key: cord-0010140-vfj8lsxl authors: Zach, Maximilian title: Conference Report date: 2005-12-12 journal: Pediatr Pulmonol DOI: 10.1002/ppul.1950040208 sha: 379159ea697aeedd2664f94f477820c5f0a1ee51 doc_id: 10140 cord_uid: vfj8lsxl nan At the 1987 meeting of the European Pediatric Respiratory Society (EPRS), invited lectures and free papers presented a cross-sectional overview of European activities in one of the youngest subspecialties of pediatrics. The researchers-a multilingual group with widely differing professional, national, and cultural backgroundsconvened for presenting their work, exchanging ideas, educating each other, and, thereby, serving the common goals represented by the Society. The following Abstracts of the free papers read at the meeting, while fairly accurately presenting current European research activities with lung diseases in children, also feature a certain lack of scientific homogeneity. This reflects the marked differences in the state of development of pediatric pulmonology in various countries and at their respective institutions. In an increasing number of teaching centers the subspecialty is gaining recognition and support, and is thus prospering; but the majority of European pediatric institutions still lack highly educated personnel as well as specialized diagnostic and therapeutic facilities. There are many reasons for this. Basic structural differences in health care services and educaeducational programs between various countries, together with factors related to more fundamental differences between the peoples of the continent, often hamper the exchange of ideas and dissemination of expertise, which would be the prerequisite for the development of uniform professional standards. Also, frequently voiced misgivings about further subspecialization within pediatrics are, at times, aimed at pediatric pulmonology. However, by holding back progress in any subsegment of pediatrics, even some of the most influential leaders of the conservative pediatric establishment may, in fact, weaken what they intend to protect: the integrity of pediatrics itself. Last, but not least, pediatric pulmonology is struggling to establish itself in a period of wide-spread reductions in medical and academic budgets. Yet, against all these odds, the new subspecialty is thriving in most of Europe, pioneered and supported by a modest number of dedicated, dynamic young researchers. To date, this lively crowd congregates in two societies: the EPRS and the more physiologically oriented Pediatric Group of the European Society for Clinical Respiratory Physiology (SEPCR). The two organizations have established close ties and share the leaders in the field among their membership. In addition, national societies and working groups have been established, providing momentum on the local scenes of different countries. The recent growth of all these organizations provides the pleasure of witnessing a steadily increasing expertise, improving academic standards, and dedicated research, that are gaining in both quantity and quality. The Helsinki meeting can rightfully be considered as a milestone in this ongoing development. -MAXIMILIAN ZACH, MD Progress in our understanding o f pulmonary immunopathology will help to lower the risks of disease, to improve the treatment of infections and possibly to develop pharmacological means of stimulating compromised o r compensatory immune mechanisms. As a rule, selective defects of pulmonary immune mechanisms will lead to infection if additional defects develop or coexist, e. g. IgG-subclass deficiencies in addition to IgA deficiency. Combined humoral immunedeficlencies predispose to recurrent o r chronic infections with purulent bacteria. In congenital T-cell deficiency viral, fungal, protozoal and mycobacterial organisms prevail. Immunodeficiencies following HIV, EEV or other viruses result in clinical syndromes resembling congenital immunedeficiency. In contrast, immunesuppression causes a wide spectrum of immunedysfunction depending on the treatment regimen. Most respiratory infections in such patients result from aspiration o r hematogeneous spread of endogenous organisms. Reactivation o f Herpes Virus o r Cytomegalovirus and acquisition of Measles, Legionella and Pneumocystis carinii are important other causes of infection. In contrast, Mumps, Rubella, Hepatitis 6 , EBV and Parainfluenza Type I, Polio, Echo and Coxsackie Viruses appear o f little significance in these patients. Analysis of several series of pulmonary infections in immunosuppressed children has shown Pneumocystis to be the most frequent organism followed by viruses, mixed infections, fungi and bacteria. This type o f analysis underestimates common bacteria whlch respond to the usual treatment regimens. All types of immunedeficiency are characterized by decreased inflammatory responses and accordingly by the absence o r by delayed appearance of radiological signs. Included are only patients with irreversible d a m 9 of bronchial walls shown by bronchography, CTscan, histology, or i n cases of known aetiology a persistent radiological changes and matched on isotope scanning. Six children (15%) had a congenital malformation (Willim-C a n p b e l l syndrane, absent pulmonary valve syndrane, lung sequestrations, cystic adenanatoid and harrartcmatous malformations). Six children (15%) suffered f r o m primary dyskinesia, and one child from a cystic fibrosis-like i l l n e s s , h a e v e r with negative m a t test results (otherwise CF excluded). In 11 children no predisposing factors =re detectable. One child suffered frcm Warner-Marshall syndrcme, and ten (25%) had a history of severe pneunonia. In 7/10 Haem. influezae was cultured frcm sputun with three Ampicillin resistant strains. Carlsen KH, Eng J, Orstavik I . Ped i at r ic Department and M icr ob io log i c a l laboratory, UllevPl Hospital, Oslo, Norway. FIfter acute bronchiolitis in infancy 51 children were prospectively followed until two years of age and clinically examined at all cases of respiratory infection and wheezing, and at regular control examinations at 1 , 1 112 and 2 years of age. At all occasions nasopharyngeal swabs were taken for bacteriological cultures, and at all respiratory infections nasopharyngeal apirates were drawn for virological examination by rapid immunofluorescence and cell cultures. FI virus infection was diagnosed in 68 of 158 infections examined, 31 with wheezing. Possible positive bacterial culture findigs were found in 63 of 141 infections examined, and in 52 o f 139 control examinations (P>0.2). More postive bacterial culture findings were done in otitis media than in other infections (P<0.005), but not more often in infections with wheezing, and not in children with especially frequent wheezing and infections. Streotococcus pneumoniae and Haemoohilus influenzae were the bacteriae most often isolated. Positive bacterial culture findings did not occur more often in cases with positive virological findings (P>O.2). RS virus and parainfluenza virus infections were more often related to wheezing than were influenza virus and adenovirus. The most frequent viruses diagnosed were adenovirus and parainfluenza virus. The role of respiratory virus infections in small children with recurrent respiratory infections 1s well established. Apart from in o t i t i s media, bacterial infections seem to play a minor role, and the bacteriae isolated probably represent colonisation of the nasopharyngeal space in many cases. This is an impoi-tant question for these children who often receive frequent courses of antibiotics. Dexamethasone and nebulized epinephrine reduced the symptoms and hastened recovery, b u t dexamethasone was more e f f e c t i v e by c l i n i c a l e v a l u a t i o n f o r dyspnoea and cough a t 6 and 12hours post admission. The p a t i e n t s g i v e n dexamethasone had a s i g n i f i c a n t l y s h o r t e r h o s p i t a l s t a y than those r e c e i v i n g placebo; t h e mean h o s p i t a l s t a y i n dexamethasone p l u s epinephrine group was 3 7~2 9 hours as compared w i t h 9 1~4 0 hours i n t h e placebo group (p 5 yrs, interval lung function tests ( L F T s ) , and compared with a control group 14470). 10 of these children with mcderate to severe as-were being chronically under-treatd, whilst a f'urther 5 children, whose control deteriorated 3 to 6 mths before death, did not receive appropriate changes in therapy. of OPD asthmatics who had nor needed emergency treatment for a least 12 months. LFTs showed lower mean FEV1 !79% vs 84%, p 0.5. In all, 10 children showed a drop in SaOZ of at least 2 2 during and/or after nebulised salbutamol. demonstrates that using 100% oxygen rather than compressed air as the driving gas prevents the hypoxia and tachycardia that occurs during administration of nebulised salbutmol in some children. We have previously demonstrated that the majority of young asthmatic children are hyperinflated even when asymptomatic. We have subsequently studied the effect of an inhaled steroid on lung volume in asthmatic children aged 2-6 years with frequent symptoms. The trial was double-blind and after a two week "run-in" patients were randomly allocated to receive either budesonide 20Oug or placebo twice daily via the nebuhaler for 6 weeks. Functional residual capacity (FX) was measured by helium gas dilution before and after the treatment period and expressed as a % predicted for height. Results are available on 23 children, mean age 4.6 years; 13 have received budesonide and 10 have received placebo. In the majority of children FRC was increased before treatment; the mean FRC was higher in the budesonide group (1402, range 96-1692) than the placebo group (123%, range 97-155a). This did not reach statistical significance. The change in FRC after budesonide (mean -17.1%) was significantly greater than after placebo (mean +4.22) p < 0.05 (Wilcoxon rank sum test). The For successful post-natal pulmonary adaptation some minimum requirements are necessary,including: initiation of regular, rhythmic and controlled breathing pattern; rapid resorption of fetal pulmonary fluid combined with the establishment of a normal alvelolar lining layer; development and maintenance of proper static and dynamic pulmonary mechanics to permit easy ventilation and sufficient gas exchange; and establishment of a physiologic ventilation-perfusion relationship. This presentation will focus only on neonatal pulmonary mechanics. The purpose of studying respiratory mechanics is to measure elasticity and frictional resistance, as well as airway resistance, in the thoracopulmonary system. It is important to analyse whether airflow in the individual parts of the bronchopulmonary system is uniform OK not, and whether relationships between elasticity and resistance vary from one area to another. Knowledge of these functional values in the neonatal period (birth until age 4 weeks) not only increases diagnostic opportunities but also assists early indication for appropriate treatment, and the critical assessment of treatment results. In the immediate postnatal stage, analysis of respiratory mechanics also offers the possibility of showing the functional state of the surfactant system, and provides information about fluid resorption in the lungs. Furthermore, the study of neonatal respiratory mechanics is an integral part of research on the respiratory distress syndrome (RDS). Such studies (postnatally and under spontaneous or artificial ventilation) enable objective assessment of the action of substances (administered both in utero and immediately after birth) that affect the surfactant system, or assessment of changes in pulmonary mechanics following surfactant instillation. Lindroth, De t of Paediatrics, University Hospital, Lund, Swezei. Several follow-u studies have reported fre ent respiratory probyems growth retardation a n r retarded psychomotor'development in BPD-patients . In a long-term follow-up stud up to the age of 10 ears we have followed $ 8 Pow birth weight inf a d s surviving after ventilator treatment in the newborn periode. Fourteen hag BPD. Pulmona mechanics shortly after ventilator treatme2 showed low compliance and hi h resistance examination one year later s%owed normalizaffon in both parameters. However at the age of 10 the BPD-patients in many resbects showed si ns of im aired lungfunctions e.g. abnormal F d l , FRC anz VTG. Lower respiratory tract disorders were common in many BPD patients during the first two years but later subsided. Weight and length develo ment were retarded during the first years but at tge a e of 6 the patients had normal rowth All atienzs were tested with Griffith &velo.menta? test. The BPD-and non-BPD patients did noe differ from a normal population. However, clumsiness and concentration difficulties were relatively common in both groups. Treatment of BpD differs in the acute and late phase. When.stil1 on ventilator the patient shall receive optimal ox genation with lowest pQSSible peak pressures. Pagent ductus arteriosus is a common complication and often needs Jigation. dose are sometimes useful in deteriorating B8Dpatients but as often have no effect Moqt of of the mbntioned drugs however have'serious side-effects which will be disc6ssed. A multiple breath nitrogen washout method was developed t o study lung function in very low birth weight infants (< 1 500 g) during ongoing mechanical ventilation. To measure ventilatory flow, the baby was placed in a whole body plethysmograph with i t s face outside. During an expiration the breathing gas was instantaneously changed t o 100% oxygen, w i t h maintained respirator setting, and the nitrogen washout course was followed. By computerized methods the functional residual capacity (FRC), nitrogen elimination pattern (distribution of ventilation) and nitrogen clearance were calculated. The use of body plethysmography also enabled simultaneous measurement of lung mechanics. So far, five VLBW infants requiring mechanical ventilation longer than during their first month of l i f e were studied repeatedly. During mechanical ventilation there was a progressive increase in FRC i n combination with an increase in lung resistance (R1). The nitrogen clearance was also increased. We conclude, that the changes in FRC, nitrogen washout course and RI reflect a progressive airway damage in infants developing BPD. Improved antenatal ultrasound facilitates both diagnosis and treatment of fetal abnormalities. Pleural effusions may now be diagnosed early in gestation and this raises the possibility that chronic drainage by pleuro-amniotic shunting may allow normal lung growth and reduce problems at resuscitation. We describe 9 cases of antenatally diagnosed pleural effusion k hydrops fetalis in whom pleuro-amniotic shunts were inserted, gestations from 24-35 weeks ( 2 cases were bilaterial). In all 9 cases there was successful drainage of the effusion without fetal distress. In 2 cases the effusion reaccumulated two weeks later, following probable fetal removal of the shunt, further shunts were inserted. One infant delivered 24 hours after the second shunting procedure at 30 weeks gestation, she developed respiratory distress syndrome but had no pleural effusion at birth. One infant delivered 6 weeks after shunting (35 weeks gestation), required minimal resuscitation but later died of pseudomonas septicaemia, there was no evidence of pulmonary hypoplasia at postmortem examination. The remaining 7 infants delivered between 35-40 weeks, requiring minimal or no resuscitation and none required drainage of pleural effusion postnatally. At follow-up there were no respiratory problems. In B infants measurements of lung function demonstrated normal lung growth. The infant delivered prematurely who had respiratory distress syndrome initially had low lung compliance but when seen at 1 year of age had functional residual capacity within the normal range. These preliminary results suggest antenatal insertion of pleuro-amniotic shunts results in chronic drainage of pleural effusions reducing problems at birth and permitting normal lung growth. but conventional antihistamines only weakly antagonize its effects at bronchial muscle H receptors; they are not therapeutically beneficial because of sedative and other side effects. devoid of side effects. We have investigated the effects of histamine blockade by terfenadine on resting bronchial tone and EIB in a randomized double blind placebo controlled trial. Twenty children (5.5-14.8 years) were studied on 2 days 48 hours apart, by PEFR and FEV measurements for 3 hours after oral placebo o r terfenadine AOmg, followed by a free running exercise test. Baseline values were the same on each study day. Terfenadine induced significant bronchodilation within 1 hour of ingestion when compared with placebo and a 32% improvement in FEVl by 3 hours (pl°C per hour) or rapid change in relative humidity (>2% per hour). The timing of night-time cough observed in this study differed from the known bathophase of circadian Cycles described in adults and children. The interpretation and possible therapeutic implications of these findings are discussed. To investigate whether chronic airways obstruction stimulates secretion of atrial natriuretic peptide (ANP) we measured plasma ANP levels in 24 consecutive asthmatic children (group A, mean age 7.9 yrs, range 4.6 to 15.7 yrs) compared to a control group of 19 healthy children. Blood samples were taken from 8.30 to 12.00 a.m. in the recumbent position after a normal breakfast. ANP was measured by direct radioimmunoassay (RIA) from unextracted plasma as described earlier. In addition, plasma aldosterone was measured in 19 asthmatic children with a commercially availiable RIA (DPC) . In Group A, mean ANP levels were increased compared to normal children (180 vs. 124 pg/ml, p=O.Oll). Mean plasma aldosterone concentration was 253 pg/m1 (range 50 to 932 pg/ml) in asthmatic children. There was a strong correlation between ANP-I and aldosterone (r= 0.70, p c 0 . 0 0 1 ) . Small airways obstruction measured by trapped gas was associated with higher ANP-levels (r= 0.44) and lower aldosterone values (r=0.76 with l/aldosterone, ~~0.01). Moreover, there was a positive correlation between aldosterone and serum IgG (r=0.61, ~~0.01). These resultssuggestthatchronichyperinflation leads to ANP secretion, probably by increasing right atrial pressure. Lower aldosterone levels can be explained by the inhibitory effects of ANP on the reninangiotensin-aldosterone axis. The clinical implications of these observations for the treatment of asthmatic children remains to be determined. During an epidemiologic study of respiratory health, 554 children (aged 6 to 15 years) attending three schools in Pisa (Italy) were enrolled. Sixty-seven of them refused to participate to the study. Remaining 487 children answered a questionnaire on respiratory symptoms and underwent pulmonary function tests (PFT) in baseline conditions and 10 min after the inhalation of 200 mcg of salbutamol. PFT were considered acceptable when at least 2 trials were obtained in which FEVl differed by 5% or less both in baseline and post-salbutamol sessions; accbrdingly, PFT from 127 children that did not meet this criterion were excluded from analysis. Three-hundred-three children, among those with acceptable PFT, were considered normal on the basis of absence of past and present respiratory symptoms. Change in FEVl after salbutamol was calculated as the difference between prebronchodilator and postbronchodilator highest values divided by the pretest value and multiplied by 100. The mean change resulted 1.37% + 0.31 (SE). This change showed highly significant by paired t-test ( p < .001). Since the distribution of values was not normal (skewness = -.55) we used the 95th percentile method to define upper normal limits: 95% of normal children had a change in FEVl lower than 9 % . In conclusion, a bronchodilation test with salbutamol should be considered positive when a change of 9 % or greater in FEVl occurs. Gotti. Pediatric Clinic, University of Pisa, ITALY. "ITALIA PROJECT" is a multicenter study on selfmanagement in childhood asthma conceived to assess the effectiveness of different programs in italian children. At the University of Pisa the program "living with asthma" was tested and its original form ( 8 lessons) was compared with a shortened form (4 lessons). Thirty-six children, aged 7 to 14 years, and their parents entered the study: ten families were assigned to the original course, 8 to the shortened form and 18 to the control group. The severity of asthma was assessed in baseline conditions: children and their parents answered a questionnaire on knowledge about asthma; parents also answered a questionnaire on anxiety. Lessons were delivered by physicians separately for children and parents in 8 or 4 weeks for long and short course, respectively. The same questionnaires were administered at the end of course. A complete reassessment of severity of disease, level of knowledge and anxiety is planed at the end of a 1 year follow-up period (april, 1987) . Preliminary results indicate that the baseline knowledge about asthma is rather high both in children and in adults (about 30% and S O % , respectively). At the end of courses the improvement in knowledge was similar for the two experimetal groups and showed inversely related to the baseline level; no substantial improvement was shown in the control group. same beneficial effect may be obtained in children below the age of two years, suffering from repeated attacks of bronchopulmonary obstruction after an initial attack of bronchiolitis. Admitted to the trail were children below the age of two years who had had one attack of bronchiolitis previously and afterwards suffered at least from one episode of bronchopulmonary obstruction. The children wdre randomly allocated to receive either placebo or beclomethasone dipropionate solution given in a nebulised form. This was given over an eigth week period,and the patients were followed up for one year. The results showed that the placebo-group(P) during this year had more respiratory infections, more bronchc pulmonary obstructions and used more symptomatic treatment than the group receiving active treatment(B). The two groups were matched in all respects except that children in P-group were somewhat older than those in the B-group. dipropionate given in a nebulised form influences the number of respiratory infections children contract after an initial episode of bronchiolitis. And it also influences the number of bronchopulmonary obstructions they get after the initial bronchiolitis. I n a l l subjects it has been made spirometric controls and a bronchial provocation t e s t with carbachok a t the s t a r t and each two weeks untiZ the end of the study.Parents have recorded a daily clinical diary on the asthma symptoms. I n both groups it has been an almost identical improvement of non specific bronchial reactivity .(p0.05). These results show t h a t bronchial hyperreactivity to exercise is dependent on the residual airway obstruction, but a wide variety of reactivity can occur. If baseline flow-values less than three standard deviations below predicted are found, however, a clinically significant response to exercise is predicted. We have studied pulmonary function tests in five groups of children from different cities with known high pollution levels of sulphur dioxide and soot. Vital capacity (VC) and forced expiratory volume in one second (FEVl), at repeat measurements (by Electronic Pneumoscreen, Jager), were found to be 20-30% lower than normal in approximately 19-47% of the exposed children. The disturbed function of ventilation (decreased VC and FEV1) was caused by the irritant effect of air pollution. Bronchospasm was not registered in any of the groups, not even after exercise testing. According to illness history, these children had problems with respiratory illness more often than children from a control group living in areas without air pollution. The control group of children had VC and FEVl values normal or above normal. By statistical analys i s of VC in the control group and the group of children from air polluted areas, a significantly high difference was obtained (t=22,53;p