds (OR 12.856, 95% CI 3.259-50.713; P=0.001), and increased proportion of neutrophils (>70%; OR 8.074, 95% CI 1.991-32.735; P=0.003).

Conclusion

Children with severe adenovirus pneumonia with a history of allergies, diminished breath sounds, and increased the proportion of neutrophils >70% may show higher risk of PB.

Clinical features and risk factors of plastic bronchitis caused by refractory Mycoplasma pneumoniae pneumonia in children: a practical nomogram prediction model

Early assessment of refractory Mycoplasma pneumoniae pneumonia (RMPP) with plastic bronchitis (PB) allows timely removal of casts using fiberoptic bronchoscopic manipulation, which relieves airway obstruction and limit sequelae development. This study aimed to analyze clinical data for risk factors and develop a nomogram for early predictive evaluation of RMPP with PB. The clinical data of 1-14 year-old patients with RMPP were retrospectively analyzed. Patients were classified into a PB or non-PB group. The general characteristics, clinical symptoms, laboratory test results, imaging findings, and microscopic changes of the two groups were compared. A statistical analysis of the risk factors for developing PB was performed, and a nomogram model of risk factors was constructed. Of 120 patients with RMPP included, 68 and 52 were in the non-PB and PB groups, respectively. Using multivariate logistic regression analysis, fever before bronchoscopy, extrapulmonary complications, pleural effusion, cough duration, and lactate dehydrogenase (LDH) levels were identified as risk factors. A nomogram was constructed based on the results of the multivariate analysis. The area under the receiver operating characteristic curve value of the nomogram was 0.944 (95% confidence interval: 0.779-0.962). The Hosmer-Lemeshow test displayed good calibration of the nomogram (p = 0.376, R2 = 0.723).

CONCLUSION

The nomogram model constructed in this study based on five risk factors (persistent fever before bronchoscopy, extrapulmonary complications, pleural effusion, cough duration, and LDH levels) prior to bronchoscopy can be used for the early identification of RMPP-induced PB.

WHAT IS KNOWN

• Refractory Mycoplasma pneumoniae pneumonia (RMPP) in children has been increasingly reported and recognized, which often leads to serious complications. • Plastic bronchitis (PB) is considered to be one of the causes of RMPP, and bronchoscopic treatment should be improved as soon as possible to remove plastic sputum thrombus in bronchus.

WHAT IS NEW

• This study determined the risk factors for RMPP-induced PB. • The nomogram model constructed in this study prior to bronchoscopy can be used for the early identification of RMPP-induced PB, which facilitate the early bronchoscopic removal of casts, thereby promoting recovery and reducing cases with poor RMPP prognosis.

Nursing Progress of Hypertonic Saline Inhalation in the Treatment of Infantile Bronchitis Based on Image Enhancement

The onset of bronchiolitis is closely related to the anatomical characteristics of the bronchi in children of this age. This kind of injury is caused by epithelial necrosis, nasal mucosa, and mucosal edema caused by narrowing and blockage of the trachea. Children with this serious phenomenon will have respiratory and heart failure, which threatens the life of children to a large extent. In this paper, based on image enhancement technology, hypertonic saline aerosol inhalation treatment of pediatric bronchiolitis nursing care, through related cases, the application of image enhancement technology in hypertonic saline aerosol inhalation therapy and pediatric bronchiolitis is analyzed, and the tone mapping function is used. Tone mapping functions, hereditary arithmetics, and slope regimes for experimental field capture and detection were used for the objective of therapeutic approaches for the treatment of pediatric capillary pneumonia by hypertonic inhalation. Experimental results show that imaging technology hypertonic inhalation can control the main symptoms of bronchiolitis in infants and young children. Inhalation of 3% saline can shorten the course of moderately chronic children to half a year and can reduce the length of hospital stay by a quarter of the original requires hospitalization time, and the cure rate of pediatric bronchiolitis is increased to 93.7%.

A Quality Improvement Approach to Influence Value-based Mucolytic Use in the PICU

INTRODUCTION

High-cost medication administration, despite lacking evidence for use, results in poor healthcare value. This work aimed to reduce dornase-alfa utilization in critically ill mechanically ventilated children.

METHODS

The project employed an observational pre-post design to develop a value-based clinical pathway to guide provider choice in mucolytic utilization in a quaternary pediatric intensive care unit. This pathway was designed to continue using low-cost mucolytic aerosols (hypertonic saline, N-acetylcysteine) but decrease new starts and total doses per 100 patient days (P100PD) dornase-alfa among patients for whom there is little to no supporting evidence. Interventions included a departmental journal club for fellow and attending physicians and a rolling introduction of the pathway to residents and respiratory therapists. Control charts serially tracked ordering changes and location-specific dornase alfa orders.

RESULTS

New dornase-alfa starts P100PD decreased by 53% (1.17-0.55), and total doses P100PD decreased by 75% (16-4). N-acetylcysteine ordering more than doubled; however, total doses of P100PD remained unchanged after the intervention. The use of 3% sodium chloride increased significantly from 0.28 to 4.15 new starts and 4.37 to 38.84 total doses P100PD. Mechanical ventilation days P100PD decreased, suggesting there were no measured adverse effects of pathway implementation. The reduction in dornase-alfa utilization resulted in a cumulative and sustained 59% mucolytic cost reduction ($2183.08-$885.77 P100PD).

CONCLUSION

A clinical pathway prioritizing pharmacoeconomics when evidence for use is lacking can improve health care value without adversely affecting patient outcomes.

Diagnosis and Management of Lymphatic Disorders in Congenital Heart Disease

Purpose of Review

Lymphatic disorders have received an increasing amount of attention over the last decade. Sparked primarily by improved imaging modalities and the dawn of lymphatic interventions, understanding, diagnostics, and treatment of lymphatic complications have undergone considerable improvements. Thus, the current review aims to summarize understanding, diagnostics, and treatment of lymphatic complications in individuals with congenital heart disease.

Recent Findings

The altered hemodynamics of individuals with congenital heart disease has been found to profoundly affect morphology and function of the lymphatic system, rendering this population especially prone to the development of lymphatic complications such as chylous and serous effusions, protein-losing enteropathy and plastic bronchitis.

Summary

Although improved, a full understanding of the pathophysiology and targeted treatment for lymphatic complications is still wanting. Future research into pharmacological improvement of lymphatic function and continued implementation of lymphatic imaging and interventions may improve knowledge, treatment options, and outcome for affected individuals.

Plastic bronchitis: A case report

Plastic bronchitis is a rare and underdiagnosed disease characterized by the formation and expectoration of bronchial casts of amorphous material, which can be potentially fatal. It is more frequent in pediatric population. Symptoms can range from chronic cough and dyspnea to respiratory failure depending on the area of the compromised airway. Casts are classified as type I when constituted by inflammatory cells and accompany diseases such as asthma and pneumonias; and type II when acellular and are associated with congenital heart diseases following procedures such as Fontan. We report the case of a male schoolchild with a history of complex congenital heart disease, treated with palliative surgery, evaluated in the emergency department for cough and respiratory distress. The mother referred expulsion of gelatinous material after coughing. During clinical evaluation, expulsion of bronchial casts was evidenced, suggesting a plastic bronchitis. He underwent a diagnostic and therapeutic bronchoscopy and received initial treatment with respiratory therapy, nebulized hypertonic saline solution, mucolytics, dornase alpha and nebulized heparin. The hospitalization revealed a stenosis of the right pulmonary artery, which was corrected with stent. The patient progressed satisfactorily with improvement of cough and expectoration. He was discharged with combined treatment, nebulized medications and those concerning his underlying disease.