Jacob A. Kaslow

The American Thoracic Society Core Curriculum updates clinicians annually in relevant topics related to pediatric pulmonary diseases. This is a summary of the Pediatric Pulmonary Medicine Core Curriculum presented at the 2024 American Thoracic Society International Conference. The curriculum focused on clinical topics that are essential to caring for patients in the intensive care unit (ICU), highlighting the specific care of patients with severe asthma, pediatric acute respiratory distress syndrome (PARDS), hemoptysis and pulmonary hemorrhage, serious cardiovascular disease within the cardiac ICU and chronic respiratory failure. In the case of severe asthma, we review risk factors for ICU admission, adjunct pharmacologic therapies and appropriate ventilatory strategies. We discuss the highlights of the recently updated PARDS guidelines are offer further diagnostic stratification including possible and at risk categories to help facilitate early intervention and possibly prevent disease progression. Though relatively rare, pediatric hemoptysis and pulmonary hemorrhage can be devastating clinical scenarios and this review includes the discussion of pharmacologic and bronchoscopic interventions that should be considered in these cases. Additionally, we provide a summary of some of the common respiratory pathophysiology encountered in the cardiac ICU, as well as the diagnostic and therapeutic interventions available to the pulmonologist. Lastly, we review the decision‐making considerations when transitioning patients from the ICU to chronic home mechanical ventilation. This manuscript aims to provide basic knowledge regarding each of these topics, in addition to up‐to‐date literature and resources for practicing pulmonologists and trainees.

Background: Children with tracheostomies require skilled medical care performed by trained caregivers or home health nursing (HHN). HHN services are often limited, resulting in increased caregiver responsibilities. We aim to evaluate HHN availability, healthcare utilization, and mortality in tracheostomy dependent children, pre and post‐COVID‐19 pandemic. Methods: Retrospective chart review of pediatric patients who underwent tracheostomy between November 2017 and September 2023. The COVID‐19 pandemic time point was defined as March 15, 2020. Demographic, clinical and outcome parameters were collected from the electronic medical record. The pre‐ and postpandemic trend of HHN hours were evaluated using correlation statistics. Results: Both groups had similar surrogate markers of medical complexity. There was no difference in the mean number of approved HHN hours, but both the mean number of HHN hours/week staffed (90 h vs. 50, p = 0.001) and mean percentage of approved HHN hours staffed (63% vs. 41%, p = 0.011) were significantly lower in the post‐COVID‐19 cohort. The trend in the pre‐COVID‐19 group was not statistically significant ( ρ = 0.087, p = 0.639); the trend in the post‐COVID‐19 group was negative ( ρ = −0.380, p = 0.001). Conclusions: Since the COVID‐19 pandemic, there has been a decrease in both the number and percentage of HHN hours staffed with no change in the number of approved HHN hours. Additionally, there was a decrease in hospital encounters in the post‐COVID‐19 group compared to pre‐COVID‐19. By assessing workforce shifts, medical providers, caregivers, and policymakers can appropriately anticipate the impact on this vulnerable population.

Objectives: To characterize an observational cohort of ventilator‐dependent infants and children with bronchopulmonary dysplasia (BPD) with or without tracheobronchomalacia (TBM) and determine the impact of TBM on the need for ventilator support, liberation from the ventilator and tracheostomy decannulation.Methods: Demographics and clinical outcomes were obtained by retrospective review from 12 centers participating in the outpatient BPD Collaborative registry. The cohort consisted of infants born between 2016 and 2021 who were dependent on invasive mechanical ventilation at home. The respiratory outcomes of those infants with TBM were compared to those who did not have TBM.Results: There were 154 subjects included and about half (48.7%) had documented TBM. Both the TBM and non‐TBM groups had similar demographic characteristics and respiratory outcomes. However, the non‐TBM were found to have lower mean birth weight (673 vs. 832 grams; p = 0.006), higher likelihood of having Nissen fundoplication (34.2% vs. 12.2%; p = 0.006) and higher use of diuretics (59.2% vs. 37.3%; p = 0.007). Both groups were similar in terms of ventilator requirements, timing of liberation from the ventilator, and rate of decannulation.Conclusions: The presence of TBM in ventilator‐dependent infants with BPD did not affect ventilator support needs, liberation from the ventilator and the rate of tracheostomy decannulation. We speculate that the relative contributions of the other components of BPD disease may play critical roles in determining the need for tracheostomy and their ultimate respiratory outcomes. A prospective multicenter study to assess the impact of TBM in severe BPD is urgently needed.

Objectives: In adults, an isolated low FEV₁ pattern (an FEV₁ below the lower limit of normal with a preserved FVC and FEV₁/FVC) has been associated with the risk of developing airway obstruction. Our objective was to examine the prevalence, stability, and clinical significance of an isolated low FEV₁ pattern in the pediatric population.Methods: We conducted a retrospective study of spirometries from children ages 6−21 years and categorized tests into spirometry patterns according to published guidelines and recent literature. In a subgroup of tests with an isolated low FEV₁ pattern, we evaluated spirometry technique. We also examined the association of having a test with an isolated low FEV₁ pattern with clinical markers of disease severity in a subgroup of children with cystic fibrosis (CF).Results: The isolated low FEV₁ pattern was uncommon across the 29,979 tests included (n = 645 [2%]). In the 263 children with an isolated low FEV₁ pattern who had a follow‐up test performed, the most frequent spirometry pattern at last test was normal (n = 123 [47%]). A primary diagnosis of CF was associated with increased odds of having at least one test with an isolated low FEV₁ pattern (OR = 8.37, 95% CI = 4.70−15.96, p < .001). The spirometry quality in a subgroup of tests with an isolated low FEV₁ pattern (n = 50) was satisfactory. In the subgroup of children with CF (n = 102), those who had a test with an isolated low FEV₁ pattern had higher odds of using oral antibiotics in the last 12 months than those who had a normal pattern (OR = 3.50, 95% CI = 1.15−10.63, p = .03).Conclusions: The isolated low FEV₁ pattern can occur repeatedly over time, usually transitions to a normal pattern, is not due to a poor spirometry technique, and could be clinically relevant in children with chronic lung diseases.

Background: Bronchopulmonary dysplasia (BPD), a common complication of prematurity, is associated with outpatient morbidities, including respiratory exacerbations. Daycare attendance is associated with increased rates of acute and chronic morbidities in children with BPD. We sought to determine if additional children in the household conferred similar risks for children with BPD.Methods: The number of children in the household and clinical outcomes were obtained via validated instruments for 933 subjects recruited from 13 BPD specialty clinics in the United States. Clustered logistic regression models were used to test for associations.Results: The mean gestational age of the study population was 26.5 ± 2.2 weeks and most subjects (69.1%) had severe BPD. The mean number of children in households (including the subject) was 2.1 ± 1.3 children. Each additional child in the household was associated with a 13% increased risk for hospital admission, 13% increased risk for antibiotic use for respiratory illnesses, 10% increased risk for coughing/wheezing/shortness of breath, 14% increased risk for nighttime symptoms, and 18% increased risk for rescue medication use. Additional analyses found that the increased risks were most prominent when there were three or more other children in the household.Conclusions: We observed that additional children in the household were a risk factor for adverse respiratory outcomes. We speculate that secondary person‐to‐person transmission of respiratory viral infections drives this finding. While this risk factor is not easily modified, measures do exist to mitigate this disease burden. Further studies are needed to define best practices for mitigating this risk associated with household viral transmission.