Pediatric long-term noninvasive respiratory support in children with central nervous system disorders

RATIONALE

The use of long-term noninvasive respiratory support is increasing in children along with an extension of indications, in particular in children with central nervous system (CNS) disorders.

OBJECTIVE

The aim of this study was to describe the characteristics of children with CNS disorders treated with long-term noninvasive respiratory support in France.

METHODS

Data were collected from 27 French pediatric university centers through an anonymous questionnaire filled for every child treated with noninvasive ventilatory support ≥3 months on 1st June 2019.

MAIN RESULTS

The data of 182 patients (55% boys, median age: 10.2 [5.4;14.8] years old [range: 0.3-25]) were collected: 35 (19%) patients had nontumoral spinal cord injury, 22 (12%) CNS tumors, 63 (35%) multiple disabilities, 26 (14%) central alveolar hypoventilation and 36 (20%) other CNS disorders. Seventy five percent of the patients were treated with noninvasive ventilation (NIV) and 25% with continuous positive airway pressure (CPAP). The main investigations performed before CPAP/NIV initiation were nocturnal gas exchange recordings, alone or coupled with poly(somno)graphy (in 29% and 34% of the patients, respectively). CPAP/NIV was started in an acute setting in 10% of the patients. Median adherence was 8 [6;10] hours/night, with 12% of patients using treatment <4 h/day. Nasal mask was the most common interface (70%). Airway clearance techniques were used by 31% of patients.

CONCLUSION

CPAP/NIV may be a therapeutic option in children with CNS disorders. Future studies should assess treatment efficacy and patient reported outcome measures.

Paediatric long term continuous positive airway pressure and noninvasive ventilation in France: A cross-sectional study

OBJECTIVE

To describe the characteristics of children treated with long term continuous positive airway pressure (CPAP) or noninvasive ventilation (NIV) in France.

DESIGN

Cross-sectional national survey.

SETTING

Paediatric CPAP/NIV teams of 28 tertiary university hospitals in France.

PATIENTS

Children aged <20 years treated with CPAP/NIV since at least 3 months on June 1st, 2019.

INTERVENTION

An anonymous questionnaire was filled in for every patient.

RESULTS

The data of 1447 patients (60% boys), mean age 9.8 ± 5.8 years were analysed. The most frequent underlying disorders were: upper airway obstruction (46%), neuromuscular disease (28%), disorder of the central nervous system (13%), cardiorespiratory disorder (7%), and congenital bone disease (4%). Forty-five percent of the patients were treated with CPAP and 55% with NIV. Treatment was initiated electively for 92% of children, while 8% started during an acute illness. A poly(somno)graphy (P(S)G) was performed prior to treatment initiation in 26%, 36% had a P(S)G with transcutaneous carbon dioxide monitoring (PtcCO₂), while 23% had only a pulse oximetry (SpO₂) with PtcCO₂ recording. The decision of CPAP/NIV initiation during an elective setting was based on the apnea-hypopnea index (AHI) in 41% of patients, SpO₂ and PtcCO₂ in 25% of patients, and AHI with PtcCO₂ in 25% of patients. Objective adherence was excellent with a mean use of 7.6 ± 3.2 h/night. Duration of CPAP/NIV was 2.7 ± 2.9 years at the time of the survey.

CONCLUSION

This survey shows the large number of children treated with long term CPAP/NIV in France with numerous children having disorders other than neuromuscular diseases.

Central-line-associated bloodstream infections in a surgical paediatric intensive care unit: Risk factors and prevention with chlorhexidine bathing

AIM

The aims of the study are to evaluate the impact of a 4% chlorhexidine (CHG4%) bathing on the occurrence of central-line-associated bloodstream infection (CLABSI) and to identify risk factors (RFs) for CLABSI in our population. This is a retrospective monocentric cohort study in the paediatric surgical intensive care unit at the Necker Enfants Malades Hospital, Paris, France.

METHODS

All hospitalised patients with central venous catheters (CVCs) in 2015 were included. CHG4% bathing was prescribed in CLABSI high-risk patients, defined by the presence of exposition factors (EFs): constitutive or acquired immunosuppression, presence of an invasive medical device (IMD) and the carriage of Staphylococcus aureus. The overall 2015 CLABSI incidence rate was compared with 2014 CLABSI incidence rate (before CHG4% bathing).

RESULTS

In all, 775 patients were analysed. Some 182 had at least one EF, and 49 received CHG4%. The incidence rates of CLABSI in 2014 and 2015 were, respectively, 6.1 and 2.3/1000 days CVC (P < 0.01). The presence of at least one EF was associated with the CLABSI's occurrence: odds ratio = 15.13 (95% confidence interval: 4.26-53.71; P < 0.0001), particularly acquired immunosuppression, IMD and S. aureus colonisation. Other RFs were age <1 year and carrying duration >16 days.

CONCLUSIONS

This study showed a significant reduction in incidence of CLABSI after introduction of a targeted CHG4% bathing protocol. Presence of IMD, S. aureus colonisation, immunosuppression, age <1 year and carrying duration >16 days were CLABSI RFs. Regarding the literature, the presence of IMD seems to be underestimated in CLABSI prevention.

Smoke inhalation injury in a 2-year-old domestic fire victim

Smoke inhalation injury is common in victims of domestic fires, among whom children are the most vulnerable. Cyanide poisoning may occur in addition to carbon monoxide poisoning and is challenging to diagnose. In France, the recommended antidotes are hydroxocobalamin for cyanide and hyperbaric oxygen for carbon monoxide. We managed a 26-month-old girl who sustained smoke inhalation injury with both carbon monoxide and cyanide poisoning during a house fire. Despite hydroxocobalamin and sodium thiosulfate therapy combined with hyperbaric oxygen, she had residual neurological impairments 3 months after the injury. The treatment challenges and detailed neurological follow-up data are described.

Iatrogenic mediastinitis in bronchiolitis: Importance of avoiding pharyngeal aspiration

An 11-month-old infant was hospitalized for his first episode of severe bronchiolitis, with pneumomediastinum on the chest x-ray performed in the emergency room before hospitalization. After a few days, the occurrence of a feverish torticollis motivated a CT scan, revealing mediastinitis. An iatrogenic perforation was objectified in the posterior wall of the esophagus, probably caused by nasopharyngeal aspiration. This exceptional case has never been reported before, except in premature infants. This encouraged us to report this case to change systematic aspiration practices and prefer nasal suctioning in healthy infants with bronchiolitis presenting to the emergency department.

Novel FOXG1 mutations associated with the congenital variant of Rett syndrome

BACKGROUND

Rett syndrome is a severe neurodevelopmental disorder representing one of the most common genetic causes of mental retardation in girls. The classic form is caused by MECP2 mutations. In two patients affected by the congenital variant of Rett we have recently identified mutations in the FOXG1 gene encoding a brain specific transcriptional repressor, essential for early development of the telencephalon.

METHODS

60 MECP2/CDKL5 mutation negative European Rett patients (classic and variants), 43 patients with encephalopathy with early onset seizures, and four atypical Rett patients were analysed for mutations in FOXG1.

RESULTS AND CONCLUSIONS

Mutations have been identified in four patients, independently classified as congenital Rett variants from France, Spain and Latvia. Clinical data have been compared with the two previously reported patients with mutations in FOXG1. In all cases hypotonia, irresponsiveness and irritability were present in the neonatal period. At birth, head circumference was normal while a deceleration of growth was recognised soon afterwards, leading to severe microcephaly. Motor development was severely impaired and voluntary hand use was absent. In contrast with classic Rett, patients showed poor eye contact. Typical stereotypic hand movements with hand washing and hand mouthing activities were present continuously. Some patients showed abnormal movements of the tongue and jerky movements of the limbs. Brain magnetic resonance imaging showed corpus callosum hypoplasia in most cases, while epilepsy was a variable sign. Scoliosis was present and severe in the older patients. Neurovegetative symptoms typical of Rett were frequently present.

Prognostic value of evoked potentials and sleep recordings in the prolonged comatose state of children. Preliminary data

OBJECTIVES

Sleep recordings and evoked potentials (EPs) were used in five comatose children to evaluate their predictive value for outcome following a severe comatose state.

METHODS AND SUBJECTS

The protocol included EEG, Brainstem Evoked Responses (BERs), Somatosensory Evoked Potentials (SEPs) and polysomnography. From 10 to 15 days post-coma (D10 to D15), EEG and clinical examinations were carried out every second day, then one day in four from 15 to 30 days post-coma (D15 to D30), and one day in seven from D30 to six months (M6). Evoked potentials and Polysomnography were recorded on D10-D15 or D30 in the second month (M2) and in M6. Of the five children, three were in anoxic coma and two in traumatic coma. All had extensive lesions and a Glasgow Coma Scale (GCS) score of less than five. The results of the EEG, polysomnographic and EP recordings were compared to the clinical outcome.

RESULTS AND CONCLUSION

In the three anoxic comas we observed BER abnormalities and the absence of SEP N20 associated with wide cortical lesions with brainstem extension. Sleep recordings showed major alterations of the wake-sleep cycle without any improvement in M6. Abnormalities included loss of the normal REM-sleep pattern associated with alteration of NREM sleep and periods of increase in motor activity without EEG arousal. This sleep pattern appeared to be associated with involvement of the brainstem. In the two traumatic comas, alterations of the early cortical SEP responses were less severe and the BERs were normal. Some sleep spindles were observed as well as the persistence of sleep cycles in the first weeks post-coma. The combined use of EEG, EPs and polysomnography improved the outcome prediction in comparison with the use of just one modality. EPs and sleep recordings were far superior to clinical evaluation and to GCS in the appreciation of the functional status of comatose children. The reappearance of sleep patterns is considered to be of favorable prognosis for outcome of the coma state, as is the presence of sleep spindles in post-trauma coma. This study showed that EPs and sleep recordings help to further distinguish between patients with good or bad outcomes.

[The sympathetic nervous system activity estimated on serum concentration of chromogranin A in patients with the chronic heart failure]

BACKGROUND

The sympathetic nervous system is markedly activated in patients with chronic heart disease. This activation can be evaluated by assessing the serum levels of chromogranin A (CgA), the protein which is present in the all neuroendocrine cells. The main human source of CgA are adrenal medullary and sympathetic nerve endings. The aim of the study was to demonstrate if serum concentration of chromogranin A correlated to severity of chronic heart failure and it can be usefulness for clinical diagnosis.

MATERIAL AND METHODS

The serum levels of CgA were measured in 123 patients. Patients with chronic heart disease (n = 100) were divided into four groups depending of the severity of heart failure--NYHA classification (B1--NYHA I, B2--NYHA II, B3--NYHA III, B4--NYHA IV). The control group consisted of 23 persons without heart disease. The patients in both groups were examined and had performed tests: electrocardiography, echocardiography, blood morphology and the blood concentrations of creatinine, glucose, electrolytes, lipids. The serum concentration of chromogranin A was assessed by specific and immunoenzymatic sandwich ELISA test.

RESULTS

The mean serum concentration of CgA in the control group was 48.43 +/- 2.97 micrograms/L. In the chronic heart disease group the concentrations of CoA increased with the degree of NYHA heart failure and in four groups (B1, B2, B3, B4) the CgA levels were: 42.10 +/- 19.52; 49.84 +/- 22.63; 73.64 +/- 34.08; 106.66 +/- 87.54 micrograms/L respectively. The concentrations in groups B3 and B4 were significantly higher than in control group. The LV ejection fraction was reduced in groups B1-B4 (mean +/- SD): 60.12 +/- 9.20; 47.45 +/- 11.10; 40.28 +/- 9.52%. The CgA concentration was significantly negatively correlated with LV ejection fraction (r = -28). The left atrium was in group B1-B4:--32.94 +/- 4.35, 38.73 +/- 7.87, 42.57 +/- 7.98, 46.32 +/- 10.67 mm. The heart rate rised with the NYHA class (the control group (mean +/- SD): 72.96 +/- 9.15/min) and in the groups B1-B4 (mean +/- SD): 78.15 +/- 14.35, 79.90 +/- 14.67; 85.40 +/- 14.11; 93.74 +/- 16.29/min. The heart rate was significantly higher in B3 and B4 groups.

CONCLUSIONS

1. The serum concentrations of chromogranin A were correlated with the severity of chronic heart failure based on NYHA classification. 2. The CgA concentrations were significantly negatively correlated with the LV ejection fraction. 3. The chromogranin A can be used as a marker of the sympathetic nervous system activation in the patients with chronic heart failure.

[Current opinions about the role of peptide C in the human organism]

This article present a review on the physiological activity and possible mechanism of action of C-peptide and clinical significance of using this hormone in the treatment of diabetes mellitus. The present results might suggest that, contrary to the prevailing view, C-peptide possesses biological activity and plays an important part in the attenuating or preventing from diabetic complications. It is important to realize that this discovery might someday revolutionize diabetes treatment, however further studies will be required to define and confirm the exact mechanism of C-peptide activity.