Füsun Ünal

Introduction‐Aim: The study evaluates the long‐term effect of COVID‐19 on lung function in children, considering symptoms, physical examination findings, radiologic and laboratory evaluations during the acute infection period (AIP). Material and Methods: This prospective, longitudinal, multicenter study involved 270 patients with confirmed SARS‐CoV‐2 infection. Patients underwent pulmonary function tests (PFTs) (spirometry, diffusion capacity of the lung for carbon monoxide (DLCO), and plethysmography) at the 3rd and 6th months of follow‐up. Clinical characteristics, radiological, and laboratory findings during AIP were analyzed to establish the relationship with PFT parameters on long‐term follow‐up. Results: The mean age was 12.97 ± 3.43 years (6–18 years), and 141(52.2%) were girls. Most patients had mild disease, while 193 patients were classified as having pneumonia. Overall mean PFT parameters were normal at the 3rd and 6th months, and FEV ₁ %, FVC%, and DLCOadj% showed statistically significant longitudinal changes. Abnormal DLCOadj was observed in patients with COVID‐19 pneumonia at the 6th month when compared with the non‐pneumonia group ( p = 0.046). At the 3rd month follow‐up, comorbidities were independently associated with abnormal FEV ₁ (OR 6.30, 95% CI 2.61–15.17, p < 0.001) and abnormal FVC (OR 3.47, 95% CI 1.72–7.00, p < 0.001). Respiratory system related abnormal physical examination findings were also independently associated with abnormal FEV ₁ (OR 3.04, 95% CI 1.13–8.21, p = 0.028). Dyspnea showed a borderline association with abnormal FVC (OR 2.11, 95% CI 0.98–4.54, p = 0.057). Pathologic chest radiography, interlobular septal thickening on thorax CT, ground‐glass opacity, fever, dyspnea, and respiratory system related abnormal physical examination findings during the AIP were associated with abnormal PFT parameters during follow‐up. Disease severity scores did not differ significantly between children with normal and abnormal. Conclusions: Most children had preserved mean pulmonary function during follow‐up after SARS‐CoV‐2 infection. However, children with COVID‐19 pneumonia, comorbidities, and respiratory system related abnormal physical examination findings during the AIP may be at increased risk for persistent functional abnormalities. Follow‐up assessment in higher‐risk children should include spirometry, and DLCO measurement should be considered when feasible.

Environmental exposure to irritants may contribute to asthma pathogenesis through increased epithelial permeability. This study aimed to investigate the association between chlorinated swimming pool exposure and allergic diseases, as well as its relationship with objective markers of airway inflammation, epithelial permeability, bronchial hyperreactivity, and atopy in elite swimmers. This cross-sectional study was conducted among pediatric swimmers attending a professional swimming club in Istanbul. All eligible participants were invited to complete the International Study of Asthma and Allergies in Childhood (ISAAC) questionnaire. A subset underwent objective assessments, including exercise-induced bronchoconstriction testing, measurement of fractional exhaled nitric oxide (FeNO), serum surfactant protein-D (SP-D), serum club cell protein (CC16), and total and aeroallergen-specific immunoglobulin E (IgE) measurements. Of the 172 invited children, 169 (98%) completed the questionnaire, and 84 (49%) underwent objective assessments (44% male; mean age 10.0 ± 2.1 years). The median duration of swimming and cumulative pool attendance were 36 months and 1430 h, respectively. The prevalence of atopy was 41.6%. Among the participating swimmers, the prevalence of asthma (ever, current, and physician-diagnosed) was 25%, 9.5%, and 15.5%, respectively. Corresponding prevalences for eczema were 16.7%, 4.8%, and 7.1%, and for allergic rhinitis were 19.0%, 19.0%, and 16.7%. Cumulative exposure to chlorinated swimming pools was not associated with allergic diseases, airway inflammation, epithelial permeability, or bronchial hyperreactivity. However, children who had been swimming for more than 72 months demonstrated higher rates of atopy and current allergic symptoms. In this cohort of elite swimmers, cumulative exposure to chlorinated swimming pools was not associated with allergic diseases or objective markers of airway inflammation. However, given the cross-sectional design, these findings should be interpreted with caution. The observed association between longer swimming duration and atopy appears to be exploratory. Overall, chlorinated pool exposure alone may be unlikely to be a major determinant of allergic disease in this population. • Chlorinated pool exposure has been proposed to contribute to asthma and allergic diseases through airway epithelial injury; however, findings in pediatric populations are inconsistent, and many studies rely primarily on questionnaire-based data without objective airway assessments. • In this cohort of elite swimmers, cumulative pool exposure was not associated with allergic diseases or objective markers of airway inflammation and epithelial integrity. However, longer swimming duration was associated with increased atopy, and subgroup analyses suggested that early-life exposure in combination with tobacco smoke may influence airway inflammation.

Introduction: Children with medical complexity are at risk of pulmonary injury due to chronic pulmonary aspiration. Our study aimed to determine the effect of multidisciplinary evaluation and periodic follow‐up of aerodigestive disorders on the final status of the respiratory conditions. Materials and Methods: Children followed for at least 1 year by the Medipol University Aerodigestive Clinic between March 2019 and August 2024 were included. Demographic data, underlying diagnoses, respiratory and nutritional status at admission, hospitalization frequency and duration, and home ventilation requirements were analyzed. Swallowing dysfunction and/or aspiration were assessed using clinical and instrumental methods. All children received tailored swallowing and nutritional therapy. Results: Of 89 children, 72 of them were followed for at least 1 year (12 died, 5 lost follow‐up). The median follow‐up period was 30 months (18–46 months). The median age during that time of admission was 30 months (11–62 months). The most common underlying conditions were neuromuscular disorders (43%), bronchopulmonary dysplasia (14%), and congenital heart disease (13%). Dysphagia was confirmed instrumentally in 61% of patients. Among tracheostomized children, 13 of 22 (60%) were successfully decannulated. Respiratory support was reduced or discontinued in 14 of 31 (45%) children. Oral feeding was achieved in 21 (29%) previously tube‐fed children. Hospitalizations decreased in all but one child, and 45 (62.5%) required no hospitalization in the year following aerodigestive clinic evaluation. Conclusions: A multidisciplinary aerodigestive approach improves respiratory outcomes in children with medical complexity by reducing the need for respiratory support, facilitating decannulation, and decreasing hospitalizations.

Background. Flexible bronchoscopy (FB) is a critical diagnostic and therapeutic tool in respiratory diseases, enabling airway assessment, sample collection, and therapeutic interventions. Despite international guidelines, practices vary widely across centers. This study aimed to assess current FB practices and to identify variations among pediatric pulmonologists in Türkiye. Methods. A descriptive cross-sectional survey was distributed via email to clinical directors of 19 centers performing FB in March 2023. The survey comprised 80 questions across seven domains: demographics, patient preparation, bronchoscopy procedure, sedation/anesthesia, discharge, bronchoscope cleaning, and respondent comments. Participants were asked to provide accurate and objective data on FB practices at their centers. Results. All 19 centers participated in the survey, achieving a 100% response rate. The median FB experience was 12.5 years (IQR: 1-30), with a median 210 procedures per year per center (min-max: 30-500; IQR: 80-250). The most frequently reported indications were atelectasis (84.2%), bronchiectasis (78.9%), suspected foreign body aspiration (52.6%), and to obtain bronchoalveolar lavage (BAL) in patients with immunodeficiency (52.6%). Nine centers (47.4%) indicated performing advanced bronchoscopic procedures, including endobronchial biopsy (31.6%), bronchoscopic intubations (26.3%), and tracheal/bronchial stent insertion (10.5%). General anesthesia (84.2%) was the predominant sedation method, and propofol (89.5%) the most frequently used agent. Premedication was used in 13 centers (68.4%), with midazolam being the most commonly used agent (76.9%). Twelve centers (63.2%) also used topical lidocaine for local anesthesia. Respondents reported the need for developing interventional procedures and increasing the number of trained bronchoscopy teams. Conclusions. This first comprehensive national survey of pediatric FB practices in Türkiye, encompassing all relevant centers, revealed significant heterogeneity in procedural approaches, particularly regarding sedation protocols, BAL techniques, and interventional capabilities. The findings underscore the importance of developing interventional procedures and enhancing the training of pediatric pulmonologists and interdisciplinary teams practicing pediatric bronchoscopy to improve patient outcomes and procedural consistency.

Backround: Our aim was to identify the factors that increase the likelihood of successful decannulation in children with tracheotomies, in order to develop corrective strategies that improve decannulation possibility. Methods: A single-center retrospective study was conducted, based on the medical records of children with tracheotomies between 2012 and 2019. This study compared the differences between children who were successfully decannulated and those for whom decannulation was not attempted. Results: Out of 171 children with tracheostomy, 59 (34.5%) successfully underwent decannulation by 2019. The mean tracheostomy duration was 46.7(±3.1) months for those with ongoing tracheostomy and 17.6(±1.8) months for decannulated children. Neurological disorders were more common in non-decannulated children, while congenital heart disease and airway abnormalities were more prevalent in decannulated children. Factors associated with lower decannulation rates were the presence of the colonization (2.4-fold) and a history of post-tracheostomy home ventilation support (2.6-fold). About 33% of the children had colonization, with higher rates observed in those requiring home ventilation support post-tracheostomy placement (p<0.001), children with feeding/swallowing disorders (p=0.005), and neurological disorders (p=0.002). Only the presence of a feeding and swallowing disorder (2.6-fold) was independently associated with colonization, irrespective of the duration of tracheostomy. Conclusion: Colonization may reduce the likelihood of successful decannulation. Clinicians may consider monitoring children with feeding/swallowing disorders and the chronic airway colonization. Additionally, providing caregiver education on infection control measures to prevent lower airway colonization could be beneficial.

Background: Complications such as parapneumonic effusion (PPE) and necrotizing pneumonia (NP) can be noted in 3% of patients with community‐acquired pneumonia and may cause functional lung damage. Objective: We aimed to investigate the short‐ and long‐term effects of PPE and NP on lung function and the impact of treatment modalities and radiological sequelae on results. Material and Methods: This multicenter retrospective study includes children aged 0–18 years hospitalized for PPE and NP after community‐acquired pneumonia. Demographic, clinical, radiological, and spirometry findings were collected during diagnosis and follow‐up. Results: Of 123 children (62 female, median age 57 [interquartile range 71.5] months), 78 were diagnosed with NP and 45 with PPE. According to the defined periods, spirometric evaluation was performed in the first 3 months in 23 patients, between the 3rd and 6th months in 27 patients, and between the 6th and 9th months in 37 patients. At 3 months post‐discharge, abnormal spirometry (18.18% restrictive, 36.36% combined spirometry) was observed with a rate of 54.54% in NP, and with a rate of 25.0% (8.33% restrictive, 16.66% combined spirometry) in PPE. At 6‐9 months, normal spirometry was observed with a rate of 87% in both groups. FVC% values increased over time in both the NP and PPE groups; however, statistically significant improvement was observed only in the PPE group. In this group, FVC% was significantly higher in the patients who received antibiotics with chest tube and/or fibrinolytic therapy ( p = 0.022). Furthermore, those without radiological sequelae had significantly higher FVC% values compared to those with sequelae ( p = 0.023) in the PPE group. Conclusion: Radiological sequelae and restrictive spirometric patterns were initially more common in NP compared to PPE. However, spirometry indicated significant improvement in both groups by the end of the 9‐month follow‐up period.

Long-term Home Mechanical Ventilation of Children in İstanbul - Thoracic Research and Practice

Background and Objectives: Children with tracheostomies are at increased risk of tracheostomy‐related complications and require extra care. Standardized training programs for caregivers can improve tracheostomy care and reduce complications. In this study, we compared caregiver knowledge and skill scores after a standardized theoretical and practical training program on tracheostomy care (IStanbul PAediatric Tracheostomy (ISPAT) project) immediately and 1 year post‐training and evaluated how this training affected the children's clinical outcomes.Materials and Methods: We included 32 caregivers (31 children) who had received standardized training a year ago and administered the same theoretical and practical tests 1 year after training completion. We recorded tracheostomy‐related complications and the number and reasons for admission to the healthcare centers. All data just before the training and 1 year after training completion were compared.Results: After 1 year of training completion, the median number of correct answers on the theoretical test increased to 16.5 from 12 at pretest (p < 0.001). Compared with pretest, at 1‐year post‐training practical skills assessment scores, including cannula exchange and aspiration, were significantly higher (both p < 0.001) and mucus plug, bleeding, and stoma infection reduced significantly (p = 0.002, 0.022, and 0.004, respectively). Hands‐on‐training scores were better than pretest but declined slightly at 1 year compared to testing immediately after training. Emergency admission decreased from 64.5% to 32.3% (p = 0.013). Hospitalization decreased from 61.3% to 35.5% (p = 0.039).Conclusion: Our findings indicate that caregiver training can lead to a persistent increase in knowledge and skill for as long as 1 year, as well as improvements in several measurable outcomes, although a slight decrease in scores warrants annual repetitions of the training program.

Introduction Flexible bronchoscopy (FB) is frequently used for assessment and treatment of patients with respiratory diseases. Our aim was to investigate the contribution of FB to diagnosis and therapy in children admitted to the intensive care units (ICU) and to evaluate the safety of FB in this vulnerable population. Methods Children less than 18 years of age who underwent FB in the five neonatal and pediatric ICUs in Istanbul between July 1st, 2015 and July 1st, 2020 were included to the study. Demographic and clinical data including bronchoscopy indications, findings, complications, and the contribution of bronchoscopy to the management were retrospectively reviewed. Results One hundred and ninety-six patients were included to the study. The median age was 5 months (range 0.3–205 months). The most common indication of FB was extubation failure (38.3%), followed by suspected airway disease. Bronchoscopic assessments revealed at least one abnormality in 90.8% patients. The most common findings were airway malacia and the presence of excessive airway secretions (47.4% and 35.7%, respectively). Positive contribution of FB was identified in 87.2% of the patients. FB had greater than 1 positive contribution in 138 patients and 80.6% of the patients received a new diagnosis. Medical therapy was modified after the procedure in 39.8% and surgical interventions were pursued in 40% of the patients. Therapeutic lavage was achieved in 18.9%. There were no major complications. Conclusion Flexible bronchoscopy is a valuable diagnostic and therapeutic tool in neonatal and pediatric ICUs and is not associated with major complications.