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Objective: There is still no consensus regarding the treatment of empyema in children. Intrapleural combination of tissue plasminogen activator and dornase alfa is a promising treatment for empyema in adults. The aim of this pilot study was to determine whether this combination is safe and successful in pediatric empyema. Methods: Previous well children diagnosed with empyema as classified by the British Thoracic Society. After chest tube insertion, intrapleurally dornase alfa 2.5 mg for 2 days and tissue plasminogen activator 0.15 mg/kg for 3 days was given after which the chest tube was clamped for 4 h. Primary outcome was safety. Results: Ten consecutive children were included (4 boys, aged 3.2 (1.3-15.0) years old). No serious adverse events were seen. One child developed urticaria but additional intervention or cessation of the trial was not needed. There was no bleeding or mortality and no additional procedures were performed. The median hospital stay after intervention was 7.5 days. Conclusions: The intrapleural treatment of dornase alfa and tissue plasminogen activator as treatment of empyema was safe in ten children with empyema. If confirmed in further studies, this combination of intrapleural therapy may improve the management of pediatric empyema.

This chapter focuses on the role of upper airway (UA) evaluation by imaging modalities in pediatric obstructive sleep apnea (OSA). This chapter emphasizes upon studies using imaging techniques that may further enhance our understanding about the mechanisms of UA obstruction leading to pediatric OSA and could assist in treatment selection.

RationaleBronchopulmonary dysplasia (BPD) is a common complication of preterm birth. Lung function and imaging are classically used to assess BPD. Functional respiratory imaging (FRI) combines a structural and functional assessment of the airways and their vasculature. We aimed to assess BPD using FRI and to correlate these findings with the clinical presentation.MethodsWe included 37 adolescents with a history of preterm birth (22 BPD cases and 15 preterm controls). The study protocol included a detailed history, lung function testing and computed tomography (CT) (at total lung capacity (TLC) and functional residual capacity (FRC)) with FRI. CT images were also assessed using the Aukland scoring system.ResultsBPD patients had lower forced expiratory volume in 1 s to forced vital capacity ratio (p=0.02) and impaired diffusion capacity (p=0.02). Aukland CT scores were not different between the two groups. FRI analysis showed higher lobar volumes in BPD patients at FRC (pConclusionThis study is the first to use FRI in research for BPD. FRI analysis showed higher lobar volumes in BPD patients, indicating air trapping and reduced inspiratory capacity. In contrast to Aukland CT scores, FRI showed more air trapping in the BPD group, suggesting that FRI might be a more sensitive detection method. Importantly, we also showed increased distal airway resistance in BPD patients. By combining structural and functional assessment, FRI may help to better understand the long-term sequelae of BPD.

Study Objectives: The complexity of the pathogenesis of obstructive sleep apnea (OSA) in children with Down syndrome (DS) is illustrated by a prevalence of residual OSA after adenotonsillectomy. The aim of this study was to investigate whether upper airway imaging combined with computation fluid dynamics could characterize treatment outcome after adenotonsillectomy in these children. Methods: Children with DS and OSA were prospectively included. All children underwent an evaluation of the upper airway and an ultra-low dose computed tomography scan of the upper airway before adenotonsillectomy. The upper airway tract was extracted from the scan and combined with computational fluid dynamics. Results were evaluated using control polysomnography after adenotonsillectomy. Results: Thirty-three children were included: 18 boys, age 4.3 +/- 2.3 years, median body mass index z-score 0.6 (-2.9 to 3.0), and median obstructive apnea-hypopnea index was 15.7 (3-70) events/h. The minimal upper airway cross-sectional area was significantly smaller in children with more severe OSA (P = .03). Nineteen children underwent a second polysomnography after adenotonsillectomy. Seventy-nine percent had persistent OSA (obstructive apneahypopnea index > 2 events/h). A greater than 50% decrease in obstructive apnea-hypopnea index was observed in 79% and these children had a significantly higher volume of the regions below the tonsils. Conclusions: This is the first study to characterize treatment outcome in children with DS and OSA using computed tomography upper airway imaging. At baseline, children with more severe OSA had a smaller upper airway. Children with a less favorable response to adenotonsillectomy had a smaller volume of regions below the tonsils, which could be due to enlargement of the lingual tonsils, glossoptosis, or macroglossia.

Sleep disorders are a common problem during childhood. The consequences are variable, and sleep disorders can influence medical, psychological and developmental aspects of the growing child. It is important to recognize sleep disorders and to treat them correctly. We discuss common sleep disorders during childhood using the 3rd edition of the International Classification of Sleep Disorders. We analyze the different sleep disorders from a clinical approach and provide an overview of adequate treatment options.Conlusion: This review discusses common sleep disorders during childhood using the 3rd edition of the International Classification of Sleep Disorders. We analyze the different sleep disorders from a clinical approach and provide an overview of adequate treatment options. What is known: • Sleep disorders are a common problem during childhood. • The consequences are variable, and sleep disorders can influence medical, psychological, and developmental aspects of the growing child. What is new: • Pediatricians should routinely screen for sleep and sleep disorders. • It is important to recognize sleep disorders and to treat them correctly.

Upper airway volume between the uvula and epiglottis is smaller in African compared to European children with OSA http://ow.ly/AgoR30evNCu

OBJECTIVE The aim of this study was to investigate whether functional respiratory imaging (FRI) or clinical examination could predict treatment outcome for obstructive sleep apnea (OSA) in normal-weight, non-syndromic children. METHODS Normal weight children diagnosed with OSA by polysomnography were prospectively included. All children got a thorough evaluation and an ultra-low dose computed tomography scan of the upper airway (UA). A 3-D reconstruction was built combined with computational fluid dynamics for FRI. Decisions on the need and type of surgery were based upon findings during drug-induced sleep endoscopy. A second polysomnography was performed 3-12 months after surgery. RESULTS Ninety-one children were included: 62 boys, 5.0 ± 2.7 years, and BMI z-score of −0.1 ± 1.2. Children with more severe OSA had a smaller volume of the overlap region between the adenoids and tonsils. Nineteen out of 60 patients had persistent OSA (oAHI >2/h). A lower conductance in the UA and a higher tonsil score predicted successful treatment. CONCLUSIONS A less constricted airway, as characterized by both FRI and a lower tonsil score, was associated with a less favorable response to (adeno) tonsillectomy. Further studies after treatment using FRI and DISE are warranted to further characterize the UA of these subjects.

Introduction and background Residual obstructive sleep apnea (OSA) is seen even in a subset of otherwise healthy children. Aims and objectives The aim of this pilot study was to identify predictors of treatment outcome in normal-weight children by functional respiratory imaging and clinical assessment. Methods Non-obese children diagnosed with OSA by polysomnography (PSG) were prospectively included. All children got a examination (including the Brodsky score as a marker of tonsil hypertrophy) and all underwent an ultra-low dose CT scan of the upper airway (UA) while being awake before treatment. A treatment modality was proposed based upon findings during clinical ENT examination and drug induced sedation endoscopy. Some children underwent a PSG after treatment. Results 75 non-obese children were included: 53M/23F, mean age 4.6±2.6 years. Median obstructive apnea/hypopnea index (oAHI) was 17(2.1-124) events/hour. 65 children had a post treatment PSG: 39 had a post-operative oAHI 50 % reduction in oAHI. There was a negative correlation between the change in oAHI after treatment and the UA volume at the overlap region between adenoids and tonsils (zone 3) (r=-0.32, p=0.021). Logistic regression analysis showed that a higher Brodsky score was a significant predictor of post-operative oAHI 50% improvement in oAHI. Conclusions A small UA volume at zone 3 is associated with a larger improvement in OSA severity after treatment. Several parameters predicted partial response following surgery, including the Brodsky score, which is relatively simple to obtain in daily practice.

Introduction: Childhood obesity is associated with an increased prevalence of obstructive sleep apnea (OSA) and a less favourable outcome of adenotonsillectomy. In this study, we investigated if measurements of 3D-reconstructions of the upper airway (UA) paired with computational fluid dynamics (CFD) correlated with OSA severity. Methods: Obese children diagnosed with obstructive sleep apnea (OSA) by polysomnography were prospectively recruited. All underwent an ultra-low dose CT scan of the UA while being awake. 3D reconstructions were built from these images and were further analysed using CFD. Results: Thirty children were included (16 boys; mean age was 9.6±3.9 years, mean BMI was 28.1±6.8 kg/m2, median obstructieve apnea/hypopnea index (oAHI) 12.9(3.1-67.3)/hour. 19 children were diagnosed with moderate-to-severe OSA (oAHI > 5). No clear differences in UA volumes or resistance were observed between children with mild and severe OSA. There was a significant correlation between oAHI and effective volume of the UA (r=-0,44; p=0,03). The minimal area was located in the overlap region in 50% subjects with mild OSA and in 33% subjects with severe OSA ( p >0.05). There was no correlation between the clinical markers of UA patency (tonsil score and Mallampati score) and OSA severity. However, tonsil score correlated negatively with UA volumes and positively with UA resistance. There was a significant positive correlation between BMI and effective volume of the UA. Conclusions In this pilot study is a negative correlation between UA volume and OSA severity. The value of this technique in improving treatment outcome needs to be investigated further.

Introduction: The prevalence of obstructive sleep apnea (OSA) in children with Down syndrome (DS) ranges between 30 to 100%. The complexity of the pathogenesis of OSA in these children is illustrated by a high incidence of residual OSA after adenotonsillectomy (AT). The aim of this study is to get a better insight in this pathogenesis through a detailed analysis of the upper airway (UA) by functional respiratory imaging. Methods: Children with DS diagnosed with OSA by polysomnography were prospectively recruited. All underwent an ultra-low dose CT scan of the UA. 3D reconstructions were built from these images and were further analyzed using computational fluid dynamics. A second polysomnography was performed 6 months after treatment. Results: Eighteen children without previous UA surgery were included (8 boys; mean age 5.4±7.5 years with a median obstructive apnea/hypopnea index (oAHI) of 17.5/hr (range 3.5-61.3)). The majority of subjects had their smallest cross-sectional area located in the overlap region between adenoids and tonsils and in the upper trachea. Tonsillar hypertrophy was inversely related to UA volume derived by imaging. 18 patients underwent tonsillectomy or AT and a post-treatment polysomnography. Sixteen of these 18 patients had a post-treatment oAHI > 2/hr. The improvement in oAHI between the first and second sleep study was correlated with baseline oAHI (r=0.83;p