Setting Discharge Goals for High Risk Infants

 A useful and much study needed since neonatologists and consulting pediatric pulmonologists rely on few reliable indicators to judge discharge readiness.  And with little guidance, often managed care restrictions may prompt premature discharge.  A baseline CO2 retention above a certain threshold always seemed like at least 1 useful measure, now supported by this South Korean study.

Children with chronic lung disease of prematurity tend to have reduced lung function, increased susceptibility to respiratory viral illness, and elevated risk for rehospitalization.  Setting goals for discharge are greatly needed in this high risk population.

Capillary partial pressure of carbon dioxide for predicting rehospitalization in preterm infants under noninvasive respiratory support with severe bronchopulmonary dysplasia

Abstract

Background

The severity of bronchopulmonary dysplasia (BPD) is an important predictor of prognosis in preterm infants. However, the severity of BPD was determined mainly by the degree of oxygen supplementation and mode of respiratory support.

Objectives

This retrospective study aimed to examine the role of partial pressure of carbon dioxide (pCO2) in predicting rehospitalization among preterm infants with severe BPD without invasive ventilation at 36 weeks' postmenstrual age (PMA).

Methods

We assessed preterm infants aged <32 gestational weeks with severe BPD who were receiving noninvasive respiratory support at 36 weeks' PMA. Patients were compared after stratifying them according to the history of rehospitalization owing to respiratory infection before a corrected age (CA) of 1 year and pCO2 measured by capillary blood gas analysis at 36 weeks' PMA.

Results

Among 54 infants who had severe BPD with noninvasive respiratory support at 36 weeks' PMA, 16 (29.6%) experienced rehospitalization due to respiratory problems. At 36 weeks' PMA, the amount of oxygen supplementation (0.30 vs. 0.28, p = 0.021) and pCO2 (62.1 vs. 53.6 mmHg, p = 0.006) were higher in the rehospitalization group than in the no rehospitalization group. Multivariate logistic analysis findings indicated that pCO2 ≥ 57.4 mmHg was the only factor associated with rehospitalization (adjusted odds ratio: 8.017, 95% confidence interval 1.239–51.859).

Conclusion

High pCO2 during noninvasive respiratory support at 36 weeks' PMA in severe BPD was associated with rehospitalization. Consideration of the degree of impairment in ventilatory capacity may improve the prediction of later respiratory outcomes in infants with BPD.

Pediatric Pulmonology

Volume56, Issue12

December 2021

Pages 3863-3869

Read abstract here.

FDA approves dupilumab for children aged 6 to 11 with moderate to severe asthma

Now that another biologic therapy is available for pediatric severe asthma, it is important to look at the indications for add on biologic therapy for asthma.  In general, there are 2 broad categories of asthma that may warrant adding an injectable biologic therapy:

1) Children and adolescents with severe asthma, poorly controlled despite compliance with high dose asthma therapy.  Here, poorly controlled may indicate frequent hospitalization, ER, or urgent care visits.  In addition, systemic steroid use and symptoms that affect quality of life (school, exercise, etc) are important considerations.

2) Children and adolescents with severe asthma that is controlled, but requires high dose asthma controller medication.  This is an important consideration because high dose inhaled glucocorticoids have been associated with a numbers of risks including reduced growth velocity, obesity, adrenal insufficiency, and ocular side effects like cataracts.

The FDA has approved dupilumab as an add-on maintenance treatment for children aged 6 to 11 years with moderate to severe asthma characterized by an eosinophilic phenotype or with oral corticosteroid-dependent asthma.
The expanded approval of dupilumab (Dupixent, Regeneron/Sanofi) to children aged 6 to 11 was based on data from the phase 3, double-blind, placebo-controlled LIBERTY ASTHMA VOYAGE trial that evaluated efficacy and safety of dupilumab compared with standard care in children with uncontrolled moderate to severe asthma. More than 90% of children in the trial had at least one concurrent type 2 inflammatory condition, according to a company press release.
“I was impressed that dupilumab met not only its primary endpoint of reduction in asthma exacerbations, but also all key secondary endpoints in the pediatric ASTHMA VOYAGE trial,” Leonard B. Bacharier, MD, professor of pediatrics at Monroe Carell Jr. Children’s Hospital at Vanderbilt University Medical Center and principal investigator of the ASTHMA LIBERTY VOYAGE trial, told Healio. “I anticipate that clinicians will begin to include dupilumab in their discussions with families of children with uncontrolled moderate-severe asthma. Many children in this age group continue to experience repeated asthma exacerbations, and experience side effects from frequent courses of systemic corticosteroids. Dupilumab’s demonstrated efficacy in significantly reducing exacerbations will allow such children greater disease control.” 

Read article here.

COVID 19 Risk With Asthma

Good News (Mostly) for Asthma Patients During Pandemic

COVID 19 has not shown the risk to asthma sufferers that many experts anticipated.  The role of biologic use and risk may still be unclear.  However, COVID 19 is a mucosal respiratory virus and can likely trigger a viral asthma exacerbation especially for those that are uncontrolled.  This is why it's important to work with your asthma specialist to optimize control especially in the problem seasons.  These include:
1) Having a written asthma action plan with clear recommendations for flare ups
2) Regular follow up with asthma specialist to monitor asthma control
3) Becoming familiar with symptoms of poor control, including frequent SABA use and exercise intolerance

Two studies presented at the European Respiratory Society (ERS) virtual meeting should reassure asthma patients and their physicians about their risks from COVID-19.

On the one hand, "no evidence of excess deaths was directly attributed to asthma" in a study of Scottish data on hospital admissions and death certificates during the first COVID-19 wave in early 2020, said Steven Smith, MRCP, of Gartnavel General Hospital in Glasgow.

And on the other, analysis of asthma patients receiving biologic drugs in Greek clinics showed no overall increase in COVID infection rates relative to the general population through April of this year, reported Andriana Papaioannou, MD, PhD, of Attikon University Hospital in Athens.

These encouraging results come against a backdrop of worry about how patients with preexisting respiratory disease, who may also be taking immune-modulating drugs, would fare during the pandemic.

There were two concerning blips in the Greek data, however. Papaioannou's group found that, among the 26 biologic-treated patients who did come down with COVID-19, nine needed hospitalization -- a considerably higher proportion than among COVID patients in the general Greek population, she said.

Read article here.

Sleepless in Lockdown

The impact of lockdown on sleep patterns of children and adolescents with ADHD

Among the consequences of COVID 19 lockdowns and extended virtual learning, a deterioration in sleep-wake patterns especially among at risk children was anticipated and now confirmed in this Italian study surveying parents with children with ADHD.   Children an adolescents were more likely to have delayed sleep time, anxiety, awakenings, and daytime sleepiness. Unfortunately, many of the maladaptive sleep patterns may take longer to reverse and require a concerted sleep strategy.

ABSTRACT

STUDY OBJECTIVES:

The current study examined the impact of home confinement (lockdown) because of the COVID-19 pandemic on the sleep patterns of children and adolescents with attention-deficit hyperactivity disorder (ADHD).

METHODS:

Nine hundred ninety-two parents of children and adolescents with ADHD filled out an anonymous online survey through the ADHD family association website. The survey investigated the sleep patterns and disturbances (using a modified version of the Sleep Disturbance Scale for Children) and screen exposure time before and during lockdown.

RESULTS:

During lockdown, 59.3% of children and 69.4% of adolescents with ADHD reported a change of bedtime, with a significant increase in patients with ADHD who went to sleep at 11 pm or later. Sleep duration, in contrast, resulted in 2 opposing processes with more children and adolescents sleeping either less than 6 hours/night or 10–11 hours/night. Among children and adolescents, respectively, 19.9% and 22% slept less than they did before lockdown, whereas 21.4% and 27.4% slept for more hours. Bedtime delay and decreased sleep duration were associated with an increase in screen time exposure. Moreover, patients with ADHD reported an increase in sleep disturbances when compared to their previous condition, mainly including difficulties falling asleep, anxiety at bedtime, night awakenings, nightmares, and daytime sleepiness.

CONCLUSIONS:

Lockdown impacted sleep-wake rhythms by strengthening the maladaptive sleep patterns reported in usual-life conditions in children and adolescents with ADHD.

CITATION:

Bruni O, Giallonardo M, Sacco R, Ferri R, Melegari MG. The impact of lockdown on sleep patterns of children and adolescents with ADHD. J Clin Sleep Med. 2021;17(9):1759–1765

Read abstract here.

Sleeping for Better Cardiovascular Health in Children and Adolescents

There is a reason why personal sleep monitoring devices have proliferated in the wearable technology space.  Poor sleep health is linked to reduced cognitive function, quality of life, and cardiovascular outcomes.  Children are not immune to these complications, but they may present differently.  Obesity, hypertension, insulin resistance, and dyslipidemia have all been correlated in some form to obstructive sleep apnea or sleep disordered breathing.

Be on the lookout for the any of the following:

1) Chronic snoring, mouth breathing, pauses in breathing during sleep especially when associated with tonsillar enlargement

2) Signs of daytime sleepiness despite adequate sleep time.  Sleep needs in children vary by age, so it is important that sleep times reflect that.  Also, it is common for sleepiness to look completely different in children.  Problems with focus, attention and labile emotions and irritability in the second half of the day are quite common.

3) Special risk populations, including children that are obese, or those that have other medical disorders known to predispose to sleep apnea, such as Down Syndrome or other craniofacial abnormalities.

Any of the above warrants evaluation with a pediatric sleep specialist to discuss testing.

AHA Releases Scientific Statement on Obstructive Sleep Apnea and Cardiovascular Health in Children and Adolescents

 In a recent scientific statement, the American Heart Association (AHA) outlined evidence highlighting the effect of obstructive sleep apnea (OSA) on the cardiovascular health of children and adolescents. The full statement was published in Journal of the American Heart Association.

The AHA noted that this statement may be used to develop future guidelines in managing OSA with regard to cardiovascular disease (CVD) risk in the pediatric population.

Epidemiology and Risk Factors

Patients with OSA experience disruption during sleep caused by upper airway obstruction. In children and adolescents, the clinical presentation of the condition can vary by age, but it is generally characterized by habitual snoring, labored breathing, gasps/snorting noises, and daytime sleepiness. According to the AHA, 1% to 6% of children and adolescents have OSA. Current evidence suggests that the OSA prevalence in a pediatric population peaks between 2 and 8 years of age and corresponds to a peak in adenotonsillar hypertrophy prevalence.

Primary risk factors for OSA in the pediatric population include obesity, allergic rhinitis, upper and lower airway disease, enlarged tonsils and adenoids, low muscle tone, neuromuscular disorders, and craniofacial malformations. In addition, sickle cell disease (SCD) may be an independent risk factor for OSA. Premature birth, or birth that occurs prior to 37 weeks’ gestation, may also be associated with an increased risk for sleep-disordered breathing among children, partially because of delayed development of respiratory control.

Read article here.

Saharan dust is headed to Texas, bringing gorgeous sunsets and allergies

Summer is not the season we typically associate with asthma control problems.  The fluctuating temperature, seasonal allergens, and the respiratory viruses are typically more associated with asthma exacerbations in the fall through spring seasons.   

 

However, the Saharan dust approaching this weak does underscore that air quality issues can be a significant problem in the summer.  With this dust comes a higher concentration of airborne particulate matter that can worsen allergies and asthma. 

 

Listed below, are 3 ways to reduce the likelihood of dust and other environmental factors worsening your child’s asthma control: 

 

1. Don’t’ forget your controllers 

 

Missing asthma controller doses during the school season is clearly a problem.  It’s easy to underestimate risk in the summer since most of the conventional triggers are not there.  Don’t do it!  If you have not been advised to stop or reduce controller medication, be sure to continues as instructed.   

2. Monitor the air quality 

 

Just like allergen monitoring, air quality reports are also available and are included in many online weather forecasts and weather smartphone apps.  Airnow.gov provided zip code specific air quality risk.  A recommendation for people with sensitive lung conditions, or an AQI score of 100 or above is usually a good indication to reduce time outdoors.  

 

3. Check with your asthma specialist 

 

If you are overdue for a visit with your asthma specialist, follow up to make sure your asthma is currently controlled.  Absence of symptoms is reassuring, but it is important to have some routine assessment of lung function to confirm this. 

HOUSTON — Saharan dust is headed to Texas! It sounds ominous, right? However, it's a weather phenomenon that happens every year around this time.

In the late spring and through the summer, plumes of dust from the Saharan Desert 5,000-miles away travel across the Atlantic, spanning into the Caribbean and as far as the Gulf of Mexico.

It's called the Saharan Air Layer, or more formally, Aerosol Optical Thickness. Experts say these plumes can dump up to 60 million tons of dust into the atmosphere. 

Satellites pick it up when the dust layer is thick, and this year it's thick enough to track. We're better at it now because of advanced satellites that can tell how much power is lost as sunlight passes through the atmosphere.  

From more intensely colored sunsets to altering air quality, there are some positive and negative impacts that come with these.

Saharan dust is filled with nutrient rich minerals that has played a role in fertilizing the Amazon Rainforest for thousands of years. The dust does sometimes travel far enough inland in the United States that it can cause unhealthy air quality. 

If you notice skies looking a hazy brown color or a pale blue, you may be dealing with Saharan dust in your forecast. If the layer is thin enough, it also creates more intense fiery sunsets.

Impact on hurricane season

These dust plumes can also impact our hurricane season. 

Tropical systems need warmth from the oceans and enough moisture high in the atmosphere to form. These dust layers are very hot and super dry, which will hinder tropical development if it’s dense enough. They also produce strong wind shear that could break apart a storm. 

Sometimes, Saharan dust can suppress thunderstorm development causing the sky to remain hazy for days and can lead to hotter days.

Last June, a massive dust layer dubbed a “Godzilla” dust plume blanketed the Caribbean. 

It was considered the largest dust storm in two decades, according to NASA scientists. 

In a recent study, they are predicting that these annual dust plumes will decrease over the next century as a result of climate change and ocean warming. 

Read article here.

Philips-Respironics CPAP and Ventilator Device Recall, What to Know

 Philips-Respironics, a medical device manufacturer for home ventilator and CPAP/BIPAP machines used to treat sleep apnea, recently announced a recall for many of their medical devices due to concerns that a sound reducing foam may degrade over time and enter into a patient's airway and lungs, posing severe medical risk.

Philips Respironics announced a voluntary recall notification (U.S. only) / field safety notice (International Markets) for Continuous and Non-Continuous Ventilators (certain CPAP, BiLevel PAP and Ventilator Devices) due to two issues related to the polyester-based polyurethane (PE-PUR) sound abatement foam used in these devices: 1) PE-PUR foam may degrade into particles which may enter the device’s air pathway and be ingested or inhaled by the user, and 2) the PE-PUR foam may off-gas certain chemicals. The foam degradation may be exacerbated by use of unapproved cleaning methods, such as ozone (see FDA safety communication on use of ozone cleaners), and off-gassing may occur during initial operation and may possibly continue throughout the device’s useful life.

Advice for Patients and Customers

Philips advises patients and customers to take the following actions:

• For patients using affected BiLevel PAP and CPAP devices: Discontinue use of your device and work with your physician or durable medical equipment (DME) provider to determine the most appropriate options for continued treatment. To continue use of your device due to lack of alternatives, consult with your physician to determine if the benefit of continuing therapy with your device outweighs the risks identified in the recall notification.
• For patients using affected life-sustaining mechanical ventilator devices: Do not stop or alter your prescribed therapy until you have talked to your physician. Philips recognizes that alternate ventilator options for therapy may not exist or may be severely limited for patients who require a ventilator for life-sustaining therapy, or in cases where therapy disruption is unacceptable. In these situations, and at the discretion of the treating clinical team, the benefit of continued usage of these ventilator devices may outweigh the risks identified in the recall notification.

Patients, physicians and DME suppliers can call Philips at 877-907-7508 for additional support.

Read article here.

Recall letter here.

Treating Sleep Apnea without CPAP

We care about the adults too.  Not all sleep apnea is the same, join us to learn about a treatment alternative.

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COVID 19 Vaccination - Why, When, and Where?

 

The SARS-COV2 virus is known to be very dangerous if not deadly to high risk populations.  Common severe complications from this virus include a life threatening pneumonia requiring hospital care.  

Two highly effective mRNA vaccines are now available (Pfizer and Moderna) in limited quantities and should become increasingly available to high risk individuals before it becomes generally available to the public.  These vaccinations DO NOT contain live virus and therefore CANNOT cause infection.  They are primarily approved for prevention of a severe COVID 19 related illness.  The Pfizer vaccination is approved for 16 and up and the Moderna vaccine is approved for 18 and up.  Both vaccination require 2 doses to be effective. We are currently in phased 1A and 1B in Texas.

Because of limited vaccine availability, CDC and many public health agencies and hospital systems are providing vaccine in a phased manner as indicated below:

Healthcare personnel and residents of long-term care facilities should be offered the first doses of COVID-19 vaccines (1a)

CDC recommends that initial supplies of COVID-19 vaccine be allocated to healthcare personnel and long-term care facility residents. This is referred to as Phase 1a. Phases may overlap. CDC made this recommendation on December 3, 2020.

Groups who should be offered vaccination next (1b and 1c)

CDC recommends that in Phase 1b and Phase 1c, which may overlap, vaccination should be offered to people in the following groups. CDC made this recommendation on December 22, 2020.

Phase 1b

• Frontline essential workers such as fire fighters, police officers, corrections officers, food and agricultural workers, United States Postal Service workers, manufacturing workers, grocery store workers, public transit workers, and those who work in the educational sector (teachers, support staff, and daycare workers.)
• People aged 75 years and older because they are at high risk of hospitalization, illness, and death from COVID-19. People aged 75 years and older who are also residents of long-term care facilities should be offered vaccination in Phase 1a.

Phase 1c

• People aged 65—74 years because they are at high risk of hospitalization, illness, and death from COVID-19. People aged 65—74 years who are also residents of long-term care facilities should be offered vaccination in Phase 1a.
• People aged 16—64 years with underlying medical conditions which increase the risk of serious, life-threatening complications from COVID-19.
• Other essential workers, such as people who work in transportation and logistics, food service, housing construction and finance, information technology, communications, energy, law, media, public safety, and public health.

Texas Department of State Health Services has provided state specific guidance about who is eligible for vaccination now.  

It includes peoples age 16 and above who may have certain underlying conditions.  Those recommendations are listed here:

Texas DSHS recommendations

People 16 years of age and older with at least one chronic medical condition that puts them at increased risk for severe illness from the virus that causes COVID-19, such as but not limited to:

• Cancer
• Chronic kidney disease
• COPD (chronic obstructive pulmonary disease)
• Heart conditions, such as heart failure, coronary artery disease or cardiomyopathies
• Solid organ transplantation
• Obesity and severe obesity (body mass index of 30 kg/m2 or higher)
• Pregnancy
• Sickle cell disease
• Type 2 diabetes mellitus

There are a variety of other chronic medical conditions that are considered possibly higher risk that may be indication for vaccination as well. That comprehensive list is here:

CDC recommendations about chronic medical conditions

Below is a link from the Texas DSHS website to help identify a vaccine provider here you:

Vaccine provider locations can be found here