Paediatric Respiratory Physicians Research Articles

Deciding with children

In my practice as a paediatric respiratory physician and working with the Children’s Bioethics Centre, I have been reflecting on the way in which children and adolescents are involved in...

Computed tomography in cystic fibrosis lung disease: a focus on radiation exposure.

Thoracic computed tomography (CT) is the imaging reference method in the diagnosis, assessment and management of lung disease. In the setting of cystic fibrosis (CF), CT demonstrates increased sensitivity compared with pulmonary function tests and chest radiography, and findings correlate with clinical outcomes. Better understanding of the aetiology of CF lung disease indicates that even asymptomatic infants with CF can have irreversible pulmonary pathology. Surveillance and early diagnosis of lung disease in CF are important to preserve lung parenchyma and to optimise long-term outcomes. CF is associated with increased cumulative radiation exposure due to the requirement for repeated imaging from a young age. Radiation dose optimisation, important for the safe use of CT in children with CF, is best achieved in a team environment where paediatric radiologists work closely with paediatric respiratory physicians, physicists and radiography technicians to achieve the best patient outcomes. Despite the radiation doses incurred, CT remains a vital imaging tool in children with CF. Radiologists with special interests in CT dose optimisation and respiratory disease are key to the appropriate use of CT in paediatric imaging. Paediatric radiologists strive to minimise radiation dose to children whilst providing the best possible assessment of lung disease.

Exploratory study of language paediatricians use to promote adherence to long-term controller medication in children with asthma

Introduction and objectivesAlthough patient centred communication is associated with patients’ daily medication adherence, the exact communication phenomena promoting high treatment adherence remain elusive. Patients and methodsWe used conversation analysis of videotaped follow-up consultations of seven outpatients (4–13 years of age) with chronic asthma and their caregivers, consulting two paediatric respiratory physicians in a practice in which high treatment adherence has been documented, to explore the language paediatricians use to promote their patients’ adherence to daily controller medication. ResultsStarting the consultation with the patient’s (and caregivers’) agenda commonly resulted in presentation of issues new to the physician. Information was mostly provided in response to patient/caregiver questions, prompting the delivery of specific information tailored to the patient’s and caregivers’ needs. Although patients and caregivers showed resistance in response to unsolicited information and advice, they always accepted the doctor’s explicit request for agreement with proposed treatment. The doctor’s description of favourable treatment results in most patients prompted caregivers’ willingness to accept treatment proposals. ConclusionsPaediatricians with a documented success in achieving adherence to controller medication in their patients with asthma tend to start consultations with the patient’s agenda, provide information in response to questions, offer reassurance on overall treatment effectiveness, and seek explicit agreement with a treatment proposal.

Update of the European paediatric respiratory medicine syllabus.

The 10-year-old European syllabus for paediatric respiratory medicine (PRM; also known as paediatric pulmonology) was updated by a consensus-based method using an expert task force for redrafting, and a subsequent Delphi process to achieve consensus. There was a high degree of consensus for the final syllabus, which has been streamlined and made more relevant to current practice. All modules are now mandatory apart from the undertaking of research projects, which is optional. Although there are still a number of countries in Europe which do not recognise PRM as a separate subspecialty, there are paediatric respiratory physicians practising in every country in Europe, and a current and harmonised European syllabus in the subspecialty remains important for defining the training and areas of practice of PRM practitioners.

Assessing the feasibility of a web-based registry for multiple orphan lung diseases: the Australasian Registry Network for Orphan Lung Disease (ARNOLD) experience.

BackgroundWe investigated the feasibility of using an online registry to provide prevalence data for multiple orphan lung diseases in Australia and New Zealand.MethodsA web-based registry, The Australasian Registry Network of Orphan Lung Diseases (ARNOLD) was developed based on the existing British Paediatric Orphan Lung Disease Registry. All adult and paediatric respiratory physicians who were members of the Thoracic Society of Australia and New Zealand in Australia and New Zealand were sent regular emails between July 2009 and June 2014 requesting information on patients they had seen with any of 30 rare lung diseases. Prevalence rates were calculated using population statistics.ResultsEmails were sent to 649 Australian respiratory physicians and 65 in New Zealand. 231 (32.4 %) physicians responded to emails a total of 1554 times (average 7.6 responses per physician). Prevalence rates of 30 rare lung diseases are reported.ConclusionsA multi-disease rare lung disease registry was implemented in the Australian and New Zealand health care settings that provided prevalence data on orphan lung diseases in this region but was limited by under reporting.

Carers' perspectives on an effective Indigenous health model for childhood asthma in the Torres Strait.

To describe parents'/carers' views of the characteristics of a clinical service model shown to improve asthma outcomes. A randomised controlled study on education intervention for childhood asthma by Indigenous health care workers. Thursday Island, Horn Island and Bamaga. Thirty-five children received the intervention and 53 were in the control group. At the last study visit 12 months after enrolment, carers were asked to give feedback about the clinical service delivered by paediatric respiratory physicians and the asthma education intervention. Additional asthma education. Carers' responses to the open-ended questions were analysed separately by three Indigenous investigators who assigned codes and developed the themes. These were then cross-checked and combined to develop an overall interpretation of the data. The carers (n = 81) of 88 children in the Torres Strait region of North Queensland reported positively to the clinical service delivery. Service was rated as excellent = 26.8%, very good = 51.2%, good = 19.5% and poor = 2.4%. Parents'/carers' views about the clinical service model were grouped into seven themes: clear communication by health professionals, service delivery, professional approach, clear transfer of knowledge and education/clinical knowledge of asthma, established rapport/caregiver satisfaction, importance of coming into the local community, and areas of concern for the carers/parents. Community-based perspectives of an effective health service model include empowered Indigenous health care workers currently attached to the medical specialist service with elements of high expertise and appropriate cultural awareness that enabled clear communication and transfer of knowledge.

Évaluation de la prescription des plans d’actions d’asthme par les médecins d’Aquitaine

Although guidelines recommend the prescription of written asthma action plans (WAAP), their use remains limited. A prospective survey was performed from 2013 to 2014. We interviewed respiratory physicians, paediatric respiratory physicians and allergologists taking care of asthmatic patients and practicing in the Aquitaine region of France, using computerized questionnaires, regarding their everyday practice in the use of WAAP. A total of 59/143 (41%) clinicians, with a mean age of 47 years, participated in the study. A total of 41/59 (69.5%) were using a WAAP (12 different models with very inhomogeneous contents, mostly targeting symptoms only). WAAP prescribers were younger than non-prescribers, were more often female, working mostly in the Gironde area, with mixed hospital and private-based activity, and were paediatric-respiratory physicians or respiratory physicians. The severity of asthma had little influence on WAAP prescriptions. In the Aquitaine region, prescription of WAAPs remains inadequate and shows large disparities. WAAP users are mostly younger female specialists.

Easing the wheeze.

Easing the wheeze.

The development of chronic cough in children following presentation to a tertiary paediatric emergency department with acute respiratory illness: study protocol for a prospective cohort study

BackgroundAcute respiratory illness, a leading cause of cough in children, accounts for a substantial proportion of childhood morbidity and mortality worldwide. In some children acute cough progresses to chronic cough (>4 weeks duration), impacting on morbidity and decreasing quality of life. Despite the importance of chronic cough as a cause of substantial childhood morbidity and associated economic, family and social costs, data on the prevalence, predictors, aetiology and natural history of the symptom are scarce. This study aims to comprehensively describe the epidemiology, aetiology and outcomes of cough during and after acute respiratory illness in children presenting to a tertiary paediatric emergency department.Methods/designA prospective cohort study of children aged <15 years attending the Royal Children’s Hospital Emergency Department, Brisbane, for a respiratory illness that includes parent reported cough (wet or dry) as a symptom. The primary objective is to determine the prevalence and predictors of chronic cough (≥4 weeks duration) post presentation with acute respiratory illness. Demographic, epidemiological, risk factor, microbiological and clinical data are completed at enrolment. Subjects complete daily cough dairies and weekly follow-up contacts for 28(±3) days to ascertain cough persistence. Children who continue to cough for 28 days post enrolment are referred to a paediatric respiratory physician for review. Primary analysis will be the proportion of children with persistent cough at day 28(±3). Multivariate analyses will be performed to evaluate variables independently associated with chronic cough at day 28(±3).DiscussionOur protocol will be the first to comprehensively describe the natural history, epidemiology, aetiology and outcomes of cough during and after acute respiratory illness in children. The results will contribute to studies leading to the development of evidence-based clinical guidelines to improve the early detection and management of chronic cough in children during and after acute respiratory illness.

G167(P) The Multi-Disciplinary Paediatric Tracheostomy Clinic

AimsTo present our experience of managing children with a tracheostomy in a Multi-Disciplinary Team clinic consisting of an ENT Consultant, Paediatric Respiratory Consultant, a Nurse Specialist and Speech and Language...

702 A Retrospective Case Note Audit of Acute Asthma Admissions to the Paediatric Department, Craigavon Area Hospital, Northern Ireland

Background and aims: Acute wheeze and asthma are common reasons for paediatric admissions to hospital in the UK. The British Thoracic Society (BTS) guidelines detail the preferred management of children admitted with acute wheeze/ asthma. National data has been collected yearly. Over one month (November 2009), this audit determined whether departmental practice followed BTS guidelines and sought to identify areas for improvement. Data collected to be compared with that from other UK hospitals participating in the national BTS asthma audit. Methods: Data analysed from twenty- two admissions coded as acute asthma exacerbation. Data collected using a proforma provided by BTS. Results: Compliance via documentation of an asthma management plan was inadequate especially for admissions under a non- respiratory paediatrician. Confirmation of recording for inhaler technique and provision of information leaflets were better. Most children admitted had a chest x-ray, a majority of which were inappropriate. A minority of children discharged had hospital follow- up (mostly to a paediatric respiratory physician). Conclusions:

Spontaneous chylothorax in a 2‐year‐old child

A previously well 2-year-old girl presented with acute respiratory distress. After multiple investigations she was diagnosed with spontaneous chylothorax, attributed to strenuous vomiting. To our knowledge, this is the second reported case of spontaneous chylothorax occurring after the neonatal period.

A rational approach to home oxygen use in infants and children

The provision of supplemental oxygen for infants and children with hypoxaemia is expensive but advantageous because it facilitates earlier discharge from hospital and enhances quality of life in the home setting. It is seen as potentially cost effective and family friendly. However, the prescription of supplemental oxygen varies greatly between neonatologists, paediatric respiratory physicians and paediatric cardiologists. There is a lack of consensus on appropriate indications for prescribing oxygen, desirable oxygen targets and clinically significant immediate and longer-term outcome measures. Of the limited studies available, most are small studies reporting the treatment of infants with chronic neonatal lung disease with inconsistent outcome measures. Such data are not readily extrapolated to older children, who are also poorly served by existing data in adult studies. Further delineation of the indications for home oxygen therapy is required together with appropriately designed and funded multicentre trials to provide evidence for optimal oxygen therapy.

Cough in children: when does it matter?

Cough is a common presenting symptom to paediatricians and paediatric respiratory physicians. The causes of chronic cough in childhood are significantly different from those in adults, and a different approach to diagnosis and management is needed. In most cases cause can be identified or a satisfactory label given. This review will cover the approach to cough in children and cover some specific causes of troublesome cough not discussed elsewhere in this mini-symposium.

Current management of acute bronchiolitis in Switzerland.

Acute bronchiolitis is the most common lower respiratory tract infection in the first year of life. Current expert opinion and scientific data suggest that pharmaceutical agents have little impact on the natural course of the disease. Postal questionnaires were sent to all Swiss paediatricians to assess their current practice for treating acute bronchiolitis in children. Of a total of 937 questionnaires, 541 (58%) were returned. Of the respondents, 422 (78%) treat children with acute bronchiolitis. Up to 99% of paediatricians used bronchodilators in the outpatient and inpatient management, either routinely (up to 62%) or occasionally (37%). Steroids were used by 41% of the respondents in outpatient management and by 57% in inpatient management. The paediatric respiratory physicians tended to use bronchodilators and corticosteroids less frequently than the general paediatricians. A wide variation in the treatment of bronchiolitis was noted. Despite lack of evidence of benefit most Swiss paediatricians use pharmaceutical agents in the management of acute bronchiolitis. In particular, bronchodilators and corticosteroids were used in inpatient management in Switzerland much more frequently than recently reported for Australian paediatricians. National guidelines could be helpful in reducing the variations in the management of acute bronchiolitis in our country.

Current management of acute bronchiolitis in Switzerland.

Acute bronchiolitis is the most common lower respiratory tract infection in the first year of life. Current expert opinion and scientific data suggest that pharmaceutical agents have little impact on the natural course of the disease. Postal questionnaires were sent to all Swiss paediatricians to assess their current practice for treating acute bronchiolitis in children. Of a total of 937 questionnaires, 541 (58%) were returned. Of the respondents, 422 (78%) treat children with acute bronchiolitis. Up to 99% of paediatricians used bronchodilators in the outpatient and inpatient management, either routinely (up to 62%) or occasionally (37%). Steroids were used by 41% of the respondents in outpatient management and by 57% in inpatient management. The paediatric respiratory physicians tended to use bronchodilators and corticosteroids less frequently than the general paediatricians. A wide variation in the treatment of bronchiolitis was noted. Despite lack of evidence of benefit most Swiss paediatricians use pharmaceutical agents in the management of acute bronchiolitis. In particular, bronchodilators and corticosteroids were used in inpatient management in Switzerland much more frequently than recently reported for Australian paediatricians. National guidelines could be helpful in reducing the variations in the management of acute bronchiolitis in our country.

Implementation of evidence-based management of acute bronchiolitis.

Implementation of clinical guidelines is frequently delayed well beyond their dissemination and the publication of clinical evidence. The recently published Australian guidelines for the management of acute viral bronchiolitis (AVB) have been evaluated by assessing the current practice of Australian paediatricians. Questionnaire survey of all Australian paediatricians and a review of the literature. Of a total of 891 questionnaires, 555 (62%) were returned. Of the respondents, 373 (67%) treated children with AVB and, of these, 232 (67%) treated 10-50 children per year. A wide variation in management practice for both outpatient and inpatient treatment of AVB was identified. Up to 70% of paediatricians who treated AVB indicated using pharmaceutical agents in their outpatient management (88% in inpatient management), most using these agents 'sometimes' or in high-risk children. Paediatric respiratory physicians tended to use bronchodilators less frequently than general paediatricians. Compared with many countries in Europe, few Australian paediatricians routinely use supplementary drugs in the inpatient managenment of AVB; in particular, bronchodilators (61 vs 7%) and corticosteroids (11 vs 1%) are used far less often. A review of the literature demonstrated that pharmaceutical agents do not influence the course of AVB. Despite a lack of evidence for their efficacy and the recommendation of the Australian guidelines, pharmaceutical agents are frequently used in the management of AVB by paediatricians in Australia, although far less than reported in a recently published European survey. Guidelines alone are not sufficient to implement change and there is a need for more specific strategies to ensure that children receive appropriate management for this common condition.

Assessment and treatment of childhood asthma

In June 1990 a meeting of Paediatric Respiratory Physicians was held near Adelaide. The guidelines for assessing and treating asthma as prepared by the Thoracic Society of Australia and New Zealand for the management of patients with asthma was considered. Although not explicitly stated, these guidelines were designed for adult asthmatics. There was complete agreement that a companion statement was needed to take into account differences between the management of children and adults. This document fulfils that role. Further recommendations are found in a statement prepared by Australian and New Zealand respiratory paediatricians following a workshop in June 1989. This present statement should be read in association with the previous documents.