Pediatric Respirology and Critical Care Medicine

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Asthma is a common condition, which is commonly, badly diagnosed and badly treated, leading to unnecessary morbidity and even death in childhood, despite which complacency about management at all levels of care persists. Asthma is an umbrella term like anaemia and arthritis and should not be used as an unqualified diagnosis. It is suggested that airway disease should be deconstructed into treatable and untreatable components, such as fixed and variable airflow obstruction and airway inflammation and infection. Every effort should be made to make an objective diagnosis, and treatment should be individualised accordingly. Objective testing for airway inflammation may include determination of atopic status, blood eosinophil count and exhaled nitric oxide; physiological testing includes peak flow measurement, comprising response to exercise and short-acting μ-2 agonists. Most school-age atopic children with recurrent wheeze respond well to low-dose inhaled corticosteroids if these are regularly and correctly administered. The provision of an asthma plan is mandatory. If response is poor, rather than uncritically escalating therapies, a review of adherence and any adverse environmental factor should be considered. Asthma attacks are a red flag sign of a bad prognosis, and should prompt a full review, and changes in the asthma plan as necessary. Also, regular reviews of progress and treatment need are mandatory, even in the well child with asthma. In all contexts, the importance of getting the basic rights cannot be overemphasised; still, asthma deaths are attributed to neglect of this principle. Other issues discussed in this review include the approach to the child who is breathless on exercise and the diagnosis of exercise-induced laryngeal obstruction; the so-called habit/honk cough; the problem of breathlessness and airway disease in the obese child, including the airway as the target of systemic inflammation; and the problem of 'asthma' complicating other airways diseases such as cystic fibrosis and extrapulmonary diseases such as sickle-cell anaemia. Overall, the main message of this review is that it should never be forgotten that asthma is a disease which kills children and should always be taken seriously.

Background: Preschool children with wheeze may develop asthma later at school age. Positive skin prick test (SPT) to common aeroallergens in preschool wheezers may be associated with a higher chance of developing asthma at school age. Methods: All patients with SPT performed for the indication of preschool wheeze, i.e., before the age of 6 years, were included in the study from 1999 to 2011. Outcome measures including asthmatic attack requiring emergency hospitalization and the need for asthma controller prescription after the age of 6 years were retrieved from the hospital database. Potential risk factors including gender, family history of asthma, blood eosinophilia, environmental tobacco exposure, personal eczema, and allergic rhinitis were also retrieved for analysis. Multiple logistic regression was performed to identify independent risk factors. Results: Altogether, 463 children were included for analysis with mean age at SPT of 3.1 ± 1.36 years and 64.6% were male. Positive SPT results were obtained in 60.5% of patients. For preschool children with wheeze, female gender (odds ratio [OR] = 1.90, 95% confidence interval [CI]: 1.04–3.46, P = 0.036), positive SPT (OR = 2.96, 95% CI: 1.40–6.24, P = 0.004), and late-onset preschool wheeze hospitalization (OR = 2.82, 95% CI: 1.42–5.61, P = 0.003) were associated with a higher chance of asthmatic hospitalization after the age of 6 years. Allergic rhinitis (OR = 4.58, 95% CI: 2.16–9.71, P < 0.001) and family history of asthma (OR = 1.82, 95% CI: 1.09–3.02, P = 0.022) were associated with higher chance for asthma controller prescription. Conclusion: For preschool wheeze, female gender, positive SPT, and late-onset preschool wheeze index are associated with a higher chance of asthmatic hospitalization after the age of 6 years while allergic rhinitis and family history of asthma are associated with a higher chance for asthma controller prescription after the age of 6 years.

Background: Allergic rhinitis (AR) is characterized by eosinophilic infiltration and immunoglobulin E (IgE)-mediated reaction after exposure to an allergen. Its severity may be correlated to fractional exhaled nitric oxide (FeNO). This study aimed to evaluate the correlation of FeNO and various parameters with severity of AR in Taiwanese children with moderate persistent asthma. Materials and Methods: The study enrolled 103 children aged 5–18 years with AR and moderate persistent asthma from the Outpatient Department, Mackay Memorial Hospital, Taipei. Based on Total Nasal Symptom Score (TNSS), the patients were divided into high-score group (TNSS ≥5) and low-score group (TNSS <5). Both groups were assessed and compared by FeNO, blood eosinophil percentage, serum total IgE level, specific IgE levels to 8 allergens, and pulmonary function tests. Results: The low-score group showed significantly lower FeNO (18.57 ± 14.47 vs. 26.83 ± 17.84 ppb; P < 0.05), lower blood eosinophil percentage (3.08 ± 3.43 vs. 4.53 ± 3.37%; P < 0.05), lower level of serum total IgE (232.64 ± 438.88 vs. 510.63 ± 732.64 IU/mL; P < 0.05), and lower specific IgE to Dermatophagoides pteronyssinus (Der p), Dermatophagoides farinae (Der f), and dog (1.80 ± 2.35 vs. 3.66 ± 2.23, P < 0.05; 1.78 ± 2.36 vs. 3.56 ± 2.31, P < 0.05; and 0.00 ± 0.00 vs. 0.29 ± 0.81, P < 0.05). There are no significant differences between two groups about forced expiratory volume in 1 s (FEV1) (96.95 ± 13.39 vs. 97.85 ± 14.98% predicted; P = 0.75), FEV1/forced vital capacity percentage (89.00 ± 9.78 vs. 90.20 ± 5.85%; P = 0.47), and forced expiratory flow 25%–75% (55.16 ± 18.48 vs. 56.75 ± 20.15% predicted; P = 0.68). Conclusions: Taiwanese children with moderate persistent asthma with more severe symptoms of AR are significantly associated with higher levels of FeNO, total IgE, specific IgE to Der p, Der f, and dog, and higher blood eosinophil percentage.

Objective: The purpose of this article is to describe and summarize the clinical manifestations and radiographic features of focal bulging of chest walls in children using plain chest radiography and computed tomography (CT) scans. Methods: From 2008 to 2014, we identified 12 patients with forked ribs younger than 18 years of age. These patients received plain chest radiography and computed tomographic scans of the chest for focal anterior chest wall protrusion at the outpatient chest clinic of a children's facility. Results: A total of 12 patients (5 girls and 7 boys; age range, 2–12 years; median, 5 years) were enrolled in this study. Six patients had right-sided costal lesions, four had left-sided lesions, and two had anomalies on both sides. The most common rib involved was the 4^th rib. Two patients with forked cartilages and one patient with forked rib were not detected in frontal radiograph but seen by CT scans only. Up to the time of this writing, the follow-up of patients revealed no progression of focal bulging. Conclusion: In otherwise healthy children with asymptomatic focal anterior chest wall bulging, forked ribs is a common cause of variation. The chest radiographs may be normal. Chest CT scans demonstrated forked ribs/cartilage as the cause of focal bulging of the chest wall unequivocally in such instances.

Online since 1^st July, 2016