Send letter to journal:
Re: Lumbar puncture and meningococcal disease

Dear Editor

We read with interest Professor Gill’s[1] concerns about complete avoidance of lumbar puncture (LP) in the emergency management of meningococcal disease according to the algorithm suggested by Pollard and colleagues.[2] However, from public health perspective, we agree with Professor Gill's remarks that the correct diagnosis and identification of strains would help in prophylaxis of contacts and prevention of clusters.[3] However we feel that there are two other potential reasons why LP would help in the management of the child with acute meningococcal disease.

There is a valuable diagnostic opportunity offered by cerebrospinal fluid (CSF) analysis, especially that by polymerase chain reaction (PCR). Meningococcal DNA detection in CSF by PCR assay is a sensitive test giving positive results even on samples taken up to 72 hours after antibiotics are initiated.[3] The ability to confirm the diagnosis on a “late” CSF sample provides an opportunity for clinicians to perform LP once a critically ill patient is stable. A study from the meningococcal reference laboratory reports that confirmation of the diagnosis has improved in Ireland after introduction of CSF PCR assay and has helped with long-term management of patients.[3]

We accept the fact that PCR is not of much use in the initial management of a suspected case, however it is of immense benefit to public health staff for management of contacts. This issue is going to be important following the recent introduction of meningococcal C vaccine. PCR assays based on sialyltrasferase (SiaD) gene sequence are able to identify and discriminate between serogroup B and C infections, allowing monitoring the effectiveness of vaccination.[4] Laboratory confirmation of clinical suspicion is an important part of management in the community. Late CSF specimen analysis can make a clear diagnosis instead of clinical description of “definite”, “probable” or “possible” cases.

We would like to mention another potential advantage of LP in cases of meningococcal septicaemia associated with signs of meningeal irritation in a clinically stable child seen in District General Hospitals. The absence of meningitis is a bad prognostic sign[5] and might lower the threshold to transfer the child to a Paediatric Intensive Care Unit. The presence of pleocytosis in the CSF might encourage medical staff to manage the child locally thereby avoiding unnecessary distress to the child and inconvenience to the family at the same time sparing an intensive care bed for another child.

We strongly agree that LP should be avoided in a seriously ill child.

R Chodhari, N Sharief

References

(1) Gill D. Emergency management of meningococcal disease. Arch Dis Child 2000;82:266-73.

(2) Pollard AJ, Britto J, Nadel S, DeMunter C, Habibi P, Levin M. Emergency management of meningococcal disease. Arch Dis Child 1999;80:290-6.

(3) Ragunathan L, Ramsay M, Borrow R Guiver M, Gray S, Kaczmarski EB. Clinical features, laboratory findings and management of meningococcal meningitis in England and Wales: report of a 1997 survey. J Infect 2000;40:74-9.

(4) Borrow R, Claus H, Guiver M, et al. Non-culture diagnosis and serogroup determination of meningococcal B and C infection by a sialyltransferase (siaD) PCR ELISA. Epidemiol Infect 1997;118:111-17.

Send letter to journal:
Re: Are cuffed endotracheal tubes really indicated in the management of meningococcal disease?

Posters relating to the early management of meningococcal disease have recently been distributed, by the Meningitis Research Foundation, to Accident and Emergency departments in the United Kingdom. These guidelines are derived from an article by Pollard et al[1] and provide a useful algorithm for the initial management of this serious condition.

However, we note the section on elective intubation and ventilation recommends consideration of a cuffed endotracheal tube. This is contradictory to standard life support guidelines,[2] which suggest that uncuffed tubes are preferable in younger children, in order to avoid oedema and mucosal injury at the cricoid ring.[3] While there is limited data to suggest that cuffed endotracheal tubes can be used with meticulous care,[4] we can find no evidence in the literature to support preferential use of cuffed tubes for the stated indication.

We feel that this discrepancy with standard anaestetic practice may lead to confusion, and could result in significant morbidity from laryngeal injury.

Dr David Pedley
Senior House Officer, Accident and Emergency

Dr Lisa Finlay
Clinical Lecturer, Tayside Institute of Child Health

Mr Michael Johnston
Consultant in Accident and Emergency Medicine
Ninewells Hospital and Medical School, Dundee, UK

References
(1) Pollard AJ, Britto J, Nadel S, et al. Emergency management of meningococcal disease. Arch Dis Child 1999;80:290-6.

(2) Advanced Life Support Group. Advanced Paediatric Life Support: The practical approach. London: BMJ Publishing Group 1998:9-10, 37-8.

(3) Hatch DJ. Prolonged nasotracheal intubation in infants and children. Lancet 1968;i:1272-5.

Send letter to journal:
Re: Re: Are cuffed endotracheal tubes really indicated in the management of meningococcal disease?

Dear Editor,

Pedley et al[1] raise concerns about the risk of upper airway trauma resulting from the use of cuffed endotracheal tubes (ETT) in paediatric airway management and indicate that they prefer to avoid the use of cuffed tubes in the acute management of children with meningococcal disease.

Experience from neonatal intensive care, paediatric anaesthesia and paediatric intensive care indicate that tightly fitting ETTs cause upper airway trauma, manifest as post-extubation stridor or later subglottic stenosis.[2][3] For this reason, the correct sized ETT should always be selected and placed in the airway with meticulous care in order to avoid these problems.

Appropriately sized, cuffed ETTs are probably not associated with immediate post-extubation problems or longer-term complications.[3-5] In addition, there are a number of advantages in using cuffed tubes: they virtually eliminate the need to repeat laryngoscopy and intubation, which is traumatic to the airway[5]; they reduce environmental contamination with inhaled drugs,[5] such as anaesthetics and nitric oxide; and the use of cuffed ETTs allows high pressure ventilation without necessitating change to a well-fitting ETT.[4]

In meningococcal disease pulmonary oedema is common as a result of capillary leakiness and high positive end expiratory pressures (PEEP) may be necessary in order to maintain oxygenation. With an uncuffed ETT, it is not uncommon for a child with this disease to require reintubation in order to treat pulmonary oedema, with risk of associated airway complications and more serious acute decompensation during the procedure. In our recent experience with over 550 children ventilated for meningococcal disease we have frequently used cuffed endotracheal tubes and are not aware of any airway trauma that has specifically resulted from their use. In those patients who do not develop severe gas exchange problems we leave the cuff deflated.

On the other hand, in the context of meningococcal disease, we have observed many occasions when uncuffed tubes have been changed to facilitate a rise in PEEP following development of pulmonary oedema, resulting in haemodynamic or respiratory decompensation. If cuffed ETTs are not available, it may be better to put a bigger or tighter tube in the trachea, with risk of airway trauma, rather than facing a situation of an emergency tube change, which can be life-threatening in an unventilatable patient with pulmonary oedema.

Correctly used, cuffed ETTs may be no more traumatic to the airway than uncuffed tubes and may greatly facilitate ventilatory management in pulmonary oedema.

Andrew J Pollard
Simon Nadel
Nilesh Mehta
Claudine De Munter
Joseph Britto
Parviz Habibi
Michael Levin

Paediatric Intensive Care Unit
Department of Paediatrics
Imperial College School of Medicine
St Mary's Hospital, London W2 1NY, UK

Address for Correspondence:
Dr Andrew J Pollard
Division of Infectious and Immunologic Disease
British Columbia’s Children’s Hospital
British Columbia Research Institute for Children's & Women's Health
950, West 28th Avenue, Room 375
Vancouver, BC V5Z 4H4, Canada

References
(1) Pedley D, Finlay L, Johnston M. Are cuffed endotracheal tubes really indicated in the management of meningococcal disease? Arch Dis Child [Rapid Response] 20 November 2000. http://adc.bmjjournals.com/cgi/eletters/archdischild;80/3/290#EL2

(2) Lee KW, Templeton JJ, Dougal RM. Tracheal tube size and post- intubation croup in children, Anesthesiology 1980;53:S325.

(3) Koka BV, Jeon IS, Andre JM, MacKay I, Smith RM. Postintubation croup in children. Anesth Analg Curr Res 1997;56:501-5.

(4) Deakers TW, Reynolds G, Stretton M, Newth CJL. Cuffed endotracheal tubes in pediatric intensive care. J Pediatr 1994;125:57-62.