Intravenous Magnesium SulfateIV was cost-saving in emergency settings for treating children with asthma exacerbations. This shift in treatment approach proved to be economically favorable, reducing the cost of hospitalization and mechanical ventilation

Background: Medical care has shifted from a paternalistic model towards one centered around patient autonomy and shared decision-making (SDM), yet the role of the pediatric patient in decision-making is unclear. Studies suggest that many children with chronic disease are capable of participating in and even making medical decisions at a young age, and yet we do not standardly involve them. Methods: This is a single center survey study investigating physician attitudes towards involvement of children in decisions regarding lung transplantation, utilizing a hypothetical case scenario with systematic manipulation of age and maturity level. We evaluated physician belief regarding ultimate decision-making authority, attempts at reconciliation of parent-child discordance, and views towards utilizing ethics and psychiatry consultation services. Results: The majority of pediatric pulmonologists believe decision-making authority rests with the parents. The effects of age and maturity are unclear. In instances of parent-child disagreement, physician are more likely to try to convince parents to defer to the child if the child is both older and more mature. Physicians are divided on the utility of ethics and psychiatry consultations. Conclusion: Involvement of children in shared decision-making is broadly supported but poorly implemented. Despite evidence that children with chronic disease may have decisional capacity starting at a young age, the majority of physicians still grant decisional authority to parents. There are numerous barriers to involving children in decisions, including legal considerations. The role of age and maturity level in influencing these decisions appears small and warrants further investigation.

The FLNA gene encodes filamin A, an actin filament cross-linking protein that is ubiquitously expressed within the body. FLNA mutation causes periventricular nodular heterotopia (PVNH) and congenital heart disease. Interstitial lung disease (ILD) related to FLNA mutation has also been reported from 2011 and can be lethal. However, there are no reports of how to combine the treatment of heart disease with the conflicting treatment of lung disease. We herein report cases of two girls with FLNA mutation and both ILD and left-to-right shunts due to congenital heart disease. They presented with respiratory symptoms in early infancy and required management with long-term intubation and ventilation. However, their respiratory status improved subsequent to the closure of their left-to-right shunts even though they were small shunts with improvement in pulmonary hypertension. This suggests that early intervention with closure of cardiac shunts can prevent further deterioration of lung damage.

Background Methods of evaluating the ventilatory response to CO2 (VRCO2) of the respiratory center include the steady-state and the rebreathing method. Although the rebreathing method can evaluate the respiratory center more in detail, the steady-state method has been mainly performed in infants. The aim of this study was to investigate whether we could perform the VRCO2 with the rebreathing method in normal infants. Methods The subjects were 80 normal infants. The gestational age was 39.9（39.3-40.3）weeks, and the birth body weight was 3,142 (2,851-3,451) grams. We performed the VRCO2 with Read’s rebreathing method, measuring the increase in minute volume (MV) in response to the increase in EtCO2 by rebreathing a closed circuit. The value of VRCO2 was calculated as follow: VRCO2 (mL/min/mmHg/kg) = ΔMV / ΔEtCO2 / Body weight. Results We performed the examination without adverse events. The age in days at examination was 3 (2-4), and the examination time was 150±38 seconds. The maximum EtCO2 was 51.1 (50.5-51.9) mmHg. The value of VRCO2 was 34.6 (29.3-42.8). Tidal volume had a greater effect on the increase in MV than respiratory rate (5.4 to 14.3 mL/kg, 44.1 to 55.9 /min, respectively). Conclusion This study suggests that the rebreathing method can evaluate the ventilatory response to high blood CO2 in a short examination time. We conclude that the rebreathing method is useful even in infants. In the future, we plan to measure the VRCO2 of preterm infants, and evaluate the respiratory center of infants in more detail.

A document by Kam-lun Ellis Hon. Click on the document to view its contents.

Abstract Lymphobronchial tuberculosis (LBTB) is tuberculous lymphadenopathy affecting the airways, which is particularly common in children with primary TB. Airway compression by lymphadenopathy causes downstream parenchymal pathology, which may ultimately result in irreversible lung destruction, if not treated timeously. CT is considered the “gold standard” for detecting mediastinal lymph nodes in children with TB. CT is also the best way of imaging the airways of children with LBTB. The CT findings of the parenchymal complications and associations of LBTB on CT have been described, but no severity classification was provided to aid management decisions. Identifying the parenchymal complications of LBTB and recognising their severity has clinical relevance. Using prior publications on LBTB and post obstructive lung injury we have used an image bank of CT scans in children with pulmonary TB, presenting with airway symptoms, to create a CT severity staging of lung injury in LBTB. The staging focuses on distinguishing non-salvageable destruction [non-enhancing or cavitated lung] from salvageable lung parenchymal disease [enhancing and non-cavitated] to inform the management decisions, which range from bronchoscopic airway clearance to surgical decompression of the compressing nodes.

Background: In Bogotá, Colombia, oxygen-dependent (OD) preterm infants are home discharged in Kangaroo Position, to a Kangaroo Mother Care program (KMCP) with ambulatory oxygen, strict follow-up and oxygen weaning protocols. Objectives: 1) to describe growth and morbimortality up to 6 months of an OD preterm infants’ cohort. 2) to explore the association between oxygen requirement, perinatal history, Hb levels, transfusions, feeding patterns and growth. Methods: Prospective cohort study. Descriptive and multivariate analysis. Results: 445 patients were recruited with 33 weeks median gestational age (GA). 21% of mothers had preeclampsia, 50% infections and 77% received antenatal corticosteroids. Upon KMCP admission, median GA, chronological age and hospital stay were 36 weeks, 19 and 17 days, respectively; 55.6% of patients had neonatal sepsis and 66.6% were admitted to Neonatal Intensive Care Unit. Patients had on average 52 days with oxygen, a median of 3200g and 42 weeks GA at oxygen weaning. Median follow-up oxygen saturation was 94% with 0.016-0.5 l/min of oxygen. One-year mortality was 0.2% and attrition 20%. At 6 months, all patients had appropriate growth and 66% were breastfeeding. Multiple regression analysis showed that higher GA, Hb levels, weight gain, and exclusive breastfeeding decreased oxygen requirement whilst invasive ventilation and transfusions had the opposite effect (R2=0.48). Conclusions: In OD preterm infants, there is a close relationship between days of oxygen requirement and GA, mechanical ventilation, Hb levels at discharge, transfusions, exclusive breastfeeding and weight gain. Strict monitoring with established protocols in an ambulatory KMCP allows adequate growth and safe oxygen weaning.

Background. Median survival age in cystic fibrosis (CF) has increased in developed countries. Scarce literature exists about survival in Latin American, especially in Mexico. The aim of our study was to assess the median age of CF patients’ survival in Mexico over a 20-year period. Methods. We conducted a retrospective study, with all patients registered and followed in the CF Center in Monterrey, Mexico from 2000 to 2020. Median survival age was the primary outcome, assessed with the Kaplan-Meier analysis. Influence of clinical, biological, and demographic factors on survival were analyzed with the Cox regression model. Results. Two-hundred five patients were included. Median survival for the cohort was 21.37 years (95% CI 17.20 – 25.55). In the multivariate Cox regression model, low socioeconomic status (hazard ratio [HR] 4.21, 95% CI 2.43 – 7.27), chronic Pseudomonas aeruginosa (P. aeruginosa) infection at 6 years (HR 10.45, 95% CI 5.66 – 19.28), and pancreatic insufficiency (HR 3.13, 1.38 – 7.13) were independent risk factors for mortality. Conclusion. Median survival in Mexican patients with CF is lower than in high-income countries, and socioeconomic status plays a conspicuous role in the disparity. To increase patient survival for those residing in low-income countries, public health authorities must design policies that fully cover diagnosis and treatment strategies for the CF population.

Background and Objectives: Extubation failure in preterm infants is associated with increased risk of mortality and morbidities. There is limited evidence to suggest if the increased morbidities are due to inherent differences among infants who fail or succeed; or whether these are due to a true respiratory setback among those who fail extubation. The aim of this study was to evaluate the respiratory status of infants who fail extubation and to assess the time taken for these infants to achieve pre-extubation respiratory status. Methods: This was a retrospective study of infants with birth weight ≤1,250 g who were born between January 2009 and December 2016. Infants were eligible if they failed first elective extubation. Extubation failure was defined as need for re-intubation within 5 days of extubation. Ventilator settings, blood gas parameters, respiratory severity score and ventilation index were used to assess respiratory status of infants. Results: Of 384 infants, 76% were successful and 24% failed extubation. Among those who failed extubation 91%, 77% and 56% infants remained intubated at 24 hours, 72 hours and 7 days, respectively. Respiratory status was worse at 24 hours and 72 hours after re-intubation when compared to pre-extubation levels. The median times for respiratory severity score and ventilation index to reach pre-extubation levels were 4 days and 7 days respectively. Conclusion: Among preterm infants, failed elective extubation is associated with a significant setback in the respiratory status. Infants who fail an extubation attempt may not achieve pre-extubation respiratory status for many days after reintubation.

Background and Objectives: Swallowing disorders lead to chronic lung aspiration. Early detection and treatment of aspiration in children with dysphagia is important to prevent lung damage. Diagnosis of aspiration, which may be silent, requires an instrumental study such as fiberoptic endoscopic evaluation of swallowing (FEES). Despite its usefulness, it is rarely practiced by pediatric pulmonologists. This study aimed to evaluate the feasibility and utility of FEES performed in the pediatric respiratory unit of a tertiary hospital, analyze the clinical characteristics, endoscopic findings and proposed treatments, and identify the factors associated with penetration or aspiration. Methods: Medical records of 373 children with suspected aspiration who were referred to the pediatric respiratory unit for FEES were reviewed retrospectively. Clinical characteristics, FEES findings, and the proposed treatments were analyzed. Results: Aspiration was seen in 47.9% of the patients. The most common associated conditions were neurological disease and prematurity. The most frequently observed endoscopic finding was altered laryngeal sensitivity (36.5%). Intervention was recommended in 54.2 % of the patients. Complications were not seen during any of the procedures. Conclusions: The FEES procedure performed by pediatric pulmonologists is a reliable method for diagnosing aspiration in children. It can be safely executed by trained pulmonologists, and significant endoscopic signs other than aspiration can guide in the diagnosis and management recommendations.

We describe six teenagers presenting with fever and severe abdominal symptoms admitted with concerns for multisystem inflammatory syndrome in children (MIS-C). Laboratory evaluation revealed elevated markers of inflammation, lymphopenia, and increased d-dimers. Imaging studies revealed multifocal airspace disease and ground-glass opacities. SARS-CoV-2 PCR and serologies were negative. All patients reported a history of vaping, prompting E-cigarette, or vaping, product use-associated lung injury (EVALI) diagnosis. MIS-C has overlapping clinical and laboratory features highlighting the added challenge of diagnosing EVALI during the COVID-19 pandemic.

Children less than 18 years of age account for an estimated 500,000 to 1.5 million global SARS-CoV-2 cases. Lower prevalence of COVID-19 among children, in addition to higher numbers of mild and asymptomatic cases, continues to provide challenges in determining appropriate prevention and treatment courses. Here, we summarize the current evidence on the transmission, clinical presentation, complications and risk factors in regards to SARS-CoV-2 in children and highlight crucial gaps in knowledge going forward. Based on current evidence, children are rarely the primary source of secondary transmission in the household or in child care and school settings and are more likely to contract the virus from an adult household member. Higher transmission rates are observed in older children (10-19 years old) compared to younger children (<10 years old). While increasing incidence of COVID-19 in neonates raises the suspicion of vertical transmission, it is unlikely that breast milk is a vehicle for transmission from mother to infant. The vast majority of clinical cases of COVID-19 in children are mild, but there are rare cases that have developed complications such as multisystem inflammatory syndrome in children (MIS-C), which often presents with severe cardiac symptoms requiring intensive care. Childhood obesity is associated with a higher risk of infection and a more severe clinical presentation. Although immediate mortality rates among children are low, long-term respiratory and developmental implications of the disease remain unknown in this young and vulnerable population.

Editorial: Respiratory outcomes post Nusinersen in Spinal Muscular Atrophy Type 11 Kate Gonski1,2 Dominic A. FitzgeraldDepartment of Respiratory Medicine, The Children’s Hospital at Westmead, Sydney, NSW, Australia 2145Discipline of Child & Adolescent Health, Sydney Medical School, Faculty of Health Sciences, University of Sydney, NSW, Australia 2145Corresponding author:Dominic A. Fitzgerald MBBS PhD FRACPClinical Professor Child & Adolescent HealthDepartment of Respiratory MedicineThe Children’s Hospital at WestmeadLocked Bag 4001Westmead, NSWAustralia, 2145.1458 words15 referencesTime to wake up and smell the roses as the real world respiratory experiences have arrived for Spinal Muscular Atrophy type 1 (SMA1)! Nusinersen, the first drug to be approved for treatment of SMA1, has changed the natural history of the disease and has now been commercially available in many countries for up to four years(1). SMA 1, the most common cause of infant death attributed to respiratory insufficiency, results from a degeneration of alpha motor neurons in the spinal cord and brainstem resulting in progressive skeletal muscle weakness of the limbs, respiratory and bulbar muscles (2). Most patients with SMA1 will have respiratory complications in the first year of life requiring therapy to support airway clearance and ventilation (2). The pan-ethnic incidence is 1 in 11,000 births (3). Milder phenotypes occur as SMA types 2 and 3 in childhood with a much better prognosis (4) and countries may offer nusinersen for these patients also.In this issue, Lavie and colleagues (5) offer insights into clinicalrespiratory outcomes from 3 years of prospective data collection in their cohort of 20 SMA1 patients treated before and after 2 years of nusinersen in Israel. Their work builds on the scientific evidence of efficacy of nusinersen primarily for motor outcomes over the last decade. A phase 3 randomised, double-blinded, sham controlled clinical trial in patients with SMA 1 showed that those treated with nusinersen had a significant motor milestone response with a higher likelihood of event-free survival(6). This group did not show a difference in the frequency of serious respiratory adverse events between the groups, thereby leaving unanswered questions about the effect of the medication on respiratory morbidity. Over the past few years, the translatability of outcomes from randomized controlled studies to current real-world outcomes has been questioned (7-9).A letter to the editor by LoMauro et al. involving children with SMA1 described a milder subset of children with SMA 1 [Described as type SMA 1c: onset between 3 and 6 months] treated with nusinersen who had an improvement in accessory muscle use and reduced daily hours of ventilation when compared to a natural history cohort (7). This was not reported in the more severe SMA 1a and 1b groups. Sansone et al. (8) published an observational, longitudinal cohort study looking at respiratory support requirements at baseline, 6 months and 10 months after nusinersen treatments in 118 children with SMA1. Semi-structured qualitative interviews from caregivers were collected at each interval. They showed that 77% of the cohort’s respiratory requirements remained stable and more than 80% of children treated before 2 years survived in contrast to the lower survival reported in natural history studies. The limitation of this study is that they used modality and number of hours of ventilation as the surrogate for respiratory function which can be influenced significantly by respiratory care, management and patient compliance. Chen et al. (9) also published follow-up data (single-centre) in SMA 1 children treated with nusinersen in order to further understand the comprehensive real-world outcomes of this new treatment. While this study was limited by its small sample size of 9, it highlighted that children with SMA1 treated with nusinersen continued to develop considerable respiratory comorbidities. Although a large amount of data has been collected over the past 5 years, there remain gaps in the understanding of many aspects of the use of nusinersen in SMA beyond modest increases in peripheral muscle strength and in particular whether these improvements will translate into reduced respiratory morbidity and less respiratory failure with dependence upon non-invasive ventilation (NIV) (10).The paper by Lavie et al. (5) contributes to our understanding with its focus on ‘real-world’ variables including starting or ongoing need for assisted ventilation, the use of mechanical insufflation-exsufflation, respiratory complications, and treatment cessation due to respiratory reasons, or death in around 15% of cases attributed to pulmonary aspiration. In essence, it is a source of modest encouragement for clinicians as the majority of children demonstrated stability of respiratory support over the first two years of treatment with nusinersen which is in itself much better than the natural history of the condition with progressive decline and death in 90% by the age of 2 years. However, there are some gaps in knowledge in this paper which will require further studies. It is unclear exactly why children started ventilation specifically, who went to tracheostomy and why others went to NIV and what their initial ventilator pressures were. Management algorithms have been available to outline this in neuromuscular diseases [11]. Further, it is unclear how many children had polysomnograms and what the results were in terms of apnoea indices, measures of hypoventilation, alterations in oxygenation and extent of transcutaneous CO2 abnormalities, other than that they were consistent with the standards of care for the treatment of children with SMA published in 2007 [12]. Further guidelines have since emerged in the nusinersen era [13]. Certainly, the positive impact of the use of NIV on respiratory outcomes, including hospitalisations, albeit in the broader neuromuscular population, has been established [14]. As would be hoped, a reduction in admissions was seen in the present study in SMA1. Nonetheless, as all clinicians appreciate, what is prescribed and what is used for the treatment of anything in “the real world” varies widely. Think of asthma preventers or any therapies in cystic fibrosis including expensive correctors. In a prospective study on real world respiratory outcomes, the absence of information on adherence with average daily hours of support from memory cards inside the NIV devices is a short-coming of the study of Lavie et al. (5). This is something which, with serial assessment of polysomnography parameters, should be addressed in future studies in SMA1 treated patients to ascertain the true rather than potentially perceived benefit of NIV.Lavie et al. (5) provide insight into the everyday clinical respiratory burden of patients with SMA1 treated with nusinersen while highlighting further areas of research. Specifically, they rightly suggest a beneficial effect with the earliest initiation of nusinersen due to the possibility that nusinersen may have an effect on preserving respiratory function if started at a younger age. This mirrors data in the larger RCT where earlier treatment was associated with better motor outcomes. Logically, this could be readily achieved with emerging increase in new born screening programs including SMA genes in countries such as Australia and Belgium [15]. This would also enable quantification of the number of copies of SMN2 genes present, missing in 30% of cases in the series of Lavie et al. (5). This stratification of genotype may be more important than ever in the nusinersen era as we improve our ability to predict outcomes beyond age of presentation [Types 1a, 1b and 1c] [13]. The argument for newborn screening for SMA, with earlier diagnosis and improved outcomes for such an expensive therapy seems persuasive.This article explores patient outcomes in a real-world setting and found that the need for assisted ventilation did not worsen as would be with the natural progression of SMA1. However, they showed no improvement either. Therefore, nusinersen is a small step forward with the promise of much more to come from gene therapy and potentially combinations of therapies. Longer term studies with international prospective data registries are warranted and should be funded by international neuromuscular societies at arm’s length from pharmaceutical companies. It is as important to document respiratory outcomes rather than just predominantly modest motor outcomes not only for SMA1 but also SMA2 and SMA3, because at the end of the day in the real world, your respiratory wellbeing determines morbidity and mortality.References1. LoMauro A, Mastella C, Alberti K, Masson R, Aliverti A, Baranello G. Effect of nusinersen on respiratory muscle function in different subtypes of type 1 spinal muscular atrophy. American Journal of Respiratory and Critical Care Medicine. 2019;200(12):1547-1550.2. Kolb SJ, Coffey CS, Yankey JW, Krosschell K, Arnold WD, Rutkove SB, et al. Natural history of infantile-onset spinal muscular atrophy. Ann Neurol. 2017; 82(6):883-8913. Sugarman EA, Nagan N, Zhu H, Akmaev VR, Zhou Z, Rohlfs EM, et al. Pan-ethnic carrier screening and prenatal diagnosis for spinal muscular atrophy: Clinical laboratory analysis of >72 400 specimens. Eur J Hum Genet. 2012; 20 (1):27-324. Farrar MA, Park SB, Vucic S, Carey KA, Turner BJ, Gillingwater TH, et al. Emerging therapies and challenges in spinal muscular atrophy. Annals of Neurology. 2017; 81(3):355-3685. Lavie M, Diamant N, Cahal M, Sadot E, Be’er M, Fatal A, Sagi L, Domany KA, Amirav I. Nusinersen for Spinal muscular Atrophy Type 1: real World Respiratory Experience. Pediatr Pulmonol 2020; XXXX; doi xxxx6. Finkel RS, Mercuri E, Darras BT, Connolly AM, Kuntz NL, Kirschner J, et al. Nusinersen versus sham control in infantile-onset spinal muscular atrophy. N Engl J Med. 2017; 377:1723-17327. LoMauro A, Mastella C, Alberti K, Masson R, Aliverti A, Baranello G. Effect of nusinersen on respiratory muscle function in different subtypes of type 1 spinal muscular atrophy. American Journal of Respiratory and Critical Care Medicine. 2019 Dec 15;200(12):1547-508. Sansone VA, Pirola A, Albamonte E, Pane M, Lizio A, et al Respiratory Needs in Patients with Type 1 Spinal Muscular Atrophy Treated with Nusinersen. The Journal of Pediatrics. 2020; 219 P223-228. E49. K-A. Chen, J. Widger, A. Teng, D.A. Fitzgerald, A. D’Silva, M. Farrar, Real-world respiratory and bulbar comorbidities of SMA type 1 children treated with nusinersen: 2-year single centre Australian experience, Paediatric Respiratory Reviews (2020), doi: httpds://doi.org/10.1016/j.prrv.2020.09.00210. Fitzgerald DA, Doumit M, Abel F. Changing respiratory expectations with the new disease trajectory of nusinersen treated spinal muscular atrophy [SMA] type 1. Paediatric Respiratory Reviews. 2018 Sep 1;2 8:11-7.11. Hull J, Aniapravan R, Chan E, Chatwin M, Forton J, Gallagher J, Gibson N, Gordon J, Hughes I, McCulloch R, Russell RR. British Thoracic Society guideline for respiratory management of children with neuromuscular weakness. Thorax. 2012 Jul 1;67(Suppl 1):i1-40.12. Wang CH, Finkel RS, Bertini ES, Schroth M, Simonds A, Wong B, Aloysius A, Morrison L, Main M, Crawford TO, Trela A. Consensus statement for standard of care in spinal muscular atrophy. Journal of child neurology. 2007 Aug;22(8):1027-49.13. Finkel RS, Mercuri E, Meyer OH, Simonds AK, Schroth MK, Graham RJ, Kirschner J, Iannaccone ST, Crawford TO, Woods S, Muntoni F. Diagnosis and management of spinal muscular atrophy: Part 2: Pulmonary and acute care; medications, supplements and immunizations; other organ systems; and ethics. Neuromuscular Disorders. 2018 Mar 1;28(3):197-207.14. Young HK, Lowe A, Fitzgerald DA, Seton C, Waters KA, Kenny E, Hynan LS, Iannaccone ST, North KN, Ryan MM. Outcome of noninvasive ventilation in children with neuromuscular disease. Neurology. 2007 Jan 16;68(3):198-201.15. Boemer F, Caberg JH, Dideberg V, Dardenne D, Bours V, Hiligsmann M, Dangouloff T, Servais L. Newborn screening for SMA in Southern Belgium. Neuromuscular Disorders. 2019 May 1;29(5):343-9.

Background: Ventilated neonates with respiratory distress may show a ventilation-perfusion (V/Q) mismatch. Objective: To evaluate the difference between the Bohr (Vd,Bohr) and Enghoff (Vd,Enghoff) dead spaces in infants by using volumetric capnography (Vcap) based on ventilator graphics and capnograms. Methods: This study enrolled 46 ventilated infants (mean birth weight, 2239 ± 640 g; mean gestational age, 35.5 ± 3.3 weeks). We performed Vcap and calculated Vd,Bohr and Vd,Enghoff when arterial blood sampling was necessary for treatment. Each measurement was classified according to the severity of acute respiratory distress syndrome (ARDS) by using the Berlin definition: severe or moderate ARDS, ratio of partial pressure of oxygen to fraction of inspired oxygen (P/F ratio) ≤ 200; mild ARDS, 200 < P/F ratio ≤ 300; and non-ARDS, 300 < P/F ratio. Next, regression analysis was performed to evaluate the correlation between the P/F ratio and the difference between Vd,Enghoff and Vd,Bohr. Results: Median Vd,Enghoff/tidal volume (VT) was significantly higher in the ARDS groups (severe or moderate: 0.60 [IQR, 0.49–0.68]; mild: 0.50 [0.43-0.59]) than in the non-ARDS group (0.45 [0.36-0.56]). The ARDS groups showed a large difference between Vd,Enghoff and Vd,Bohr (severe or moderate: median, 0.23 [0.15-0.30]; mild: median, 0.14 [0.09-0.21] vs. control: median, 0.09 [0.06-0.13]). The regression analysis for the relationship between P/F ratio and Vd,Enghoff - Vd,Bohr showed a negative correlation (r = -0.55, p < 0.001). Conclusion: Ventilated neonates with respiratory distress showed a large difference between Vd,Enghoff and Vd,Bohr, possibly reflecting a low V/Q mismatch and right-to-left shunting.

An Unusual Case of Necrotizing Pneumonia Presenting with Acute Kidney InjuryUgur Berkay Balkanci, MDSchool of Public Health, University of Minnesota, Minneapolis, MNDavid J. Sas, DODivision of Pediatric Nephrology and Hypertension, Department of Pediatrics and Adolescent Medicine, Mayo Clinic, Rochester, MinnesotaNadir Demirel, MDDivision of Pediatric Pulmonology, Department of Pediatrics and Adolescent Medicine, Mayo Clinic, Rochester, MinnesotaCorresponding Author:Nadir Demirel, MDDivision of Pediatric Pulmonology200 First Street SWRochester, MN 55906Tel. No.: 5075380754Fax No.: [email protected] words: postinfectious glomerulonephritis, pneumothorax, complications, complicated pneumoniaFinancial Disclosure: The authors have indicated they have no financial relationships relevant to this article to disclose.Funding: No external funding.Short title: “An unusual case of necrotizing pneumonia”To the Editor:Lower respiratory tract infections are the most common reason for hospitalization in the pediatric age group in the United States. Although pneumonia is prevalent, complicated pneumonia such as empyema, lung abscess and necrotizing pneumonia (NP) is uncommon in children1. The prevalence of complicated pneumococcal pneumonia decreased significantly after the introduction of the thirteen-valent pneumococcal vaccine in 20101. NP in the pediatric population is a severe disease characterized by extensive destruction and liquefaction of the lung tissue resulting in loss of the pulmonary parenchymal architecture, cavitation of the lung, and pleural involvement. Renal complications of complicated pneumonia are rare and mostly reported as atypical hemolytic uremic syndrome (HUS)2. Post-infectious glomerulonephritis (PIGN) is an unexpected complication of bacterial pneumonia3.We report a six-year-old otherwise healthy fully vaccinated girl with a 4-day history of fever, abdominal pain, vomiting, non-bloody diarrhea, and poor oral intake. Parents reported decreased urine output and dark-colored urine on the day of admission. Initial evaluation revealed serum creatinine of 5.01 mg/dL and blood urea nitrogen of 86 mg/dL, elevated acute phase reactants suggesting acute kidney injury (AKI) in the setting of an undiagnosed acute infectious process. The patient was admitted with decreased effective circulatory volume. Urinalysis revealed hematuria with <25% dysmorphic red blood cells (RBCs), proteinuria, pyuria, and RBC casts and granular casts, suggestive of acute glomerulonephritis.She was started on intermittent hemodialysis at day 2 of admission to address uremia, fluid overload, and hyperphosphatemia. A renal biopsy revealed diffuse exudative glomerulonephritis, consistent with infection-related glomerulonephritis. ASO, Anti-DNase B were negative; C3, C4 levels were low. She was treated with pulse IV methylprednisolone 10mg/kg/day for three days. The first 5 days in the hospital, the patient remained afebrile and her lung exam was normal without respiratory symptoms.On day six of admission, she developed acute right-sided chest pain and shortness of breath during hemodialysis. Chest x-ray (CXR) revealed a large right-sided tension pneumothorax, prompting therapeutic chest tube placement. Repeat CXR revealed reexpansion of the right lung and a significant right upper lobe consolidation with an ovoid hyperlucency and an air-fluid level. A chest CT scan confirmed the diagnosis of NP with multiple cavities (Image).Flexible bronchoscopy was performed with bronchoalveolar lavage revealing 42% neutrophils and negative cultures. She was treated with broad spectrum intravenous antibiotics.During admission, she developed hypertension, well-controlled with scheduled enalapril and amlodipine, as well as isradipine as needed. On day 14 of admission, hemodialysis was discontinued as kidney function improved, and chest tube was removed. She was discharged at day 26 of admission on intravenous ceftriaxone and oral metronidazole to complete 30 days of treatment. A repeat chest CT at end of treatment showed complete resolution of NP. Renal functions and blood pressure normalized on follow up.NP is characterized by persistent high fevers and prolonged hospitalizations even with appropriate antibiotic treatment1. Most often, NP affects immunocompetent children with no underlying risk factors4. The pathophysiology of this complication is acute liquefactive necrosis of the lung parenchyma which results in the development of pneumatoceles4. The most common pathogen causing NP is Streptococcus pneumoniae followed by Staphylococcus aureus and Streptococcus pyogenes. Other rarer bacterial and viral pathogens are Mycoplasma pneumonia, Influenza, and Adenovirus1. Identifying the microbiologic pathogen can be challenging and is only made in 50% of cases1. In our case, we did not isolate the causative microorganism. NP typically resolves without residual morbidity, even after a protracted course1,4.Pleural involvement is almost universal in NP, and the course of pleural disease often determines duration and outcome, particularly as it relates to the complication of bronchopleural fistula (BPF)1. BPF is most likely due to the necrotic development of a connection between bronchial space and pleural space4. BPF formation is associated with a significantly longer hospital stay in children with NP4. Yet, most cases heal without surgical intervention4. Tension pneumothorax has been observed as a rare complication of NP1.Renal involvement in complicated pneumonia is rare. Atypical HUS has been reported as a complication of pneumonia, particularly associated with empyema. (most commonly due to invasive Streptococcus pneumoniae)2. In a case series of 37 cases of atypical HUS, 34 patients (92%) had pneumonia with 10 patients (29%) with NP5. Less commonly, pneumonia can be associated with PIGN. PIGN is the most common glomerulonephritis in children worldwide. Pneumonia-associated PIGN is rare. In a case series from the US, PIGN accounted for 0.15% of admissions for pneumonia and 0.39% of admissions for glomerulonephritis6. Pneumonia-associated PIGN is known to be caused by various bacterial pathogens including Streptococcus pneumoniae, Staphylococcus aureus, Mycoplasma pneumoniae, Chlamydia pneumoniae, Nocardia, and Coxiella burnetii3. Different from the usual presentation of the PIGN (in which the time interval between a pharyngeal group A Streptococcal infection and PIGN is 6 to 10 days), pneumonia-associated PIGN is usually concomitant with the pulmonary disease3,6.Our case is unusual in several ways: pneumonia-associated PIGN typically presents with respiratory symptoms first, and acute kidney injury developing during the course of pneumonia3. More surprisingly, the patient developed NP which is characterized by even more severe respiratory symptoms1. Yet, our patient presented without respiratory complaints and pneumonia became apparent only after the development of pneumothorax. We could only identify 2 cases of pneumonia-associated PIGN who presented with renal involvement before pulmonary complaints6,7. Also, previous cases in the literature of pneumonia-associated PIGN report mostly a non-complicated course of pulmonary disease3,6. In a case series of 11 children with pneumonia-associated PIGN, only one case developed a small empyema6. Similarly, the majority of the reported cases of pneumonia-associated PIGN describe a benign course of renal disease3,6. Our patient’s kidney failure progressed rapidly, and she required 2 weeks of intermittent hemodialysis and a three-day course of pulse steroid therapy. At present, systemic corticosteroids are not recommended for patients with complicated pneumonia. A Cochrane review including 17 randomized controlled trials, of which four were conducted on children, found that corticosteroid therapy reduced mortality and morbidity in adults with severe CAP, and morbidity, but not mortality, in adults and children with non-severe CAP1. We speculate that pulse steroid treatment may have modified the course of NP in our patient.This case suggests an atypical presentation of NP with predominant renal complications is possible. Pediatricians should be aware of renal complications of respiratory diseases. Systemic steroids should be considered in the treatment of NP.References:1. de Benedictis FM, Kerem E, Chang AB, Colin AA, Zar HJ, Bush A. Complicated pneumonia in children. Lancet 2020;396:786-798.2. Spinale JM, Ruebner RL, Kaplan BS, Copelovitch L. Update on Streptococcus pneumoniae associated hemolytic uremic syndrome. Curr Opin Pediatr 2013;25:203-208.3. Carceller Lechón F, de la Torre Espí M, Porto Abal R, Écija Peiró JL. Acute glomerulonephritis associated with pneumonia: a review of three cases. Pediatr Nephrol 2010;25:161-164.4. Sawicki GS, Lu FL, Valim C, Cleveland RH, Colin AA. Necrotising pneumonia is an increasingly detected complication of pneumonia in children. Eur Respir J 2008;31:1285-1291.5. Banerjee R, Hersh AL, Newland J, Beekmann SE, Polgreen PM, Bender J, Shaw J, Copelovitch L, Kaplan BS, Shah SS. Streptococcus pneumoniae-associated Hemolytic Uremic Syndrome Among Children in North America. Pediatr Infect Dis J 2011;30:736-739.6. Srivastava T, Warady BA, Alon US. Pneumonia-associated acute glomerulonephritis. Clin Nephrol 2002;57:175-182.7. Schachter J, Pomeranz A, Berger I, Wolach B. Acute glomerulonephritis secondary to lobar pneumonia. Int J Pediatr Nephrol 1987;8:211-214.

To assess the impact of COVID-19 restrictions on cystic fibrosis (CF) pulmonary exacerbations (PEx) we performed a retrospective review of PEx events at our CF Center and compared the rate of PEx in 2019 vs 2020. Restrictions on social interaction due to the COVID-19 pandemic were associated with a lower rate of PEx at our pediatric CF Center, suggesting that these restrictions also reduced exposure to other respiratory viral infection in children with CF.

Neuromuscular medicine is being revolutionized by new genetic and molecular therapies. The purpose of this Special Issue is to present an overview of these new therapies, to examine their cardiopulmonary effects, and to consider the future of neuromuscular cardiopulmonary care. The emphasis will be on Duchenne muscular dystrophy (DMD) and, to a lesser extent, spinal muscular atrophy (SMA), as these are the diseases with the most robust new drug development and related cardiopulmonary outcome data. This Special Issue contains articles on a number of relevant topics, including an overview of new genetic and molecular therapies for DMD, examining the currently available cardiopulmonary outcome data; and a critical examination of pulmonary outcome measures, assessing which outcomes should be used in treatment studies. We will provide an overview of cardiopulmonary phenotypic variability and discordance and their implications for assessing patient prognosis and response to therapies, and present a new perspective on neuromuscular-induced sleep-disordered breathing, viewed in the context of new and emerging therapies. Finally, we will consider which cardiac imaging modalities should be used as outcome measures in studies assessing DMD heart function, and take a look at novel therapeutic approaches to DMD heart disease, including management of rhythm disorders and heart failure, and the use of left ventricular assist devices.

Background Normal values (>80%) of Forced Expiratory Volume in one second (FEV1) in patients with Cystic fibrosis (CF) may lead to the interpretation that there is no lung disease. This study is a comprehensive analysis of lung involvement in CF patients having normal FEV1. Methods Patients were recruited from two CF Centers: Hadassah Medical Center, Jerusalem and Vall d’ Hebron Hospital, Barcelona. Lung disease was assessed by lung clearance index (LCI), chest CT-Brody Score, respiratory cultures, number of pulmonary exacerbations (PEx) and days of antibiotic treatment in the year prior to the assessment. Results Of the 247 patients, 89 (36%) had FEV1 ≥80% and were included in the study (mean age 17.6 range 4.25-49 years). Chronic P. aeruginosa infection was found in 21%, and 31% had at least one major PEx in the year prior to the study. Abnormally elevated LCI was found in 86% of patients, ranging between 7.52-18.97, and total Brody score (TBS) was abnormal in 92% (range 5.0-96.5). Patients with chronic P. aeruginosa had significantly higher LCI (p=0.01) and TBS (p=0.01) which were associated with more major PEx (p = 0.04 and p<0.001, respectively) and more days of intravenous (IV) antibiotic treatment in the preceding year (p=0.03 and p=0.002, respectively). Conclusions Most CF patients with normal FEV1 have already physiological and structural lung abnormalities which were associated with more PEx and IV antibiotic treatment.