Emergency presentation and management of acute severe asthma in children

Acute severe asthma is one of the most common medical emergency situations in childhood, and physicians caring for acutely ill children are regularly faced with this condition. In this article we present a summary of the pathophysiology as well as guidelines for the treatment of acute severe asthma in children. The cornerstones of the management of acute asthma in children are rapid administration of oxygen, inhalations with bronchodilators and systemic corticosteroids. Inhaled bronchodilators may include selective b2-agonists, adrenaline and anticholinergics. Additional treatment in selected cases may involve intravenous administration of theophylline, b2-agonists and magnesium sulphate. Both non-invasive and invasive ventilation may be options when medical treatment fails to prevent respiratory failure. It is important that relevant treatment algorithms exist, applicable to all levels of the treatment chain and reflecting local considerations and circumstances

Lung function at term in extremely preterm-born infants: A regional prospective cohort study

Objectives: To compare lung function of extremely preterm (EP)-born infants with and without bronchopulmonary dysplasia (BPD) with that of healthy term-born infants, and to determine which perinatal characteristics were associated with lung function at term and how predictive these measurements were for later respiratory health in EP-born infants. Methods: Perinatal variables were recorded prospectively, and tidal breathing parameters were measured at term-equivalent age using electromagnetic inductance plethysmography. Respiratory morbidity was defined by hospital readmissions and/or treatment with asthma medications during the first year of life. Results: Fifty-two EP-born infants (mean gestational age 261, range 226–276 weeks) and 45 term-born infants were included. There was evidence of significant airway obstruction, higher tidal volumes and increased minute ventilation in the EP-born infants with and without BPD, although generally more pronounced for those with BPD. Male gender, antenatal steroids and number of days on continuous positive airway pressure were associated with lung function outcomes at term. A prediction model incorporating two unrelated tidal breathing parameters, BPD, birth weight z-score and gender, predicted respiratory morbidity in the first year of life with good accuracy (area under the curve 0.818, sensitivity and specificity 81.8% and 75.0%, respectively). Conclusion: Lung function measured at term-equivalent age was strikingly abnormal in EP-born infants, irrespective of BPD. Tidal breathing parameters may be of value in predicting future pulmonary health in infants born premature.publishedVersio

The immunology of the periodic fever, aphthous stomatitis, pharyngitis and cervical adenitis syndrome; what can the tonsils reveal. A literature review.

Under embargo until: 25.11.2020Objectives: Tonsillectomy (TE) or adenotonsillectomy (ATE) may have a beneficial effect on the clinical course in children with the periodic fever, aphthous stomatitis, pharyngitis and cervical adenitis (PFAPA) syndrome. However, an immunological reason for this effect remains unknown. This literature review summarizes the current knowledge regarding the immunological role of the tonsils in the PFAPA syndrome. Methods: We searched PubMed, Medline, EMBASE and Cochrane for papers written in English dated from 1 January 1987 to 30 April 2019. The search included all studies reporting histological, immunological or microbiological workup of tonsil specimens from children aged 0–18 years with PFAPA. Results: Thirteen articles reported histological, immunological or microbiological workup of tonsil specimens in children with PFAPA. The histology of tonsil specimens from children with PFAPA displayed chronic tonsillar inflammation with lymphoid hyperplasia. No uniform immunological pattern was identified, but some studies found fewer B-lymphocytes and smaller germinal centers in PFAPA compared to controls. A difference in tonsillar microbiota between PFAPA and controls was found in one study. Conclusion: A uniform immunological or microbiological pattern explaining the clinical effect of TE in children with PFAPA has not been revealed. Future targeted immunological studies of tonsils in PFAPA patients could possibly illuminate the understanding of the immunology in this disease.acceptedVersio

Veien fra teori til praksis. En kvalitativ studie om hvordan medisinstudenter erfarer sammenhengen mellom teori og praksis i utdanningen.

Denne oppgaven ser nærmere på den medisinske profesjonsutdanningen, og hvordan medisinstudenter erfarer hvordan er det å befinne seg i kvalifiseringsprosessen til å bli profesjonelle yrkesutøvere som leger. Det empiriske materialet som benyttes er basert på kvalitative intervju med ti medisinstudenter fra ulike læresteder i Norge. Oppgaven fokuserer på hvordan studentene erfarer sammenhengen mellom teoretisk kunnskap og praktisk yrkesutøvelse i utdanningen. Som teoretisk begrepsapparat benyttes Harald Grimens begreper meningsfulle sammenhenger og praktiske synteser, Bert van Oers begrep rekontekstualisering, samt Donald Schöns praksisteori, med særlig vekt på begrepet refleksjon i handling. Analysens sentrale poeng er at medisinstudentene til en viss grad synliggjør et gap mellom teori og praksis i utdanningen og uttrykker det gjennom å beskrive at utdanningen mangler et mellomledd mellom teori og praksis. Likevel opplever studentene at teori og praksis henger sammen når de klarer å konstruere meningsfulle sammenhenger mellom ulike former for kunnskap og kompetanser som er relevante for yrkesutøvelsen. Opplevelsen av meningsfulle sammenhenger er ikke nødvendigvis noe som kommer eksplisitt frem i undervisningen, men erfares ofte gjennom en refleksiv holdning til egen utvikling og når studentene aktivt tar tak i det som de mener er viktig for å utvikle seg til å bli gode leger. Materialet synliggjør i tillegg noen momenter ved utdanningen som har innvirkning på deres opplevelse av sammenheng mellom teori og praksis. Det knyttes primært til den pedagogiske kvaliteten på undervisningen, formidling av klinisk rettet teori, betydningen av god og systematisk veiledning, utvikling av relasjonell og refleksiv kompetanse, samt utvikling av profesjonell identitet. Avslutningsvis argumenteres det for at gapet mellom teori og praksis også kan forstås som noe fruktbart dersom det stimulerer til refleksiv utvikling og fordi teoretisk kunnskap kan ha en viktig egenverdi

Compliance with Guidelines and Efficacy of Heart Rate Monitoring during Newborn Resuscitation: A Prospective Video Study

Objective: Newborn resuscitation guidelines recommend initial assessment of heart rate (HR) and initiation of positive pressure ventilation (PPV) within 60 s after birth in non-breathing newborns. Pulse oximeter (PO) and electrocardiogram (ECG) are suggested methods for continuous HR monitoring during resuscitation. Our aim was to evaluate compliance with guidelines and the efficacy of PO versus ECG monitoring in real-life newborn resuscitations. Methods: In this prospective observational study, we video recorded resuscitations of newborns ≥34 weeks of gestation receiving PPV at birth. Results: 104 resuscitations were analysed. Median (IQR) time from birth to arrival at the resuscitation bay was 48 (22–68) s (n = 62), to initial HR assessment 70 (47–118) s (n = 61), and to initiation of PPV 78 (42–118) s (n = 62). Initial HR assessment (stethoscope or palpation) and initiation of PPV were achieved within 60 s for 35% of the resuscitated newborns. Time to initial HR assessment and initiating PPV was significantly longer following vaginal deliveries than caesarean sections: 84 (70–139) versus 44 (30–66) s (p < 0.001) and 93 (73–139) versus 38 (30–66) s (p < 0.001). Time from birth and sensor application to provision of a reliable HR signal from PO versus ECG was 348 (217–524) (n = 42) versus 174 (105–277) s (n = 30) (p < 0.001) and 199 (77–352) (n = 65) versus 16 (11–22) s (n = 52) (p < 0.001). Conclusion: Initial HR assessment and initiation of PPV were achieved within 60 s after birth in only 1/3 of newborn resuscitations. When applied for continuous HR monitoring, ECG was superior to PO in time to achieve reliable HR signals in real-life resuscitations.publishedVersio

SABRE: a multicentre randomised control trial of nebulised hypertonic saline in infants hospitalised with acute bronchiolitis

Aim Acute bronchiolitis is the commonest cause for hospitalisation in infancy. Supportive care remains the cornerstone of current management and no other therapy has been shown to influence the course of the disease. It has been suggested that adding nebulised hypertonic saline to usual care may shorten the duration of hospitalisation. To determine whether hypertonic saline does have beneficial effects we undertook an open, multi-centre parallel-group, pragmatic RCT in ten UK hospitals. Methods Infants admitted to hospital with a clinical diagnosis of acute bronchiolitis and requiring oxygen therapy were randomised to receive usual care alone or nebulised 3% hypertonic saline (HS) administered 6-hourly. Randomisation was within 4 h of admission. The primary outcome was time to being assessed as ‘fit’ for discharge with secondary outcomes including time to discharge, incidence of adverse events together with follow up to 28 days assessing patient centred health related outcomes. Results A total of 317 infants were recruited to the study. 158 infants were randomised to HS (141 analysed) and 159 to standard care (149 analysed). There was no difference between the two arms in time to being declared fit for discharge (hazard ratio: 0−95, 95% CI: 0.75−1.20) nor to actual discharge (hazard ratio: 0.97, 95% CI: 0.76−1.23). There was no difference in adverse events. One infant in the HS group developed bradycardia with desaturation. Conclusion This study does not support the use of nebulised HS in the treatment of acute bronchiolitis over usual care with minimal handlings. ClinicalTrials.gov registration number NCT01469845

Incidence of newborn resuscitative interventions at birth and short-term outcomes: A regional population-based study

Objectives To determine the incidence and characteristics of resuscitative interventions at different gestational ages and short-term outcomes after resuscitation. Design, setting and patients A prospective observational study in an unselected population at Stavanger University Hospital, Norway, from October 2016 until September 2017. Interventions Using a data collection form and video recordings, we registered and analysed resuscitative interventions. Main outcome measures Incidence of continuous positive airway pressure (CPAP), positive pressure ventilation (PPV), intubation, chest compressions and intravenous fluid or epinephrine boluses. Short-term outcomes of resuscitated newborns. Results All 4693 newborns in the study period were included in the study. Two hundred and ninety-one (6.2%) newborns received interventions in the first minutes of life beyond drying and stimulation. PPV was provided in 170 (3.6%) while CPAP (without PPV) was provided in 121 (2.6%) newborns. Duration of PPV was median (IQR) 106 s (54–221). Intubations were performed in 19 (0.4%) newborns, with a mean (SD) intubation time of 47 (21) s. Ten (0.2%) newborns received chest compressions and epinephrine was administrated in three (0.1%) newborns. Sixty-three per cent of the treated newborns from 34 weeks’ gestational age were returned to parental care without further follow-up.publishedVersio

Lung function and bronchial hyperreactivity from 11 to 18 years in children with bronchiolitis in infancy.

Background Various trajectories for lung function and bronchial hyper‐reactivity (BHR) from early childhood to adulthood are described, including puberty as a period with excessive lung growth. Bronchiolitis in infancy may be associated with increased risk of developing chronic obstructive pulmonary disease, but the development of respiratory patterns during puberty is poorly characterized for these children. We aimed to study the development and trajectories of lung function and BHR from 11 to 18 years of age in children hospitalized for bronchiolitis in infancy. Methods Infants hospitalized for bronchiolitis at the University Hospitals in Stavanger and Bergen, Norway, during 1997‐1998, and an age‐matched control group, were included in a longitudinal follow‐up study and examined at 11 and 18 years of age with spirometry and methacholine provocation test (MPT). The MPT data were managed as dose‐response slope (DRS) in the statistical analyses. Changes in lung function and DRS from 11 to 18 years of age were analyzed by generalized estimating equations, including interaction terms. Results z‐scores for forced vital capacity (FVC), forced expiratory volume in first second (FEV1), FEV1/FVC ratio, and DRS were not different from 11 to 18 years of age in both the post‐bronchiolitis and the control group. The trajectories from 11 to 18 years did not differ between the two groups. BHR at age 11 was independently associated with asthma at age 18. Conclusion Children hospitalized for bronchiolitis had stable predicted lung function and BHR from 11 to 18 years of age. The lung function trajectories were not different from controls.publishedVersio

Blood eosinophils during bronchiolitis: Associations with atopy, asthma and lung function in young adults

Aim: To study if blood eosinophils during bronchiolitis were associated with atopy, asthma and lung function in young adults and if these associations differed between respiratory syncytial virus (RSV) bronchiolitis and non-RSV bronchiolitis. Methods: This historical cohort enrolled 225 subjects. Blood eosinophils were measured during bronchiolitis in infancy, and the subjects were invited to a follow-up at 17–20 years of age including questionnaires for asthma and examinations of lung function and atopy. Results: The level of eosinophils was positively associated with subsequent atopy in the unadjusted analysis, but not in the adjusted analysis, and not with asthma. There was a negative association between the level of eosinophils and forced vital capacity (FVC) (−0.11; −0.19, −0.02) and forced expiratory volume in first second (FEV1) (−0.12; −0.21, −0.03) (regression coefficient; 95% confidence interval). The non-RSV group had higher levels of eosinophils during bronchiolitis, but there was no interaction between the level of eosinophils and RSV status for any outcome. Conclusions: The level of eosinophils during bronchiolitis was negatively associated with lung function in young adult age, but we found no associations with atopy or asthma. These associations were not different after RSV bronchiolitis compared to non-RSV bronchiolitis.publishedVersio

Asthma, atopy and lung function in young adults after hospitalisation for bronchiolitis in infancy: impact of virus and sex

Background: Hospitalisation for bronchiolitis is a risk factor for asthma and impaired lung function during childhood, but outcomes in young adults are poorly described. Our primary aim was to study the prevalence of asthma and atopy, and lung function at 17–20 years of age after bronchiolitis in infancy and, secondarily, the impact of viral aetiology (respiratory syncytial virus (RSV) vs non-RSV) and sex on these outcomes. Methods: This Norwegian cohort study enrolled 225 young adults hospitalised for bronchiolitis in infancy during 1996–2001 and 167 matched control subjects. The follow-up included questionnaires for asthma and examinations of lung function and atopy. Outcomes were analysed by mixed effects regressions. Results: Current asthma was more frequent in the postbronchiolitis group versus the control group: 25.1% (95% CI 19.0% to 31.2%) vs 13.1% (95% CI 7.9% to 18.2%), but not atopy: 44.3% (95% CI 37.1% to 51.5%) vs 48.2% (95% CI 40.5% to 55.8%), adjusted predicted proportions (95% CIs). Asthma prevalence did not differ between the RSV group and the non-RSV group: 24.0% (95% CI 16.1% to 32.0%) vs 23.8% (95% CI 12.8% to 34.7%) nor between sexes. Forced expiratory volume in 1 s (FEV1), the ratio FEV1/forced vital capacity (FVC), and forced expiratory flow between 25% and 75% of FVC, were lower in the postbronchiolitis group. Conclusion: Young adults hospitalised for bronchiolitis had higher prevalence of asthma, but not atopy, and a more obstructive lung function pattern than control subjects. The asthma prevalence was high after both RSV bronchiolitis and non-RSV bronchiolitis, and there was no difference between sexes. Bronchiolitis in infancy is associated with respiratory morbidity persisting into young adulthood.publishedVersio