Professionals Guide Archives - Page 2 of 7 - CHILD AND CHEST HEALTH CARE

Artificial Intelligence in Childhood Asthma Management-Dr Deo Kumar Jha,M.D.,Pediatrician and Pulmonologist,Ghaziabad,Delhi and NCR

Pediatrician and Pediatric Pulmonologist Dr.Dev Kumar Jha,Formerly at AIIMS,New Delhi - 05 Jan, 2024 - Professionals Guide, - 0 Comment

Artificial intelligence enabled Stethoscope(StethoMe) ,when applied to chest,records both continuous sound like wheeze and non continuous sound like crackles. It also records heart rate and respiratory rate. It then transfers the data wirelessly to mobile app enabled with Artificial Intelligence(AI) ,which analyzes it and gives the report. It also gives the ratio of duration of inspiration to expiration(I:E) which is an important parameter for detection of asthma exacerbation.

StethoMe is CE Certified Class 11a medical device,and AI has been trained after recording of more than 10000 respiratory sounds.

In a study published in Annals of family medicine, 52 children in which 63.5% were male, ,between the age of 0-5 years,38 children in which 76.3% were male between the age of 6 to 17 years, and 59 adults in which 27.1% were male were enrolled.

They were given StethoMe and in addition to it ,they were also given Pulse oximeter and Peak flow meter(For PEF monitoring).

All participants performed the examination,one time, daily with the device thirty minutes after taking regular asthma medication as a controller for first 14 days then at least once in a week.

They performed the examination twice daily during the period of felt exacerbation in the form of increased symptoms.

Participants performed 6442 complete examinations and they produced 41872 recordings.

6.4% participants were excluded from the study as they did not meet the quality criteria.

A total of 17 physicians,2 from internal medicine,4 Pulmonologists,9 Pediatricians,5 Allergologists,and 4 family medicine specialists analyzed the data in which few of them were having double specializations.

Researchers obtained ROC(Researchers operating characteristic) and AUC (Area under curve)

Among young children the best discriminator for exacerbation was wheeze intensity with an AUC of 84% (95% CI, 82%-85%).

Among older children the best discriminator was ronchi intensity with AUC of 81% (95% CI, 79%-84%)

Accordinng to GINA guideline, the diagnosis of asthma exacerbation in children should be based on subjective symptoms but the symptoms reported by care givers in this age group is not sufficient for the diagnosis of excerbation or exclusion of exacerbation with an AUC of 72% (95% CI, 70.1%-73.9% as per the research.

The data provided by StethoMe along with Peak flow meter and SpO2 was the best for assessment of asthma exacerbation in all age groups.

CONCLUSION:The data provided by StethoMe-respiratory sounds,heart rate,inspiratory and expiratory ratio enabled with AI is very useful without PEF in detecting Asthma exacerbation specially in children below 5 years of age

REFERENCES:: Emeryk A, et al. Ann Fam Med. 2023;doi:10.1370/afm.3039.

Dr Deo Kumar Jha,M.D., Child and Child Chest Specialist,Ghaziabad, Delhi and NCR

Treatment of cystic fibrosis,now available for children,Dr. Deo Kumar Jha, M.D.,Pediatrician and Pulmonologist,Ghaziabad,Delhi and NCR

Pediatrician and Pediatric Pulmonologist Dr.Dev Kumar Jha,Formerly at AIIMS,New Delhi - 29 Dec, 2023 - Professionals Guide, - 0 Comment

Cystic fibrosis is a genetic disease with Autosomal recessive pattern.

It is more commonly seen in children born out of consanguineously married couples

It was considered a diagnosis of children from western countries,till Dr Sushil Kumar Kabra,from AIIMS,New Delhi made the diagnosis,approachable and affordable,by developing an indegenous instrument to measure the sweat chloride level ,essential for the diagnosis of cystic fibrosis in children.

It primarily affects respiratory systems ,gastrointestinal system and genitourinary system.

The primary pathology is mutation of CFTR gene ,responsible for transport of electrolytes which carry water with it across the cell membrane.

The mutation,causes the secretions in respiratory tract ,gastrointestinal tract and genitourinary tract,very thick.

The sufferer,gets difficulties in clearing secretions from the respiratory airways,bacteria get stuck in the thick secretions and the child develops repeated episodes of cough,visits many clinicians with very little benefits,till the final diagnosis of cystic fibrosis is made at the centre with expertise in CF (Cystic fibrosis). Chest X-Ray at initial stage shows only bilateral hyperinflation which is easily confused with asthma.

As per the gastrointestinal system,initially there is frequent watery diarrhoea,and later on constipation and intestinal obstruction popularly known as meconium ileus equivalent occurs in older children. Some children may be born with intestinal obstruction ,called meconium ileus.

Adults may suffer from infertility due to absence of vas deference in male and tube blockage in female .

The diagnosis is based on sweat chloride analysis,and mutaion analysis.

The most common mutation is seen on delta 508 F location of gene,all over the world.

The only option for the treatment till recent years was supportive therapy, in the form of enzyme LIPASE with meals,hypertonic saline inhalation to make the respiratory secretions thin,and chest physiotherapy to induce cough and taking out the pulled secretions to make airways clean. Inhalational steroids to subside the airways inflammation and keep it in control and antibiotics to treat and prevent respiratory tract infections,known in this case as pulmonary exacerbation due to infections..

In the past few years,there have been many multicentric research which gave the medicines that regulate CFTR gene.

In a study on 506 children aged 12 years or more,ELEXACAFTOR 200mg,IVACAFTOR 150mg and TEZACAFTOR 100 mg were given 12 hourly for 144 weeks.

At the end of 144 weeks, there was significant improvement in lung functions in the form of mean rise of 14.1% in FEV1 and marked decrease in pulmonary exacerbation,0.2 per year only.

The BMI went up with mean increase of 1.61 kg/metre square.

Cystic fibrosis questionaire was also also improved.

There was marked improvement in symptoms.

Adverse effects were moderate and the main adverse effect was infective Pulmonary exacerbation,followed by cough ,headache,oropharyngeal pain and nasopharyngitis

This therapy is popularly known as triple therapy or ETI therapy.

This is very costly therapy but safe and effective with its limitation of availability.

Dr Deo Kumar Jha,M.D., Pediatrician and Pulmonologist,Ghaziabad,Delhi and NCR,www.childandchestdoctor.com,You Tube channel-Dr Deo Kumar Jha

REFERENCE: Daines CL, et al. Eur Respir J. 2023;doi:10.1183/13993003.02029-2022:

DUPILUMAB, EFFECTIVE TREATMENT FOR ASTHMA IN CHILDREN,Dr Deo Kumar Jha ,M.D,Pediatrician and Pulmonologist,Delhi-NCR

Pediatrician and Pediatric Pulmonologist Dr.Dev Kumar Jha,Formerly at AIIMS,New Delhi - 15 Dec, 2023 - Professionals Guide, - 0 Comment

When asthma is not controlled even on high dose inhalational corticosteroids with other controller with or without oral corticosteroids,it is called severe therapy resistant asthma(STRA).

If the child is diagnosed with type 2 airway inflammaton, biologics are the choice in these scenario.

There are so many biologics in the market but few are approved for children.

According to a study on 408 children with the mean age of 8.9 years ,Dupilumab was found to be consistently effective and safe.

Dupilumab was used as an injection by subcutaneous route.

It was given in the dose of 100mg,twice in a week for children equal to or less than 30 kg of weight.

For children more than 30 kg of weight ,the dose was 200 mg biweekly.

According to the study protocol,the dose was increased to 300 biweekly in children equal to or less than 30 kg of weight in mid study period.

The treatment was given for a period of 52 weeks.

At the end of the study period, common adverse effects were nasopharyngitis in 9%,pharyngitis in 6%, upper respiratory infection in 8% and eosinophilia in 3 %,

Serious adverse effects were seen only in 7 children

This study concluded that ,Dupilumab decreased the level of type 2 inflammatory biomarkers like level of serum IgE and blood eosinophils significantly.

It also concluded that ,this is the only biologic agent which reduced the number of asthma exacerbations as well as consistently and significantly improved lung function as measured by spirometry in the form of significant improvement in FEV1.

REFERENCES:

Bacharier LB, Maspero JF, Katelaris CH, et al. Assessment of long-term safety and efficacy of dupilumab in children with asthma (LIBERTY ASTHMA EXCURSION): an open extension study,Lancet Respir Med. Published online November 10, 2023. doi:10.1016/S2213-2600(23)00303-X

Tonsil removal for improvement in behaviour of children,Dr Deo Kumar Jha,MD.Pediatrician and Pulmonologist,Delhi-NCR

Pediatrician and Pediatric Pulmonologist Dr.Dev Kumar Jha,Formerly at AIIMS,New Delhi - 08 Dec, 2023 - Child Health Guides,Common Childhood Disease,Parents’ Guide,Professionals Guide, - 0 Comment

Sleep disordered breathing(SDB) is a common problem in children.

It has been ignored for years till there has been a facility to diagnose it.

Now,there is a facility for early detection of this common problem by a test called polysomnography.

Enlargement of tonsils and adenoid are the main cause of this disorder in children

The main cause of enlargement of tonsil and adenoids for a prolonged period of time is ALLERGY.

Parents are usually not aware of this problem in their children.

The common symptom is snoring in child with frequent disturbances of sleep.

It is graded by hypoapnea/apnea index(HPI) on polysomnography.

The child gradually develops behavioral changes,attention deficit,cognitive problems,day time sleepiness and later on hypertension.

There are two modes of treatment ,one is watchful observation and second is removal of tonsil.

Study was done on 458 children of the mean age of 6 years.

At the end of 12 months of follow up 394(86%),children were available.

It was observed that there was no significant difference between the two groups for the cognitive function.

There was a significant improvement in day time sleepiness and behavioral problems in the group who underwent adenotonsillectomy(surgical removal of adenoid and tonsil) ,moreover,the quality of life were better in the group who opted for the surgical removal of adenoid and tonsil.

CONCLUSION: In case of mild sleep disorderd breathing ,adenotonsillectomy is not advisable for improvement in attention deficit or cognitive problem.

REFERENCES:

Tonsil, adenoid removal improved sleep quality, some behavioral problems in children with mild sleep apnea. https://www.newswise.com/articles/tonsil-adenoid-removal-improved-sleep-quality-some-behavioral-problems-in-children-with-mild-sleep-apnea. Published Dec. 5, 2023. Accessed Dec. 5, 2023.

Depression and financial instability of Parents-more asthma symptoms in children,Dr Deo Kumar Jha,MD.Pediatrician and Pulmonologist,Delhi-NCR

Pediatrician and Pediatric Pulmonologist Dr.Dev Kumar Jha,Formerly at AIIMS,New Delhi - 16 Nov, 2023 - Professionals Guide, - 0 Comment

Asthma is the most common chronic respiratory disease in children.

It is responsible for significant days of school absenteeism.

It gives financial burden to the family by frequent visits to OPD and emergency department.

Child has to spend many sleepless nights during the period of symptoms.

It also disturbs the sleep of parents and the whole family.

Sleepless nights leads to decrease in work efficiency of child and parents.

According to the first study of its kind on 3900 Australian children,between the age of 1-15 years,the researcher observed that ,wheezing episodes in children with stressed parents were far more than the children with parents having no stress or negligible stress.

Specifically they observed that the wheezing episodes were 77% more in children of parents leading a stressful life with moderate to severe stresses, 55% more in children with mother having depression and 40% more in children with parents facing financial hardships.

Environmental factors which trigger asthma are well known in the form of pollutants,allergens,environmental tobacco smokes which are modifiable.

Depression and anxiety in children are also known to trigger asthma.

But Psychosocial factors, like parental stress due to workload or career making,depression and anxiety in parents, and financial hardships faced by parents are less recognised or ignored factors which may trigger symptoms of asthma.

In the care of asthmatic children, psychosocial factors should be addressed so as to control the symptoms of asthma

REFERENCES:

Shahunja KM, Sly PD, Mamun A. Trajectories of psychosocial environmental factors and their associations with asthma symptom trajectories among children in Australia. Pediatric Pulmonology. 2023:ppul.26733. doi: 10.1002/ppul.26733

Facts of inhaler medications-Dr Deo Kumar Jha,MD. Pediatrician and Pulmonologist,Delhi-NCR

Pediatrician and Pediatric Pulmonologist Dr.Dev Kumar Jha,Formerly at AIIMS,New Delhi - 20 Oct, 2023 - Child Health Guides,Common Childhood Disease,Medical Guide,Parents’ Guide,Professionals Guide, - 0 Comment

Advantages of inhaler medications

ROUTES– This medicine goes through the direct routes ,to a site where its action is required unlike oral medications ,which enters the mouth then goes to stomach,then abosrbed in stomach and enters the blood and the blood takes it to the site where it has to work.So ,any hidrance in the path can lower the amount of drug,whereas in case of inhalational route ,there is little chance of hindrance in delivery of drug.

DOSE– Inhalational medications come in microgram which is invisible to the naked eyes,unlike oral medications, which comes in miligram and in the form of tablets or syrups which anyone can see and the quantitiy is 1000 times more than the inhalational medicines for the same action.

Onset of Action-inhalational medicines starts working within minutes unlike oral medicines which may take an hour to start action

Adverse/Side effects- Since,the quantity of inhalational medicines are very very less and it goes directly to the target site,its adverse effects are almost nil even on long time use

MYTHS- There is a false belief that inhalational medicines cause addiction and patient will always require it and can not remain without it. It is baseless belief as the medicines in inhalational routes are the same as in oral medicines and it is not going to make a patient addicted to it. The need and duration of therapy depends on the severity of the disease

THE DEVICE

1.If spacer with valve is used with or without mask,the drug delivery into the target site is approximately 20% and depostion over the throat is about 10-20%

2. If only MDI is used without spacer the drug delivery is only approximately 10% to the target site and almost 50% gets deposited over the throat

3. In cases of use with nebulizer the drug delivery to the target organ is between 1-5% and 50-60% get deposited over the throat

4. In cases of rotahaler, only 1-5% drugs goes to the target site and almost 60% get deposited over the throat

CONCLUSION– 1.Inhalational medications are better than oral medications for long term use

2. Only MDI should not be used directly.It should always be combined with appropriate spacer/ holding chamber

Incidental diagnosis of Tuberculosis on Bronchoscopy,Dr.Deo Kumar Jha,M.D.,Pediatrician and Pediatric Pulmonologist Ghaziabad Noida Delhi NCR

Pediatrician and Pediatric Pulmonologist Dr.Dev Kumar Jha,Formerly at AIIMS,New Delhi - 26 Aug, 2022 - Professionals Guide, - 0 Comment

12 years female child visited me with the complaint of single episode of hemoptysis.

There was no history of fever,no history of cough other than the present single episode of cough.

There was no history of loss of appetite or weight loss in last 3 months

There was no contact with Tuberculosis patient in past 2 years

On examination -The anthropometry was appropriate for the age,General physical examination was normal

On systemic examination- Chest on auscultation revealed deep inspiratory crackles over right mammary region

On investigation-Chest X-ray showed consolidation in the right mid zone

Montoux test was non reactive,CBC was non contributory

There was no cough after that single episode so sputum could not be collected and nothing came after induced sputum.

The child did not allow gastric aspiration even after counselling.

Coagulation profile was normal

At this time I planned bronchoscopy to look for the region of hemoptysis.

On bronchoscopy,there was a clot in right bronchus intermedius and collected BAL fluid

BAL fluid was sent for CBNAAT and it came positive for Mycobacterium tubrculosis which was sensitive to Rifampicin

ATT was started from DOTS centre and the child id doing well.

This is the unusual presentation of tuberculosis in children with a single episode of cough with hemoptysis and no other symptoms.

Monkeypox-another threat after COVID-19 ,Dr.Dev(Dr.D.K.Jha) M.D.,Pediatrician and Pediatric Pulmonologist,Rajendra Nagar,Ghaziabad,Delhi NCR

Pediatrician and Pediatric Pulmonologist Dr.Dev Kumar Jha,Formerly at AIIMS,New Delhi - 22 May, 2022 - Child Health Guides,Medical Guide,Professionals Guide, - 0 Comment

As the name suggests,this disease comes in human from animal,so it is called a zoonotic disease

It is caused by monkeypox virus from the family of poxviridae

It resembles closely with small pox

It comes from animal to human from direct contact with blood,body fluids or muco-cutaneous lesions of infected animals

The natural reservoir is not clear till now but most likely it is rodents-Rope squirrel,tree squirrel

Possible risk factor for getting infected is eating inadequately cooked meat or other products of infected animals

Human to human transmission occurs via close contact with respiratory secretions,objects used by infected persons or mucocutaneous lesions

Prolonged face to face contact may result in transmission of virus through respiratory droplets.

The incubation period is 6-13 days with a range of 5-21 days

Clinical picture can be divided into 2 phases- Invasion phase and eruption phase

INVASION PHASE -It lasts between 0-5 days and characterised by high fever,intense headache,body pain ,back pain ,profound weakness and lymphadenopathy.

Lymphadenopathy differentiates it from other similar viral diseases with rash like measles and chicken pox

ERUPTION PHASE-Skin eruption starts from 1-3 days of start of fever.

Rashes are seen more concentrated over the face and extremities ,less over the trunk.

Rashes may affect palms,soles,oral mucosa and most dangerously the cornea which may be lead to corneal opacity

Rashes evolves from macules to papules to vesicles to pustules, sequentially

These rashes may be few to thousands,crusts and fall off

Rashes may coalesce and a large portion of skin may slough off

It is a self limiting disease and gets spontaneously cured after 2-4 weeks

It may be complicated by secondary bacterial infections,bronchopneumonia,sepsis,encephalitis,corneal involvement and loss of vision

The case fatality(mortality) has been reported to be very high recently and it is 3%-6%

Diagnosis is done by polymerase chain reaction of lesions.

TREATMENT is only symptomatic and only antiviral recommended is TECOVIRIMAT

PREVENTION-Small pox vaccination is very effective but not available now

Recently two doses vaccines for Monkeypox has been recommended but not widely available so personal protection is the cornerstone for prevention

REFERENCES:WORLD HEALTH ORGANISATION(WHO),MONKEYPOX,19 May 22

How to predict Asthma Severity and adverse outcome in children,Dr.Dev,M.D.,Pediatrician and Pediatric Pulmonologist,Noida, Ghaziabad Delhi NCR

Pediatrician and Pediatric Pulmonologist Dr.Dev Kumar Jha,Formerly at AIIMS,New Delhi - 02 Apr, 2022 - Professionals Guide, - 0 Comment

It is very difficult to predict the course of asthma in children.

Some children with asthma as a diagnosis by physician,do not have any problem after a few months.

Some children with asthma go on to wheeze for years together.

Some children have only mild symptoms although for a prolonged period of time.

Some children require repeated hospital admissions for treatment

Few children require ICU admission and others may require mechanical ventilation

There is very few longitudinal studies for the factors which can tell that, how severe the asthma will be in a particular child

To know that ,researchers from National Taiwan University Hospital studied on 699 children with diagnosis of asthma.The study was done between September 2004 to December 2018 on 2 cohorts.One cohort of 383 children with levels of serum allergen sensitization with blood eosinophil level and other cohorts of 313 children with blood eosinophil level only

Researchers wanted to know the longitudinal outcomes of asthma in children related to serum total IgE level,blood eosinophil level ,serum specific allergen sensitization and dosages of inhalational steroids(ICS) used to control the asthma in children.

It was a retrospective study and data were collected for variability in Peak Expiratory flow(PEF),maximum predicted percentage of Peak expiratory flow,asthma severity and asthma control.

Study revealed that the severity of asthma was more in association with increased level of blood eosinophil (odds ratio [OR]: 1.043; 95% CI: 1.002–1.086; P =.0392) AND with sensitization to molds(OR: 2.2485; 95% CI: 1.3253–3.8150; P =.0027).

It was also seen over the time that, the allergen sensitization and dosage of Inhalational steroid used had the best area under receivers operator curve for asthma severity(0.5918),asthma control(0.6441),variability of PEF(0.6885) and percentage prediction of PEF(0.6609)

CONCLUSION:1.It was concluded from the study that the risk of adverse outcome was related to total serum IgE level,blood eosinophil level and specific allergen sensitization

2. Long term outcome was related to allergen sensitization and dosages of ICS used to control asthma in children

REFERENCES;

Lee JH, Lin YT, Chu AL, et al. Predictive characteristics to discriminate the longitudinal outcomes of childhood asthma: a retrospective program-based study. Pediatr Res. Published online January 24, 2022. doi:10.1038/s41390-022-01956-6

virus-The most common trigger for asthma exacerbation in children,Dr.Dev,M.D.,Pediatrician and Pediatric Pulmonologist,Rajendra Nagar,Ghaziabad,Delhi NCR

Pediatrician and Pediatric Pulmonologist Dr.Dev Kumar Jha,Formerly at AIIMS,New Delhi - 06 Mar, 2022 - Child Health Guides,Common Childhood Disease,Medical Guide,Professionals Guide, - 0 Comment

Asthma exacerbation Asthma is the most common chronic disease in children.

The exact cause of asthma is not clear but there are several theories to explain the cause of asthma.

It is the interaction of genetic predisposition and environment which causes asthma to manifest in children.

Although not a single theory can explain the causation of asthma ,it is clear that, it is a heterogenous disease and there are so many triggers of its exacerbation.

Among triggers, there are ,allergens,pollutants,exertion,cold air,pollens,molds,and sudden change in ambient temperature

Among viruses ,Respiratory Synsytial virus(RSV),rhinovirus,influenza virus and seasonal coronavirus are known triggers for asthma exacerbation in children.

Investigators hypothesized that VIRUSES are the most important triggers for pediatric asthma exacerbation. To prove this ,the investigator studied on children admitted with severe asthma exacerbation in various hospitals form 2014 through 2021. Asthma exacerbation was confirmed through electronic records by continuous use of inhalational salbutamol. Viral testing were done on all children to confirm viral infection.

Investigators studied asthma exacerbation 15 -52 weeks after CDC implemented non pharmaceutical measures to prevent spread of Corona virus disease 2019 ,which limits the spread of virus from person to person including corona virus.These measures are physical distancing,use of mask and respiratory ettiquets.

The average rate of weekly asthma exacerbation in children decreased from approximately 64 % during the period of 2014 to 2019 to approximately 13% in 2020.

The average rate of viral infection positivity decreased from approximately 56% during the period of 2014 to 2019 to approximately 30% in 2020.

Researchers also observed that there was no change significantly in the environmental level of molds,pollens,pollutants and AQI(air quality index)

Researches found that, among various triggers for asthma exacerbation in children ,viral infections were most closely related which was obvious by the measures adopted to spread COVID 19 ,decreased the exacerbation of asthma.

It was concluded that ,measures to minimise viral infections in children will translate into fewer excerbation of asthma in children.

REFERENCES:

Poole A, Holcomb M, Jamieson A, et al. Social distancing reveals determinants of pediatric asthma exacerbations. Presented at: American Academy of Allergy, Asthma & Immunology (AAAAI) 2022 Annual Meeting; February 25–28, 2022; Phoenix, AZ. Abstract 178.