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toddlers
Posters / Paediatric Respiratory Reviews 13S1 (2012) S51–S85
between the lower lip and chin and the mouth opening distances provided the most reliable and reproducible measurement for our purposes. These were used to categorize the scans into small, medium and large clusters. ‘Average’ face models were developed for each cluster and used to design an optimally sealing mask with minimal dead space using appropriate software (Fig). The resulting mask contour was used to design the Soothermask,® a unique mask that enables children, suckling on their own pacifier inserted through a slot in the front of the mask, to create an effective and very gentle seal by means of atmospheric pressure on the pacifier disc with little additional caregiver force.
Figure: An ‘average’ model face with mask matching the facial topographical contour.
The mask has a relatively wide rim designed to both improve the mask-face seal, and accommodate variations in facial size within a cluster. Conclusions: Soothermask® is the first mask, based on face-recognition techniques designed specifically for delivering aerosolized medications to infants and young children. It accurately follows facial contours and gently seals to the child’s face, minimizing leakage of medication, and providing a small dead space with minimal application pressure. L03-166 Nasal aerosol delivery to the lower respiratory tract may be superior to oral delivery in infants/toddlers I. Amirav1 , A. Halamish2 , M. Newhouse3 . 1 Ziv Medical center, Rosh Pina, Israel; 2 Technosaf, Karkur, Israel; 3 McMaster Univ. Faculty of Health Sciences, Hamilton, Canada Introduction: Aerosol delivery to the lower respiratory tract (LRT) can be accomplished by either the oral or nasal routes. The oral route has long been considered superior due to greater nasal turbulence and resistance. Some evidence exists to support this notion in adults and children. However, no data about the difference in LRT aerosol deposition between these two routes exist for infants. The aim of this study was to compare nasal and oral delivery of aerosol in appropriate, anatomically correct, replicas of infants’ faces containing both nasal and oral upper airways to the level of the trachea, the latter representing the dose delivered to the LRT/lung parenchyma. Methods: Three replicas representing infants/toddlers aged 5, 14 and 20 months were studied and aerosol delivery by either the oral or nasal route for each of the replicas was measured. A radio-labelled (99mDTPA) normal saline solution aerosol was generated by a Respimat® inhaler and aerosol was delivered via a Respichamber and an air tight mask. A breath simulator was connected to the replicas and an absolute filter at the ‘tracheal’ opening captured the aerosol representing LRT dose. Age-appropriate mask dimensions and breathing patterns were employed for each of the airway replicas. Two different tidal volumes (Vt) were used for comparing the nasal vs oral routes. Results: In all three airway replicas, nasal delivery to the LRT was greater than oral (27.1% vs 19.1% in the small model, 20.8% vs 16.4% in the medium model and 30.8% vs 29.2% in the large model). The difference was highly significant in the two younger models and non-significant in the largest one. The difference tended to
S73
decrease with increasing age. A similar pattern was observed with both low and high tidal volumes. Conclusion: Nasal aerosol delivery may be superior to oral delivery in infants/toddlers, in contrast to older children and adults. L04-212 Flexible bronchoscopic extraction of tracheobronchial foreign bodies in children: lessons learnt – a 10 year experience from North India V. Singh, M.U. Tak, I. Kinimi, S. Patra, A. Parakh. Lady Hardinge Medical College and Kalawati Saran Children’s Hospital Pediatrics, New Delhi, India Objectives: To describe our experience in Tracheobronchial foreign body (TFB) extraction using flexible bronchoscopy (FOB) in children (<18 years) over the past 10 years. Design: Retrospective analysis. Methods: Records of children <18 years who underwent FOB at Kalawati Saran Children’s Hospital between January 2001 and December 2011 with a final diagnosis of TFB were reviewed. Demographic data (age and sex), clinical and radiological details, bronchoscopic findings, success rates of extraction of TFBs and reasons for failure and complications were analyzed. FOB was performed with the patient under conscious sedation. TFB extraction was done using urological instruments like spiral wire basket forceps. Results: A total of 326 children with a final diagnosis of TFB and where removal was attempted with FOB are included in the final analysis. Median age of the cases was 1.5 years (range 5 mo to 12 years, 64% males). The right main bronchus, left main bronchus and trachea were the site of lodgment of TFB in 30%, 30% and 24% cases respectively. The majority of the FB were of vegetable origin 250 (77%) with peanuts being the predominant foreign body (53%). Fifteen of the cases were referred as the initial attempt at extraction by rigid bronchoscopy had failed totally or partially. Twenty-three children were significantly hypoxic pre-procedure of whom 7 cases were received with ventilatory support. While in 36 cases extraction by FOB was unsuccessful (either dormia could not be negotiated or FB could not be grasped due to physical nature or size of the TFB). In 14 children who had glottic TFB, dormia removal with FOB was not attempted as this is not the best suited tool. TFB were successfully removed by FOB in 276/312 cases with a success rate of 89%. A tenth of the cases desaturated further during extraction but this was very transient lasting less than a minute and was alleviated by temporary withdrawal of the scope and continued oxygenation, except in one child who became apnoeic after the foreign body got stuck in the glottic opening. The TFB was pushed back to one of the bronchus and the patient recovered after brief bag and mask ventilation. Unfortunately, one child expired as extraction was attempted. In this case, the sharp end of the stone aspirated by him pierced the bronchus leading to a complete obstruction across carina and pneumomediastinum. About 5% patients had bleeding from the granulation tissue which could be controlled by local instillation of adrenaline. Ten patients required a repeat FOB as initial attempt failed; 4 of these had FB embedded in large granulation tissue and the procedure was repeated after a brief course of steroids while 5 needed repeat procedure for the residual small pieces, and 1 had a repeat FOB since the previous procedure was abandoned because of poor general condition. Conclusions: Flexible bronchoscopic extraction of pediatric TFBs can be performed with minimal risks and complications with a high success rate. It can be done safely even in very sick and hypoxic children where alternative facilities are not available and a skilled operator familiar with the technique is available.
between the lower lip and chin and the mouth opening distances provided the most reliable and reproducible measurement for our purposes. These were used to categorize the scans into small, medium and large clusters. ‘Average’ face models were developed for each cluster and used to design an optimally sealing mask with minimal dead space using appropriate software (Fig). The resulting mask contour was used to design the Soothermask,® a unique mask that enables children, suckling on their own pacifier inserted through a slot in the front of the mask, to create an effective and very gentle seal by means of atmospheric pressure on the pacifier disc with little additional caregiver force.
Figure: An ‘average’ model face with mask matching the facial topographical contour.
The mask has a relatively wide rim designed to both improve the mask-face seal, and accommodate variations in facial size within a cluster. Conclusions: Soothermask® is the first mask, based on face-recognition techniques designed specifically for delivering aerosolized medications to infants and young children. It accurately follows facial contours and gently seals to the child’s face, minimizing leakage of medication, and providing a small dead space with minimal application pressure. L03-166 Nasal aerosol delivery to the lower respiratory tract may be superior to oral delivery in infants/toddlers I. Amirav1 , A. Halamish2 , M. Newhouse3 . 1 Ziv Medical center, Rosh Pina, Israel; 2 Technosaf, Karkur, Israel; 3 McMaster Univ. Faculty of Health Sciences, Hamilton, Canada Introduction: Aerosol delivery to the lower respiratory tract (LRT) can be accomplished by either the oral or nasal routes. The oral route has long been considered superior due to greater nasal turbulence and resistance. Some evidence exists to support this notion in adults and children. However, no data about the difference in LRT aerosol deposition between these two routes exist for infants. The aim of this study was to compare nasal and oral delivery of aerosol in appropriate, anatomically correct, replicas of infants’ faces containing both nasal and oral upper airways to the level of the trachea, the latter representing the dose delivered to the LRT/lung parenchyma. Methods: Three replicas representing infants/toddlers aged 5, 14 and 20 months were studied and aerosol delivery by either the oral or nasal route for each of the replicas was measured. A radio-labelled (99mDTPA) normal saline solution aerosol was generated by a Respimat® inhaler and aerosol was delivered via a Respichamber and an air tight mask. A breath simulator was connected to the replicas and an absolute filter at the ‘tracheal’ opening captured the aerosol representing LRT dose. Age-appropriate mask dimensions and breathing patterns were employed for each of the airway replicas. Two different tidal volumes (Vt) were used for comparing the nasal vs oral routes. Results: In all three airway replicas, nasal delivery to the LRT was greater than oral (27.1% vs 19.1% in the small model, 20.8% vs 16.4% in the medium model and 30.8% vs 29.2% in the large model). The difference was highly significant in the two younger models and non-significant in the largest one. The difference tended to
S73
decrease with increasing age. A similar pattern was observed with both low and high tidal volumes. Conclusion: Nasal aerosol delivery may be superior to oral delivery in infants/toddlers, in contrast to older children and adults. L04-212 Flexible bronchoscopic extraction of tracheobronchial foreign bodies in children: lessons learnt – a 10 year experience from North India V. Singh, M.U. Tak, I. Kinimi, S. Patra, A. Parakh. Lady Hardinge Medical College and Kalawati Saran Children’s Hospital Pediatrics, New Delhi, India Objectives: To describe our experience in Tracheobronchial foreign body (TFB) extraction using flexible bronchoscopy (FOB) in children (<18 years) over the past 10 years. Design: Retrospective analysis. Methods: Records of children <18 years who underwent FOB at Kalawati Saran Children’s Hospital between January 2001 and December 2011 with a final diagnosis of TFB were reviewed. Demographic data (age and sex), clinical and radiological details, bronchoscopic findings, success rates of extraction of TFBs and reasons for failure and complications were analyzed. FOB was performed with the patient under conscious sedation. TFB extraction was done using urological instruments like spiral wire basket forceps. Results: A total of 326 children with a final diagnosis of TFB and where removal was attempted with FOB are included in the final analysis. Median age of the cases was 1.5 years (range 5 mo to 12 years, 64% males). The right main bronchus, left main bronchus and trachea were the site of lodgment of TFB in 30%, 30% and 24% cases respectively. The majority of the FB were of vegetable origin 250 (77%) with peanuts being the predominant foreign body (53%). Fifteen of the cases were referred as the initial attempt at extraction by rigid bronchoscopy had failed totally or partially. Twenty-three children were significantly hypoxic pre-procedure of whom 7 cases were received with ventilatory support. While in 36 cases extraction by FOB was unsuccessful (either dormia could not be negotiated or FB could not be grasped due to physical nature or size of the TFB). In 14 children who had glottic TFB, dormia removal with FOB was not attempted as this is not the best suited tool. TFB were successfully removed by FOB in 276/312 cases with a success rate of 89%. A tenth of the cases desaturated further during extraction but this was very transient lasting less than a minute and was alleviated by temporary withdrawal of the scope and continued oxygenation, except in one child who became apnoeic after the foreign body got stuck in the glottic opening. The TFB was pushed back to one of the bronchus and the patient recovered after brief bag and mask ventilation. Unfortunately, one child expired as extraction was attempted. In this case, the sharp end of the stone aspirated by him pierced the bronchus leading to a complete obstruction across carina and pneumomediastinum. About 5% patients had bleeding from the granulation tissue which could be controlled by local instillation of adrenaline. Ten patients required a repeat FOB as initial attempt failed; 4 of these had FB embedded in large granulation tissue and the procedure was repeated after a brief course of steroids while 5 needed repeat procedure for the residual small pieces, and 1 had a repeat FOB since the previous procedure was abandoned because of poor general condition. Conclusions: Flexible bronchoscopic extraction of pediatric TFBs can be performed with minimal risks and complications with a high success rate. It can be done safely even in very sick and hypoxic children where alternative facilities are not available and a skilled operator familiar with the technique is available.