Airway Clearance In Children Research Articles

Exploring the Parental Perspectives and Experiences With the Use of a Home Mechanical Insufflation-Exsufflation Device.

A mechanical insufflation-exsufflation (MI-E) device is a commonly used tool for airway clearance in children with an ineffective cough. Whereas the device has been shown to have multiple benefits, limited evidence exists regarding parents' experiences with its home use in the Canadian context. This study's objective was to explore the perspectives and experiences of parents who receive service through the IWK Health Centre and use an MI-E device at home with their child. The study used an interpretive description design. Semi-structured interviews, conducted with 9 participants, were audio recorded and transcribed verbatim. Transcripts were analyzed using a reflective thematic process. Seven mothers and 2 fathers were interviewed. Following analysis, 3 themes were identified: (1) Learning about the MI-E device described participants' journey from becoming aware of the device to acquiring knowledge and skills about its use; (2) using the device detailed the integral role the MI-E device played in their lives, including decisions around use, and parental role; and (3) changing lives outlined the physical, emotional, and social benefits the device provided to the child and their family. Participants provided detailed descriptions of their journey from learning to integrating the MI-E device into their child's daily routine and family life. Its multiple associated benefits improved the child's and their family's quality of life. However, better education on its use was highlighted as a need for both parents and the health care professionals who work with them.

Clinical Profile and Outcome of Children Using Mechanical Insufflation Exsufflation Device (Cough Assist) at a Tertiary Care Hospital in Bangalore, India

Abstract Background and Objective: Children with neuromuscular disorders (NMDs) face a higher risk of recurrent pneumonias. Mechanical insufflation–exsufflation (MI-E) is a technique designed to enhance cough effectiveness, improve mucus clearance, and ultimately enhance lung health by boosting expiratory airflow and cough peak flow in coordination with a cough. We assessed the safety and adverse effects of MI-E in our cohort. Materials and Methods: This retrospective study was conducted over a period of 1.5 years at a tertiary care hospital in Bangalore, South India. Children between 1 and 18 years of age were included in the study. The demographic details of each child were collected from hospital records, along with the indication for starting MI-E and the duration of usage of MI-E. Results: Thirty-three children (18 boys) were started on MI-E. The most common indication was spinomuscular atrophy. Before the start of MI-E, 30 children were on noninvasive ventilation and 13 had a tracheostomy. The median insufflation and exsufflation pressures used were in the range of +15 to 25 cm H2O and −15 to −25 cm H20, respectively. Auto mode was used in all the cases, and 28 children used it on a long-term basis. There was a decrease in the frequency of hospitalization (especially in children with NMD). Adherence was very good without any evidence of barotrauma or any other complications. Conclusions: We found that the MI-E device is a valuable tool for aiding airway clearance in children with NMDs. Its use not only prevents intensive care unit admissions, reducing hospital stay duration but many times mitigates the need for hospital admissions altogether.

484 Usage trends, attitudes, and barriers to airway clearance in children with cystic fibrosis

484 Usage trends, attitudes, and barriers to airway clearance in children with cystic fibrosis

Effectiveness of Nebulization Therapy with Chest Physiotherapy After Nebulization on Airway Clearance in Children with Bronchopneumonia

Bronchopneumonia accounts for 15% of all deaths of children under five. The primary nursing problem of bronchopneumonia patients is ineffective airway clearance which can lead to more severe problems such as shortness of breath and even death. Management of airway ineffectiveness can be done by nebulization and corticosteroids, chest physiotherapy, suctioning and effective coughing. Nebulization accompanied by chest physiotherapy can remove secretions or phlegm effectively. This study aims to analyze the differences in airway clearance before and after nebulization and chest physiotherapy in the control and intervention groups in bronchopneumonia children. The research design used is Quasi-Experimental. A sample of 36 respondents with bronchopneumonia children was divided into two groups, namely control and intervention groups, which were obtained by consecutive sampling. Data collection techniques used observation sheets. The data analysis used in this study is the Mann-Whitney Test. The results showed that before chest physiotherapy after nebulization, all respondents had ineffective airway clearance (100%) in both the intervention and control groups. After chest physiotherapy after nebulization, almost half of the respondents in the intervention group had adequate airway clearance (44.4%). In contrast, in the control group, a small proportion of respondents had adequate airway clearance (16.7%). The analysis showed a p-value of 0.001, meaning there is a significant difference in airway clearance after being given nebulization and chest physiotherapy interventions in the intervention and control groups. Researchers hope that in future studies, airway clearance levels can be included. Thus, chest physiotherapy is effectively used for airway clearance in children after nebulization.

Therapeutic Management with Airway Clearance in Children with Robin Sequence and Association with Swallowing Outcomes: A Systematic Review and Meta-analysis.

Dysphagia in Robin Sequence can be present in varying degrees, requiring multidisciplinary management and specific swallowing assessment by a specialist. Most studies published to date have evaluated only respiratory outcomes, and the available evidence on the improvement of swallowing is questionable. To conduct a systematic review and meta-analysis of studies evaluating swallowing in children with Robin Sequence before and after airway clearance procedures. The research question was developed based on the PICO strategy. The literature search was performed in electronic databases and gray literature. Studies were selected by 3 independent reviewers. The risk of bias and level of evidence of the studies were assessed. A proportion meta-analysis was performed to calculate the prevalence of dysphagia after airway clearance procedures. The search identified 4938 studies, 5 of which were included. All studies had limitations in terms of design and sample size. The prevalence of dysphagia after airway clearance was obtained by analyzing treatment subgroups: mandibular distraction osteogenesis, mandibular distraction osteogenesis + tracheostomy tube, and nasopharyngeal tube. Clinical and/or instrumental assessment was assessed by a swallowing specialist. The meta-analysis was precluded by the limitations of the studies, especially regarding sample size, which affected the accuracy of the findings. Dysphagia remained unresolved in 55% of children (95% CI 1-99%). The methodological quality of the studies indicated a high risk of bias and very low level of evidence. It was not possible to confirm that airway clearance techniques used in Robin Sequence improve dysphagia.

Implementation of Nursing Care by Providing Nebulizers to Asthmatic Children with Ineffective Airway Clearance Problems

Asthma is one of the main non-communicable diseases and asthma is a chronic disease in which the airways of the lungs become inflamed and narrow. Asthma trigger factors are often found in the environment both inside and outside the home, but children with a family history of asthma have a greater risk of developing asthma. Apart from that, factors that trigger asthma are divided into two groups, namely genetic, including bronchial atopy/allergy, eczema; environmental trigger factors, such as motor vehicle fumes, cigarette smoke, burning rubbish, humidity in the house, and allergens such as house dust and animal dander. Method: The case study used in this research is descriptive in a case study design to explore the implementation of nursing care providing nebulizers with the problem of ineffective airway clearance in children with asthma at Bhayangkara Hospital, Palembang. The approach used is a nursing care approach which includes assessment, nursing diagnosis, nursing intervention, nursing implementation, and nursing evaluation. Results: The results of the research after the implementation of asthma management nursing with a Nebulizer in Asthma patients were proven to have an impact on improving breathing frequency because it had the effect of improving sputum production so that it was very influential in the process of improving breathing frequency/shortness of breath. Conclusion: Implementation of Nursing Care by Giving Nebulizers to asthmatic children with hygiene problems ineffective airway can be done because it is more effective for asthma patients and improves respiratory frequency.

Quantity and quality of airway clearance in children and young people with cystic fibrosis

Children and young people with CF (CYPwCF) get advice about using positive expiratory pressure (PEP) or oscillating PEP (OPEP) devices to clear sticky mucus from their lungs. However, little is known about the quantity (number of treatments, breaths, or sets) or quality (breath pressures and lengths) of these daily airway clearance techniques (ACTs) undertaken at home. This study used electronic pressure sensors to record real time breath-by-breath data from 145 CYPwCF (6–16y) during routine ACTs over 2 months. ACT quantity and quality were benchmarked against individual prescriptions and accepted recommendations for device use. In total 742,084 breaths from 9,081 treatments were recorded. Individual CYPwCF maintained consistent patterns of ACT quantity and quality over time. Overall, 60% of CYPwCF did at least half their prescribed treatments, while 27% did fewer than a quarter. About 77% of pre-teens did the right number of daily treatments compared with only 56% of teenagers. CYPwCF usually did the right number of breaths. ACT quality (recommended breath length and pressure) varied between participants and depended on device. Breath pressures, lengths and pressure-length relationships were significantly different between ACT devices. PEP devices encouraged longer breaths with lower pressures, while OPEP devices encouraged shorter breaths with higher pressures. More breaths per treatment were within advised ranges for both pressure and length using PEP (30–31%) than OPEP devices (1–3%). Objective measures of quantity and quality may help to optimise ACT device selection and support CYPwCF to do regular effective ACTs.

Implementation of Chest Physiotherapy in Children with Tuberculosis to Manage Ineffective Airway Clearance

Objective: This case study aims to describe the nursing care process and analyze the administration of chest physiotherapy to treat ineffective airway clearance in children diagnosed with tuberculosis. Method: This research is a case study research using random sampling technique for the sampling process. The samples used were children diagnosed with tuberculosis, being hospitalized, and experiencing ineffective airway clearance. The study was conducted in March 2022. Data collection used a nursing assessment format for children, a physical examination format, and an interview guide format. The nursing care process is carried out from the initial stage of assessment to evaluation. Result: The main complaint expressed was a fever that went up and down, often felt nauseated, coughed up phlegm that was difficult to expel. The data findings showed wheezing, cyanotic skin color, and an increase in respiratory rate and pulse. The patient experiences ineffective airway clearance. Effective chest and cough physiotherapy interventions were given for 3 days during the treatment period and showed that the results of walking clearance were not effectively resolved. This condition is seen from the phlegm that has come out, there are no additional breath sounds, the respiratory rate and pulse are within normal limits. Conclusion: The provision of effective chest physiotherapy and coughing interventions proved to be able to overcome ineffective airway clearance. Research recommendations to be able to combine alternative non-pharmacological techniques in overcoming ineffective airway clearance in children, especially with tuberculosis.

Re: Effectiveness of hypertonic saline nebulization in airway clearance in children with noncystic fibrosis bronchiectasis: A randomized control trial

Re: Effectiveness of hypertonic saline nebulization in airway clearance in children with noncystic fibrosis bronchiectasis: A randomized control trial

Effectiveness of hypertonic saline nebulization in airway clearance in children with non‐cystic fibrosis bronchiectasis: A randomized control trial

Failure to expectorate mucus resulting in progressive airway damage is the hallmark of bronchiectasis. Therefore effective airway clearance techniques (ACT) is the key step in its management. The aim of this study was to evaluate the efficacy of 3% hypertonic saline (HS) pre-medication in ACT in children with non cystic fibrosis (non-CF) bronchiectasis. In this randomized crossover control trial five to 15 year old children, diagnosed with non-CF bronchiectasis were randomized either to receive 200 µg of inhaled salbutamol followed by HS nebulization (test) or only 200 µg of inhaled salbutamol, before chest physiotherapy which is the conventional ACT (controls) for 8 weeks. Inhaled salbutamol was administered via a pressurized metered dosed inhaler with a valved holding chamber. After completion of first phase both groups went through one month washout period, before being crossed over to the opposite arms in the second phase. Spirometric parameters and number of exacerbations were recorded at the end of phase I, washout period and phase II. Fifty two out of 63 enrolled completed the study. Baseline characteristics of the two groups were similar. A significantly higher mean improvement was seen in predicted forced expiratory volume in 1 s in the HS arm during phase 1 (HS = 14.15 ± 5.50 vs. conventional = 5.04 ± 5.55, p = .001) and phase II (HS = 10.81 ± 5.51 vs. conventional = 3.54 ± 5.13, p = .001) compared to conventional ACT arm. HS group showed a significantly higher mean improvement in predicted forced vital capacity in phase I (HS = 13.77 ± 5.73 vs. conventional = 7.54 ± 4.90, p = .001) and phase II, (HS = 9.42 ± 7.00 vs. conventional = 4.42 ± 4.00, p = .003). Mean number of exacerbations experienced by a single child during phase I (2 months) were significantly less (p = .001) in HS arm (0.42 ± 0.64) compared to that of conventional arm (1.30 ± 1.05) butthis difference was not significant in phase II (HS = 0.65 ± 0.74 and conventional = 1.03 ± 0.77, p = .074). Incorporating HS nebulization into ACT is an effective strategy to improve dynamic lung volumes and morbidity in children with non-CF bronchiectasis.

Effects of music therapy as an adjunct to chest physiotherapy in children with cystic fibrosis: A randomized controlled trial

Airway clearance therapy (ACT) is considered an important approach to improve airway clearance in children with cystic fibrosis (CF). Daily ACT administration requires substantial commitments of time and energy that complicate ACT and reduce its benefits. It is crucial to establish ACT as a positive routine. Music therapy (MT) is an aspect of integrative strategies to ameliorate the psycho-emotional consequences of chronic diseases, and a MT intervention could help children with CF between the ages of 2 and 17 develop a positive response. The aim of this randomized controlled trial was to evaluate the effects of specifically composed and recorded instrumental music as an adjunct to ACT. We compared the use of specifically composed music (Treated Group, TG), music that the patient liked (Placebo Group, PG), and no music (Control Group, CG) during the usual ACT routine in children with CF aged from 2 to 17. The primary outcomes, i.e., enjoyment and perception of time, were evaluated via validated questionnaires. The secondary outcome, i.e., efficiency, was evaluated in terms of avoided healthcare resources. Enjoyment increased after the use of the specifically composed music (children +0.9 units/parents +1.7 units; p<0.05) compared to enjoyment with no music (0 units) and familiar music (+0.5 units). Perception of time was 11.1 min (±3.9) less than the actual time in the TG (p<0.05), 3.9 min (±4.2) more than the actual time in the PG and unchanged in the CG. The potential cost saving related to respiratory exacerbations was €6,704.87, while the cost increased to €33,524.35 in the CG and to €13,409.74 in the PG. In conclusion, the specifically composed, played and compiled instrumental recorded music is an effective adjunct to ACT to establish a positive response and is an efficient option in terms of avoided costs.Trial registered as ISRCTN11161411. ISRCTN registry (www.isrctn.com).

Prognostic indicators of short-term survival of ineffective airway clearance in children with acute respiratory infection: a longitudinal study

Background: Studies that establish the indicators of clinical status deterioration of Ineffective airway clearance remain scarce. Prognostic studies provide data for nurses identify clinical indicators that suggest a higher chance of early development of a nursing diagnosis. Objective: To identify the prognostic indicators of short-term survival of ineffective airway clearance (IAC) in children with acute respiratory infection (ARI). Design: A prospective open cohort study. Methods: This study was with a group of 136 children with acute respiratory infection who were followed for a minimum of six and a maximum of ten consecutive days. Children who had not completed six days of monitoring or who were carriers of diseases that would alter the specific symptoms of respiratory infection were excluded. The survival rate of ineffective airway clearance was calculated using Nelson-Aalen's method. A Cox regression model was used to analyze the influence of clinical indicators on survival time of this diagnosis. Results: The diagnosis survival rate was extremely low (only 0.4% on the 5th day of follow-up). The greatest reduction in survival rate was observed in the first 48 h (survival rate = 2.5%). Four defining characteristics associated with a worse prognosis of IAC among children with ARI: ineffective cough (RR = 5.86; 95% CI: 3.53–9.72), absence of cough (RR = 2.92; 95% CI: 1.68–5.08), adventitious breath sounds (RR = 2.47; 95% CI: 2.01–3.03), and diminished breath sounds (RR = 1.23; 95% CI: 1.05–1.45). Conclusion: Four clinical indicators showed a strong relationship with an increased risk of worsening clinical status associated with this nursing diagnosis. Impact statement: Clinical deterioration related to ineffective airway clearance among children with acute respiratory infection is fast and requires particular attention from nurses.

Mechanical Insufflation-Exsufflation Versus Conventional Chest Physiotherapy in Children With Cerebral Palsy.

The cough mechanism is often impaired in children with quadriplegic spastic cerebral palsy, accounting for the high prevalence of pneumonia and atelectasis requiring prolonged hospitalization. Conventional chest physiotherapy (CPT) is a current technique recommended at the onset of lower-respiratory infections in cerebral palsy. Previous studies have demonstrated the usefulness of mechanical insufflation-exsufflation (MI-E) in children with neuromuscular disease. To date, there has been no study of MI-E in children with quadriplegic spastic cerebral palsy. The objective of the study is to compare the efficacy in reducing hospital stay and improvement of atelectasis between MI-E and CPT in children with quadriplegic spastic cerebral palsy with lower-respiratory infections. This study is a randomized controlled trial. Children with quadriplegic spastic cerebral palsy, age 6 months to 18 y, admitted for lower-respiratory infections and/or atelectasis at King Chulalongkorn Memorial Hospital between June 1, 2014, and March 31, 2015, were recruited. Those with pneumothorax, severe pneumonia, active tuberculosis, and shock were excluded. Children were randomized into the MI-E or CPT group. The MI-E group received MI-E (3 therapies/d), and the CPT group received CPT (1 therapy/d). Vital signs per protocol and chest radiograph as needed were recorded. There were 22 children enrolled in the study, 11 in the MI-E and 11 in the CPT group. Demographic data were comparable in both groups. The length of hospital stay was similar in both groups (MI-E 4-24 d vs CPT 6-42 d, P = .15). There were 17 subjects with atelectasis (MI-E [n = 9] versus CPT [n = 8]). In this atelectasis subgroup, MI-E had shortened therapy time when compared with CPT (2.9 ± 0.8 d vs 3.9 ± 0.6 d, P = .01). No complications were observed. MI-E is proven to be beneficial in shortening the duration of airway clearance in children with quadriplegic spastic cerebral palsy presenting with lower-respiratory infections and atelectasis. MI-E is a safe and efficient intervention for airway clearance.

Autogenic Drainage in Children With Cystic Fibrosis.

Airway clearance is an essential part of the management of cystic fibrosis (CF) as it facilitates clearance of viscous pulmonary secretions. This review aimed to determine the effect of autogenic drainage (AD) and assisted autogenic drainage (AAD) compared with no, sham, or other types of airway clearance in children with CF. Two pediatric randomized cross-over trials were identified on the use of AD in children with CF; no studies were available on the use of AAD. In one study AD had a positive influence on the Huang score, and is preferred over postural drainage in this population. We could not determine the efficacy of AD and AAD in children with CF. We recommend the implementation of pediatric-specific randomized controlled trials with adequate sample sizes, appropriate clinical outcome measures, and analysis of adverse effects.

Clinical indicators of ineffective airway clearance in children with acute respiratory infection.

The identification of clinical indicators with good predictive ability allows the nurse to minimize the existing variability in clinical situations presented by the patient and to accurately identify the nursing diagnosis, which represents the true clinical condition. The purpose of this study was to analyze the accuracy of NANDA-I clinical indicators of the nursing diagnosis ineffective airway clearance (IAC) in children with acute respiratory infection. This was a prospective cohort study conducted with a group of 136 children and followed for a period of time ranging from 6 to 10 consecutive days. For data analysis, the measures of accuracy were calculated for clinical indicators, which presented statistical significance in a generalized estimated equation model. IAC was present in 91.9% of children in the first assessment. Adventitious breath sounds presented the best measure of accuracy. Ineffective cough presented a high value of sensitivity. Changes in respiratory rate, wide-eyed, diminished breath sounds, and difficulty vocalizing presented high positive predictive values. In conclusion, adventitious breath sounds showed the best predictive ability to diagnose IAC in children with respiratory acute infection.

Desobstrução ineficaz de vias aéreas em crianças com infecção respiratória aguda

This cross-sectional study was performed with 151 children inpatients of a pediatric hospital in Northeastern Brazil, with the objective to analyze the accuracy of the defining characteristics of the diagnoses ineffective airway clearance in children with acute respiratory infection. A thorough respiratory evaluation was performed and the diagnostic inference was developed by specialists. The most frequent defining characteristics were adventitious breath sounds, ineffective cough, dyspnea, and changes in respiratory rate. Ineffective airway clearance was present in 37.7% of the sample. Agitation was the characteristic with the highest sensitivity. Dyspnea, adventitious breath sounds, orthopnea, changes in respiratory rate and agitation presented higher specificity for the diagnosis. In conclusion, the defining characteristics showed different performances to correctly classify children with infective airway clearance. Studies like this can contribute for a correct nursing diagnostic inference and for the implementation of more effective interventions, thus improving the quality of health care.Descriptors: Respiratory Tract Infections; Nursing Diagnosis; Child.

Treatment response of airway clearance assessed by single-breath washout in children with cystic fibrosis

We studied the ability of 4 single-breath gas washout (SBW) tests to measure immediate effects of airway clearance in children with CF. 25 children aged 4-16 years with CF performed pulmonary function tests to assess short-term variability at baseline and response to routine airway clearance. Tidal helium and sulfur hexafluoride (double-tracer gas: DTG) SBW, tidal capnography, tidal and vital capacity nitrogen (N2) SBW and spirometry were applied. We analyzed the gasses' phase III slope (SnIII--normalized for tidal volume) and FEV1 from spirometry. SnIII from tidal DTG-SBW, SnIII from vital capacity N2-SBW, and FEV1 improved significantly after airway clearance. From these tests, individual change of SnIII from tidal DTG-SBW and FEV1 exceeded short-term variability in 10 and 6 children. With the tidal DTG-SBW, an easy and promising test for peripheral gas mixing efficiency, immediate pulmonary function response to airway clearance can be assessed in CF children.

Exercise with incorporated expiratory manoeuvres was as effective as breathing techniques for airway clearance in children with cystic fibrosis: a randomised crossover trial

: Can a session of exercise with incorporated expiratory manoeuvres substitute for a session of breathing techniques for airway clearance in children with cystic fibrosis? Are children with cystic fibrosis as co-operative and satisfied with the exercise regimen as with the breathing techniques?. Randomised, cross-over trial with concealed allocation and intention-to-treat analysis. 34 children with cystic fibrosis in a stable clinical state. Participants underwent two 20-min airway clearance interventions on two scheduled clinic days: one involving three bouts of various whole-body exercise modalities each followed by independent expiratory manoeuvres, and the other involving breathing control, thoracic expansions with manual expiratory compressions, and the forced expiratory technique. Wet weight of expectorated sputum, change in lung function, co-operation with treatment, perceived treatment quality, and satisfaction with treatment were all assessed after each intervention. The wet weight of sputum after exercise was 0.6g higher after the exercise intervention, which was not statistically or clinically significant (95% CI -0.2 to 1.4). However, lung function and participant satisfaction with the treatment were both significantly better after the exercise intervention. Co-operation with treatment and perceived treatment quality were equally high for each intervention. A session of various whole-body exercises interspersed with independent expiratory manoeuvres could be an acceptable substitute for a session of breathing control, thoracic expansions with manual expiratory compressions, and the forced expiratory technique in children with mild cystic fibrosis lung disease.

Clinical indicators of ineffective airway clearance in children with congenital heart disease

To analyse the sensitivity and specificity of clinical indicators of ineffective airway clearance in children with congenital heart disease and to identify the indicators that have high predictive power. The precise establishment of nursing diagnoses has been found to be one of the factors contributing to higher quality of care and cost reduction in healthcare institutions. The use of indicators to diagnose ineffective airway clearance could improve care of children with congenital heart disease. Design. Longitudinal study. Participants consisted of 45 children, <or=1 year of age, with congenital heart disease, who had not had definitive or palliative surgical correction. Six assessments were made at 2-day intervals. Each clinical indicator was defined based on previously established operational criteria. Sensitivity, specificity and positive and negative predictive values of each indicator were calculated based on a model for the longitudinal data. A nursing diagnosis of ineffective airway clearance was made in 31% of patients on the first assessment, rising to 71% on the last assessment, for a 40% increase. Sensitivity was highest for Changes in Respiratory Rates/Rhythms (0.99), followed by Adventitious Breath Sounds (0.97), Sputum Production (0.85) and Restlessness (0.53). Specificity was higher for Sputum Production (0.92), followed by Restlessness (0.73), Adventitious Breath Sounds (0.70) and Changes in Respiratory Rates/Rhythms (0.17). The best positive predictive values occurred for Sputum Production (0.93) and Adventitious Breath Sounds (0.80). Adventitious Breath Sounds followed by Sputum Production were the indicators that had the best overall sensitivity and specificity as well as the highest positive predictive values. The use of simple indicators in nursing diagnoses can improve identification of ineffective airway clearance in children with congenital heart disease, thus leading to early treatment of the problem and better care for these children.

Commentary on da Silva VM, de Oliviera Lopes MV, de Araujo TL, Ciol MA, de Carvahlo EC (2009) Clinical indicators of ineffective airway clearance in children with congenital heart disease. Journal of Clinical Nursing 18, 729–736

The problem with trying to develop lists of clinical indicators is that everyone has to have their say. Therefore, far from becoming definitive, meaningful lists with any utility in clinical practice, such lists – sometimes formulated as checklists or inventories – become a reflection of those who compiled them rather than a reflection of what is wrong with the patients in whom diagnosis may mean the difference between life and death. Thus, the present paper by da Silva et al. (2008) is a valuable contribution, not only to the literature on childhood cardiology in particular, but also to the nursing and medical diagnostics in general. On reading papers like this one I am left with the opinion that if only a committee had not been called to do this in the first place but that a lone researcher, or small team, had been ‘let loose’ with the symptoms and meticulously checked each one for sensitivity and specificity then progress would have been made long ago. Such is the benefit of hindsight, but it does appear – from this study at least – that the majority, in fact, of the putative symptoms are useless with respect to actual diagnosis of ineffective airway clearance in children with congenital heart disease. I have experienced a similar phenomenon when trying to develop questionnaires using a group of people; everyone wants their item to be included and once included, not only does the questionnaire grow by it risks losing the ‘directness’ that well crafted but also short questionnaires can give without any guarantee that the ‘authenticity’ of the questionnaire has been increased. Directness refers to the ability of the questionnaire really to measure the phenomenon under study without measuring other phenomena, while the authenticity refers to the assurance that vital aspects of the phenomenon have not been omitted; analogous to sensitivity and specificity. While there is currently no measure of authenticity and directness, as questionnaires produce a range of scores and not a diagnosis, where dichotomous outcomes exist there is a definitive epidemiological method for evaluating this using sensitivity and specificity. The paper by da Silva et al. indicates why the study of sensitivity and specificity is vital and, as they say: ‘being able to identify IAC, by observing fewer indicators could save time in the diagnosis process’. Yes, it wastes less time and puts fewer lives at risk and has the potential to improve patient care. I enjoyed this paper and would recommend it to anyone who doubts the value of such studies. My only query, and one which I could not have resisted had I been gathering these data, was why the receiver operating characteristics were not studied too. The study is excellent as it stands but this would have provided another dimension.