RESP/01(P) PRIMARY PULMONARY HYPERTENSION
Rajwanti K.Vaswani , Chaitali D.Warang, Milind S. Tullu, Keya R. Lahiri.
Department of Pediatrics, Seth G.S.Medical College and King Edward Memorial Hospital, Parel, Mumbai, 400012
Introduction: Primary pulmonary hypertension is a rare disease in the pediatric population and is mainly a diagnosis of exclusion. It is a progressive disease without definite cure and is associated with increased morbidity & mortality. Case: A nine-year-old girl presented with breathlessness on exertion, palpitations & giddiness for 6 months and pedal edema for 4 days. She had cardiac failure & further examination revealed pulmonary hypertension. An ejection systolic murmur grade III/VI was heard in the pulmonary area. Chest radiograph revealed cardiomegaly with prominent pulmonary conus with peripheral pruning of blood vessels. The only abnormality detected on 2D-echocardiographic and color doppler examination was pulmonary arterial systolic pressure gradient of 90mm Hg, suggesting primary pulmonary hypertension. On HRCT of chest, the lung fields were normal. Prothrombotic workup was negative. The child was treated with oral calcium channel blocker (nifedepine). Discussion: Pulmonary hypertension is usually seen in congenital or acquired valvular heart disease, chronic parenchymal lung disease, pulmonary thromboembolism, collagen vascular diseases & pulmonary vasculitis. Primary pulmonary hypertension is defined as pulmonary hypertension with normal pulmonary artery wedge pressure and in the absence of other secondary causes. The speculated mechanism is altered ratio of prostacyclin to thromboxane with ultimate remodelling of pulmonary vasculature. Clinical features are insidious onset breathlessness, chest pain and syncope; the mean time between the onset & diagnosis being about 2 years. Cardiac catheterization is essential for absolute diagnosis and also to determine the extent of reversibility of pulmonary vasoconstriction. Therapy includes short acting titrable vasodilators i.e. prostacyclin/adenosine or long-term calcium channel blockers i.e. nifedipine/ diltiazem. Long-term anticoagulation improves the survival. Role of sildenafil and oral arginine supplements is in experimental stages in children. Palliative surgery i.e. atrial septostomy may be required for refractory cardiac failure Conclusion: A diagnosis of primary pulmonary hypertension should be considered in children after ruling out common secondary causes and has implications in terms of therapy and long term prognosis.
RESP/02(O) ASSESSMENT OF CLINICAL CRITERIA AND PULSE-OXIMETRY IN IDENTIFICATION OF HYPOXAEMIA IN ACUTE LOWER RESPIRATORY TRACT INFECTIONS IN CHILDREN UNDER FIVE YEARS OF AGE.
Seena Thampi, Pushpa Chaturvedi
Deptt. of Pediatrics, Mahatma Gandhi Institute of Medical Sciences, Sewagram, Wardha-442102
Acute lower respiratory tract infections (ALRI) are commonest cause of death in children of developing countries.Most ALRI deaths are from pneumonia, the major fatal complication of which is hypoxaemia. Hence this prospective observational study was conducted to primarily predict clinical surrogates of hypoxaemia by comparing the clinical signs and symptoms with pulse-oximetry.Design : Children 0- 60 months were enrolled in the study, with signs & symptoms of ALRI ( as per the WHO criteria) and divided in 3 groups of 0-2, 3-12 and 13-60 months each.History and examination was done as per the proforma, Spo2 values were recorded by pulse-oximetry and chest x-ray was taken of all cases.Result & conclusion :-(i) 40.6% children with ALRI in under 5 age group were hypoxic.(ii)Best clinical predictors of hypoxia in the three age groups were - (a) 0-2 months -chest recessions, grunt, inability to feed, cynosis,nasal flaring, head nodding, RR >=80 / minute.(b) 3-12 months - chest recessions, head nodding, post-tussive vomitting, RR>=50/ minute,grunt, history of rapid breathing ,inability to feed, crepts/ wheeze, nasal flaring. (c) 13-60 months - chest recessions, inability to feed, history of rapid breathing, RR>= 40/minute, crepitations, cynosis. (iii) Hypoxaemia was more prevalent in infants than in older children.(iv) Radiological pneumonia was a sensitive predictor of hypoxaemia in children 1-5 years of age.
RESP/03(P) ASSESSMENT OF LUNG FUNCTION (SPIROMETRY) IN NON-ASTHMATIC SCHOOL CHILDREN WITH RECURRENT URI
Prateek Sharma, Shweta Dubey
Introduction: Cough and upper respiratory tract infection is the most common manifesation in the children prone for hyperreactive airway if these symptoms left without treatment it may alter the lung function. Aims and Objectives: This study has been undertaken to assess the lung function of non asthamatic children with recurrent URIs.: Study Design : Matched Case Contro, Study. Setting : Various schools of Jabalpur (M.P.) Material and Methods:233 symptomatic non-asthamatic school children of 8-18 yrs is selected through preformed questionnaire, 128 closely matched children were taken as control. These children subjected to spirometry for assessment of lung function done with PortableTurbine Spirometer (Spirodec). Various parameter of lung function indices PEFR MMEFR, FVC, FEV1 were assessed. These data were subjected to statistical analysis by Chi Square Test. Results: Statistically significant changes (p<0.0001) in lung function are observed in case . 88% of children had changes PEFR followed by FEF25-75, FEV1, FVC .PEFR is observed to be most sensitive to detect alteration in lung function in our study. Episodes of frequent cough and cold > 3 episode. 81.5% is most common complaints followed by breathless ness on exertion(80%). (62.2%) allergic rhinitis, (60.5%) symptoms of emotional upset,(45.9%) night cough. statistically significant(p<0.0001) of study group revealed family history of respiratory problem and asthma also has found to be Conclusion: Lung function is altered in children with recurrent URI.Episodes of frequent cough and cold is most common symptom. Of the lung function PEFR most frequently lung altered but nonspecific.FEF25-75 is most sensitive & specific lung function.
RESP/04(O) CORRELATION OF CLINICAL PNEUMONIA WITH RADIOLOGICALCHANGES IN CHILDREN LESS THAN 5 YEARS
S.Shuba, S.Amullya, M.B.Raghu, Radha Kumar
Sri Ramachandra Medical College and Research Institute, Porur, Chennai- 600116
Objective: X-ray is normally considered the gold standard for diagnosis of pneumonia as the yield of organism from blood culture is poor and doing a lung aspiration for diagnosis has its risks. This study was undertaken to see if there is a correlation between clinical diagnosis of pneumonia based on the WHO criteria and radiological changes and to see if any particular symptom or sign showed better correlation and better predictive value. Materials and methods: This was a prospective study done from June 1999 to August 2000 in Sri Ramachandra Medical college & Research Institute. All children < 5 years who were hospitalized who had a clinical diagnosis of pneumonia by the ARI control program were included in the study i.e. those who had symptoms of respiratory infection with tachipnoea. Tachipnoea was defined as RR > 60/min in <2 months, >50 upto 1 year and >40 upto 5 years. All children with cardiovascular disease, asthma, tuberculosis and neurological disorders were excluded. X-rays, blood culture and blood counts were done for all patients. The X-ray was interpreted by a radiologist who was unaware of the clinical findings and the data was analysed using Epi6 Results: A total of 80 children were included in the study. The age was from 40 days to 3.5 years. 42(53%) were < 1 year and 22% in 1- 2 year age. 50% belonged to lower socioeconomic group. 73% had normal nutritional status, 16% had grade I and 11% had grade II malnutrition. Breathlessness was the primary reason for bringing the child to hospital in 65% of cases. 54/80(68%) had radiological changes. Among this 31% had consolidation, 15% bronchopneumonia15% had hyperinflation with perihilar infiltration, pleural effusion in 4% and collapse in 3%. Among the symptoms only fever had some correlation with radiological changes (p<0.0235, RR 1.57). The sensitivity and specificity was 81% and 42%, positive predictive value was 75%. Breathlessness and cough had good sensitivity, but poor specificity. Among the signs also fever showed a good correlation (p <0.00004, RR 2.47) especially fever ³ than102°F (p <0.0009). Fever had a sensitivity of 80% and specificity of 88%and PPV 88%. Bronchial breath sound was present in 4 patients only and all had radiological changes but the number was too small to calculate the significance. Crackles and wheeze did not show any significant correlation. Blood culture was positive only in 5 cases and leucocytosis did not correlate with radiological changes. Conclusion: Temperature especially ³ 102°F in a child clinically diagnosed to have pneumonia is more likely to be associated with radiological changes.
RESP/05(P) EVALUATION OF EFFECTIVENESS OF VARIOUS INHALATIONAL DEVICES N ACUTE ATTACK OF BRONCHIAL ASTHMA
Ashok Kumar Singh, Lokesh Sharma, Akhlaque Ahmad, S.P. Goel
Department of Pediatrics, L.L.R.M. Medical College and associated S.B.V.P Hospital,Meerut, 250004
Objective: To evaluate the effectiveness of various inhalational devices in acute attack of bronchial asthma. Design: Prospective longitudinal study.Setting: Pediatric ward, emergency and outpatient department of tertiary level hospital. Method: A total of 80 cases (age 2 to 12 years) of bronchial asthma were studied in 4 groups, with 20 cases in each group, using four different types of inhalational devices, viz. MDI with spacer (Group I), Rotahaler (Group II), Nebulizer (Group III and Accuhaler (Group IV). Result: All the children showed improvement in clinical score from basal values of 58, 46, 65 and 38 to 32, 21, 38 and 18 which comes out to be 44.8%, 54.3%, 41.3% and 52.6%, in Groups I, II, III and IV respectively, after 60 minutes of inhalation (p <0.05; significant). Percentage in improvement in PEFR at 60 minutes were 28.94, 28.43, 28.33 and 25.28 in respective groups, which was insignificant (p >0.05), when compared with different groups. Conclusions: The four inhalational devices used were equally effective in controlling acute attack of bronchial asthma.Key words: Inhalational devices, acute bronchial asthma, PEFR
RESP/06(P) IgE AND EOSINOPHILIA AS A MARKER OF BRONCHIAL ASTHMA IN CHILDREN
Shalini Soi, Puneet Jairath, Kamaljeet Kaur, Baljinder Kaur, K.K.Locham
Deptt. of Pediatrics, Govt. Medical College/Rajindra Hospital, Patiala - 147001
Objectives : To evaluate IgE and eosinophilia in bronchial asthma. Methods : 40 children upto the age of 15 years admitted in department of Paediatrics, Govt. Medical College and Rajindra Hospital, Patiala were the subjects of study. Children were grouped according to age for the purpose of study into less than 2 years, 2-5 years, 5-10 years, 10-15 years and more than 15 years. Age, sex, address, detailed history and examination, laboratory parameters in the form of x-rays, IgE and eosinophil count were recorded on pretested proforma. Data so obtained was analysed. Results : Out of 40 children, 35 (87.5%) were males, 5 (12.5%) were females. 15 (37.5%) children each presented in the age group of less than 2 years and 2-5 years, 10 (25%) presented in 5-10 years age group. No child presented in more than 15 years of age group. 28 (70%) children were having mild intermittent bronchial asthma, 9 (22.5%) were having mild persistent asthma while 3 (75%) were having moderate persistent asthma. 25 (62.5%) children came with moderate attack, 15 (37.5%) of children came with mild attack. Levels of IgE were raised in mild intermittent, mild persistent, moderate persistent asthma in 14 (35%), 6 (15%), 1 (2%) children respectively. Acute eosinophil counts were raised in mild intermittent, mild persistent and moderate persistent asthma in 6 (15%), 2 (5%), 2 (5%) of children respectively. Conclusions : IgE and eosinophil count are good markers of asthma. Levels of IgE increase with increasing severity of asthma.
RESP/07(P) FOREIGN BODY ASPIRATION: EXPERIENCE WITH 85 PATIENTS
Y.K. Sarin
Deptt. of Pediatric Surgery, Maulana Azad Medical College, New Delhi-110002
Objectives of the study: Foreign body (FB) aspiration is a common emergency in children. Aim: We report our experience of bronchoscopic retrieval of aspirated FBs in children. Methods used: 85 patients with FB aspiration were managed over 4½ years (2001-05). 3/4th of patients presented in first 3 years of life. Classical history was forthcoming in 2/3rd of patients. Classical localizing chest signs were noted in only 1/4th of patients. Chest radiograph revealed radio-opaque FB in 9 cases, while hyperinflation on the affected side, collapse of pulmonary lobe, and secondary consolidation were observed in 60 patients. 46 patients had their diagnosis confirmed on flexible bronchoscopy under sedation by the pediatric pulmonologist before referral; this intervention was redundant in all but 13 children (unequivocal diagnoses (n=7), long-standing FBs with multiple interventions elsewhere (n=6)). Results: FB retrieval using rigid bronchoscope was successful 84 times. FB was lodged in trachea, right and left bronchi in 21.1%, 56.6%, and 22.3% of patients respectively. Retrieved FBs included vegetable seeds (78%), metallic (11%), and plastic (11%) objects. 15 patients required more than one bronchoscopic intervention for FB retrieval. Surprisingly, vegetable FBs did not provoke severe inflammation in the majority. Most patients had dramatic recovery. One patient with concomitant dengue fever had spontaneous pneumothorax and cardio-respiratory arrest during the procedure. He was revived and administered ventilatory support. FB was retrieved on a later attempt. He died during an ill-advised ‘weaning off the ventilator’ attempt in ICU 6 days after the procedure. Conclusion: FB removal using rigid bronchoscope is safe and rewarding procedure. Diagnostic flexible bronchoscopy is not warranted in majority of such patients.
RESP/08(P) OPEN DECORTICATION FOR CHILDREN WITH CHRONIC EMPYEMA THORACIS
Y.K. Sarin
Deptt. of Pediatric Surgery, Maulana Azad Medical College, New Delhi-110002
Objectives of the study: There is a disagreement between medical and surgical pediatricians about the appropriate therapy for chronic empyema thoracis (CET). We report outcome analysis of open decortications done for CET. Methods used: 59 patients with CET, aged 7 months to 11 years, who underwent open decortication over 7 years (1998-2005), were retrospectively studied. The indications of open decortication included organized empyema with lung entrapment and persistent bronchopleural fistula (BPF). Most of the patients had late presentations, inadequate medial treatment before referral, and wrong siting of intercostal drainage tubes. All patients had pre-operative chest X-ray and CT scan, and pleural fluid microbiology. Thoracotomy was done through bed of resected 6th rib. Extensive resection of the visceral and the parietal pleurae was done. The excised pleura were sent for histopathological evaluation. Post-operative chest roentgenograms were done to monitor lung expansion. Anti-tubercular therapy was given to the proven tubercular patients. Results: Decortication was well justified for 56/59 patients. Significant blood loss occurred intra-operatively that was replaced. Ventilatory support was required post-operatively in 2 patients. 53/58 patients had complete lung expansion. Of the 5 patients that showed no/ minimal improvement, 2 had successful redo decortication; 2 refused any further intervention and absconded. 2 patients died of unrelated causes; both these deaths were avoidable. 2 patients developed BPF that closed spontaneously. The commonest infecting organisms were Pseudomonas and Staphylococcus aureus. 4 patients had biopsy proven tuberculosis. Post-operative hospital stay ranged from 4-32 days (average 11 days). Conclusion: Open decortication is an effective and safe method of treatment for the patients of CET.