Faculty Bibliography

BACKGROUND:Fractional exhaled nitric oxide (FeNO) can objectively guide clinical practice in the assessment, diagnosis, and treatment of eosinophilic airway inflammation. FeNO values may be affected by current smoking, but the role of tobacco smoke exposure (TSE) is understudied. OBJECTIVE:This study investigated the associations between biochemically validated and self-reported TSE and FeNO levels among U.S. nonsmoking adolescents without asthma. METHODS:National Health and Nutrition Examination Survey 2007-2012 data were used. TSE was assessed via serum cotinine and self-reported measures. We assessed FeNO continuously and using cutpoints of >35 ppb and >50 ppb to indicate likely eosinophilic inflammation in children and adults, respectively. We conducted linear and logistic regression adjusting for potential covariates. RESULTS:Overall, 34.0% of adolescents had low cotinine (0.05-2.99 ng/ml), 6.2% had high cotinine (≥3.00 ng/ml), and 11.9% had home TSE. Compared to adolescents with no/minimal cotinine, adolescents with high cotinine were at reduced odds to have FeNO >35 ppb (adjusted odds ratio [aOR] = 0.54, 95%CI = 0.43,0.69). Adolescents with low cotinine had lower FeNO values (β = -2.05, 95%CI = -3.61,-0.49), and were also at decreased odds to have FeNO >35 ppb (aOR = 0.74, 95%CI = 0.66,0.83) and FeNO >50 ppb (aOR = 0.62, 95%CI = 0.53,0.72). Adolescents with home TSE were at reduced odds to have FeNO >50 ppb (aOR = 0.72, 95%CI = 0.57,0.91) than adolescents without home TSE. Adolescents with a higher number of cigarettes/day smoked inside their home were at reduced odds to have FeNO >35 ppb (OR = 0.98, 95%CI = 0.97,0.99) and FeNO >50 ppb (OR = 0.98, 95%CI = 0.96,0.99). CONCLUSIONS:TSE was associated with decreased FeNO levels. The addition of TSE may be clinically important when interpreting thresholds for FeNO.

Tracheoesophageal fistula (TEF) with esophageal atresia (EA) is a common congenital anomaly that is associated with significant respiratory morbidity throughout life. The objective of this document is to provide a framework for the diagnosis and management of the respiratory complications that are associated with the condition. As there are no randomized controlled studies on the subject, a group of experts used a modification of the Rand Appropriateness Method to describe the various aspects of the condition in terms of their relative importance, and to rate the available diagnostic methods and therapeutic interventions on the basis of their appropriateness and necessity. Specific recommendations were formulated and reported as Level A, B, and C based on whether they were based on "strong", "moderate" or "weak" agreement. The tracheomalacia that exists in the site of the fistula was considered the main abnormality that predisposes to all other respiratory complications due to airway collapse and impaired clearance of secretions. Aspiration due to impaired airway protection reflexes is the main underlying contributing mechanism. Flexible bronchoscopy is the main diagnostic modality, aided by imaging modalities, especially CT scans of the chest. Noninvasive positive airway pressure support, surgical techniques such as tracheopexy and rarely tracheostomy are required for the management of severe tracheomalacia. Regular long-term follow-up by a multidisciplinary team was considered imperative. Specific templates outlining the elements of the clinical respiratory evaluation according to the patients' age were also developed.

AIM/OBJECTIVE:Children with respiratory conditions benefit from care provided by pediatric pulmonologists. As these physicians are a small portion of the overall pediatric workforce, it is necessary to understand the practices and career plans of these specialists. METHODS:An internet survey was developed by the American Academy of Pediatrics Division of Workforce and Medical Education Policy and sent to members of the American Academy of Pediatrics and American College of Chest Physicians who identified as pediatric pulmonary physicians. RESULTS:Responses were received from 485 physicians and were compared to the results of a similar survey done in 1997. Of those completing the survey, 63% were male and 37% female, with increased number of females since the earlier poll. The average calculated age was 56 years. They worked 54 h per week, down from 59 h in the prior survey. Pediatric pulmonologists are overwhelmingly clinicians (92%) with major responsibilities for administration (79%), teaching (78%), and research. Basic science research was rarely reported (7%). Pediatric pulmonologists felt that referrals had become more complicated in the recent past. Nearly all planned to maintain Pediatric Pulmonology Sub-board certification, though one third planned to cut back on clinical workload in the next decade. Many were concerned that the number needed in the profession in a decade would be inadequate with significant concerns about funding for those positions. CONCLUSION/CONCLUSIONS:Overall, these results reflect the current state of the workforce and the need to monitor the supply of practitioners in the future.

Asthma and obesity are both prevalent conditions that appear related, but the etiology for this association remains unclear. This study examines whether asthma is associated with obesity and physical activity limits 10 years later among a subsample from the National Longitudinal Survey of Youth 1979 who were age 40 at baseline. We addressed selection bias using inverse-propensity score weighting (N?=?5077), and confirmed the results with full matching (N?=?5041), and with both methods we estimated new sampling weights so that the sample would remain nationally representative. Both matched sampling methods balanced adults with asthma versus those without asthma on all 7 covariates: baseline obesity, sex, race/ethnicity, family income, poverty status, general health status and physical activity limits. Before matching, baseline asthma was significantly associated with developing obesity 10 years later in an unadjusted model [OR?=?1.44 (1.10-1.90)], but not in the multivariable model [OR?=?1.15 (0.80-1.67)]. Baseline asthma was not associated with obesity 10 years later after inverse propensity weighting [OR (95% CI?=?1.03 (0.69-1.53)] and full matching [1.16 (0.75-1.80)]. Results remained similar after excluding subjects with baseline obesity. In a cumulative logistic model using complex survey and full matching weights, those with baseline asthma had 83% greater odds of reporting physical activity limits compared to those without asthma, OR?=?1.83 (1.21-2.76). Baseline asthma was not associated with obesity among either a nationally representative sample of middle-aged adults or a non-obese subset. However, asthma was associated with physical activity limits in the full matched sample. Asthma disease management programs should communicate that asthma does not imply obesity and also encourage exercise within the physical limitations of their populations. Selection bias on factors such as low socioeconomic status may explain previous asthma-obesity associations

BACKGROUND:Home oxygen therapy is often required in children with chronic respiratory conditions. This document provides an evidence-based clinical practice guideline on the implementation, monitoring, and discontinuation of home oxygen therapy for the pediatric population. METHODS:A multidisciplinary panel identified pertinent questions regarding home oxygen therapy in children, conducted systematic reviews of the relevant literature, and applied the Grading of Recommendations, Assessment, Development, and Evaluation approach to rate the quality of evidence and strength of clinical recommendations. RESULTS:After considering the panel's confidence in the estimated effects, the balance of desirable (benefits) and undesirable (harms and burdens) consequences of treatment, patient values and preferences, cost, and feasibility, recommendations were developed for or against home oxygen therapy specific to pediatric lung and pulmonary vascular diseases. CONCLUSIONS:Although home oxygen therapy is commonly required in the care of children, there is a striking lack of empirical evidence regarding implementation, monitoring, and discontinuation of supplemental oxygen therapy. The panel formulated and provided the rationale for clinical recommendations for home oxygen therapy based on scant empirical evidence, expert opinion, and clinical experience to aid clinicians in the management of these complex pediatric patients and identified important areas for future research.