Faculty Bibliography

PURPOSE: Reflux esophagitis (ReE) and eosinophilic esophagitis (EoE) are associated with the presence of eosinophils in esophageal mucosa and are considered to be important co-morbid factors for chronic cough and asthma in adults. We hypothesize that esophageal eosinophils related to ReE and EoE are present in children with refractory asthma and chronic cough and correlate with airway eosinophilia. METHODS: We performed a retrospective analysis of medical records of children who underwent "triple endoscopy" (sleep laryngoscopy, bronchoscopy with bronchoalveolar lavage (BAL) and endobronchial biopsy (EBB), and esophagogastroduodenoscopy with esophageal biopsy (EsB)) at our Aerodigestive Center for evaluation of refractory asthma and cough. Inclusion criteriawere cough for 8 weeks or more with no response to trial of antibiotics and systemic/inhaled corticosteroids (ICS), poor control of asthma symptoms, and/or airflowlimitations and air trapping despite use ICS or ICS/long-acting beta-agonist combination. Children with known cystic fibrosis, primary ciliary dyskinesia and aspiration into airway were excluded. RESULTS: Thirty-two children (22 males) met inclusion criteria. Nineteen had refractory asthma and 13 had chronic cough. There were no significant complications recorded after procedures including EBB. Eosinophils (>1%) were present in BAL of 8 (25%) children. EBB showed eosinophils in 17 (53%) children. There were a total of 19 children with eosinophils isolated from the airway (either BAL or EBB), 4 (21%) had them in BAL alone, 8 (42%) in EBB only, and 7 (37%) in both BAL and EBB. EoE was diagnosed in 6 children (19%) and ReE in 13 (41%). EsB revealed esophageal eosinophils in 47% of children. Presence of eosinophils in EsB was related to presence of eosinophils in EBB chi² (1, N = 32), p = 0.026, but not BAL (p=0.89). CONCLUSIONS: ReE and EoE with esophageal eosinophils was present in 47% of children with refractory asthma and chronic cough. There is a significant relationship between airway and esophageal eosinophils, which becomes evident only when EBB is performed for detection of airway eosinophils. Further research is required for understanding the association of airway and esophageal eosinophilia in the development and management of refractory asthma and cough

BACKGROUND: Children with medical complexity have a high prevalence of sleep disorders. However, outpatient polysomnography to evaluate for these conditions may be difficult to perform because of lack of skilled nursing care. The aim of this study was to explore polysomnography indications in hospitalized children and assess its impact on patient care. METHODS: Data from 85 inpatient polysomnographies of 70 children hospitalized between March and December 2014 were retrospectively collected. RESULTS: Sixty percent of patients were boys with ages 6.5 +/- 6 years. Chronic respiratory failure was present in 33.8%, airway obstruction due to defects of the tracheobronchial tree or craniofacial abnormalities in 54.3%, neurological complications of the perinatal period in 22.9%, genetic syndromes and neurodegenerative disorders in 31.4%, congenital myopathies in 5.7%, metabolic diseases in 4.3% and congenital cyanotic heart defects in 4.3%. Indications for polysomnography included assessment of chronic pulmonary disease (60%), ventilator requirements (41.2%), apnea/desaturation (23.5%), and acute life-threatening events (1.2%). Abnormal results were found in 89.4%. The observed diagnosis was obstructive sleep apnea in 64.7%, signs of chronic lung disease in 34.1%, hypoventilation in 9.4%, periodic breathing in 3.5%, and periodic limb movement of sleep in 4.7%. The following interventions were performed: adjustment of ventilator parameters (45.8%), positive airway pressure initiation (24.7%), otorhinolaryngology referral (30.6%), supraglottoplasty (2.4%), tracheostomy decannulation (2.4%), and tracheostomy placement (3.5%). Nine patients had available follow-up polysomnograms, all showing improvement in sleep variables after adherence to recommended interventions. CONCLUSIONS: In patients with medical complexity, inpatient polysomnographies give invaluable information to guide immediate medical decision making and should be strongly considered if resources allow this.

We present a case of an ex-28-week, extremely low-birth-weight infant who was transferred to our institution for bronchoscopically assisted removal of an aspirated foreign body. This case presented several challenges because of the patient's extreme prematurity as well as the need for repeated tracheal extubations and reintubations during the procedure to accommodate surgical instruments in the patient's airway. We discuss the respiratory physiology, common comorbidities, and management of aspirated foreign bodies in the premature infant and emphasize the importance of clear communication in the operating room between the multidisciplinary team of physicians involved in this patient's care.

INTRODUCTION:: Distal airway secretions can be sampled by bronchoscopic bronchoalveolar lavage (B-BAL), blind protected BAL (BP-BAL) and tracheal aspirates (TA). We quantitatively compared the cultures of distal airway secretions from BP-BAL, B-BAL, and TA and assessed the efficacy of the three above methods in diagnosing bronchitis in tracheostomized children. METHOD:: Twenty children with tracheostomies underwent BP-BAL, B-BAL and TA. Samples were sent for quantitative bacterial cultures. Diagnosis of bronchitis was made based on a validated visual grading system as well as on positive quantitative culture in the BAL fluid. Diagnostic agreement between cultures obtained by the three methods and the visual grading scores was determined by kappa statistics. RESULTS:: Diagnosis of bronchitis by visual grading score had substantial agreement with BP-BAL, moderate agreement with B-BAL, and fair agreement with TA. BP-BAL had significantly lower pathogenic colonies (P<0.05) than either B-BAL or TA. CONCLUSION:: BP-BAL allows for more accurate sampling of lower airway secretions in tracheostomized children and is more accurate in the diagnosis of bronchitis in this group.

BACKGROUND:: Children with neurological impairment often suffer from insufficient airway secretion clearance, which substantially increases their respiratory morbidity. The goal of the study was to assess the clinical feasibility of high frequency chest wall compression (HFCWC) therapy in neurologically impaired children with respiratory symptoms. METHODS:: This was a single-center, investigator initiated, prospective study. Twenty two patients were studied for 12 months before and 12 months after initiation of HFCWC therapy, 15 patients were followed up for additional 12 months. The threshold of compliance with HFCWC therapy was 70%. The amounts of pulmonary exacerbations, which required hospitalization, were recorded. RESULTS:: Forty five percent of study patients required hospital admission before initiation of HFCWC therapy. This rate decreased to 36% after the first year of treatment and to 13% after the second year of treatment. There was a statistically significant reduction of the number of hospital days at follow-up relative to before treatment. Use of either the cough assist device or tracheostomy did not significantly interact over time with hospitalization days. CONCLUSIONS:: Prolonged HFCWC therapy may reduce the number of hospitalizations in neurologically impaired children.

INTRODUCTION: Gastroesophageal reflux (GER) is common in children with airway disorders. Previous studies have shown an association between upper airway obstruction and GER in experimental animal models. However, the cause and effect relationship between intrathoracic airway obstruction (IAO) and GER is obscure. The goal of this study is to investigate the association between IAO and GER using the canine model. METHODS: In sedated dogs, a telemetric implant was placed subcutaneously (with one pressure sensor tip each in intrapleural space and abdomen) to monitor intrapleural pressure (IPP) and intrabdominal pressure (IAP). The IPP and the IAP were monitored intraoperatively and in conscious dogs on the 7th to 10th postoperative days. GER was assessed by determining the reflux index (RI), based on the intraesophageal pH recording performed continuously for a 24 hr period using a pH probe. After 2-3 weeks following placement of the telemetric implant, IAO was surgically created in the dog. After maintaining IAO for 2 weeks, the IPP, IAP, and pH measurements were monitored again following the same protocol as before IAO. RESULTS: After the creation of IAO, there was no significant change observed in the mean RI either in the distal (P = 0.716) or proximal (P = 0.962) esophageal lumens. The IPP became significantly more negative (P = 0.006) and the IAP turned significantly negative (P < 0.001) from being positive compared to the respective values before IAO. However, transdiaphragmatic pressure (Pdi) did not change significantly (P = 0.08). CONCLUSION: We conclude that moderate IAO does not cause GER in our animal model. It can be explained by the absence of significant change in Pdi after creation of IAO.