Title: Major aortopulmonary collateral artery aneurysms- a rare cause of airway narrowing

Real-time ultrasound guided segmental bronchoscopic insufflation in a Tay-Sachs patient with atelectasisMatej Šapina, MD, PhD1,2,3*, Bojana Olujić, MD1,2, Tihana Nađ, MD1,2, Hrvoje Vinković, MD1,2, Zdravka Krivdić Dupan, MD1,2, Nikolina Hamidović, MD1, Mia Damašek, MD1,2, Krešimir Milas, MD1, Željko Zubčić, MD, PhD1,2, and Ivan Erić, MD, PhD1,21University hospital center Osijek, 31000 Osijek, Croatia2Medical faculty Osijek, 31000 Osijek, Croatia3Faculty of dental medicine and health Osijek, 31000 Osijek, Croatia*Corresponding author: [email protected]: +385 31 512 279Keywords: bronchoscopy, atelectasis, Tay-Sachs diseaseIntroductionTo the Editor,Atelectasis is the collapse of lung tissue and is a common problem in patients suffering from severe neurological diseases. Treatment depends on the underlying cause, and ranges from respiratory physiotherapy, mucus clearance methods, and in some cases bronchoscopic interventions. If left untreated recurrent infections may occur, along with impaired gas exchange and in the long run fibrosis of the affected area1.A female patient at the age of 3 years with Tay-Sachs disease and consequent severe global psychomotor delay and epilepsy was initially admitted due to a respiratory infection to the neuropediatric department, where she developed an epileptic status and desaturation, prompting a transfer to the Intensive Care Unit. The refractory epileptic status resolved only with several antiepileptics, which lead to intubation requiring invasive mechanical ventilation, after which the patient stabilized.An attempt to reduce sedation the next day resulted in repeated seizures. On the third day, inflammatory parameters increased, with a radiological finding suggestive of pneumonia and a large left atelectasis confirmed by ultrasound. Antibiotics were empirically started, and Moraxella catarrhalis and Adenovirus in the respiratory tract were obtained in the cultures.Lung ultrasound showed a large consolidation in the dorsal upper two thirds of the left hemithorax. Due to the size of the atelectasis, we decided to perform bedside bronchoscopy.A single use paediatric flexible bronchoscope (Ambu® aScope™ 5 Broncho) was introduced through the ETT. The tracheobronchial morphology did not show any obstructions. We applied our recently published modified segmental insufflation technique, however without the use of surfactant2.First, a bronchoalveolar lavage was performed for microbiological and cytological analysis, followed by ultrasound guided bronchoscopic treatment of the affected area. The patient was positioned on the right lateral decubitus position. As described previously, a cuff pressure manometer (AG Cuffill Cuff) and a 50 ml syringe were attached to a three-way stopcock connected to the bronchoscope’s working channel. Pressure controlled segmental insufflation of the lingula and upper lobe was performed directly observing an aeration of the atelectatic areas on the ultrasound with no complications.Subsequent ultrasound monitoring resulted in total expansion of the affected lung and resolution of inflammation, confirmed radiologically (Figure 1.). The patient could be safely extubated and transferred to the wards. No reoccurrence of atelectasis was observed.ConclusionThe treatment of pediatric atelectasis poses a challenge, with limited approaches available and a lack of evidence-based guidelines to guide clinical decision-making. A question that remains to be answered is not only the mode of treatment, but timing. Even with bronchoscopic treatment, different methods exist. In obstructive atelectasis, the approach is simple - to eliminate the obstruction, however, nonobstructive atelectasis remain challenging. Bronchoscopic lung insufflation technique has been explored in adults, with limited cases reported in children3. Several case reports utilized pressure-controlled insufflation with or without surfactant in long standing atelectasis as an add on treatment2; 4.We believe that patients with severe neurological diseases require special attention regarding their susceptibility for developing atelectasis5. Our approach is early bronchoscopic pressure-controlled insufflation in non-obstructive atelectasis. Depending on the duration, we additionally instill surfactant in long standing ones.Ultrasound is recently being used in lung recruitment maneuvers to monitor lung expansion, however, it was only recently reported to be utilized for segmental insufflation monitoring in a spinal muscular atrophy type I patient4. However, to our best knowledge, our case report is the first successful use on a Tay-Sachs patient using real time ultrasound monitoring during pressure-controlled segmental bronchoscopic insufflation. The benefits of ultrasound guidance is the direct visualisation of lung expansion reducing the need for fluoroscopic radiation exposure of visualisation and further monitoring. Besides it increases the safety of the procedure allowing for detection of development of pneumothorax.In conclusion, pressure controlled real-time ultrasound guided bronchoscopic segmental insufflation, with its low-cost, lightweight, and flexible setup, seems to be a safe and promising new modality for treatment of non-obstructive atelectasis, especially in children requiring complex care.FIGURESFigure 1. On the left a large left sided atelectasis can be seen causing the mediastinal shift. On the right complete regression of the atelectasis is observed before extubatingReferences1. Ogake S, Bellinger C. 2020. Role of bronchoscopy in atelectasis. Clinical Pulmonary Medicine. 27(1):30-32.2. Šapina M, Olujic B, Nađ T, Vinkovic H, Dupan ZK, Bartulovic I, Milas K, Kos M, Divkovic D, Zubčić Z. 2023. Bronchoscopic treatment of pediatric atelectasis: A modified segmental insufflation‐surfactant instillation technique. Pediatric Pulmonology.3. Abu‐Hasan MN, Chesrown SE, Jantz MA. 2013. Successful use of bronchoscopic lung insufflation to treat left lung atelectasis. Pediatric Pulmonology. 48(3):306-309.4. Esteban IA, Osona B, Ballestín AS, Rubio CC, de Mendiola JMFP, Gómez VA, López ME, Vicente JCDC. 2024. Bronchoscopic segmental alveolar recruitment in a patient with spinal muscular atrophy and massive atelectasis. Pediatric pulmonology.5. St‐Laurent A, Zysman‐Colman Z, Zielinski D. 2022. Respiratory prehabilitation in pediatric anesthesia in children with muscular and neurologic disease. Pediatric Anesthesia. 32(2):228-236.

FEV 1/FVC normally decreases through childhood, increases briefly during early adolescence, and then declines throughout life. The physiology behind this temporary increase during early adolescence is not well understood. The objective of this study was to determine if this pattern also occurs in children with asthma. Design: Single-center, cross-sectional, retrospective analysis of pulmonary function tests (PFTs) obtained over a 5-year period in children 5 to 18 years of age with persistent asthma. Results: 1,793 patients satisfied all inclusion and exclusion criteria. Mean age (± SD) was 10.4 ± 3.8 years. 48% were female. Mean FEV 1 /FVC was 0.83 ± .09. FEV 1 /FVC in children with persistent asthma declined from age 5 to age 11 by 5.7 % compared to 7.3% in healthy girls, and 5.8% compared to 9.4% in healthy boys. FEV 1/FVC increased by 1.2% until age 16 in children with asthma, compared to 2.2% in healthy girls, and 2.5% compared to 2.3% in healthy boys. The ratio was lower in obese children with asthma at all ages but demonstrated the same curvilinear shape as in healthy children. In absolute terms, FEV 1 grew proportionately more than FVC during early adolescence, so the ratio of FEV 1/FVC increased during that period. The curvilinear shape of the curve remained in postbronchodilator testing, though significantly blunted. Conclusions: The “Shepherd’s Hook” pattern in the FEV 1/FVC curve is preserved in children with persistent asthma. This was also true in obese patients with asthma, although their FEV 1/FVC ratios were lower throughout all stages of childhood and adolescence.

Objectives: To determine the time to ventilator liberation and decannulation after tracheostomy placement in children with bronchopulmonary dysplasia (BPD) and pulmonary hypertension. Methods: A prospective cohort study included all children (<18 years old) who underwent tracheostomy between 2015 and 2021 with or without a diagnosis of BPD. The primary outcome measures were times to mechanical ventilator liberation, tracheostomy decannulation, or death with tracheostomy in place. Patient demographics, associated comorbidities, and outcomes were compared between groups. Results: A total of 318 children met inclusion with a median (interquartile, IQR) age at tracheostomy of 6.9 (IQR: 4.1 – 49.2) months and 54% (N=170) were male. A diagnosis of BPD was made for 43% (N=136) and this group was younger at tracheostomy placement (5.2 vs. 24.5 months, P<.001) and more often had pulmonary hypertension (65% vs. 24%, P<.001) than children without BPD. Children with BPD spent a median of 2.92 years (IQR: 1.60 – 4.03) on mechanical ventilation compared to 1.84 years (IQR: 0.84 – 3.60) for children without BPD ( P=.003). Unadjusted estimation of time to decannulation was longer for children with BPD (HR=0.92, 95% CI: 0.62 – 1.38). The adjusted survival analysis for time to mortality included pulmonary hypertension as a variable of significance (aHR= 2.5, 95% CI: 1.43 – 4.40). Conclusion: The presence of BPD is associated with an increased duration of mechanical ventilation and time to tracheostomy decannulation. Pulmonary hypertension is associated with an increased mortality risk among this vulnerable population of children.

Rationale: In the outpatient setting, inhaled corticosteroids (ICS) are frequently given to children with bronchopulmonary dysplasia (BPD) for treatment of respiratory and asthma associated symptoms. In this study we sought to determine if correlations existed between ICS use and ICS initiation and patient characteristics and outpatient respiratory outcomes. Methods: This study included children with the diagnosis of BPD (n=661) who were seen in outpatient pulmonary clinics at the Children’s Hospital of Philadelphia between 2016-2021. Chart review was used to determine patient demographics, use and timing of ICS initiation, asthma diagnosis and acute care usage following initial hospital discharge. Results: At the first pulmonary visit, 9.2% of children had been prescribed an ICS at NICU discharge, 13.9% had been prescribed an ICS after NICU discharge but before their first pulmonary appointment, and 6.9% were prescribed an ICS at completion of initial pulmonary visit. Children started on an ICS as outpatients, had a higher likelihood of ER visits (adjusted OR: 2.68 ±0.7), hospitalizations (4.81 ± 1.16) and a diagnosis of asthma (3.58 ± 0.84), compared to children never on an ICS. Of those diagnosed with asthma, children prescribed an ICS in the outpatient setting received the diagnosis at an earlier age. No associations between NICU BPD severity scores and ICS use were found. Conclusions: This study identifies an outpatient BPD phenotype associated with ICS use and ICS initiation independent of NICU severity score. Additionally, outpatient ICS initiation correlates with a subsequent diagnosis of asthma and acute care usage in children with BPD.

Opportunities for Trauma-Informed Medical Care in Cystic FibrosisTo the Editor:People living with Cystic Fibrosis (PwCF) face a lifetime of potentially traumatic medical experiences. These experiences can range from invasive medical treatments (e.g. venipuncture, nasogastric tube placement) to daily illness-related events (e.g. illness related bullying). These experiences place PwCF at high risk for a type of posttraumatic stress called Medical Traumatic Stress (MTS)[1]. With the growing recognition of the high prevalence and impact of MTS, we anticipate that cystic fibrosis care teams may soon be tasked with integrating trauma-informed medical care into their clinical practices. CF care teams are well poised to prevent and screen for MTS because they 1) create the environment for many illness-related experiences; 2) have established workflows for mental health screening; and, in many cases, 3) have trusting relationships with PwCF and their families. Here, we seek to highlight the opportunities for implementing trauma-informed medical care within the cystic fibrosis-specific context.MTS is defined as the psychological and physiological responses of children and their families to pain, injury, serious illness, medical procedures, and invasive or frightening treatment experiences[2]. MTS is common in PwCF – 55% of these youth report experiencing potentially traumatic medical experiences and 30% report MTS symptoms[1]. MTS symptoms have the potential to impact medical care, health outcomes and quality of life[3].While highly effective modulator therapies may decrease the frequency and severity of medical care, PwCF have identified these therapies as an additional source of potentially traumatic experiences[4]. New potentially traumatic medical experiences in modulator-eligible PwCF can include lost sense of purpose as their identity shifts from a “sick” person to a “well” person; survivor guilt from benefiting from therapies not available to others; and financial distress as they face planning for a longer than anticipated life expectancy [4]. The challenge of navigating the healthcare system, such as advocating with care teams and insurance companies, has been identified as potentially traumatic by PwCF, particularly those who are modulator-ineligible[4].A trauma-informed approach to medical care may be helpful for cystic fibrosis care teams to mitigate MTS. The Pediatric Psychosocial Preventive Health Model (PPPHM) provides a framework for tiered implementation of trauma-informed medical care[5]. It includes recommendations for universal practices gauged towards all children and families, targeted approaches for those at high risk of developing MTS, and treatment for those with severe, escalating, or persistent MTS symptoms (Figure 1).Universal MTS interventions for PwCF include prevention and screening. Preventive interventions can include MTS awareness education for all PwCF, family members of PwCF and cystic fibrosis care team members. This education can highlight approaches to modifying potentially traumatic medical experiences and identifying MTS symptoms that indicate the need for further support. Universal systems interventions may also include the implementation of workflows to minimize the traumatic potential of healthcare experiences (e.g. workflows to minimize needle distress with comfort positioning, numbing cream, and distraction as part of standard care. Care teams can also integrate shared decision-making processes to optimize patient perception of control and implement systems that facilitate communication between cystic fibrosis care team and PwCF.While annual mental health screening for depression and anxiety is the current recommendation for all PwCF, healthcare providers should consider integrating routine MTS screening into their practice. Screening workflows can include screening for patient risk factors and MTS symptoms, as well as family member symptoms of MTS. Currently, there are no screening tools designed to specifically capture the cystic fibrosis experience of MTS; however, acute stress screeners such as the Acute Stress Checklist for Children can aid in the identification of MTS, thereby guiding providers on who to refer for further mental health assessments or support. One common concern regarding screening for MTS is managing the burden of time as well as supporting those PwCF who screen at-risk. Thus, in planning for MTS screening, teams ought to consider the time required for screening, appropriate training for those performing the screening, and the development of a clear workflow for management and referrals. While these barriers require a thoughtful approach to processes and care, the benefits outweigh the consequences of not screening. MTS is present for many regardless of if screening occurs and screening allows the medical team to optimize overall healthcare.The second tier of the PPPHM recommends targeted approaches to MTS for those with risk factors or early symptoms. Possible MTS risk factors in PwCF include parent posttraumatic stress disorder, high daily medication burden, and emergency room and intensive care [1]. Interventions for PwCF who have MTS risk factors or early symptoms may include increasing support during potentially traumatic medical experiences (e.g. having a child life expert prepare a patient before a procedure); altering the medical care plan when possible (e.g. minimizing daily medication burden); educating family members on what to say to PwCF before, during, and after potentially traumatic medical experiences; and integrating patient-specific resilience factors into individualized coping and support plans. In some cases, brief therapeutic psychological interventions may help address specific symptoms (e.g., targeted CBT needle phobia interventions, behavioral sleep interventions, brief psychoeducation interventions).The third tier of the PPPHM recommends treatment for MTS symptoms that impact medical care or impair daily functions. PwCF with significant MTS symptoms should be referred to a mental health provider with expertise in the treatment of trauma symptoms. Ideally, the provider should have familiarity with chronic medical conditions, and, ideally, cystic fibrosis specifically. While we do not yet have evidence-based MTS-specific interventions for PwCF, approaches may include cognitive behavioral techniques such as restructuring of hospital-related thoughts, behavioral activation, or trauma-focused cognitive behavioral therapy. Mental health providers could also collaborate with families and cystic fibrosis care teams to develop an individualized plan for minimizing re-traumatization and reducing the impact of MTS on medical care and quality of life.In summary, given the substantial impact that MTS can have on PwCF, cystic fibrosis care teams should consider integrating trauma-informed approaches into the medical care of PwCF to optimize overall health (including mental health). Comprehensive approaches to MTS mitigation in PwCF include 1) universal awareness, prevention, and screening, 2) targeted interventions for those at high risk, and 3) individualized MTS treatment administered by mental health professionals. To optimize cystic fibrosis care with attention to MTS, future research should prioritize more definitive identification of MTS risk factors, the development of validated cystic fibrosis-specific MTS screening tools, the creation and dissemination of evidence-based MTS prevention programs, and the development of evidence-based MTS mental health interventions tailored to PwCF.Figure 1: Application of the Pediatric Psychosocial Preventative Health Model to Cystic Fibrosis. Adapted with permission from the Center for Healthcare Delivery Science at Nemours Children’s Health System 2018-2019. All rights reserved[5].

Introduction This study aimed to describe the epidemiology and etiologies of critical respiratory diseases of ex-premature infants (EPIs) admitted to pediatric intensive care unit (PICU). In addition, we described the outcomes and resources used of EPIs and identified associated factors for mortality of these infants. Materials and Methods Infants ≤2 years old with acute respiratory illnesses admitted to PICU of Vietnam National Children’s Hospital from November 2019 to April 2021 were enrolled. We compared respiratory pathogens, outcomes, and PICU resources utilized between term infants and EPIs. Univariate followed by multivariable regression analysis were used to evaluate the association between risk factors and mortality. Results Among 1,183 patients aged ≤2 years were admitted for critical respiratory illness, 202 (17.1%) were EPIs. Respiratory viruses were detected in 53.5% and 38.2% among EPIs and term infants, respectively. Compared to term infants, a higher proportion of EPIs required mechanical ventilation (MV) (66.5 vs. 85.6%, p<0.005) and vasopressor support (10.7 vs. 37.6%, p<0.005). EPIs had a longer median duration of PICU stay (11.0 [IQR: 7; 22] vs. 6.0 days [IQR: 3; 11], p=0.09), hospital stay (21.5 [IQR: 13; 40] vs. 10.0 days [IQR: 5; 18], p<0.005) and case fatality rate (31.3% vs. 22.6%) compared to term infants. In EPIs, PIM3 score [ (aOR): 1.51; 95% (CI): 1.30-1.75] and PELOD2 score at admission (aOR: 1.41; 95% CI: 1.08-1.85) were associated with mortality. Conclusion EPIs with critical respiratory illnesses constituted a significant population in the PICU and required more PICU support and had worse clinical outcomes compared to term infants.

Medication Utilization and Lung Function Changes

Background: Diagnosis and treatment of obstructive sleep apnea (OSA) in infants and young children is challenging because of its clinical heterogeneity and lack of age-specific guidelines. Aim: We report the management and treatment outcome of OSA in children below two years of age. Treatment decisions were based upon the pattern of upper airway (UA) obstruction, clinical presentation and OSA severity. Methods: Retrospective, non-randomized observational cohort study at a tertiary center. Children with OSA who underwent an UA evaluation (drug-induced sleep endoscopy or direct laryngoscopy) were included. Results: The study population comprised 100 patients, 57 boys and 43 girls, with a median age of 0.72 years (range 0.0-2.0) and OSA confirmed by polysomnography. Multilevel UA collapse was present in 26%, (adeno)tonsillar hypertrophy in 31% and 21% had laryngomalacia. Laryngomalacia was more common in children below six months of age and adenotonsillar hypertrophy was observed mainly in children older than 1.5 year of age. Treatment improved OSA severity in the entire study population with a significant reduction in obstructive apnea/hypopnea index from 10.8/h (range 2.1-99.1) to 1.7/h (range 0.0-73.0) (p<0.001), an improvement in mean oxygen saturation from 96.9% (range 88.9-98.4) to 97.4% (range 92.3-99.0) (p<0.001) and in minimal oxygen saturation from 85.4% (range 37.0-96.0) to 88.8% (range 51.0-95.5) (p<0.001). Conclusion: Multidisciplinary management of young children with OSA guided by the pattern of UA obstruction and OSA severity, results in favorable treatment outcomes. The pattern of UA obstruction changes in the first two years of life from a dynamic collapse to structural abnormalities.

Clinical Correspondence

Impact of Nirsevimab on Admission to Pediatric Intensive Care Unit because of RSV Bronchiolitis: unicentric observational study from 2017-2024

A document by Velda Ocasio Ramírez. Click on the document to view its contents.

Atypical presentation and management of a neonate with alveolar capillary dysplasia: A case reportTo the Editor,Alveolar capillary dysplasia with misalignment of capillary veins (ACD/MCV) is a rare interstitial lung disease caused by maldevelopment of alveoli and capillaries. Neonates typically present with intractable pulmonary hypertension within the first 48 hours of life and have a very short life expectancy 1. However, atypical cases have been described with a late, less fulminant clinical presentation and prolonged survival on pulmonary vasodilators, providing a window for bilateral lung transplantation 2.Case presentationOur patient is a female neonate born at 37 weeks of gestation, weighing 3080 gr after an uncomplicated pregnancy. She was admitted to the neonatal intensive care unit (NICU) at the age of two hours due to pneumothorax, which was managed conservatively and absorbed. On the second day of life, she was intubated due to worsening respiratory distress. Over the next several days, unsuccessful extubation trials were attempted. Eventually, she was weaned off oxygen on the 11th day. However, on postnatal day 16, significant respiratory deterioration was noted. Echocardiography revealed moderate pulmonary hypertension, and sildenafil and dopamine were initiated. The patient’s clinical condition and echocardiography findings gradually deteriorated. High-frequency oscillatory ventilation (HFOV) was commenced with a fraction of inspired oxygen (fiO2) up to 1.0. As our patient continued to deteriorate (maximum oxygenation index OI:32 on day 23), we used intravenous iloprost as a pulmonary vasodilator, titrated up to 20 ng/kg/min in combination with levosimendan up to 0.1 mcg/kg/min, to improve cardiac contractility and reduce afterload and pulmonary resistance. Of note, nitric oxide was unavailable in our center at this time. Although gradual improvement in pulmonary hypertension was noticed, our patient developed severe pulmonary edema, which was managed with a continuous intravenous infusion of furosemide titrated up to 0.4mg/kg/h. Intravenous medications were gradually withdrawn, and we could switch to conventional ventilation on the day of life 34. The infant was extubated ten days later.Computed tomography of the lungs showed bilateral symmetrical ground-glass opacification, and genetic testing with whole exome sequencing (WES) revealed a heterozygous missense variant of the FOXF1 gene (c.229T>C;p.Phe77Leu) in exon 1.Our patient remained stable on a high-flow nasal cannula (HFNC) until the 68th day when she was reintubated, and echocardiography revealed severe pulmonary hypertension. On the 72nd day of life, she was transferred to another NICU at the request of her parents. She remained intubated, treatment with pulmonary vasodilators was continued, and finally, a tracheostomy was performed. She eventually died at five months of age. The parents have consent to report the medical details of the neonate.

Misconceptions on Behavioral Cough Suppression Therapy for Pediatric Nonspecific Cough: A Response to Weinberger and Buettner’s Commentary on Fujiki et al.Laurie Slovarp, PhD, School of Speech, Language, Hearing, & Occupational Sciences, University of MontanaMarie Jette, PhD, Department of Otolaryngology – Head and Neck Surgery, University of Colorado Anschutz Medical CampusJane Reynolds, PhD, School of Speech, Language, Hearing, & Occupational Sciences, University of MontanaAmanda Gillespie, PhD, Department of Otolaryngology and Head and Neck Surgery, Emory UniversityJulie Barkmeier-Kraemer, PhD, Division of Otolaryngology – Head and Neck Surgery, University of UtahMary Sandage, PhD, Speech, Language, and Hearing Sciences, Auburn UniversityJaclyn Smith, PhD, Biology, Medical and Health Sciences, The University of ManchesterJemma Haines, BSc(Hons), Medical and Health Sciences, The University of Manchester, Manchester University NHS Foundation TrustAnne Vertigan, PhD, School of Medicine and Public Health, University of NewcastleStuart Mazzone, PhD, Department of Anatomy and Physiology, University of MelbourneCorresponding author: Laurie Slovarp, PhD,School of Speech, Language, Hearing, & Occupational Sciences, University of Montana, Missoula, MT, 59812. [email protected] (p) 406-243-2107 (f) 406-243-2362 Orcid ID: 0000-0002-3547-4092Key words : pediatric chronic cough, habit cough, suggestion therapy, speech-language pathologyFunding : noneConflicts of Interest: The authors declare no conflicts of interest.Author Contributions :Laurie Slovarp: conceptualization, writing original draft, review and editingMarie Jette: conceptualization, writing original draft, review and editingJane Reynolds: conceptualization, writing original draft, review and editingAmanda Gillespie: conceptualization, writing original draft, review and editingJulie Barkmeier-Kraemer: review and editingMary Sandage: review and editingJaclyn Smith: review and editingJemma Haines: review and editingAnne Vertigan: review and editingStuart Mazzone: writing, review, and editingAbstract/Summary : This commentary responds to Weinberger and Buettner’s critique of Fujiki et al.’s study on behavioral cough suppression therapy (BCST) for pediatric chronic cough. While acknowledging their contributions, it addresses inaccuracies and clarifies key aspects of BCST. The commentary highlights discrepancies in terminology, challenges assertions regarding diagnostic evaluations, and emphasizes the need for controlled trials to assess treatment efficacy.In their engagement with the study by Fujiki et al.1, Weinberger and Buettner2 bring attention to critical aspects of behavioral cough suppression therapy (BCST) and pediatric chronic cough treatment. While their contributions are valued, it is imperative to address certain inaccuracies and clarify key aspects of the study and BCST provided by specialized speech-language pathologists (SLPs).Firstly, Weinberger & Buettner inaccurately state that Fujiki et al. identified the children as having ”behavioral cough.” The term ”behavioral cough” in the paper was used only in the context of ”behavioral cough suppression therapy,” describing the treatment rather than the children’s cough diagnosis. The authors, in fact, used the term ”nonspecific cough/tic cough” in accordance with current CHEST and ERS guidelines3-5. Weinberger & Buettner’s assertion that ”historical evidence and current practice support “habit cough” as the appropriate diagnosis” lacks substantiation and contradicts contemporary CHEST guidelines5. We are particularly puzzled by Weinberger & Buettner’s advocacy for the term habit cough when Dr. Weinberger is listed as an author on a 2015 CHEST guidelines publication that explicitly advises against the use of these terms, deeming them ”out of date and inaccurate”5.Weinberger & Buettner also criticize the use of extensive evaluations for the children in the sample, arguing that “habit cough” can be diagnosed based on clinical presentation alone—specifically in the presence of a barking or honking cough and absence of the cough during sleep. Interestingly, the same CHEST guidelines, of which Weinberger is an author, specifically cautions against using the diagnostic terms of “psychogenic” or “habit cough” solely based on a barking or honking sound or the absence of cough during sleep, stating that these three clinical presentations lack specificity5. A barking or honking cough can occur with other diseases such as tracheomalacia or bronchiectasis6; and it is well documented that sleep inhibits the cough reflex in adults even when an organic disease process is identified7; 8. Without evidence to the contrary, it is should be assumed that sleep similarly suppresses cough in children. Further, the purpose of Fujiki et al.’s paper was to examine whether BCST improves cough in children and to describe cough characteristics and comorbidities, not to advocate for extensive assessments. Although, it is noteworthy that laryngoscopy revealed structural laryngeal pathology in several cases, challenging Weinberger & Buettner’s assertion that the described assessments were unjustified.Regarding the treatment described in Fujiki et al., Weinberger & Buettner characterize BCST as an “alternative to suggestion therapy.” This overlooks that BCST instructs in strategies to suppress cough, akin to his “suggestion therapy.” Therefore, it seems that BCST is not necessarily an alternative but rather a similar therapy with a different name. This overlap emphasizes the need for clarity in terminology. Importantly, in adults with chronic cough a loss of centrally (brain) mediated cough suppression has been demonstrated using functional brain imaging9.  Although empirical data in children is not available, it seems conceivable that similar mechanisms may be in operation, providing a neurobiological basis for why cough suppression training is often beneficial and supporting the use of terminology that emphasizes this aspect of the therapy.Additionally, Weinberger & Buettner’s argument that 45 pediatric pulmonologists ”already indicate they readily diagnose habit cough and successfully treat with suggestion therapy,” implies a stance against SLP treatment. However, considering there are thousands of pediatric pulmonologists in the U.S. alone, the sample size of 45 falls short of substantiating the claim that ”many” pulmonologists universally adopt this approach or that additional clinicians, such as SLPs, are unnecessary to assist these patients effectively. The argument lacks robust evidence and fails to account for the role of additional clinicians, such as SLPs, to address pediatric chronic cough effectively. Further, a substantial proportion of children in Fujiki et al.’s sample presented with phonotraumatic lesions (e.g., vocal nodules), which SLPs are specifically trained to address through behavioral treatment.Lastly, Weinberger & Buettner suggest that conducting a controlled trial for suggestion therapy is impractical due to the reported low frequency of referrals. We disagree that the size of the population is a valid argument for not conducting a randomized controlled trial. A control group is needed to robustly assess the efficacy of any treatment, particularly in the case of cough interventions which are particularly vulnerable to placebo effect10; 11. Weinberger & Buettner suggest that it would be unethical to withhold suggestion therapy for the sake of a randomized clinical trial; however, one could easily design a study that allowed for those randomized to a control treatment to be eligible for suggestion therapy upon completion of the control arm. Given Dr. Weinberger’s data suggests suggestion therapy eliminates nonspecific/tic cough in less than one week, such children would need to wait no more than one to two weeks before becoming eligible for suggestion therapy and it should be possible to demonstrate such a substantial effect in a relatively small number of subjects in a randomized controlled trial.We agree with Dr. Weinberger that SLP skills vary. As is the case with any clinical discipline, there are many subspecialties in the field of speech-language pathology and varying levels of skill and expertise within those subspecialties. BCST training is not standard in SLP training programs, and, therefore, requires special training.In conclusion, we think these clarifications underscore the importance of understanding Fujiki et al.’s paper in its correct context, and will advance a more nuanced and informed discussion on pediatric cough disorders and BCST’s role in treatment. We acknowledge Weinberger & Buettner’s contribution to pediatric cough management. The data reported in this letter and other publications12; 13, although anecdotal, suggests that behavioral treatment focused on cough suppression is effective. Given this, we encourage Weinberger and Buettner to complete a randomized controlled efficacy trial. If the data confirms efficacy, the study would significantly elevate the legitimacy of the treatment, increasing its use by other practitioners and benefitting pediatric patients with chronic cough.REFERENCES1. Fujiki RB, Wright ML, Fujiki AE, Thibeault SL. 2023. Factors influencing behavioral cough suppression therapy in children with nonspecific chronic cough. Pediatr Pulmonol. 58(12):3466-3477.2. Weinberger M, Buettner D. 2024. The habit cough syndrome. Pediatr Pulmonol. 59(2):260-262.3. Chang AB, Oppenheimer JJ, Irwin RS, Panel CEC. 2020. Managing chronic cough as a symptom in children and management algorithms: CHEST guideline and expert panel report. Chest. 158(1):303-329.4. Morice AH, Millqvist E, Bieksiene K, Birring SS, Dicpinigaitis P, Domingo Ribas C, Hilton Boon M, Kantar A, Lai K, McGarvey L et al. 2020. ERS guidelines on the diagnosis and treatment of chronic cough in adults and children. Eur Respir J. 55(1).5. Vertigan AE, Murad MH, Pringsheim T, Feinstein A, Chang AB, Newcombe PA, Rubin BK, McGarvey LP, Weir K, Altman KW et al. 2015. Somatic cough syndrome (previously referred to as psychogenic cough) and tic cough (previously referred to as habit cough) in adults and children: CHEST guideline and expert panel report. Chest. 148(1):24-31.6. Spinou A, Lee KK, Sinha A, Elston C, Loebinger MR, Wilson R, Chung KF, Yousaf N, Pavord ID, Matos S et al. 2017. The objective assessment of cough frequency in bronchiectasis. Lung. 195(5):575-585.7. Lee KK, Birring SS. 2010. Cough and sleep. Lung. 188 Suppl 1:S91-94.8. Power JT, Stewart IC, Connaughton JJ, Brash HM, Shapiro CM, Flenley DC, Douglas NJ. 1984. Nocturnal cough in patients with chronic bronchitis and emphysema. Am Rev Respir Dis. 130(6):999-1001.9. Ando A, Smallwood D, McMahon M, Irving L, Mazzone SB, Farrell MJ. 2016. Neural correlates of cough hypersensitivity in humans: Evidence for central sensitisation and dysfunctional inhibitory control. Thorax. 71(4):323-329.10. Eccles R. 2009. Central mechanisms iv: Conscious control of cough and the placebo effect. Handb Exp Pharmacol. (187):241-262.11. Eccles R. 2010. Importance of placebo effect in cough clinical trials. Lung. 188 Suppl 1:S53-61.12. Lokshin B, Lindgren S, Weinberger M, Koviach J. 1991. Outcome of habit cough in children treated with a brief session of suggestion therapy. Ann Allergy. 67(6):579-582.13. Weinberger M, Hoegger M. 2016. The cough without a cause: Habit cough syndrome. J Allergy Clin Immunol. 137(3):930-931.

A breath of fresh air: Does spontaneous breathing and early repair in neonates with very mild congenital diaphragmatic hernia lead to earlier discharge? Dear Editor:We read with great interest the article by Kipfmueller et al. that investigated the feasibility and outcomes of a spontaneous breathing approach (SBA) versus immediate intubation in neonates with prenatally diagnosed very mild CDH and found that it appears to be feasible and beneficial1. The authors present an approach that is quite novel - spontaneous breathing and enteral feeding in the pre-surgical repair phase. We compliment the authors for their attempt to address an issue very relevant to the acute management of CDH. Nonetheless, we feel compelled to highlight some aspects that should be considered for adequate interpretation of their findings.The study’s sample size is quite small (n=24), but the fact that the investigators found statistical significance for numerous associations despite such a small sample size demonstrates the strength of the relationships.  It is a common misconception that statistical significance due to chance (i.e., Type I error) is more likely when the sample size is small, although low power due to the small sample size is actually difficult to overcome2. However, when evaluating Table 1, after matching on observed-to-expected lung-to-head-ratio (o/e LHR), liver position, gestational age at delivery, birth weight, and defect size, we note that prerepair characteristics such as early feeding, Oxygenation Index (OI) and FiO2, and Apgar at 10min are still significantly imbalanced between the SBA and standard treatment groups, which raises concerns about potential confounding. For this reason, we recommend the authors complement the unadjusted analyses they report with multivariable regression analyses that compare SBA versus standard treatment after controlling for Apgar 10, OI and FiO2, although the study sample size of n=24 would typically be considered too small for this kind of multivariable regression analysis. Per the authors, 39 patients met their prenatal eligibility criteria. A better and more meaningful comparison of outcomes would be to compare the 8 patients that underwent SBA versus the remaining 31 patient that met their predetermined ’eligibility criteria’ and did not undergo planed SBA. Using this approach would diminish the potential differences in cohort caused by severity of hernia defect, given the fact that some patients in the standard treatment group required patch repair. In the study, the authors incorporated the post natally determined CDH defect size into the matching process; we would advise against using defect size for matching as it cannot be replicated prospectively.The authors utilized the Mann-Whitney U test and Fisher’s exact test to compare the SBA versus standard treatment groups in terms of quantitative and categorical variables, respectively.  These methods ignore the dependence structure in the data resulting from matching. Although this type of oversight is common, we would recommend analyzing the data differently. Utilizing mixed-effects linear models and generalized estimating equations for quantitative and categorical outcomes, respectively, would appropriately accommodate the clustering of study patients due to matching.We were impressed by the decision to initiate enteral feeding prior to surgery and wonder if this approach could be a gut priming strategy favoring outcomes beyond the need for parenteral nutrition3. However, while novel and potentially beneficial, this strategy carries with it risks and will need to be investigated further before others will choose to adopt such a practice.Overall, the authors tackle an important subject and their findings raise questions on whether routine intubation is beneficial for infants with mild CDH. As SBA infants were compared to those with more severe hernias, the observed differences noted between groups are likely a reflection of the severity of lung hypoplasia and not a result of the intervention. We encourage the authors to further explore this strategy with a larger multicenter study to draw meaningful conclusions from the study results.Clinicians should be cautious of implementing guideline changes based on retrospective studies, as prospective studies do not always validate inferences derived from retrospectives studies, such as permissive hypercapnia to prevent bronchopulmonary dysplasia in extremely low birth weight infants (ELBW)4. Centers that perform early repair could consider an SBA approach for a well-defined cohort of infants with mild CDH, as it appears this can decrease the duration of ventilation and length of hospital stay. However, this precision-based medicine approach would be best evaluated by a prospective study to assess the benefits and risks of implementing this strategy.1. Kipfmueller F, Leyens J, Pugnaloni F, et al. Spontaneous breathing in selected neonates with very mild congenital diaphragmatic hernia.Pediatr Pulmonol. 2024;59(3):617-624.2. Jones SR, Carley S, Harrison M. An introduction to power and sample size estimation. Emerg Med J. 2003;20(5):453-458.3. Ratsika A, Codagnone MC, O’Mahony S, Stanton C, Cryan JF. Priming for Life: Early Life Nutrition and the Microbiota-Gut-Brain Axis.Nutrients. 2021;13(2):423.4. Thome UH, Genzel-Boroviczeny O, Bohnhorst B, et al. Neurodevelopmental outcomes of extremely low birthweight infants randomised to different PCO(2) targets: the PHELBI follow-up study.Arch Dis Child Fetal Neonatal Ed. 2017;102(5):F376-F382.The authors have disclosed no conflicts of interest.

Caring for children with asthma continues to be an essential responsibility of the pediatric pulmonologist. In this Pediatric Pulmonology Year in Review, we summarize the significant publications focused on pediatric asthma that have been published over the last year. We will discuss new findings that assist in the diagnosis and evaluation of pediatric asthma, highlight risk factors and social determinants that impact successful care, and discuss new interventions and treatment modalities for acute exacerbations and maintenance control. We hope this review can provide new insights and guidance for implementation into clinical practice within the field of pediatric asthma.

Background: One-third of people with cystic fibrosis (PwCF) are food insecure, with profound negative implications for their health. This qualitative study explored lived experiences with food insecurity among PwCF or their caregivers and summarized their perspectives on food insecurity screening in the CF programs where they receive care. Methods: Semi-structured qualitative interviews were conducted with two groups: (1) adults with CF and (2) parents or caregivers of children with CF. PwCF or their caregivers with previously documented food insecurity were referred for participation by pediatric and adult CF programs across the United States. Interviews were recorded and transcribed, and data were coded and analyzed by two independent coders using a content-analysis approach with a constant comparative method to generate themes. Results: A total of 26 participants from 22 CF programs were interviewed. The sample included 17 adults with CF and 9 parents of children with CF. Participants were predominantly White (88%) and female (92%). Five overarching themes emerged: (1) Food insecurity among CF patients and their families is onerous; (2) Financial constraints imposed by the CF disease contribute to food insecurity; (3) Federal and state programs provide limited food assistance, and other support is minimal; (4) Shame and stigma engulf conversations around food insecurity with CF care teams; (5) Food insecurity screening in clinical settings is critical. Conclusions: Food insecurity among PwCF is invisible, but its consequences are dire. Assistance is limited, screening is inconsistent, and stigma is widespread. There is an urgent need to normalize food insecurity screening, standardize the screening process, and expand food assistance programs for PwCF.

Background: The estimated prevalence of tracheobronchomalacia (TBM) in children is about 1:2100. Tracheomalacia (TM) prevalence is higher in patients with chronic lung disease such as bronchiectasis and cystic fibrosis (CF) and may contribute to increased morbidity. Objective: To determine the prevalence and assess clinical features of TM, TBM and bronchomalacia (BM) in patients with primary ciliary dyskinesia (PCD). Methods: We performed a retrospective case-note review of all children with a confirmed or highly likely diagnosis of PCD attending Oslo University Hospital between 2000-2021. We selected those who had undergone flexible fiberoptic bronchoscopy (FB) and in whom the presence of TBM was assessed. We retrieved demographic and clinical data, including airway symptoms, PCD-diagnostic criteria, indication for bronchoscopy, the presence of lobar atelectasis, bacteriology and the descriptive and unblinded video-recorded results of FB. Complications occurring during and after bronchoscopy were noted. Results: Of 71 children with PCD, 32 underwent FB and were included in the review. The remaining 39 were included for TBM prevalence calculation only. Median age at FB was 6.0 y (3.1 – 11.9). Twenty-two children (69%) had intrathoracic airway malacia. Four (13%) had isolated TM, seven (22%) had TBM, and 11 (34%) had isolated BM affecting either main (n=4) or lobar bronchi (n=7) (LBM), including four with associated lobar atelectasis. FB related complications, one major, 12 minor, were documented in 13 children (41%). Conclusion: We found a high prevalence of TBM among children with PCD undergoing FB. This may represent a significant comorbidity and have implications for patient management.