Associations between polysomnography measurements and postoperative adverse respiratory events in children with neuromuscular disease

STUDY OBJECTIVES

To determine if polysomnographic cardiorespiratory outcomes are associated with and could have the potential to predict the presence of postoperative adverse respiratory events in children with neuromuscular disease undergoing any surgical procedure.

METHODS

A retrospective cohort study was conducted at a tertiary pediatric institution. The study population included individuals with neuromuscular disease admitted for a surgical intervention under general anesthetic who had undergone a polysomnogram within 1 year before surgical intervention. Polysomnographic indices and postoperative adverse respiratory events were collected through chart review. Multivariable logistic regression was used to model postoperative adverse respiratory events, where PSG results were considered primary predictors.

RESULTS

Postoperative adverse respiratory events occurred in 25/61 (41%) of individuals and consisted mainly of desaturations requiring intervention 33 (73%), airway obstruction 15 (33%), and atelectasis (22%). Results from the unadjusted and adjusted logistic regression models indicated that saturation nadir and bulbar dysfunction individually were independent risk factors for postoperative adverse respiratory events with the highest areas under the receiver operating characteristic curve. A multivariable prediction model using these 2 risk factors provided an area under the receiver operating characteristic curve of 0.74 (95% confidence interval, 0.65-0.83).

CONCLUSIONS

Knowing that nocturnal oxygen saturation nadir and the presence of bulbar dysfunction are potential predictors of postoperative adverse respiratory events is useful for future counseling of families and surgical planning, in an effort to improve perioperative management and reduce adverse events.

Intrapleural Dornase and Tissue Plasminogen Activator in pediatric empyema (DTPA): a study protocol for a randomized controlled trial

BACKGROUND

A randomized controlled trial of adults with empyema recently demonstrated decreased length of stay in hospital in patients treated with intrapleurally administered dornase alfa and fibrinolytics compared to fibrinolytics alone. Whether this treatment strategy is safe and effective in children remains unknown.

METHODS/DESIGN

This study protocol is for a superiority, placebo-controlled, parallel-design, multicenter randomized controlled trial. The participants are previously well children admitted to a children's hospital with a diagnosis of empyema requiring chest tube insertion and fibrinolytics administered intrapleurally. Children will be randomized after the treating physician has decided that pleural drainage is required but prior to chest tube insertion. After chest tube insertion, participants in the treatment group will receive intrapleurally administered tissue plasminogen activator (tPA) 4 mg followed by dornase alfa 5 mg. Participants in the placebo group will receive tPA 4 mg followed by normal saline. Study treatments will be administered once daily for 3 days. All participants, parents or caregivers, clinicians, and research personnel will remain blinded. The primary outcome is length of stay from chest tube insertion to discharge from hospital. Secondary outcomes include time to meeting discharge criteria, chest tube duration, fever duration, need for additional procedures, adverse events, hospital readmission, cost of hospitalization, and mortality.

DISCUSSION

This multicenter randomized controlled trial will assess the safety, effectiveness, and cost-effectiveness of combined treatment with dornase alfa and fibrinolytics compared to fibrinolytics alone for the treatment of empyema in children.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT01717742 . Registered on 8 October 2012.

Bronchial artery-pulmonary artery malformation as a cause of cryptogenic hemoptysis

A 12-year-old girl with two episodes of massive hemoptysis was found to have a localized pulmonary hemorrhage on bronchoscopy. Multiple investigations including a computed tomography (CT) angiogram failed to identify the cause. Catheterization of the pulmonary and bronchial vessels uncovered a bronchial artery to pulmonary artery fistula, which was embolized by interventional radiology. This is the first pediatric case of this type of anomaly and it illustrates the importance of angiography in the investigation of cryptogenic hemoptysis.

Nocturnal hypoventilation: predictors and outcomes in childhood progressive neuromuscular disease

OBJECTIVES

To determine: (a) prevalence of clinically unsuspected nocturnal hypoventilation (NH) in a clinic population of children with progressive neuromuscular disease; (b) whether NH can be predicted from clinical/laboratory parameters; and (c) change over 1 year in pulmonary function decline, quality of life and attention in children with NH treated with non-invasive positive pressure ventilation (NPPV) compared with children without NH.

DESIGN

Prospective cohort study.

SETTING

Two tertiary-care paediatric neuromuscular clinics.

PATIENTS

46 children (6-17 years) with progressive neuromuscular disease without neurocognitive impairment or dystrophinopathy.

INTERVENTIONS

Polysomnography, pulmonary function, manual muscle strength, quality of life (CHQ-PF50) and Conners questionnaires.

OUTCOME MEASURES

(a) Prevalence of NH; (b) predictive value of surrogate clinical measures for NH; and (c) differences in change over 1 year in pulmonary function, muscle strength, quality of life and attention between children with and without NH.

RESULTS

Prevalence of NH was 14.8%, 95% CI 8.0% to 25.7%. Maximal sensitivity and specificity for NH were achieved with thresholds of forced vital capacity <70% and forced expiratory volume in 1 s <65% predicted (sensitivities: 71.4, 71.4; specificities: 64.1, 79.5). Scoliosis also predicted NH (sensitivity 88.9; specificity 80.4). Over 1 year, those with NH had a greater increase in residual volume/total lung capacity (0.075 (-0.003 to 0.168) vs -0.03 (-0.065 to 0.028)), decline in muscle strength (-0.67 (-0.90 to 0.10) vs 0.53 (-0.05 to 0.90)) and worsened perception of health status.

CONCLUSIONS

15% of subjects had clinically unsuspected NH, predicted by moderate pulmonary function test impairment and scoliosis. Over 1 year those with NH had increased gas trapping, decline of muscle strength and worse perception of health status, despite NPPV.

Pulmonary arteriovenous malformations in children: outcomes of transcatheter embolotherapy

OBJECTIVE

To describe outcomes of transcatheter embolotherapy (TCE) in children with pulmonary arteriovenous malformations (PAVMs).

STUDY DESIGN

Chart and imaging review of all children (age </=18 years) treated for PAVMs by TCE at three hereditary hemorrhagic telangiectasia centers.

RESULTS

All 42 treated patients were included, with a mean age of 12 years (range, 4 to 18). Cyanosis was present in 25 of 42 patients (60%). Hemoptysis had occurred in 3 of 42 patients (7%) and neurologic complications (stroke, cerebral abscess) occurred in 8 patients (19%) before assessment. PAVMs were focal in 30 of 42 (71%) and diffuse in 12 of 42 (29%) patients. TCE was performed for 172 PAVMs and 35 diffuse regions (regional TCE). Follow-up was obtained in 38 of 42 (90%) patients (mean, 7 years). After TCE in patients with focal PAVMs, oxygenation improved significantly, with no further complications from the PAVMs. Reperfusion was noted in 23 of 153 (15%) PAVMs. Eighteen of 23 (78 %) of these were retreated, with documented aneurysmal involution in 10 of 13 (77%) patients. TCE complications included pleuritic chest pain (24% of sessions) and deployment complications (device paradoxical embolization or device misplacement) (3% of sessions, 1% of PAVMs), with no long-term complications.

CONCLUSIONS

PAVMs cause life-threatening complications in children; treatment with TCE is safe, with complication rates comparable to adult rates.

Hemoptysis: a rare cause can be related to a bronchial varix due to pulmonary venous obstruction

Bronchial varices, which have rarely been described in the radiology literature, can be the result of pulmonary venous obstruction and may present with hemoptysis. This case is an illustration of this rare condition, which correlates CT findings with bronchoscopic findings. We also describe the findings on phase-contrast MR that demonstrated reversed diastolic flow in the branch pulmonary artery supplying the affected lung.

Infant-mother attachment and nutrition in children with cystic fibrosis

The association between nutritional status (percentage of weight for height) and infant-mother relationship was studied over 4 years in 38 children diagnosed with cystic fibrosis in the first year of life. Infant-mother relationship was assessed in a standardized laboratory observation. Although they could not be distinguished medically from the others at the time of diagnosis, infants showing a specific form of insecure relationship with their mothers (insecure-avoidant) differed from the others in: (1) failure to improve in nutritional status in the first year; (2) continuing decline in weight for height in the first 3 years; and (3) significantly lower weight for height at 1, 2, and 3 years of age. These data suggest that attention to mother-infant relationships, particularly feeding interactions, may improve nutritional status in children with cystic fibrosis.

Pseudomonas cepacia infection in cystic fibrosis: an emerging problem

The prevalence of Pseudomonas cepacia infection increased from 10% in 1971 to 18% by 1981 in a population of approximately 500 patients with cystic fibrosis. Carriage of P. aeruginosa has remained unchanged at 70% to 80% over the same period. Patients infected with P. cepacia have greater impairment of pulmonary function than those with P. aeruginosa. A syndrome characterized by high fever, severe progressive respiratory failure, leukocytosis, and elevated erythrocyte sedimentation rate has occurred in eight patients over the past 3 years, with a 62% fatality rate. Because P. cepacia strains are uniformly resistant to ticarcillin, piperacillin, and aminoglycosides, and because ceftazidime is ineffective despite in vitro activity, treatment of these infections is very difficult. Prevention of acquisition and effective treatment of P. cepacia in patients with cystic fibrosis are now major clinical problems in our clinic.