American College of Chest Physicians (ACCP)/ American Academy of Pediatrics (AAP): Pediatric Pulmonology

FORT LAUDERDALE, FLA. – More children are achieving long-term survival following repair of a congenital diaphragmatic hernia, but "this new group of survivors does not appear to have much greater sequelae," Dr. Melinda Solomon said.

For example, despite early pulmonary hypertension and decreased pulmonary artery size, their cardiac function tends to be normal in adulthood. Exercise impairments tend to be mild as well, Dr. Solomon said at a seminar on pediatric pulmonology sponsored by the American College of Chest Physicians and the American Academy of Pediatrics.

"The issue used to be: Can we get these patients to survive and make it to adulthood?" Dr. Solomon said.

They are not entirely free of adverse sequelae, however; obstructive findings and the incidence of asthmalike symptoms can be significantly increased in this population, according to long-term follow-up studies. Recurrence of the hernia is also a lifelong concern, said Dr. Solomon of the division of respiratory medicine at the Hospital for Sick Children in Toronto.

In a long-term follow-up study done in the Netherlands, mean forced expiratory volume in 1 second (FEV₁) was significantly lower among 53 survivors at –1.63, compared with 0.08 among controls (Eur. J. Respir. 2009;34:1140-7). "Prebronchodilatation, the FEV₁ was below the lower limit of normal in 46% of patients but not in controls," Dr. Solomon said. The residual volume/total lung capacity (RV/TLC) ratio exceeded the upper limit of normal in 52% of affected children and in none of the controls, a significant difference.

The same study did not reveal a difference in exercise performance between groups. "This is good news" that children with congenital diaphragmatic hernia can have normal exercise capacity in adulthood, Dr. Solomon said.

All cardiac indexes from exercise testing were within the normal range in another follow-up study of 23 children and 23 case-matched controls at the Hospital for Sick Children (Pediatr. Pulmonol. 2006;41:522-9).

Echocardiography revealed that "they actually had very good myocardial function but, as expected, a smaller pulmonary artery on the affected side," Dr. Solomon said. Pulmonary function testing revealed abnormalities even 10-16 years after treatment, she added, but FEV₁ was in the normal range. For example, mean FEV₁ as percent predicted was 83% in patients versus 98% in controls; mean RV/TLC ratio was 31% in patients versus 22% in controls.

Some degree of obstructive disease is common among survivors. Airway hyperactivity with asthmalike symptoms, for example, can last well into adulthood, Dr. Solomon said. It is sometimes difficult to determine who should be prescribed bronchodilators, she added. The 2009 study in the Netherlands found that 28% of affected children responded to these agents, compared with 6% of controls.

Musculoskeletal abnormalities such as scoliosis, pectus excavatum, and chest wall asymmetry develop in almost one-third of patients, Dr. Solomon said. "This often bothers the family as the respiratory issues resolve. It’s important to warn them in advance."

Long-term neurocognitive function remains unclear, and sensorineural hearing loss and its association with congenital diaphragmatic hernia are controversial (Int. J. Pediatr. Otorhinolaryngol. 2010;74:1176-9). Because such hearing loss occurs both in those who undergo extracorporeal membrane oxygenation and in those who don’t, the underlying etiology remains unknown, she said.

Another unanswered question is whether patch repair or video-assisted thoracic surgery (VATS) yields better long-term outcomes, Dr. Solomon said. Although many studies in the literature point to a higher recurrence rate with patch repairs, at her institution, "VATS has a much higher incidence of recurrence."

Congenital diaphragmatic hernia occurs in about 1 in every 3,000 live births. About 85% are left sided, the classic posterolateral Bochdalek hernia. Comorbidities affect approximately 40%-50% of these children; congenital heart disease, in particular, is associated with an increased risk of mortality.

Dr. Solomon said she had no relevant financial disclosures.

FORT LAUDERDALE, FLA. – More children are achieving long-term survival following repair of a congenital diaphragmatic hernia, but "this new group of survivors does not appear to have much greater sequelae," Dr. Melinda Solomon said.

For example, despite early pulmonary hypertension and decreased pulmonary artery size, their cardiac function tends to be normal in adulthood. Exercise impairments tend to be mild as well, Dr. Solomon said at a seminar on pediatric pulmonology sponsored by the American College of Chest Physicians and the American Academy of Pediatrics.

"The issue used to be: Can we get these patients to survive and make it to adulthood?" Dr. Solomon said.

They are not entirely free of adverse sequelae, however; obstructive findings and the incidence of asthmalike symptoms can be significantly increased in this population, according to long-term follow-up studies. Recurrence of the hernia is also a lifelong concern, said Dr. Solomon of the division of respiratory medicine at the Hospital for Sick Children in Toronto.

In a long-term follow-up study done in the Netherlands, mean forced expiratory volume in 1 second (FEV₁) was significantly lower among 53 survivors at –1.63, compared with 0.08 among controls (Eur. J. Respir. 2009;34:1140-7). "Prebronchodilatation, the FEV₁ was below the lower limit of normal in 46% of patients but not in controls," Dr. Solomon said. The residual volume/total lung capacity (RV/TLC) ratio exceeded the upper limit of normal in 52% of affected children and in none of the controls, a significant difference.

The same study did not reveal a difference in exercise performance between groups. "This is good news" that children with congenital diaphragmatic hernia can have normal exercise capacity in adulthood, Dr. Solomon said.

All cardiac indexes from exercise testing were within the normal range in another follow-up study of 23 children and 23 case-matched controls at the Hospital for Sick Children (Pediatr. Pulmonol. 2006;41:522-9).

Echocardiography revealed that "they actually had very good myocardial function but, as expected, a smaller pulmonary artery on the affected side," Dr. Solomon said. Pulmonary function testing revealed abnormalities even 10-16 years after treatment, she added, but FEV₁ was in the normal range. For example, mean FEV₁ as percent predicted was 83% in patients versus 98% in controls; mean RV/TLC ratio was 31% in patients versus 22% in controls.

Some degree of obstructive disease is common among survivors. Airway hyperactivity with asthmalike symptoms, for example, can last well into adulthood, Dr. Solomon said. It is sometimes difficult to determine who should be prescribed bronchodilators, she added. The 2009 study in the Netherlands found that 28% of affected children responded to these agents, compared with 6% of controls.

Musculoskeletal abnormalities such as scoliosis, pectus excavatum, and chest wall asymmetry develop in almost one-third of patients, Dr. Solomon said. "This often bothers the family as the respiratory issues resolve. It’s important to warn them in advance."

Long-term neurocognitive function remains unclear, and sensorineural hearing loss and its association with congenital diaphragmatic hernia are controversial (Int. J. Pediatr. Otorhinolaryngol. 2010;74:1176-9). Because such hearing loss occurs both in those who undergo extracorporeal membrane oxygenation and in those who don’t, the underlying etiology remains unknown, she said.

Another unanswered question is whether patch repair or video-assisted thoracic surgery (VATS) yields better long-term outcomes, Dr. Solomon said. Although many studies in the literature point to a higher recurrence rate with patch repairs, at her institution, "VATS has a much higher incidence of recurrence."

Congenital diaphragmatic hernia occurs in about 1 in every 3,000 live births. About 85% are left sided, the classic posterolateral Bochdalek hernia. Comorbidities affect approximately 40%-50% of these children; congenital heart disease, in particular, is associated with an increased risk of mortality.

Dr. Solomon said she had no relevant financial disclosures.

FORT LAUDERDALE, FLA. – More children are achieving long-term survival following repair of a congenital diaphragmatic hernia, but "this new group of survivors does not appear to have much greater sequelae," Dr. Melinda Solomon said.

For example, despite early pulmonary hypertension and decreased pulmonary artery size, their cardiac function tends to be normal in adulthood. Exercise impairments tend to be mild as well, Dr. Solomon said at a seminar on pediatric pulmonology sponsored by the American College of Chest Physicians and the American Academy of Pediatrics.

"The issue used to be: Can we get these patients to survive and make it to adulthood?" Dr. Solomon said.

They are not entirely free of adverse sequelae, however; obstructive findings and the incidence of asthmalike symptoms can be significantly increased in this population, according to long-term follow-up studies. Recurrence of the hernia is also a lifelong concern, said Dr. Solomon of the division of respiratory medicine at the Hospital for Sick Children in Toronto.

In a long-term follow-up study done in the Netherlands, mean forced expiratory volume in 1 second (FEV₁) was significantly lower among 53 survivors at –1.63, compared with 0.08 among controls (Eur. J. Respir. 2009;34:1140-7). "Prebronchodilatation, the FEV₁ was below the lower limit of normal in 46% of patients but not in controls," Dr. Solomon said. The residual volume/total lung capacity (RV/TLC) ratio exceeded the upper limit of normal in 52% of affected children and in none of the controls, a significant difference.

The same study did not reveal a difference in exercise performance between groups. "This is good news" that children with congenital diaphragmatic hernia can have normal exercise capacity in adulthood, Dr. Solomon said.

All cardiac indexes from exercise testing were within the normal range in another follow-up study of 23 children and 23 case-matched controls at the Hospital for Sick Children (Pediatr. Pulmonol. 2006;41:522-9).

Echocardiography revealed that "they actually had very good myocardial function but, as expected, a smaller pulmonary artery on the affected side," Dr. Solomon said. Pulmonary function testing revealed abnormalities even 10-16 years after treatment, she added, but FEV₁ was in the normal range. For example, mean FEV₁ as percent predicted was 83% in patients versus 98% in controls; mean RV/TLC ratio was 31% in patients versus 22% in controls.

Some degree of obstructive disease is common among survivors. Airway hyperactivity with asthmalike symptoms, for example, can last well into adulthood, Dr. Solomon said. It is sometimes difficult to determine who should be prescribed bronchodilators, she added. The 2009 study in the Netherlands found that 28% of affected children responded to these agents, compared with 6% of controls.

Musculoskeletal abnormalities such as scoliosis, pectus excavatum, and chest wall asymmetry develop in almost one-third of patients, Dr. Solomon said. "This often bothers the family as the respiratory issues resolve. It’s important to warn them in advance."

Long-term neurocognitive function remains unclear, and sensorineural hearing loss and its association with congenital diaphragmatic hernia are controversial (Int. J. Pediatr. Otorhinolaryngol. 2010;74:1176-9). Because such hearing loss occurs both in those who undergo extracorporeal membrane oxygenation and in those who don’t, the underlying etiology remains unknown, she said.

Another unanswered question is whether patch repair or video-assisted thoracic surgery (VATS) yields better long-term outcomes, Dr. Solomon said. Although many studies in the literature point to a higher recurrence rate with patch repairs, at her institution, "VATS has a much higher incidence of recurrence."

Congenital diaphragmatic hernia occurs in about 1 in every 3,000 live births. About 85% are left sided, the classic posterolateral Bochdalek hernia. Comorbidities affect approximately 40%-50% of these children; congenital heart disease, in particular, is associated with an increased risk of mortality.

Dr. Solomon said she had no relevant financial disclosures.

FORT LAUDERDALE, FLA. – More children are achieving long-term survival following repair of a congenital diaphragmatic hernia, but "this new group of survivors does not appear to have much greater sequelae," Dr. Melinda Solomon said.

For example, despite early pulmonary hypertension and decreased pulmonary artery size, their cardiac function tends to be normal in adulthood. Exercise impairments tend to be mild as well, Dr. Solomon said at a seminar on pediatric pulmonology sponsored by the American College of Chest Physicians and the American Academy of Pediatrics.

"The issue used to be: Can we get these patients to survive and make it to adulthood?" Dr. Solomon said.

They are not entirely free of adverse sequelae, however; obstructive findings and the incidence of asthmalike symptoms can be significantly increased in this population, according to long-term follow-up studies. Recurrence of the hernia is also a lifelong concern, said Dr. Solomon of the division of respiratory medicine at the Hospital for Sick Children in Toronto.

In a long-term follow-up study done in the Netherlands, mean forced expiratory volume in 1 second (FEV₁) was significantly lower among 53 survivors at –1.63, compared with 0.08 among controls (Eur. J. Respir. 2009;34:1140-7). "Prebronchodilatation, the FEV₁ was below the lower limit of normal in 46% of patients but not in controls," Dr. Solomon said. The residual volume/total lung capacity (RV/TLC) ratio exceeded the upper limit of normal in 52% of affected children and in none of the controls, a significant difference.

The same study did not reveal a difference in exercise performance between groups. "This is good news" that children with congenital diaphragmatic hernia can have normal exercise capacity in adulthood, Dr. Solomon said.

All cardiac indexes from exercise testing were within the normal range in another follow-up study of 23 children and 23 case-matched controls at the Hospital for Sick Children (Pediatr. Pulmonol. 2006;41:522-9).

Echocardiography revealed that "they actually had very good myocardial function but, as expected, a smaller pulmonary artery on the affected side," Dr. Solomon said. Pulmonary function testing revealed abnormalities even 10-16 years after treatment, she added, but FEV₁ was in the normal range. For example, mean FEV₁ as percent predicted was 83% in patients versus 98% in controls; mean RV/TLC ratio was 31% in patients versus 22% in controls.

Some degree of obstructive disease is common among survivors. Airway hyperactivity with asthmalike symptoms, for example, can last well into adulthood, Dr. Solomon said. It is sometimes difficult to determine who should be prescribed bronchodilators, she added. The 2009 study in the Netherlands found that 28% of affected children responded to these agents, compared with 6% of controls.

Musculoskeletal abnormalities such as scoliosis, pectus excavatum, and chest wall asymmetry develop in almost one-third of patients, Dr. Solomon said. "This often bothers the family as the respiratory issues resolve. It’s important to warn them in advance."

Long-term neurocognitive function remains unclear, and sensorineural hearing loss and its association with congenital diaphragmatic hernia are controversial (Int. J. Pediatr. Otorhinolaryngol. 2010;74:1176-9). Because such hearing loss occurs both in those who undergo extracorporeal membrane oxygenation and in those who don’t, the underlying etiology remains unknown, she said.

Another unanswered question is whether patch repair or video-assisted thoracic surgery (VATS) yields better long-term outcomes, Dr. Solomon said. Although many studies in the literature point to a higher recurrence rate with patch repairs, at her institution, "VATS has a much higher incidence of recurrence."

Congenital diaphragmatic hernia occurs in about 1 in every 3,000 live births. About 85% are left sided, the classic posterolateral Bochdalek hernia. Comorbidities affect approximately 40%-50% of these children; congenital heart disease, in particular, is associated with an increased risk of mortality.

Dr. Solomon said she had no relevant financial disclosures.

FORT LAUDERDALE, FLA. – More children are achieving long-term survival following repair of a congenital diaphragmatic hernia, but "this new group of survivors does not appear to have much greater sequelae," Dr. Melinda Solomon said.

For example, despite early pulmonary hypertension and decreased pulmonary artery size, their cardiac function tends to be normal in adulthood. Exercise impairments tend to be mild as well, Dr. Solomon said at a seminar on pediatric pulmonology sponsored by the American College of Chest Physicians and the American Academy of Pediatrics.

"The issue used to be: Can we get these patients to survive and make it to adulthood?" Dr. Solomon said.

They are not entirely free of adverse sequelae, however; obstructive findings and the incidence of asthmalike symptoms can be significantly increased in this population, according to long-term follow-up studies. Recurrence of the hernia is also a lifelong concern, said Dr. Solomon of the division of respiratory medicine at the Hospital for Sick Children in Toronto.

In a long-term follow-up study done in the Netherlands, mean forced expiratory volume in 1 second (FEV₁) was significantly lower among 53 survivors at –1.63, compared with 0.08 among controls (Eur. J. Respir. 2009;34:1140-7). "Prebronchodilatation, the FEV₁ was below the lower limit of normal in 46% of patients but not in controls," Dr. Solomon said. The residual volume/total lung capacity (RV/TLC) ratio exceeded the upper limit of normal in 52% of affected children and in none of the controls, a significant difference.

The same study did not reveal a difference in exercise performance between groups. "This is good news" that children with congenital diaphragmatic hernia can have normal exercise capacity in adulthood, Dr. Solomon said.

All cardiac indexes from exercise testing were within the normal range in another follow-up study of 23 children and 23 case-matched controls at the Hospital for Sick Children (Pediatr. Pulmonol. 2006;41:522-9).

Echocardiography revealed that "they actually had very good myocardial function but, as expected, a smaller pulmonary artery on the affected side," Dr. Solomon said. Pulmonary function testing revealed abnormalities even 10-16 years after treatment, she added, but FEV₁ was in the normal range. For example, mean FEV₁ as percent predicted was 83% in patients versus 98% in controls; mean RV/TLC ratio was 31% in patients versus 22% in controls.

Some degree of obstructive disease is common among survivors. Airway hyperactivity with asthmalike symptoms, for example, can last well into adulthood, Dr. Solomon said. It is sometimes difficult to determine who should be prescribed bronchodilators, she added. The 2009 study in the Netherlands found that 28% of affected children responded to these agents, compared with 6% of controls.

Musculoskeletal abnormalities such as scoliosis, pectus excavatum, and chest wall asymmetry develop in almost one-third of patients, Dr. Solomon said. "This often bothers the family as the respiratory issues resolve. It’s important to warn them in advance."

Long-term neurocognitive function remains unclear, and sensorineural hearing loss and its association with congenital diaphragmatic hernia are controversial (Int. J. Pediatr. Otorhinolaryngol. 2010;74:1176-9). Because such hearing loss occurs both in those who undergo extracorporeal membrane oxygenation and in those who don’t, the underlying etiology remains unknown, she said.

Another unanswered question is whether patch repair or video-assisted thoracic surgery (VATS) yields better long-term outcomes, Dr. Solomon said. Although many studies in the literature point to a higher recurrence rate with patch repairs, at her institution, "VATS has a much higher incidence of recurrence."

Congenital diaphragmatic hernia occurs in about 1 in every 3,000 live births. About 85% are left sided, the classic posterolateral Bochdalek hernia. Comorbidities affect approximately 40%-50% of these children; congenital heart disease, in particular, is associated with an increased risk of mortality.

Dr. Solomon said she had no relevant financial disclosures.

FORT LAUDERDALE, FLA. – More children are achieving long-term survival following repair of a congenital diaphragmatic hernia, but "this new group of survivors does not appear to have much greater sequelae," Dr. Melinda Solomon said.

For example, despite early pulmonary hypertension and decreased pulmonary artery size, their cardiac function tends to be normal in adulthood. Exercise impairments tend to be mild as well, Dr. Solomon said at a seminar on pediatric pulmonology sponsored by the American College of Chest Physicians and the American Academy of Pediatrics.

"The issue used to be: Can we get these patients to survive and make it to adulthood?" Dr. Solomon said.

They are not entirely free of adverse sequelae, however; obstructive findings and the incidence of asthmalike symptoms can be significantly increased in this population, according to long-term follow-up studies. Recurrence of the hernia is also a lifelong concern, said Dr. Solomon of the division of respiratory medicine at the Hospital for Sick Children in Toronto.

In a long-term follow-up study done in the Netherlands, mean forced expiratory volume in 1 second (FEV₁) was significantly lower among 53 survivors at –1.63, compared with 0.08 among controls (Eur. J. Respir. 2009;34:1140-7). "Prebronchodilatation, the FEV₁ was below the lower limit of normal in 46% of patients but not in controls," Dr. Solomon said. The residual volume/total lung capacity (RV/TLC) ratio exceeded the upper limit of normal in 52% of affected children and in none of the controls, a significant difference.

The same study did not reveal a difference in exercise performance between groups. "This is good news" that children with congenital diaphragmatic hernia can have normal exercise capacity in adulthood, Dr. Solomon said.

All cardiac indexes from exercise testing were within the normal range in another follow-up study of 23 children and 23 case-matched controls at the Hospital for Sick Children (Pediatr. Pulmonol. 2006;41:522-9).

Echocardiography revealed that "they actually had very good myocardial function but, as expected, a smaller pulmonary artery on the affected side," Dr. Solomon said. Pulmonary function testing revealed abnormalities even 10-16 years after treatment, she added, but FEV₁ was in the normal range. For example, mean FEV₁ as percent predicted was 83% in patients versus 98% in controls; mean RV/TLC ratio was 31% in patients versus 22% in controls.

Some degree of obstructive disease is common among survivors. Airway hyperactivity with asthmalike symptoms, for example, can last well into adulthood, Dr. Solomon said. It is sometimes difficult to determine who should be prescribed bronchodilators, she added. The 2009 study in the Netherlands found that 28% of affected children responded to these agents, compared with 6% of controls.

Musculoskeletal abnormalities such as scoliosis, pectus excavatum, and chest wall asymmetry develop in almost one-third of patients, Dr. Solomon said. "This often bothers the family as the respiratory issues resolve. It’s important to warn them in advance."

Long-term neurocognitive function remains unclear, and sensorineural hearing loss and its association with congenital diaphragmatic hernia are controversial (Int. J. Pediatr. Otorhinolaryngol. 2010;74:1176-9). Because such hearing loss occurs both in those who undergo extracorporeal membrane oxygenation and in those who don’t, the underlying etiology remains unknown, she said.

Another unanswered question is whether patch repair or video-assisted thoracic surgery (VATS) yields better long-term outcomes, Dr. Solomon said. Although many studies in the literature point to a higher recurrence rate with patch repairs, at her institution, "VATS has a much higher incidence of recurrence."

Congenital diaphragmatic hernia occurs in about 1 in every 3,000 live births. About 85% are left sided, the classic posterolateral Bochdalek hernia. Comorbidities affect approximately 40%-50% of these children; congenital heart disease, in particular, is associated with an increased risk of mortality.

Dr. Solomon said she had no relevant financial disclosures.

FORT LAUDERDALE, FLA. – When it’s necessary to mechanically ventilate a child with acute asthma, first stabilize the patient and then set the ventilator optimally to avoid major complications, Dr. Veda L. Ackerman said.

Intubation and initial ventilator set-up are the most critical times and require a high level of clinical skill, Dr. Ackerman said at a symposium on pediatric pulmonology sponsored by the American College of Chest Physicians and the American Academy of Pediatrics.

Supplemental oxygen to maintain saturation above 92% and an inhaled, short-acting beta-2 agonist such as albuterol also are important to lessen an acute asthma exacerbation, Dr. Ackerman said. Administer systemic steroids for all moderate to severe episodes that do not respond completely to beta-2 agonists, she said. Also consider adding the anticholinergic ipratropium bromide to combat any moderate to severe asthma attack.

This is standard of care in most emergency departments, but some children need more, Dr. Ackerman said.

The next step is intubation. "I had not seen a child with asthma intubated for years until the economy sank a few years ago. Then I saw three or four kids who died because they had not been taking their meds" and had acute episodes, said Dr. Ackerman, a pediatric intensivist at Riley Hospital for Children, Indianapolis.

Your decision to intubate or not to intubate relies on your clinical judgment, not on any specific pH or partial pressure of carbon dioxide (PaCO₂), Dr. Ackerman said. Keep in mind that generally fewer than 10% of children admitted to a pediatric ICU for severe asthma require intubation. Absolute indications include cardiopulmonary arrest, obtundation, profound hypoxemia unresponsive to therapy, and mixed respiratory and metabolic acidosis.

Once you decide to intubate, there is only a minimal margin of error if the child is hypoxic, acidotic, and fatigued, Dr. Ackerman said. An effective rapid sequence intubation relies on preoxygenation with 100% oxygen using a facemask during spontaneous breathing and a combination of ketamine and a benzodiazepine for sedation and analgesia. "Avoid assisted breathing with an Ambu bag until the tube is placed, or you will have emesis or worsening of your air trapping." Also consider use of a cuffed endotracheal tube because some children require high ventilatory pressures in the ICU.

In the "next critical 5 minutes" after intubation, a natural tendency for many clinicians may be to hyperventilate the patient using a self-inflating bag valve mask resuscitator such as an Ambu bag. This is ill advised, Dr. Ackerman said. "In the asthmatic child, this will impede exhalation, leading to worsening hypercapnia and acidosis with potential cardiac collapse, as well as increased risk of barotrauma due to worsening hyperinflation," she said.

"Eventually, the best thing is to put them on a ventilator," Dr. Ackerman said. Reversal of hypoxemia, relief of respiratory muscle fatigue, and allowing enough time for inflammation and bronchospasm to respond to systemic steroids and bronchodilator therapy are among the goals of ventilation. "These kids are exhausted and need to rest."

Initial ventilator settings are based on physician choice. Most clinicians use volume control, although pressure control can be used instead to leak peak pressure, Dr. Ackerman said. Assist control or pressure-regulated volume control are other ventilator options. "There is no evidence to suggest one mode is superior, provided one understands the specific characteristics of each mode," she said.

"We start at 100% oxygen. There is no reason to worry about hyperoxygenation of a child with asthma," Dr. Ackerman said. Tidal volume is initially set between 8 and 12 mL/kg to achieve adequate chest movement with each ventilator breath and to keep peak pressures below 50. Set the rate below the physiologic breathing rate for the child to allow enough time for the exhalation phase, she advised. The inspiratory-expiratory ratio should be at least 1:4, but may need to go as high as 1:8. "You don’t want to stack the breaths," as barotrauma may result if a breath is not fully exhaled before the subsequent breath starts, she added.

Permissive hypercapnia is another strategy to minimize risk of barotrauma. "CO₂ is not going to hurt the child if the pH is at a normal level," Dr. Ackerman said. Limited duration, permissive hypercapnia is accomplished by reducing tidal volume to 7 mL/kg or less, keeping peak airway pressure a maximum of 40 cm H₂O, and allowing PaCO₂ to rise no more than 10 mm Hg per hour up to a maximum of 80-100 mm Hg. At the same time, maintain oxygen saturation above 90%, allow at least 4 seconds for expiration, and set low minute ventilation (10 L/min or less) and low respiratory rate (fewer than 10 breaths per minute) (Intensive Care Med. 2006;32:501-10).

In addition to barotrauma, monitor patients for any signs of ventilator-associated pneumonia, massive gastrointestinal bleeding, and hypotension and circulatory compromise from poor venous return, Dr. Ackerman said. "If there is an acute change, think pneumothorax unless proven otherwise."

Dr. Ackerman said that she had no relevant disclosures.

FORT LAUDERDALE, FLA. – When it’s necessary to mechanically ventilate a child with acute asthma, first stabilize the patient and then set the ventilator optimally to avoid major complications, Dr. Veda L. Ackerman said.

Intubation and initial ventilator set-up are the most critical times and require a high level of clinical skill, Dr. Ackerman said at a symposium on pediatric pulmonology sponsored by the American College of Chest Physicians and the American Academy of Pediatrics.

Supplemental oxygen to maintain saturation above 92% and an inhaled, short-acting beta-2 agonist such as albuterol also are important to lessen an acute asthma exacerbation, Dr. Ackerman said. Administer systemic steroids for all moderate to severe episodes that do not respond completely to beta-2 agonists, she said. Also consider adding the anticholinergic ipratropium bromide to combat any moderate to severe asthma attack.

This is standard of care in most emergency departments, but some children need more, Dr. Ackerman said.

The next step is intubation. "I had not seen a child with asthma intubated for years until the economy sank a few years ago. Then I saw three or four kids who died because they had not been taking their meds" and had acute episodes, said Dr. Ackerman, a pediatric intensivist at Riley Hospital for Children, Indianapolis.

Your decision to intubate or not to intubate relies on your clinical judgment, not on any specific pH or partial pressure of carbon dioxide (PaCO₂), Dr. Ackerman said. Keep in mind that generally fewer than 10% of children admitted to a pediatric ICU for severe asthma require intubation. Absolute indications include cardiopulmonary arrest, obtundation, profound hypoxemia unresponsive to therapy, and mixed respiratory and metabolic acidosis.

Once you decide to intubate, there is only a minimal margin of error if the child is hypoxic, acidotic, and fatigued, Dr. Ackerman said. An effective rapid sequence intubation relies on preoxygenation with 100% oxygen using a facemask during spontaneous breathing and a combination of ketamine and a benzodiazepine for sedation and analgesia. "Avoid assisted breathing with an Ambu bag until the tube is placed, or you will have emesis or worsening of your air trapping." Also consider use of a cuffed endotracheal tube because some children require high ventilatory pressures in the ICU.

In the "next critical 5 minutes" after intubation, a natural tendency for many clinicians may be to hyperventilate the patient using a self-inflating bag valve mask resuscitator such as an Ambu bag. This is ill advised, Dr. Ackerman said. "In the asthmatic child, this will impede exhalation, leading to worsening hypercapnia and acidosis with potential cardiac collapse, as well as increased risk of barotrauma due to worsening hyperinflation," she said.

"Eventually, the best thing is to put them on a ventilator," Dr. Ackerman said. Reversal of hypoxemia, relief of respiratory muscle fatigue, and allowing enough time for inflammation and bronchospasm to respond to systemic steroids and bronchodilator therapy are among the goals of ventilation. "These kids are exhausted and need to rest."

Initial ventilator settings are based on physician choice. Most clinicians use volume control, although pressure control can be used instead to leak peak pressure, Dr. Ackerman said. Assist control or pressure-regulated volume control are other ventilator options. "There is no evidence to suggest one mode is superior, provided one understands the specific characteristics of each mode," she said.

"We start at 100% oxygen. There is no reason to worry about hyperoxygenation of a child with asthma," Dr. Ackerman said. Tidal volume is initially set between 8 and 12 mL/kg to achieve adequate chest movement with each ventilator breath and to keep peak pressures below 50. Set the rate below the physiologic breathing rate for the child to allow enough time for the exhalation phase, she advised. The inspiratory-expiratory ratio should be at least 1:4, but may need to go as high as 1:8. "You don’t want to stack the breaths," as barotrauma may result if a breath is not fully exhaled before the subsequent breath starts, she added.

Permissive hypercapnia is another strategy to minimize risk of barotrauma. "CO₂ is not going to hurt the child if the pH is at a normal level," Dr. Ackerman said. Limited duration, permissive hypercapnia is accomplished by reducing tidal volume to 7 mL/kg or less, keeping peak airway pressure a maximum of 40 cm H₂O, and allowing PaCO₂ to rise no more than 10 mm Hg per hour up to a maximum of 80-100 mm Hg. At the same time, maintain oxygen saturation above 90%, allow at least 4 seconds for expiration, and set low minute ventilation (10 L/min or less) and low respiratory rate (fewer than 10 breaths per minute) (Intensive Care Med. 2006;32:501-10).

In addition to barotrauma, monitor patients for any signs of ventilator-associated pneumonia, massive gastrointestinal bleeding, and hypotension and circulatory compromise from poor venous return, Dr. Ackerman said. "If there is an acute change, think pneumothorax unless proven otherwise."

Dr. Ackerman said that she had no relevant disclosures.

FORT LAUDERDALE, FLA. – When it’s necessary to mechanically ventilate a child with acute asthma, first stabilize the patient and then set the ventilator optimally to avoid major complications, Dr. Veda L. Ackerman said.

Intubation and initial ventilator set-up are the most critical times and require a high level of clinical skill, Dr. Ackerman said at a symposium on pediatric pulmonology sponsored by the American College of Chest Physicians and the American Academy of Pediatrics.

Supplemental oxygen to maintain saturation above 92% and an inhaled, short-acting beta-2 agonist such as albuterol also are important to lessen an acute asthma exacerbation, Dr. Ackerman said. Administer systemic steroids for all moderate to severe episodes that do not respond completely to beta-2 agonists, she said. Also consider adding the anticholinergic ipratropium bromide to combat any moderate to severe asthma attack.

This is standard of care in most emergency departments, but some children need more, Dr. Ackerman said.

The next step is intubation. "I had not seen a child with asthma intubated for years until the economy sank a few years ago. Then I saw three or four kids who died because they had not been taking their meds" and had acute episodes, said Dr. Ackerman, a pediatric intensivist at Riley Hospital for Children, Indianapolis.

Your decision to intubate or not to intubate relies on your clinical judgment, not on any specific pH or partial pressure of carbon dioxide (PaCO₂), Dr. Ackerman said. Keep in mind that generally fewer than 10% of children admitted to a pediatric ICU for severe asthma require intubation. Absolute indications include cardiopulmonary arrest, obtundation, profound hypoxemia unresponsive to therapy, and mixed respiratory and metabolic acidosis.

Once you decide to intubate, there is only a minimal margin of error if the child is hypoxic, acidotic, and fatigued, Dr. Ackerman said. An effective rapid sequence intubation relies on preoxygenation with 100% oxygen using a facemask during spontaneous breathing and a combination of ketamine and a benzodiazepine for sedation and analgesia. "Avoid assisted breathing with an Ambu bag until the tube is placed, or you will have emesis or worsening of your air trapping." Also consider use of a cuffed endotracheal tube because some children require high ventilatory pressures in the ICU.

In the "next critical 5 minutes" after intubation, a natural tendency for many clinicians may be to hyperventilate the patient using a self-inflating bag valve mask resuscitator such as an Ambu bag. This is ill advised, Dr. Ackerman said. "In the asthmatic child, this will impede exhalation, leading to worsening hypercapnia and acidosis with potential cardiac collapse, as well as increased risk of barotrauma due to worsening hyperinflation," she said.

"Eventually, the best thing is to put them on a ventilator," Dr. Ackerman said. Reversal of hypoxemia, relief of respiratory muscle fatigue, and allowing enough time for inflammation and bronchospasm to respond to systemic steroids and bronchodilator therapy are among the goals of ventilation. "These kids are exhausted and need to rest."

Initial ventilator settings are based on physician choice. Most clinicians use volume control, although pressure control can be used instead to leak peak pressure, Dr. Ackerman said. Assist control or pressure-regulated volume control are other ventilator options. "There is no evidence to suggest one mode is superior, provided one understands the specific characteristics of each mode," she said.

"We start at 100% oxygen. There is no reason to worry about hyperoxygenation of a child with asthma," Dr. Ackerman said. Tidal volume is initially set between 8 and 12 mL/kg to achieve adequate chest movement with each ventilator breath and to keep peak pressures below 50. Set the rate below the physiologic breathing rate for the child to allow enough time for the exhalation phase, she advised. The inspiratory-expiratory ratio should be at least 1:4, but may need to go as high as 1:8. "You don’t want to stack the breaths," as barotrauma may result if a breath is not fully exhaled before the subsequent breath starts, she added.

Permissive hypercapnia is another strategy to minimize risk of barotrauma. "CO₂ is not going to hurt the child if the pH is at a normal level," Dr. Ackerman said. Limited duration, permissive hypercapnia is accomplished by reducing tidal volume to 7 mL/kg or less, keeping peak airway pressure a maximum of 40 cm H₂O, and allowing PaCO₂ to rise no more than 10 mm Hg per hour up to a maximum of 80-100 mm Hg. At the same time, maintain oxygen saturation above 90%, allow at least 4 seconds for expiration, and set low minute ventilation (10 L/min or less) and low respiratory rate (fewer than 10 breaths per minute) (Intensive Care Med. 2006;32:501-10).

In addition to barotrauma, monitor patients for any signs of ventilator-associated pneumonia, massive gastrointestinal bleeding, and hypotension and circulatory compromise from poor venous return, Dr. Ackerman said. "If there is an acute change, think pneumothorax unless proven otherwise."

Dr. Ackerman said that she had no relevant disclosures.

FORT LAUDERDALE, FLA. – Despite a lack of definitive evidence, airway clearance strategies are commonly employed in children with cystic fibrosis and other lung diseases, Dr. Veda L. Ackerman said.

"Unfortunately, we don’t really know very much about airway clearance. We do it a lot, but we don’t have a lot of data," Dr. Ackerman said at a seminar on pediatric pulmonology, which was sponsored by the American College of Chest Physicians and the American Academy of Pediatrics.

For instance, the only pediatric study comparing airway clearance to no such therapy was published in 1983 and assessed eight patients with cystic fibrosis (J. Pediatr. 2003;103:538-42).

"Intuitively and intellectually, airway clearance makes a lot of sense. But [it is important to] think about whether we are helping or hurting when we prescribe airway clearance," said Dr. Ackerman, a pediatric intensivist at Riley Hospital for Children and a pediatric pulmonologist in private practice in Indianapolis.

Oxygen desaturation, gastroesophageal reflux, aspiration, hyperventilation, and "guilt for the family from lack of adherence" are potential adverse events associated with prescription of airway clearance, Dr. Ackerman said.

There are "no data to support the use of one airway clearance technique over the other," Dr. Ackerman said. Chest physiotherapy (CPT), positive expiratory pressure (PEP) valve, Cardinal Health’s Flutter device, Smiths Medical’s Acapella system, Medical Acoustics’ Lung Flute device, airway clearance vests, and Smiths Medical’s EzPAP device are among the options.

No definitive data exist to support use of CPT in an asymptomatic child with cystic fibrosis, Dr. Ackerman said. This patient population is prone to adverse events, especially gastroesophageal reflux with or without aspiration. CPT also requires a significant time commitment on the part of families. Despite these concerns, "I still do recommend it" for some patients.

Airway clearance devices "jiggle, shake, or use sound waves to loosen mucus off the airway walls so secretions can be coughed up," Dr. Ackerman said. Success with these devices is often technique dependent.

The PEP valve is portable, takes 10-15 minutes to clear the airway, and can be used with aerosolized medications. However, Dr. Ackerman’s institution uses the Flutter "much more than the PEP valve," she said. This device "tends to be used for families who cannot put time into CPT or when the child goes to Grandma’s or on a sleepover." The device loosens mucus through expiratory oscillation, so it may be less effective at lower airflows, such as those used for small children or patients with more severe lung disease. The device has to be held at a precise angle to maximize oscillation, she added. Each use of the Flutter device takes about 10-15 minutes.

The Acapella system combines the benefits of the PEP valve and airway vibrations to mobilize secretions, Dr. Ackerman said. The mechanism of action is similar to that of the Flutter, except that the Acapella has a valve-magnet device to interrupt expiratory flow and thus can be used at any angle.

"All of these devices cost less than $100," Dr. Ackerman said. "These may – and I said may – be better than doing nothing at all."

Contraindications to the PEP valve, Flutter, and Acapella include pneumothorax, hemoptysis, and esophageal varices. Lung surgery is another contraindication, Dr. Ackerman said, because use of airway-clearance devices can cause an air leak or can break down an anastomosis site. A pulmonary embolus is another contraindication, but "fortunately we do not see this often in pediatrics." A perforated ear drum is also a contraindication to these airway devices "because it causes pain."

The Lung Flute uses a different strategy (acoustic waves) to increase mucociliary clearance. It vibrates the chest in a way that is similar to the way a reed instrument vibrates when it’s played, Dr. Ackerman said. "There are no pediatric data, but it is cheap and easy to use." The Lung Flute is used more commonly for patients with chronic obstructive pulmonary disorder and not as much in cystic fibrosis.

Airway clearance vests deliver pulses of air pressure to the chest wall. The vest loosens mucus through shearing at the air/mucus interface, and compression causes clearance through repetitive peak expiratory flows that expel mucus like small coughs.

"You should not get compression of the airway itself; only the chest wall is compressed," Dr. Ackerman said. In contrast, "if you blow hard enough with the Acapella, Flutter, or PEP, you could get airway collapse." An airway clearance vest costs approximately $10,000, and obtaining insurance approval can be difficult; reimbursement policies vary from state to state.

The EzPAP device clears airways through positive airway pressure in a way that is similar to intermittent positive pressure breathing. It is approved by the Food and Drug Administration for lung expansion therapy and the prevention and treatment of atelectasis. Although no peer-reviewed data are available, many children are using EzPAP because respiratory therapists believe in this device, Dr. Ackerman said.

For more information, Dr. Ackerman recommended the American College of Chest Physicians’ Evidence-Based Guidelines for Nonpharmacologic Airway Clearance Therapies (Chest 2006;129:250S-9S), which were published in 2006 but are still applicable in 2011, she added.

Dr. Ackerman said that she had no relevant financial disclosures.

FORT LAUDERDALE, FLA. – Despite a lack of definitive evidence, airway clearance strategies are commonly employed in children with cystic fibrosis and other lung diseases, Dr. Veda L. Ackerman said.

"Unfortunately, we don’t really know very much about airway clearance. We do it a lot, but we don’t have a lot of data," Dr. Ackerman said at a seminar on pediatric pulmonology, which was sponsored by the American College of Chest Physicians and the American Academy of Pediatrics.

For instance, the only pediatric study comparing airway clearance to no such therapy was published in 1983 and assessed eight patients with cystic fibrosis (J. Pediatr. 2003;103:538-42).

"Intuitively and intellectually, airway clearance makes a lot of sense. But [it is important to] think about whether we are helping or hurting when we prescribe airway clearance," said Dr. Ackerman, a pediatric intensivist at Riley Hospital for Children and a pediatric pulmonologist in private practice in Indianapolis.

Oxygen desaturation, gastroesophageal reflux, aspiration, hyperventilation, and "guilt for the family from lack of adherence" are potential adverse events associated with prescription of airway clearance, Dr. Ackerman said.

There are "no data to support the use of one airway clearance technique over the other," Dr. Ackerman said. Chest physiotherapy (CPT), positive expiratory pressure (PEP) valve, Cardinal Health’s Flutter device, Smiths Medical’s Acapella system, Medical Acoustics’ Lung Flute device, airway clearance vests, and Smiths Medical’s EzPAP device are among the options.

No definitive data exist to support use of CPT in an asymptomatic child with cystic fibrosis, Dr. Ackerman said. This patient population is prone to adverse events, especially gastroesophageal reflux with or without aspiration. CPT also requires a significant time commitment on the part of families. Despite these concerns, "I still do recommend it" for some patients.

Airway clearance devices "jiggle, shake, or use sound waves to loosen mucus off the airway walls so secretions can be coughed up," Dr. Ackerman said. Success with these devices is often technique dependent.

The PEP valve is portable, takes 10-15 minutes to clear the airway, and can be used with aerosolized medications. However, Dr. Ackerman’s institution uses the Flutter "much more than the PEP valve," she said. This device "tends to be used for families who cannot put time into CPT or when the child goes to Grandma’s or on a sleepover." The device loosens mucus through expiratory oscillation, so it may be less effective at lower airflows, such as those used for small children or patients with more severe lung disease. The device has to be held at a precise angle to maximize oscillation, she added. Each use of the Flutter device takes about 10-15 minutes.

The Acapella system combines the benefits of the PEP valve and airway vibrations to mobilize secretions, Dr. Ackerman said. The mechanism of action is similar to that of the Flutter, except that the Acapella has a valve-magnet device to interrupt expiratory flow and thus can be used at any angle.

"All of these devices cost less than $100," Dr. Ackerman said. "These may – and I said may – be better than doing nothing at all."

Contraindications to the PEP valve, Flutter, and Acapella include pneumothorax, hemoptysis, and esophageal varices. Lung surgery is another contraindication, Dr. Ackerman said, because use of airway-clearance devices can cause an air leak or can break down an anastomosis site. A pulmonary embolus is another contraindication, but "fortunately we do not see this often in pediatrics." A perforated ear drum is also a contraindication to these airway devices "because it causes pain."

The Lung Flute uses a different strategy (acoustic waves) to increase mucociliary clearance. It vibrates the chest in a way that is similar to the way a reed instrument vibrates when it’s played, Dr. Ackerman said. "There are no pediatric data, but it is cheap and easy to use." The Lung Flute is used more commonly for patients with chronic obstructive pulmonary disorder and not as much in cystic fibrosis.

Airway clearance vests deliver pulses of air pressure to the chest wall. The vest loosens mucus through shearing at the air/mucus interface, and compression causes clearance through repetitive peak expiratory flows that expel mucus like small coughs.

"You should not get compression of the airway itself; only the chest wall is compressed," Dr. Ackerman said. In contrast, "if you blow hard enough with the Acapella, Flutter, or PEP, you could get airway collapse." An airway clearance vest costs approximately $10,000, and obtaining insurance approval can be difficult; reimbursement policies vary from state to state.

The EzPAP device clears airways through positive airway pressure in a way that is similar to intermittent positive pressure breathing. It is approved by the Food and Drug Administration for lung expansion therapy and the prevention and treatment of atelectasis. Although no peer-reviewed data are available, many children are using EzPAP because respiratory therapists believe in this device, Dr. Ackerman said.

For more information, Dr. Ackerman recommended the American College of Chest Physicians’ Evidence-Based Guidelines for Nonpharmacologic Airway Clearance Therapies (Chest 2006;129:250S-9S), which were published in 2006 but are still applicable in 2011, she added.

Dr. Ackerman said that she had no relevant financial disclosures.

FORT LAUDERDALE, FLA. – Despite a lack of definitive evidence, airway clearance strategies are commonly employed in children with cystic fibrosis and other lung diseases, Dr. Veda L. Ackerman said.

"Unfortunately, we don’t really know very much about airway clearance. We do it a lot, but we don’t have a lot of data," Dr. Ackerman said at a seminar on pediatric pulmonology, which was sponsored by the American College of Chest Physicians and the American Academy of Pediatrics.

For instance, the only pediatric study comparing airway clearance to no such therapy was published in 1983 and assessed eight patients with cystic fibrosis (J. Pediatr. 2003;103:538-42).

"Intuitively and intellectually, airway clearance makes a lot of sense. But [it is important to] think about whether we are helping or hurting when we prescribe airway clearance," said Dr. Ackerman, a pediatric intensivist at Riley Hospital for Children and a pediatric pulmonologist in private practice in Indianapolis.

Oxygen desaturation, gastroesophageal reflux, aspiration, hyperventilation, and "guilt for the family from lack of adherence" are potential adverse events associated with prescription of airway clearance, Dr. Ackerman said.

There are "no data to support the use of one airway clearance technique over the other," Dr. Ackerman said. Chest physiotherapy (CPT), positive expiratory pressure (PEP) valve, Cardinal Health’s Flutter device, Smiths Medical’s Acapella system, Medical Acoustics’ Lung Flute device, airway clearance vests, and Smiths Medical’s EzPAP device are among the options.

No definitive data exist to support use of CPT in an asymptomatic child with cystic fibrosis, Dr. Ackerman said. This patient population is prone to adverse events, especially gastroesophageal reflux with or without aspiration. CPT also requires a significant time commitment on the part of families. Despite these concerns, "I still do recommend it" for some patients.

Airway clearance devices "jiggle, shake, or use sound waves to loosen mucus off the airway walls so secretions can be coughed up," Dr. Ackerman said. Success with these devices is often technique dependent.

The PEP valve is portable, takes 10-15 minutes to clear the airway, and can be used with aerosolized medications. However, Dr. Ackerman’s institution uses the Flutter "much more than the PEP valve," she said. This device "tends to be used for families who cannot put time into CPT or when the child goes to Grandma’s or on a sleepover." The device loosens mucus through expiratory oscillation, so it may be less effective at lower airflows, such as those used for small children or patients with more severe lung disease. The device has to be held at a precise angle to maximize oscillation, she added. Each use of the Flutter device takes about 10-15 minutes.

The Acapella system combines the benefits of the PEP valve and airway vibrations to mobilize secretions, Dr. Ackerman said. The mechanism of action is similar to that of the Flutter, except that the Acapella has a valve-magnet device to interrupt expiratory flow and thus can be used at any angle.

"All of these devices cost less than $100," Dr. Ackerman said. "These may – and I said may – be better than doing nothing at all."

Contraindications to the PEP valve, Flutter, and Acapella include pneumothorax, hemoptysis, and esophageal varices. Lung surgery is another contraindication, Dr. Ackerman said, because use of airway-clearance devices can cause an air leak or can break down an anastomosis site. A pulmonary embolus is another contraindication, but "fortunately we do not see this often in pediatrics." A perforated ear drum is also a contraindication to these airway devices "because it causes pain."

The Lung Flute uses a different strategy (acoustic waves) to increase mucociliary clearance. It vibrates the chest in a way that is similar to the way a reed instrument vibrates when it’s played, Dr. Ackerman said. "There are no pediatric data, but it is cheap and easy to use." The Lung Flute is used more commonly for patients with chronic obstructive pulmonary disorder and not as much in cystic fibrosis.

Airway clearance vests deliver pulses of air pressure to the chest wall. The vest loosens mucus through shearing at the air/mucus interface, and compression causes clearance through repetitive peak expiratory flows that expel mucus like small coughs.

"You should not get compression of the airway itself; only the chest wall is compressed," Dr. Ackerman said. In contrast, "if you blow hard enough with the Acapella, Flutter, or PEP, you could get airway collapse." An airway clearance vest costs approximately $10,000, and obtaining insurance approval can be difficult; reimbursement policies vary from state to state.

The EzPAP device clears airways through positive airway pressure in a way that is similar to intermittent positive pressure breathing. It is approved by the Food and Drug Administration for lung expansion therapy and the prevention and treatment of atelectasis. Although no peer-reviewed data are available, many children are using EzPAP because respiratory therapists believe in this device, Dr. Ackerman said.

For more information, Dr. Ackerman recommended the American College of Chest Physicians’ Evidence-Based Guidelines for Nonpharmacologic Airway Clearance Therapies (Chest 2006;129:250S-9S), which were published in 2006 but are still applicable in 2011, she added.

Dr. Ackerman said that she had no relevant financial disclosures.

FORT LAUDERDALE, FLA. – Despite a lack of definitive evidence, airway clearance strategies are commonly employed in children with cystic fibrosis and other lung diseases, Dr. Veda L. Ackerman said.

"Unfortunately, we don’t really know very much about airway clearance. We do it a lot, but we don’t have a lot of data," Dr. Ackerman said at a seminar on pediatric pulmonology, which was sponsored by the American College of Chest Physicians and the American Academy of Pediatrics.

For instance, the only pediatric study comparing airway clearance to no such therapy was published in 1983 and assessed eight patients with cystic fibrosis (J. Pediatr. 2003;103:538-42).

"Intuitively and intellectually, airway clearance makes a lot of sense. But [it is important to] think about whether we are helping or hurting when we prescribe airway clearance," said Dr. Ackerman, a pediatric intensivist at Riley Hospital for Children and a pediatric pulmonologist in private practice in Indianapolis.

Oxygen desaturation, gastroesophageal reflux, aspiration, hyperventilation, and "guilt for the family from lack of adherence" are potential adverse events associated with prescription of airway clearance, Dr. Ackerman said.

There are "no data to support the use of one airway clearance technique over the other," Dr. Ackerman said. Chest physiotherapy (CPT), positive expiratory pressure (PEP) valve, Cardinal Health’s Flutter device, Smiths Medical’s Acapella system, Medical Acoustics’ Lung Flute device, airway clearance vests, and Smiths Medical’s EzPAP device are among the options.

No definitive data exist to support use of CPT in an asymptomatic child with cystic fibrosis, Dr. Ackerman said. This patient population is prone to adverse events, especially gastroesophageal reflux with or without aspiration. CPT also requires a significant time commitment on the part of families. Despite these concerns, "I still do recommend it" for some patients.

Airway clearance devices "jiggle, shake, or use sound waves to loosen mucus off the airway walls so secretions can be coughed up," Dr. Ackerman said. Success with these devices is often technique dependent.

The PEP valve is portable, takes 10-15 minutes to clear the airway, and can be used with aerosolized medications. However, Dr. Ackerman’s institution uses the Flutter "much more than the PEP valve," she said. This device "tends to be used for families who cannot put time into CPT or when the child goes to Grandma’s or on a sleepover." The device loosens mucus through expiratory oscillation, so it may be less effective at lower airflows, such as those used for small children or patients with more severe lung disease. The device has to be held at a precise angle to maximize oscillation, she added. Each use of the Flutter device takes about 10-15 minutes.

The Acapella system combines the benefits of the PEP valve and airway vibrations to mobilize secretions, Dr. Ackerman said. The mechanism of action is similar to that of the Flutter, except that the Acapella has a valve-magnet device to interrupt expiratory flow and thus can be used at any angle.

"All of these devices cost less than $100," Dr. Ackerman said. "These may – and I said may – be better than doing nothing at all."

Contraindications to the PEP valve, Flutter, and Acapella include pneumothorax, hemoptysis, and esophageal varices. Lung surgery is another contraindication, Dr. Ackerman said, because use of airway-clearance devices can cause an air leak or can break down an anastomosis site. A pulmonary embolus is another contraindication, but "fortunately we do not see this often in pediatrics." A perforated ear drum is also a contraindication to these airway devices "because it causes pain."

The Lung Flute uses a different strategy (acoustic waves) to increase mucociliary clearance. It vibrates the chest in a way that is similar to the way a reed instrument vibrates when it’s played, Dr. Ackerman said. "There are no pediatric data, but it is cheap and easy to use." The Lung Flute is used more commonly for patients with chronic obstructive pulmonary disorder and not as much in cystic fibrosis.

Airway clearance vests deliver pulses of air pressure to the chest wall. The vest loosens mucus through shearing at the air/mucus interface, and compression causes clearance through repetitive peak expiratory flows that expel mucus like small coughs.

"You should not get compression of the airway itself; only the chest wall is compressed," Dr. Ackerman said. In contrast, "if you blow hard enough with the Acapella, Flutter, or PEP, you could get airway collapse." An airway clearance vest costs approximately $10,000, and obtaining insurance approval can be difficult; reimbursement policies vary from state to state.

The EzPAP device clears airways through positive airway pressure in a way that is similar to intermittent positive pressure breathing. It is approved by the Food and Drug Administration for lung expansion therapy and the prevention and treatment of atelectasis. Although no peer-reviewed data are available, many children are using EzPAP because respiratory therapists believe in this device, Dr. Ackerman said.

For more information, Dr. Ackerman recommended the American College of Chest Physicians’ Evidence-Based Guidelines for Nonpharmacologic Airway Clearance Therapies (Chest 2006;129:250S-9S), which were published in 2006 but are still applicable in 2011, she added.

Dr. Ackerman said that she had no relevant financial disclosures.

FORT LAUDERDALE, FLA. – Despite a lack of definitive evidence, airway clearance strategies are commonly employed in children with cystic fibrosis and other lung diseases, Dr. Veda L. Ackerman said.

"Unfortunately, we don’t really know very much about airway clearance. We do it a lot, but we don’t have a lot of data," Dr. Ackerman said at a seminar on pediatric pulmonology, which was sponsored by the American College of Chest Physicians and the American Academy of Pediatrics.

For instance, the only pediatric study comparing airway clearance to no such therapy was published in 1983 and assessed eight patients with cystic fibrosis (J. Pediatr. 2003;103:538-42).

"Intuitively and intellectually, airway clearance makes a lot of sense. But [it is important to] think about whether we are helping or hurting when we prescribe airway clearance," said Dr. Ackerman, a pediatric intensivist at Riley Hospital for Children and a pediatric pulmonologist in private practice in Indianapolis.

Oxygen desaturation, gastroesophageal reflux, aspiration, hyperventilation, and "guilt for the family from lack of adherence" are potential adverse events associated with prescription of airway clearance, Dr. Ackerman said.

There are "no data to support the use of one airway clearance technique over the other," Dr. Ackerman said. Chest physiotherapy (CPT), positive expiratory pressure (PEP) valve, Cardinal Health’s Flutter device, Smiths Medical’s Acapella system, Medical Acoustics’ Lung Flute device, airway clearance vests, and Smiths Medical’s EzPAP device are among the options.

No definitive data exist to support use of CPT in an asymptomatic child with cystic fibrosis, Dr. Ackerman said. This patient population is prone to adverse events, especially gastroesophageal reflux with or without aspiration. CPT also requires a significant time commitment on the part of families. Despite these concerns, "I still do recommend it" for some patients.

Airway clearance devices "jiggle, shake, or use sound waves to loosen mucus off the airway walls so secretions can be coughed up," Dr. Ackerman said. Success with these devices is often technique dependent.

The PEP valve is portable, takes 10-15 minutes to clear the airway, and can be used with aerosolized medications. However, Dr. Ackerman’s institution uses the Flutter "much more than the PEP valve," she said. This device "tends to be used for families who cannot put time into CPT or when the child goes to Grandma’s or on a sleepover." The device loosens mucus through expiratory oscillation, so it may be less effective at lower airflows, such as those used for small children or patients with more severe lung disease. The device has to be held at a precise angle to maximize oscillation, she added. Each use of the Flutter device takes about 10-15 minutes.

The Acapella system combines the benefits of the PEP valve and airway vibrations to mobilize secretions, Dr. Ackerman said. The mechanism of action is similar to that of the Flutter, except that the Acapella has a valve-magnet device to interrupt expiratory flow and thus can be used at any angle.

"All of these devices cost less than $100," Dr. Ackerman said. "These may – and I said may – be better than doing nothing at all."

Contraindications to the PEP valve, Flutter, and Acapella include pneumothorax, hemoptysis, and esophageal varices. Lung surgery is another contraindication, Dr. Ackerman said, because use of airway-clearance devices can cause an air leak or can break down an anastomosis site. A pulmonary embolus is another contraindication, but "fortunately we do not see this often in pediatrics." A perforated ear drum is also a contraindication to these airway devices "because it causes pain."

The Lung Flute uses a different strategy (acoustic waves) to increase mucociliary clearance. It vibrates the chest in a way that is similar to the way a reed instrument vibrates when it’s played, Dr. Ackerman said. "There are no pediatric data, but it is cheap and easy to use." The Lung Flute is used more commonly for patients with chronic obstructive pulmonary disorder and not as much in cystic fibrosis.

Airway clearance vests deliver pulses of air pressure to the chest wall. The vest loosens mucus through shearing at the air/mucus interface, and compression causes clearance through repetitive peak expiratory flows that expel mucus like small coughs.

"You should not get compression of the airway itself; only the chest wall is compressed," Dr. Ackerman said. In contrast, "if you blow hard enough with the Acapella, Flutter, or PEP, you could get airway collapse." An airway clearance vest costs approximately $10,000, and obtaining insurance approval can be difficult; reimbursement policies vary from state to state.

The EzPAP device clears airways through positive airway pressure in a way that is similar to intermittent positive pressure breathing. It is approved by the Food and Drug Administration for lung expansion therapy and the prevention and treatment of atelectasis. Although no peer-reviewed data are available, many children are using EzPAP because respiratory therapists believe in this device, Dr. Ackerman said.

For more information, Dr. Ackerman recommended the American College of Chest Physicians’ Evidence-Based Guidelines for Nonpharmacologic Airway Clearance Therapies (Chest 2006;129:250S-9S), which were published in 2006 but are still applicable in 2011, she added.

Dr. Ackerman said that she had no relevant financial disclosures.

FORT LAUDERDALE, FLA. – Despite a lack of definitive evidence, airway clearance strategies are commonly employed in children with cystic fibrosis and other lung diseases, Dr. Veda L. Ackerman said.

"Unfortunately, we don’t really know very much about airway clearance. We do it a lot, but we don’t have a lot of data," Dr. Ackerman said at a seminar on pediatric pulmonology, which was sponsored by the American College of Chest Physicians and the American Academy of Pediatrics.

For instance, the only pediatric study comparing airway clearance to no such therapy was published in 1983 and assessed eight patients with cystic fibrosis (J. Pediatr. 2003;103:538-42).

"Intuitively and intellectually, airway clearance makes a lot of sense. But [it is important to] think about whether we are helping or hurting when we prescribe airway clearance," said Dr. Ackerman, a pediatric intensivist at Riley Hospital for Children and a pediatric pulmonologist in private practice in Indianapolis.

Oxygen desaturation, gastroesophageal reflux, aspiration, hyperventilation, and "guilt for the family from lack of adherence" are potential adverse events associated with prescription of airway clearance, Dr. Ackerman said.

There are "no data to support the use of one airway clearance technique over the other," Dr. Ackerman said. Chest physiotherapy (CPT), positive expiratory pressure (PEP) valve, Cardinal Health’s Flutter device, Smiths Medical’s Acapella system, Medical Acoustics’ Lung Flute device, airway clearance vests, and Smiths Medical’s EzPAP device are among the options.

No definitive data exist to support use of CPT in an asymptomatic child with cystic fibrosis, Dr. Ackerman said. This patient population is prone to adverse events, especially gastroesophageal reflux with or without aspiration. CPT also requires a significant time commitment on the part of families. Despite these concerns, "I still do recommend it" for some patients.

Airway clearance devices "jiggle, shake, or use sound waves to loosen mucus off the airway walls so secretions can be coughed up," Dr. Ackerman said. Success with these devices is often technique dependent.

The PEP valve is portable, takes 10-15 minutes to clear the airway, and can be used with aerosolized medications. However, Dr. Ackerman’s institution uses the Flutter "much more than the PEP valve," she said. This device "tends to be used for families who cannot put time into CPT or when the child goes to Grandma’s or on a sleepover." The device loosens mucus through expiratory oscillation, so it may be less effective at lower airflows, such as those used for small children or patients with more severe lung disease. The device has to be held at a precise angle to maximize oscillation, she added. Each use of the Flutter device takes about 10-15 minutes.

The Acapella system combines the benefits of the PEP valve and airway vibrations to mobilize secretions, Dr. Ackerman said. The mechanism of action is similar to that of the Flutter, except that the Acapella has a valve-magnet device to interrupt expiratory flow and thus can be used at any angle.

"All of these devices cost less than $100," Dr. Ackerman said. "These may – and I said may – be better than doing nothing at all."

Contraindications to the PEP valve, Flutter, and Acapella include pneumothorax, hemoptysis, and esophageal varices. Lung surgery is another contraindication, Dr. Ackerman said, because use of airway-clearance devices can cause an air leak or can break down an anastomosis site. A pulmonary embolus is another contraindication, but "fortunately we do not see this often in pediatrics." A perforated ear drum is also a contraindication to these airway devices "because it causes pain."

The Lung Flute uses a different strategy (acoustic waves) to increase mucociliary clearance. It vibrates the chest in a way that is similar to the way a reed instrument vibrates when it’s played, Dr. Ackerman said. "There are no pediatric data, but it is cheap and easy to use." The Lung Flute is used more commonly for patients with chronic obstructive pulmonary disorder and not as much in cystic fibrosis.

Airway clearance vests deliver pulses of air pressure to the chest wall. The vest loosens mucus through shearing at the air/mucus interface, and compression causes clearance through repetitive peak expiratory flows that expel mucus like small coughs.

"You should not get compression of the airway itself; only the chest wall is compressed," Dr. Ackerman said. In contrast, "if you blow hard enough with the Acapella, Flutter, or PEP, you could get airway collapse." An airway clearance vest costs approximately $10,000, and obtaining insurance approval can be difficult; reimbursement policies vary from state to state.

The EzPAP device clears airways through positive airway pressure in a way that is similar to intermittent positive pressure breathing. It is approved by the Food and Drug Administration for lung expansion therapy and the prevention and treatment of atelectasis. Although no peer-reviewed data are available, many children are using EzPAP because respiratory therapists believe in this device, Dr. Ackerman said.

For more information, Dr. Ackerman recommended the American College of Chest Physicians’ Evidence-Based Guidelines for Nonpharmacologic Airway Clearance Therapies (Chest 2006;129:250S-9S), which were published in 2006 but are still applicable in 2011, she added.

Dr. Ackerman said that she had no relevant financial disclosures.

FORT LAUDERDALE, FLA.  – Your patients with cystic fibrosis or other pulmonary conditions may ask you if and when it’s safe for them to fly on an airplane.

How you respond can depend in part on their travel history, how long they will be exposed to increased cabin pressure, and if they are immunocompromised or have other risk factors for infection that are related to airborne pathogens, Dr. Susan L. Millard said.

Photo credit: © Eray/Fotolia.com

Severe respiratory insufficiency, right heart failure or hemodynamic instability, and active pneumothorax are absolute contraindications to air travel, according to 30 experts who wrote a consensus statement for traveling with cystic fibrosis (J. Cyst. Fibros. 2010;9:385-99).

These first-ever European recommendations are useful because they address preparations for travel (for example, vaccinations and packing medication), important considerations during travel, and issues specific to the immunocompromised, Dr. Millard said at a pediatric pulmonology seminar, which was sponsored by the American College of Chest Physicians and the American Academy of Pediatrics.

Air travel for pulmonology patients can be difficult, Dr. Millard noted, because "the environment is very dangerous." The cabin is pressurized, alveolar partial pressure falls with increasing altitude, and the partial pressure of oxygen is inversely proportional to altitude. Because the Joint Aviation Authorities stipulated that mean cabin pressure match an altitude of 8,000 feet, "this means they want us to all have an oxygen saturation of about 90%."

Supplemental oxygen during air travel can help patients, but identification of appropriate candidates varies. Guidelines from the American Thoracic Society and British Thoracic Society (Thorax 2002;57:289-304)recommend that patients with chronic lung disease be able to maintain an arterial oxygen tension greater than 50 mm Hg or 6.6 kilopascals (kPa), Dr. Millard said. However, because they tend to be younger than COPD (chronic obstructive pulmonary disease) patients and generally have no increased cardiovascular risk, use of such a cutoff value could be an oversimplification for patients with cystic fibrosis, said Dr. Millard, a pediatric pulmonologist at Helen DeVos Children’s Hospital in Grand Rapids, Mich.

Hypoxia during flight is a major concern. Consider whether your patient will be able to sustain hyperventilation that is spurred by hypoxia while on the airplane. Significant bronchospasm, for example, could impede prolonged hyperventilation, Dr. Millard said.

Consider a hypoxia inhalation test in advance of travel. This test requires that patients breathe a hypoxic mixture of 15% oxygen with nitrogen for 20 minutes to predict their reaction to hypoxia at 8,000 feet. Supplemental oxygen is recommended if their arterial oxygen tension drops below 50-55 mm Hg or 6.6-7.4 kPa.

"The hypoxia inhalation test is found to be safe," Dr. Millard said. Applicability outside the clinic setting is a concern, however: "The problem is, they are sitting. This may not fully represent the physical stress and environmental variability of air travel," including Transportation Security Administration screening and walking long distances.

For this reason, some experts advise also screening patients with a walk test prior to their trip, Dr. Millard said. The American Thoracic Society provides guidelines for conducting a functional exercise evaluation called a 6-minute walk test, for example (Am. J. Resp. Crit. Care Med. 2002;166:111-7).

Patients who require supplemental oxygen are permitted to use their own approved portable oxygen concentrator (POC) on all airlines that operate in the United States. POCs weigh 8-10 pounds and batteries last an average of about 4 hours, Dr. Millard said. Also, some POCs are pulse generated, meaning the patient must be able to inspire strongly enough to get oxygen.

Advise your patients or their families to check in advance if their airline requires approval from a physician for POC use, Dr. Millard said. "I had a patient who gave me 48 hours notice that they were going to fly. I had to fill out a form ahead of time for the airline."

Pulmonology patients also may request a travel letter, "which is especially important if they are going through customs," Dr. Millard said. Include their insurance information, your contact information, the telephone number for the clinic, and a list of medications (and approximate quantities required).

Airborne infection risk is another major concern. Most commercial aircraft recirculate 50% of the air delivered to the passenger cabin, Dr. Millard said. Ideally, the aircraft features HEPA (high-efficiency particulate air) filters, although the U.S. Federal Aviation Authority (FAA) and the U.K. Civil Aviation Authority do not mandate this level of filtration.

Dr. Millard cited a study that supports transmission of H1N1 influenza during flight (Epidemiol. Health 2010;32:e2010006). Officials at the Korea Centers for Disease Control and Prevention determined that an infected woman who flew from Los Angeles to Seoul in 2009 infected other passengers. The study includes a seating map of the Boeing 747 that shows where she and other passengers who got sick were seated.

"People are trying to figure this out to make [air travel] safer," Dr. Millard said. For example, one set of researchers assessed the ability of commercially available biosensors to detect airborne pathogens on airplanes (PLoS One 2011;6:e14520). With the current technology, however, only steady-state bacteria concentrations were detected in cases in which at least seven infected passengers either coughed 20 times per hour or sneezed 4 times an hour. And no sensor in the study detected airborne viruses well. Sensors with improved sensitivity and/or the screening of individual patients for respiratory illnesses prior to boarding might reduce the infection risk, Dr. Millard said.

For a list of POC devices that have been approved by the FAA, visit www.faa.gov/about/initiatives/cabin_safety/portable_oxygen/.

For additional guidance from the TSA on traveling with supplemental oxygen or other medical devices, you can refer patients to www.tsa.gov/travelers/airtravel/specialneeds/editorial_1374.shtm.

Dr. Millard said that she had no relevant disclosures.

FORT LAUDERDALE, FLA.  – Your patients with cystic fibrosis or other pulmonary conditions may ask you if and when it’s safe for them to fly on an airplane.

How you respond can depend in part on their travel history, how long they will be exposed to increased cabin pressure, and if they are immunocompromised or have other risk factors for infection that are related to airborne pathogens, Dr. Susan L. Millard said.

Photo credit: © Eray/Fotolia.com

Severe respiratory insufficiency, right heart failure or hemodynamic instability, and active pneumothorax are absolute contraindications to air travel, according to 30 experts who wrote a consensus statement for traveling with cystic fibrosis (J. Cyst. Fibros. 2010;9:385-99).

These first-ever European recommendations are useful because they address preparations for travel (for example, vaccinations and packing medication), important considerations during travel, and issues specific to the immunocompromised, Dr. Millard said at a pediatric pulmonology seminar, which was sponsored by the American College of Chest Physicians and the American Academy of Pediatrics.

Air travel for pulmonology patients can be difficult, Dr. Millard noted, because "the environment is very dangerous." The cabin is pressurized, alveolar partial pressure falls with increasing altitude, and the partial pressure of oxygen is inversely proportional to altitude. Because the Joint Aviation Authorities stipulated that mean cabin pressure match an altitude of 8,000 feet, "this means they want us to all have an oxygen saturation of about 90%."

Supplemental oxygen during air travel can help patients, but identification of appropriate candidates varies. Guidelines from the American Thoracic Society and British Thoracic Society (Thorax 2002;57:289-304)recommend that patients with chronic lung disease be able to maintain an arterial oxygen tension greater than 50 mm Hg or 6.6 kilopascals (kPa), Dr. Millard said. However, because they tend to be younger than COPD (chronic obstructive pulmonary disease) patients and generally have no increased cardiovascular risk, use of such a cutoff value could be an oversimplification for patients with cystic fibrosis, said Dr. Millard, a pediatric pulmonologist at Helen DeVos Children’s Hospital in Grand Rapids, Mich.

Hypoxia during flight is a major concern. Consider whether your patient will be able to sustain hyperventilation that is spurred by hypoxia while on the airplane. Significant bronchospasm, for example, could impede prolonged hyperventilation, Dr. Millard said.

Consider a hypoxia inhalation test in advance of travel. This test requires that patients breathe a hypoxic mixture of 15% oxygen with nitrogen for 20 minutes to predict their reaction to hypoxia at 8,000 feet. Supplemental oxygen is recommended if their arterial oxygen tension drops below 50-55 mm Hg or 6.6-7.4 kPa.

"The hypoxia inhalation test is found to be safe," Dr. Millard said. Applicability outside the clinic setting is a concern, however: "The problem is, they are sitting. This may not fully represent the physical stress and environmental variability of air travel," including Transportation Security Administration screening and walking long distances.

For this reason, some experts advise also screening patients with a walk test prior to their trip, Dr. Millard said. The American Thoracic Society provides guidelines for conducting a functional exercise evaluation called a 6-minute walk test, for example (Am. J. Resp. Crit. Care Med. 2002;166:111-7).

Patients who require supplemental oxygen are permitted to use their own approved portable oxygen concentrator (POC) on all airlines that operate in the United States. POCs weigh 8-10 pounds and batteries last an average of about 4 hours, Dr. Millard said. Also, some POCs are pulse generated, meaning the patient must be able to inspire strongly enough to get oxygen.

Advise your patients or their families to check in advance if their airline requires approval from a physician for POC use, Dr. Millard said. "I had a patient who gave me 48 hours notice that they were going to fly. I had to fill out a form ahead of time for the airline."

Pulmonology patients also may request a travel letter, "which is especially important if they are going through customs," Dr. Millard said. Include their insurance information, your contact information, the telephone number for the clinic, and a list of medications (and approximate quantities required).

Airborne infection risk is another major concern. Most commercial aircraft recirculate 50% of the air delivered to the passenger cabin, Dr. Millard said. Ideally, the aircraft features HEPA (high-efficiency particulate air) filters, although the U.S. Federal Aviation Authority (FAA) and the U.K. Civil Aviation Authority do not mandate this level of filtration.

Dr. Millard cited a study that supports transmission of H1N1 influenza during flight (Epidemiol. Health 2010;32:e2010006). Officials at the Korea Centers for Disease Control and Prevention determined that an infected woman who flew from Los Angeles to Seoul in 2009 infected other passengers. The study includes a seating map of the Boeing 747 that shows where she and other passengers who got sick were seated.

"People are trying to figure this out to make [air travel] safer," Dr. Millard said. For example, one set of researchers assessed the ability of commercially available biosensors to detect airborne pathogens on airplanes (PLoS One 2011;6:e14520). With the current technology, however, only steady-state bacteria concentrations were detected in cases in which at least seven infected passengers either coughed 20 times per hour or sneezed 4 times an hour. And no sensor in the study detected airborne viruses well. Sensors with improved sensitivity and/or the screening of individual patients for respiratory illnesses prior to boarding might reduce the infection risk, Dr. Millard said.

For a list of POC devices that have been approved by the FAA, visit www.faa.gov/about/initiatives/cabin_safety/portable_oxygen/.

For additional guidance from the TSA on traveling with supplemental oxygen or other medical devices, you can refer patients to www.tsa.gov/travelers/airtravel/specialneeds/editorial_1374.shtm.

Dr. Millard said that she had no relevant disclosures.

FORT LAUDERDALE, FLA.  – Your patients with cystic fibrosis or other pulmonary conditions may ask you if and when it’s safe for them to fly on an airplane.

How you respond can depend in part on their travel history, how long they will be exposed to increased cabin pressure, and if they are immunocompromised or have other risk factors for infection that are related to airborne pathogens, Dr. Susan L. Millard said.

Photo credit: © Eray/Fotolia.com

Severe respiratory insufficiency, right heart failure or hemodynamic instability, and active pneumothorax are absolute contraindications to air travel, according to 30 experts who wrote a consensus statement for traveling with cystic fibrosis (J. Cyst. Fibros. 2010;9:385-99).

These first-ever European recommendations are useful because they address preparations for travel (for example, vaccinations and packing medication), important considerations during travel, and issues specific to the immunocompromised, Dr. Millard said at a pediatric pulmonology seminar, which was sponsored by the American College of Chest Physicians and the American Academy of Pediatrics.

Air travel for pulmonology patients can be difficult, Dr. Millard noted, because "the environment is very dangerous." The cabin is pressurized, alveolar partial pressure falls with increasing altitude, and the partial pressure of oxygen is inversely proportional to altitude. Because the Joint Aviation Authorities stipulated that mean cabin pressure match an altitude of 8,000 feet, "this means they want us to all have an oxygen saturation of about 90%."

Supplemental oxygen during air travel can help patients, but identification of appropriate candidates varies. Guidelines from the American Thoracic Society and British Thoracic Society (Thorax 2002;57:289-304)recommend that patients with chronic lung disease be able to maintain an arterial oxygen tension greater than 50 mm Hg or 6.6 kilopascals (kPa), Dr. Millard said. However, because they tend to be younger than COPD (chronic obstructive pulmonary disease) patients and generally have no increased cardiovascular risk, use of such a cutoff value could be an oversimplification for patients with cystic fibrosis, said Dr. Millard, a pediatric pulmonologist at Helen DeVos Children’s Hospital in Grand Rapids, Mich.

Hypoxia during flight is a major concern. Consider whether your patient will be able to sustain hyperventilation that is spurred by hypoxia while on the airplane. Significant bronchospasm, for example, could impede prolonged hyperventilation, Dr. Millard said.

Consider a hypoxia inhalation test in advance of travel. This test requires that patients breathe a hypoxic mixture of 15% oxygen with nitrogen for 20 minutes to predict their reaction to hypoxia at 8,000 feet. Supplemental oxygen is recommended if their arterial oxygen tension drops below 50-55 mm Hg or 6.6-7.4 kPa.

"The hypoxia inhalation test is found to be safe," Dr. Millard said. Applicability outside the clinic setting is a concern, however: "The problem is, they are sitting. This may not fully represent the physical stress and environmental variability of air travel," including Transportation Security Administration screening and walking long distances.

For this reason, some experts advise also screening patients with a walk test prior to their trip, Dr. Millard said. The American Thoracic Society provides guidelines for conducting a functional exercise evaluation called a 6-minute walk test, for example (Am. J. Resp. Crit. Care Med. 2002;166:111-7).

Patients who require supplemental oxygen are permitted to use their own approved portable oxygen concentrator (POC) on all airlines that operate in the United States. POCs weigh 8-10 pounds and batteries last an average of about 4 hours, Dr. Millard said. Also, some POCs are pulse generated, meaning the patient must be able to inspire strongly enough to get oxygen.

Advise your patients or their families to check in advance if their airline requires approval from a physician for POC use, Dr. Millard said. "I had a patient who gave me 48 hours notice that they were going to fly. I had to fill out a form ahead of time for the airline."

Pulmonology patients also may request a travel letter, "which is especially important if they are going through customs," Dr. Millard said. Include their insurance information, your contact information, the telephone number for the clinic, and a list of medications (and approximate quantities required).

Airborne infection risk is another major concern. Most commercial aircraft recirculate 50% of the air delivered to the passenger cabin, Dr. Millard said. Ideally, the aircraft features HEPA (high-efficiency particulate air) filters, although the U.S. Federal Aviation Authority (FAA) and the U.K. Civil Aviation Authority do not mandate this level of filtration.

Dr. Millard cited a study that supports transmission of H1N1 influenza during flight (Epidemiol. Health 2010;32:e2010006). Officials at the Korea Centers for Disease Control and Prevention determined that an infected woman who flew from Los Angeles to Seoul in 2009 infected other passengers. The study includes a seating map of the Boeing 747 that shows where she and other passengers who got sick were seated.

"People are trying to figure this out to make [air travel] safer," Dr. Millard said. For example, one set of researchers assessed the ability of commercially available biosensors to detect airborne pathogens on airplanes (PLoS One 2011;6:e14520). With the current technology, however, only steady-state bacteria concentrations were detected in cases in which at least seven infected passengers either coughed 20 times per hour or sneezed 4 times an hour. And no sensor in the study detected airborne viruses well. Sensors with improved sensitivity and/or the screening of individual patients for respiratory illnesses prior to boarding might reduce the infection risk, Dr. Millard said.

For a list of POC devices that have been approved by the FAA, visit www.faa.gov/about/initiatives/cabin_safety/portable_oxygen/.

For additional guidance from the TSA on traveling with supplemental oxygen or other medical devices, you can refer patients to www.tsa.gov/travelers/airtravel/specialneeds/editorial_1374.shtm.

Dr. Millard said that she had no relevant disclosures.

FORT LAUDERDALE, FLA.  – Your patients with cystic fibrosis or other pulmonary conditions may ask you if and when it’s safe for them to fly on an airplane.

How you respond can depend in part on their travel history, how long they will be exposed to increased cabin pressure, and if they are immunocompromised or have other risk factors for infection that are related to airborne pathogens, Dr. Susan L. Millard said.

Photo credit: © Eray/Fotolia.com

Severe respiratory insufficiency, right heart failure or hemodynamic instability, and active pneumothorax are absolute contraindications to air travel, according to 30 experts who wrote a consensus statement for traveling with cystic fibrosis (J. Cyst. Fibros. 2010;9:385-99).

These first-ever European recommendations are useful because they address preparations for travel (for example, vaccinations and packing medication), important considerations during travel, and issues specific to the immunocompromised, Dr. Millard said at a pediatric pulmonology seminar, which was sponsored by the American College of Chest Physicians and the American Academy of Pediatrics.

Air travel for pulmonology patients can be difficult, Dr. Millard noted, because "the environment is very dangerous." The cabin is pressurized, alveolar partial pressure falls with increasing altitude, and the partial pressure of oxygen is inversely proportional to altitude. Because the Joint Aviation Authorities stipulated that mean cabin pressure match an altitude of 8,000 feet, "this means they want us to all have an oxygen saturation of about 90%."

Supplemental oxygen during air travel can help patients, but identification of appropriate candidates varies. Guidelines from the American Thoracic Society and British Thoracic Society (Thorax 2002;57:289-304)recommend that patients with chronic lung disease be able to maintain an arterial oxygen tension greater than 50 mm Hg or 6.6 kilopascals (kPa), Dr. Millard said. However, because they tend to be younger than COPD (chronic obstructive pulmonary disease) patients and generally have no increased cardiovascular risk, use of such a cutoff value could be an oversimplification for patients with cystic fibrosis, said Dr. Millard, a pediatric pulmonologist at Helen DeVos Children’s Hospital in Grand Rapids, Mich.

Hypoxia during flight is a major concern. Consider whether your patient will be able to sustain hyperventilation that is spurred by hypoxia while on the airplane. Significant bronchospasm, for example, could impede prolonged hyperventilation, Dr. Millard said.

Consider a hypoxia inhalation test in advance of travel. This test requires that patients breathe a hypoxic mixture of 15% oxygen with nitrogen for 20 minutes to predict their reaction to hypoxia at 8,000 feet. Supplemental oxygen is recommended if their arterial oxygen tension drops below 50-55 mm Hg or 6.6-7.4 kPa.

"The hypoxia inhalation test is found to be safe," Dr. Millard said. Applicability outside the clinic setting is a concern, however: "The problem is, they are sitting. This may not fully represent the physical stress and environmental variability of air travel," including Transportation Security Administration screening and walking long distances.

For this reason, some experts advise also screening patients with a walk test prior to their trip, Dr. Millard said. The American Thoracic Society provides guidelines for conducting a functional exercise evaluation called a 6-minute walk test, for example (Am. J. Resp. Crit. Care Med. 2002;166:111-7).

Patients who require supplemental oxygen are permitted to use their own approved portable oxygen concentrator (POC) on all airlines that operate in the United States. POCs weigh 8-10 pounds and batteries last an average of about 4 hours, Dr. Millard said. Also, some POCs are pulse generated, meaning the patient must be able to inspire strongly enough to get oxygen.

Advise your patients or their families to check in advance if their airline requires approval from a physician for POC use, Dr. Millard said. "I had a patient who gave me 48 hours notice that they were going to fly. I had to fill out a form ahead of time for the airline."

Pulmonology patients also may request a travel letter, "which is especially important if they are going through customs," Dr. Millard said. Include their insurance information, your contact information, the telephone number for the clinic, and a list of medications (and approximate quantities required).

Airborne infection risk is another major concern. Most commercial aircraft recirculate 50% of the air delivered to the passenger cabin, Dr. Millard said. Ideally, the aircraft features HEPA (high-efficiency particulate air) filters, although the U.S. Federal Aviation Authority (FAA) and the U.K. Civil Aviation Authority do not mandate this level of filtration.

Dr. Millard cited a study that supports transmission of H1N1 influenza during flight (Epidemiol. Health 2010;32:e2010006). Officials at the Korea Centers for Disease Control and Prevention determined that an infected woman who flew from Los Angeles to Seoul in 2009 infected other passengers. The study includes a seating map of the Boeing 747 that shows where she and other passengers who got sick were seated.

"People are trying to figure this out to make [air travel] safer," Dr. Millard said. For example, one set of researchers assessed the ability of commercially available biosensors to detect airborne pathogens on airplanes (PLoS One 2011;6:e14520). With the current technology, however, only steady-state bacteria concentrations were detected in cases in which at least seven infected passengers either coughed 20 times per hour or sneezed 4 times an hour. And no sensor in the study detected airborne viruses well. Sensors with improved sensitivity and/or the screening of individual patients for respiratory illnesses prior to boarding might reduce the infection risk, Dr. Millard said.

For a list of POC devices that have been approved by the FAA, visit www.faa.gov/about/initiatives/cabin_safety/portable_oxygen/.

For additional guidance from the TSA on traveling with supplemental oxygen or other medical devices, you can refer patients to www.tsa.gov/travelers/airtravel/specialneeds/editorial_1374.shtm.

Dr. Millard said that she had no relevant disclosures.

FORT LAUDERDALE, FLA.  – Your patients with cystic fibrosis or other pulmonary conditions may ask you if and when it’s safe for them to fly on an airplane.

How you respond can depend in part on their travel history, how long they will be exposed to increased cabin pressure, and if they are immunocompromised or have other risk factors for infection that are related to airborne pathogens, Dr. Susan L. Millard said.

Photo credit: © Eray/Fotolia.com

Severe respiratory insufficiency, right heart failure or hemodynamic instability, and active pneumothorax are absolute contraindications to air travel, according to 30 experts who wrote a consensus statement for traveling with cystic fibrosis (J. Cyst. Fibros. 2010;9:385-99).

These first-ever European recommendations are useful because they address preparations for travel (for example, vaccinations and packing medication), important considerations during travel, and issues specific to the immunocompromised, Dr. Millard said at a pediatric pulmonology seminar, which was sponsored by the American College of Chest Physicians and the American Academy of Pediatrics.

Air travel for pulmonology patients can be difficult, Dr. Millard noted, because "the environment is very dangerous." The cabin is pressurized, alveolar partial pressure falls with increasing altitude, and the partial pressure of oxygen is inversely proportional to altitude. Because the Joint Aviation Authorities stipulated that mean cabin pressure match an altitude of 8,000 feet, "this means they want us to all have an oxygen saturation of about 90%."

Supplemental oxygen during air travel can help patients, but identification of appropriate candidates varies. Guidelines from the American Thoracic Society and British Thoracic Society (Thorax 2002;57:289-304)recommend that patients with chronic lung disease be able to maintain an arterial oxygen tension greater than 50 mm Hg or 6.6 kilopascals (kPa), Dr. Millard said. However, because they tend to be younger than COPD (chronic obstructive pulmonary disease) patients and generally have no increased cardiovascular risk, use of such a cutoff value could be an oversimplification for patients with cystic fibrosis, said Dr. Millard, a pediatric pulmonologist at Helen DeVos Children’s Hospital in Grand Rapids, Mich.

Hypoxia during flight is a major concern. Consider whether your patient will be able to sustain hyperventilation that is spurred by hypoxia while on the airplane. Significant bronchospasm, for example, could impede prolonged hyperventilation, Dr. Millard said.

Consider a hypoxia inhalation test in advance of travel. This test requires that patients breathe a hypoxic mixture of 15% oxygen with nitrogen for 20 minutes to predict their reaction to hypoxia at 8,000 feet. Supplemental oxygen is recommended if their arterial oxygen tension drops below 50-55 mm Hg or 6.6-7.4 kPa.

"The hypoxia inhalation test is found to be safe," Dr. Millard said. Applicability outside the clinic setting is a concern, however: "The problem is, they are sitting. This may not fully represent the physical stress and environmental variability of air travel," including Transportation Security Administration screening and walking long distances.

For this reason, some experts advise also screening patients with a walk test prior to their trip, Dr. Millard said. The American Thoracic Society provides guidelines for conducting a functional exercise evaluation called a 6-minute walk test, for example (Am. J. Resp. Crit. Care Med. 2002;166:111-7).

Patients who require supplemental oxygen are permitted to use their own approved portable oxygen concentrator (POC) on all airlines that operate in the United States. POCs weigh 8-10 pounds and batteries last an average of about 4 hours, Dr. Millard said. Also, some POCs are pulse generated, meaning the patient must be able to inspire strongly enough to get oxygen.

Advise your patients or their families to check in advance if their airline requires approval from a physician for POC use, Dr. Millard said. "I had a patient who gave me 48 hours notice that they were going to fly. I had to fill out a form ahead of time for the airline."

Pulmonology patients also may request a travel letter, "which is especially important if they are going through customs," Dr. Millard said. Include their insurance information, your contact information, the telephone number for the clinic, and a list of medications (and approximate quantities required).

Airborne infection risk is another major concern. Most commercial aircraft recirculate 50% of the air delivered to the passenger cabin, Dr. Millard said. Ideally, the aircraft features HEPA (high-efficiency particulate air) filters, although the U.S. Federal Aviation Authority (FAA) and the U.K. Civil Aviation Authority do not mandate this level of filtration.

Dr. Millard cited a study that supports transmission of H1N1 influenza during flight (Epidemiol. Health 2010;32:e2010006). Officials at the Korea Centers for Disease Control and Prevention determined that an infected woman who flew from Los Angeles to Seoul in 2009 infected other passengers. The study includes a seating map of the Boeing 747 that shows where she and other passengers who got sick were seated.

"People are trying to figure this out to make [air travel] safer," Dr. Millard said. For example, one set of researchers assessed the ability of commercially available biosensors to detect airborne pathogens on airplanes (PLoS One 2011;6:e14520). With the current technology, however, only steady-state bacteria concentrations were detected in cases in which at least seven infected passengers either coughed 20 times per hour or sneezed 4 times an hour. And no sensor in the study detected airborne viruses well. Sensors with improved sensitivity and/or the screening of individual patients for respiratory illnesses prior to boarding might reduce the infection risk, Dr. Millard said.

For a list of POC devices that have been approved by the FAA, visit www.faa.gov/about/initiatives/cabin_safety/portable_oxygen/.

For additional guidance from the TSA on traveling with supplemental oxygen or other medical devices, you can refer patients to www.tsa.gov/travelers/airtravel/specialneeds/editorial_1374.shtm.

Dr. Millard said that she had no relevant disclosures.

FORT LAUDERDALE, FLA.  – Your patients with cystic fibrosis or other pulmonary conditions may ask you if and when it’s safe for them to fly on an airplane.

How you respond can depend in part on their travel history, how long they will be exposed to increased cabin pressure, and if they are immunocompromised or have other risk factors for infection that are related to airborne pathogens, Dr. Susan L. Millard said.

Photo credit: © Eray/Fotolia.com

Severe respiratory insufficiency, right heart failure or hemodynamic instability, and active pneumothorax are absolute contraindications to air travel, according to 30 experts who wrote a consensus statement for traveling with cystic fibrosis (J. Cyst. Fibros. 2010;9:385-99).

These first-ever European recommendations are useful because they address preparations for travel (for example, vaccinations and packing medication), important considerations during travel, and issues specific to the immunocompromised, Dr. Millard said at a pediatric pulmonology seminar, which was sponsored by the American College of Chest Physicians and the American Academy of Pediatrics.

Air travel for pulmonology patients can be difficult, Dr. Millard noted, because "the environment is very dangerous." The cabin is pressurized, alveolar partial pressure falls with increasing altitude, and the partial pressure of oxygen is inversely proportional to altitude. Because the Joint Aviation Authorities stipulated that mean cabin pressure match an altitude of 8,000 feet, "this means they want us to all have an oxygen saturation of about 90%."

Supplemental oxygen during air travel can help patients, but identification of appropriate candidates varies. Guidelines from the American Thoracic Society and British Thoracic Society (Thorax 2002;57:289-304)recommend that patients with chronic lung disease be able to maintain an arterial oxygen tension greater than 50 mm Hg or 6.6 kilopascals (kPa), Dr. Millard said. However, because they tend to be younger than COPD (chronic obstructive pulmonary disease) patients and generally have no increased cardiovascular risk, use of such a cutoff value could be an oversimplification for patients with cystic fibrosis, said Dr. Millard, a pediatric pulmonologist at Helen DeVos Children’s Hospital in Grand Rapids, Mich.

Hypoxia during flight is a major concern. Consider whether your patient will be able to sustain hyperventilation that is spurred by hypoxia while on the airplane. Significant bronchospasm, for example, could impede prolonged hyperventilation, Dr. Millard said.

Consider a hypoxia inhalation test in advance of travel. This test requires that patients breathe a hypoxic mixture of 15% oxygen with nitrogen for 20 minutes to predict their reaction to hypoxia at 8,000 feet. Supplemental oxygen is recommended if their arterial oxygen tension drops below 50-55 mm Hg or 6.6-7.4 kPa.

"The hypoxia inhalation test is found to be safe," Dr. Millard said. Applicability outside the clinic setting is a concern, however: "The problem is, they are sitting. This may not fully represent the physical stress and environmental variability of air travel," including Transportation Security Administration screening and walking long distances.

For this reason, some experts advise also screening patients with a walk test prior to their trip, Dr. Millard said. The American Thoracic Society provides guidelines for conducting a functional exercise evaluation called a 6-minute walk test, for example (Am. J. Resp. Crit. Care Med. 2002;166:111-7).

Patients who require supplemental oxygen are permitted to use their own approved portable oxygen concentrator (POC) on all airlines that operate in the United States. POCs weigh 8-10 pounds and batteries last an average of about 4 hours, Dr. Millard said. Also, some POCs are pulse generated, meaning the patient must be able to inspire strongly enough to get oxygen.

Advise your patients or their families to check in advance if their airline requires approval from a physician for POC use, Dr. Millard said. "I had a patient who gave me 48 hours notice that they were going to fly. I had to fill out a form ahead of time for the airline."

Pulmonology patients also may request a travel letter, "which is especially important if they are going through customs," Dr. Millard said. Include their insurance information, your contact information, the telephone number for the clinic, and a list of medications (and approximate quantities required).

Airborne infection risk is another major concern. Most commercial aircraft recirculate 50% of the air delivered to the passenger cabin, Dr. Millard said. Ideally, the aircraft features HEPA (high-efficiency particulate air) filters, although the U.S. Federal Aviation Authority (FAA) and the U.K. Civil Aviation Authority do not mandate this level of filtration.

Dr. Millard cited a study that supports transmission of H1N1 influenza during flight (Epidemiol. Health 2010;32:e2010006). Officials at the Korea Centers for Disease Control and Prevention determined that an infected woman who flew from Los Angeles to Seoul in 2009 infected other passengers. The study includes a seating map of the Boeing 747 that shows where she and other passengers who got sick were seated.

"People are trying to figure this out to make [air travel] safer," Dr. Millard said. For example, one set of researchers assessed the ability of commercially available biosensors to detect airborne pathogens on airplanes (PLoS One 2011;6:e14520). With the current technology, however, only steady-state bacteria concentrations were detected in cases in which at least seven infected passengers either coughed 20 times per hour or sneezed 4 times an hour. And no sensor in the study detected airborne viruses well. Sensors with improved sensitivity and/or the screening of individual patients for respiratory illnesses prior to boarding might reduce the infection risk, Dr. Millard said.

For a list of POC devices that have been approved by the FAA, visit www.faa.gov/about/initiatives/cabin_safety/portable_oxygen/.

For additional guidance from the TSA on traveling with supplemental oxygen or other medical devices, you can refer patients to www.tsa.gov/travelers/airtravel/specialneeds/editorial_1374.shtm.

Dr. Millard said that she had no relevant disclosures.