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Adolescence is often a time of emotional upheaval and it is no wonder that many respiratory diseases with a psychosomatic component find their origins or time of exacerbation during this time of life. Adolescents who present with unexplained respiratory diseases may also suffer from some form of psychosomatic illness. Recognition of the psychological contributions to symptoms related to the respiratory tract is essential for practitioners who care for adolescents. This article includes some of the more common respiratory or related conditions that have psychological etiologies or components and are encountered in the adolescent patient. These include psychogenic cough, sighing dyspnea, hyperventilation, vocal cord dysfunction, and emotional state as a trigger for asthma. This review provides a general discussion of these conditions and an overview of issues related to psychological/psychiatric evaluation and the reluctance of patients and their parents to access mental health treatment.

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The problems of tobacco addiction have evolved over centuries. The possible relationship between smoking and oral cancer was recognized as early as the 19th century. The use of tobacco results in an estimated 4 million deaths each year worldwide. Approximately 3,000 adolescents start smoking every day; 4.5 million children and adolescents smoke cigarettes; 1 million use smokeless tobacco. This article reviews the effects of environmental tobacco smoke and primary smoking on lung health and maturation and the pathophysiology of smoking-related pulmonary disease. Smoking prevention and timely smoking cessation will significantly reduce the risk of not only lung diseases (chronic obstructive pulmonary disease, cancer, chronic bronchitis, asthma, etc.) but also suboptimal lung growth during preadolescent and adolescent years.

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OBJECTIVE: To investigate the effects of chronic tobramycin treatment on distortion product otoacoustic emission (DPOAE) latencies and response growth detection thresholds in human subjects to determine the sensitivity of these DPOAE features to ototoxic damage. DESIGN: Six groups of children in two different age ranges were tested: three groups in the 7 to 14 yr age range, i.e., six children with normal hearing, four cystic fibrosis (CF) patients who received no aminoglycosides, and eight CF patients who received low- to moderate-cumulative doses of tobramycin (< 1250 mg/kg) for respiratory infections; and three groups of five subjects each in the 15 to 23 yr age range, i.e., the healthy group and the CF groups that received low- (< 285 mg/kg) and moderate-(1000 to 2000 mg/kg) cumulative drug dosages. The aggregate drug dosages compiled longitudinally over the past 5 yr were used to group the drug-treated CF patients. All subjects showed normal audiometric profiles (< or = 25 dB HL in the conventional frequency region and age-appropriate thresholds as described by Osterhammel and Osterhammel [1979] in the high-frequency region) and DP-grams (absolute DPOAE and noise amplitudes being consistent with the normative data obtained with the CUBeDIS system at this institution). RESULTS: Even though the audiometric profiles and DP-grams of all drug-treated CF groups were identical to their healthy counterparts, the DPOAE latencies and growth function thresholds showed significant changes. Whereas low and low-to-moderate doses of tobramycin were related to DPOAE latency prolongations, higher cumulative drug doses of 1000 to 2000 mg/kg produced significant reductions in DPOAE latencies. Response growth detection thresholds at high frequencies showed significant elevations in all CF patient groups treated with tobramycin, regardless of drug dosages, as compared with the control subjects. CONCLUSIONS: DPOAE amplitudes may not reflect the earliest changes produced by chronic aminoglycoside treatment, suggesting that cochlear ototoxicity may be more effectively monitored through the assessment of latencies and response growth detection thresholds. These findings pertain at least to the early stages of ototoxicity development, specifically during chronic tobramycin treatment. In light of the small sample size, however, these outcomes must be considered as tentative.

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STUDY OBJECTIVE: A preliminary study comparing the efficacy and safety of the flutter device (Flutter) to standard, manual chest physiotherapy (CPT) in hospitalized cystic fibrosis (CF) patients undergoing an acute pulmonary exacerbation. DESIGN: Open label, comparative trial with alternate assignment. SETTING: Community and childrens' hospital acute-care wards. PARTICIPANTS: Twenty-two CF patients (ages 8 to 44 years) undergoing a total of 33 hospitalizations for acute pulmonary exacerbation. INTERVENTIONS: Complete pulmonary function tests (PFTs) were done at baseline (admission), weekly, and upon discharge from the hospital. Clinical score (CS) was determined at the time of hospital admission and at discharge. Participants were assigned to receive supervised Flutter therapy or standard, manual CPT four times per day during the hospitalization. Patients were monitored for complications, including hemoptysis, hypoxemia, and pneumothorax. RESULTS: The groups (CPT and Flutter) did not differ at baseline in demographics or Shwachman score, nor was length of hospitalization different. Significant improvements were noted from admission to discharge in CS and PFT results within each group. Mean percent change in CS and PFT results between CPT and Flutter groups showed no significant difference from hospital admission to discharge. Subsequent power analysis using the observed difference in percent change from admission to discharge for FEV1 indicated that to attain 80% power at alpha = 0.05, a sample of 219 subjects in each group would be necessary. SUMMARY: Comparative trials of airway clearance techniques with sufficient sample size are lacking. Although the Flutter appears to be a useful device for independent, cost-effective, and safe administration of CPT in this pilot study, a much larger clinical trial would be necessary to make definitive conclusions.

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Stasis of viscid secretions in cystic fibrosis (CF) leads to chronic infection, inflammation, and lung destruction. Chest physiotherapy (CPT) has been used for many years to assist in the removal of these secretions. However, the need for independently administered CPT exists, particularly for adolescents and the older CF patient. Two devices, the intrapulmonary percussive ventilator (IPV) and the Flutter device (Flutter) have been promoted for this purpose. This study compares these devices to standard, manual CPT. There was no difference in sputum quantity produced with any method studied. Transiently lower oxygen saturation was noted with standard CPT compared with the IPV and Flutter. Inconsistent but significant improvements in flow rates were noted with the two devices compared to standard CPT. Important trends to lower lung volumes, probably indicating decreased air trapping, were also noted with all three therapies at 1 and 4 hours after administration. There were no adverse effects with any treatment regimen. Larger and longer studies of these devices compared to standard CPT and with each other are warranted to assess their value for independent administration of CPT in CF patients and to determine long-term effects on maintenance of pulmonary function.

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The role of the medial efferent system in altering and/or regulating outer hair cell function in the mammalian cochlea has been proposed by a number of investigators. This study measured contralateral suppression of distortion product otoacoustic emissions (DPOAEs) in cystic fibrosis (CF) patients, treated for lung infections with low to moderate cumulative doses of tobramycin, to ascertain the contributions of the efferent-based mechanisms in the development of ototoxicity. The results showed significant suppression of DPOAEs in tobramycin-treated children compared to both nondrug-treated CF and normal children of similar ages. Since DPOAE amplitudes were comparable across the drug-treated and control groups of subjects, pronounced DPOAE suppression in the drug-treated group may be attributed to the instability of the cochlear amplifier induced by the tobramycin treatment. These findings also suggest that enhanced contralateral suppression may be the first sign of a developing ototoxicity.

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Every young person with a respiratory disability should be given the opportunity to maximize his or her exercise potential. Conditions such as asthma, affecting some 14 to 15 million people and cystic fibrosis (CF), affecting about 30,000 people in the U.S., may exclude young people from sports participation. And yet regular aerobic exercise and weight training have been shown to provide significant psychological and physical benefits to people with lung disease and diseases of the respiratory muscles and chest wall. The authors document the effects of asthma, CF, and neuromuscular diseases on aerobic exercise to prevent unnecessary limitations on participation due to inaccurate preconceived notions of sports of exercise capacity in chronically ill adolescents.

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Concentrations of carotenoids are low in patients with cystic fibrosis (CF) and are associated with essential fatty acid deficiency and increased markers of inflammation. We conducted single- and multiple-dose studies of beta-carotene supplementation in patients with CF. Dose-proportional increases in beta-carotene concentrations were found, although clearance was independent of dose. Large doses of beta-carotene were necessary to achieve normal plasma levels.

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Impaired mucociliary clearance due to defective ion and water transport and the effects of chronic airway infections lead to stasis of secretions and progressive pulmonary damage in patients with cystic fibrosis (CF). Methods to improve removal of tenacious lung secretions in CF patients contribute to slowing the decline in respiratory function. We have evaluated an intrapulmonary percussive ventilator (IPV), which is a device designed to enhance airway clearance and preserve lung function. A previous pilot study by us had determined that the device was acceptable to patients and is safe. We undertook a 6 month parallel comparative trial of the IPV versus standard, manual chest physiotherapy in 16 CF children and adults. No significant differences in spirometric measures, numbers of hospitalizations, use of oral or IV antibiotics, or anthropometric measurements were detected between the standard aerosol/chest physiotherapy group and the IPV group over the duration of the trial. Patient acceptance, as determined by participant survey, was good. The device appeared to be safe and durable. It was concluded that the IPV is as effective as standard aerosol and chest physiotherapy in preserving lung function and anthropometric measures, and there was no difference in the use of antibiotics and hospitalizations.

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STUDY OBJECTIVE: To compare the intrapulmonary percussive ventilator (IPV) to chest physiotherapy (P&PD) with respect to acute changes in (1) pulmonary function and (2) sputum physical properties in patients with cystic fibrosis (CF). DESIGN: Randomized crossover. SETTING: Community-based CF referral center. PARTICIPANTS: Nine nonhospitalized person (range, 7 to 40 years; median, 12.4 years) with moderate to excellent Shwachman scores. INTERVENTIONS: Three treatment regimens: (1) 2.5 mg albuterol delivered via IPV (internal percussive component activated); (2) 2.5 mg. albuterol delivered via IPV (internal percussive component inactivated), followed by P&PD; and (3) 2.5 mg albuterol delivered via updraft nebulizer, followed by P&PD. MEASUREMENTS AND RESULTS: Outcome measures included pulmonary function testing (PFTs) and quantitative and qualitative sputum analysis. Among the three treatment groups, there were no significant differences in the change in predicted PFTs 1 h or 4 h after treatment, nor in the volume of sputum expectorated in the first 4 or in the subsequent 20 h. Among patients receiving IPV, more serious disease was associated with greater improvement in FEF25-75 1 h after treatment, but these differences disappeared by 4 h. There were no meaningful differences in viscoelastic characteristics of sputum expectorated after each treatments. Participants reported general satisfaction with no adverse effects while using IPV. CONCLUSIONS: This initial pilot study suggests (1) stable patients with CF tolerated one treatment of IPV without adverse sequelae, and (2) IPV was as effective as standard aerosol and P&PD in improving short-term PFT results and enhancing sputum expectoration.

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The carotenoids are potent antioxidants with the ability to quench singlet oxygen and other toxic oxygen species. We studied 17 patients with cystic fibrosis (CF) and 10 normal children to assess plasma levels of four carotenoids, beta-carotene, alpha-carotene, lutein, and lycopene, by high-performance liquid chromatography. We found significantly lower plasma levels of specific carotenoids in children with CF than in normal control subjects. The standardization of carotenoid levels for total cholesterol did not significantly attenuate these differences. No differences in total carotene intake were apparent between the groups. Carotenoid levels did not correlate with fat absorption or measures of adiposity in children with CF. Additionally, levels of selected carotenoids correlated negatively with serum IgG levels, an indirect measure of inflammation. The differences in plasma carotenoid levels between children with CF and normal children may be due to rapid turnover of carotenoids, perhaps through quenching of toxic oxygen species in inflammatory states of CF. Studies assessing supplementation of these antioxidants should be considered.

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An 18-month-old boy was seen in the pediatric pulmonary clinic with a history of wheezing, stridor and intolerance to solid foods. Barium esophagram revealed distal esophageal stenosis and subsequently an H-type TEF at surgery. Following the surgery to repair both lesions the child continues to do well.

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