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Correspondence |

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Bruce K. Rubin, MD, MEngr, MBA, FCCP
Author and Funding Information

Virginia Commonwealth University Richmond, VA

Bruce Rubin, MD, MEngr, MBA, Jessie Ball duPont Professor and Chair, Department of Pediatrics, Professor of Biomedical Engineering, Virginia Commonwealth University School of Medicine, 1001 East Marshall St, PO Box 980646, Richmond, VA 23298; e-mail: brubin@vcu.edu


Dr. Rubin has no conflict of interest to disclose.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/site/misc/reprints.xhtml).


© 2009 American College of Chest Physicians


Chest. 2009;136(2):650-651. doi:10.1378/chest.09-0928
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To the Editor:

I thank Dr. Paul for his passionate interest in our article.1 He appears to have four concerns with this publication. The first of these is that case report data were “missing” and viral test results were absent, leading to a misdiagnosis. This child presented to the emergency department (ED) in midsummer when the positive predictive value of respiratory syncytial virus (RSV) testing is compromised by low background prevalence.2 Thus, RSV testing during the summer is not recommended. More important is that the results of RSV testing would be irrelevant. Vicks VapoRub (VVR) [Proctor & Gamble (P&G); Cincinnati, OH] was used because this infant had symptoms of a viral infection. Her subsequent problem was consistent with our studies in the ferret showing that the mucociliary disruption caused by VVR was most detectable in animals with airway inflammation induced by endotoxin (lipopolysaccharide). These grandparents brought their granddaughter to the ED because of a sudden and rapid deterioration. Dr. Abanses was concerned about the possibility of foreign body aspiration. When he asked these astute grandparents to tell him what occurred that could have precipitated this sudden change, they volunteered that the deterioration occurred a very shortly after VVR was placed under her nose. The rapid deterioration and the rapid and complete resolution within hours are not consistent with the natural history of bronchiolitis or other respiratory virus infection. To suggest that these grandparents are unreliable witnesses because they had not read fine print warnings on the jar of VVR is absurd.

Dr. Paul's second concern is with the results of the animal studies. Rather than just preparing a case report, we wish to determine if there was a plausible mechanism to explain how VVR caused this problem. Our ferret studies clearly show a dose response to VVR, leading to mucus hypersecretion and disruption of mucociliary clearance consistent with acute inflammation, with changes being seen even at a lower aerosol concentration than that encountered by this child. As detailed in the article, the ferret is a well-accepted model system for evaluating airway inflammation and mucociliary function. Although these results were clear and consistent with VVR contributing to inflammation- induced mucociliary dysfunction, we deferred the submission of this manuscript to see whether knowing about this problem would help our ED physicians recognize this in other children. Over the next 2 years, additional children presented with similar complaints also associated with the nasal use of VVR. At this point, we submitted this manuscript to allow physicians and parents to be aware of this problem.

Dr. Paul appears to be offended by our use of “fooling the brain” to describe the perception of increased airflow after activation of the nasal transient receptor potential (TRP) channel by menthol. Distinct from his example, while opioids directly block pain receptors, TRP channels are part of the cold receptor system. When these channels are activated, it typically produces the sensation of cold and an appropriate physiologic response. However, menthol activation of the TRP-M8 ion channel in the nose is interpreted in the brain as a sensation of increased airflow. While opioids truly block pain, this sensation of increased airflow triggered by menthol is associated with no change in airflow.3 The clearest description of this would be “fooling the brain.”

Finally, on January 9, 2009, while this article was under embargo, Dr. Paul wrote to Mr. Ray Koteras, Director of Technical and Medical Services at the American Academy of Pediatrics (AAP), asking that he share comments similar to those in his letter with key physicians in the AAP. Dr. Paul admitted having a conflict of interest and said he would not be commenting to the media but that his talking points might help others respond to the media. However, within days Dr. Paul gave many media interviews. He told MSNBC “this article is at best incomplete and at worst irresponsible.”4 He told National Public Radio that he takes issue with this study stating, “People for one hundred years have been using VVR and I hear from parents that their parents used it when they were kids and their parents when they were kids.”5 Dr. Paul was quoted by the Business Courier of Cincinnati that this manuscript was “a real stretch.” “It's really unbelievable … and it really calls into question for me that they had an agenda here,” he said.6 Unlike Dr. Paul, who has received funding from P&G to study VVR in 150 children to determine if this makes then feel better, I could not obtain funding to conduct these studies. This research was performed by Drs. Abanses and Arima using discretionary funds that I pulled together. I am delighted that both of these men are now academic clinician-scientists. If this was my “agenda,” I am happy to confess.

I have been impressed with the response of P&G confirming that VVR should never be used in children under the age of 2 nor placed under or in the nose of anyone. They have expressed a genuine interest in learning more about the phenomena that we described. Since the time of publication of this article, there have been nearly 30 additional cases reported to me by parents and physicians from around the world. With the cooperation of P&G, I have urged each of these physicians and parents to report their observations directly to the company.

Abanses JC, Arima S, Rubin BK. Vicks VapoRub induces mucin secretion, decreases ciliary beat frequency, and increases tracheal transport in the ferret trachea. Chest. 2009;135:143-148. [PubMed] [CrossRef]
 
American Academy of Pediatrics Committee on Infections Disease Red book: 2006 report of the committee on infectious disease. 2006;27th ed. Elk Grove Village, IL American Academy of Pediatrics:561-562
 
Lindemann J, Tsakiropoulou E, Scheithauer MO, et al. Impact of menthol inhalation on nasal mucosal temperature and nasal patency. Am J Rhinol. 2008;22:402-405. [PubMed]
 
Aleccia J. There's the rub: Vicks might make kids sicker; misuse of popular salve may boost respiratory distress in babies, toddlers.Accessed June 20, 2009 Available at:http://www.msnbc.msn.com/id/28628924.
 
Neighmond P. Clearing things up: Vicks' effectiveness in kids.Accessed June 20, 2009 Available at:http://www.npr.org/templates/story/story.php?storyId=99361709.
 
Biank Fasig J. P&G's Vicks subject of safety study.Accessed June 20, 2009 Available at:http://cincinnati.bizjournals.com/cincinnati/stories/2009/01/12/daily23.html.
 

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References

Abanses JC, Arima S, Rubin BK. Vicks VapoRub induces mucin secretion, decreases ciliary beat frequency, and increases tracheal transport in the ferret trachea. Chest. 2009;135:143-148. [PubMed] [CrossRef]
 
American Academy of Pediatrics Committee on Infections Disease Red book: 2006 report of the committee on infectious disease. 2006;27th ed. Elk Grove Village, IL American Academy of Pediatrics:561-562
 
Lindemann J, Tsakiropoulou E, Scheithauer MO, et al. Impact of menthol inhalation on nasal mucosal temperature and nasal patency. Am J Rhinol. 2008;22:402-405. [PubMed]
 
Aleccia J. There's the rub: Vicks might make kids sicker; misuse of popular salve may boost respiratory distress in babies, toddlers.Accessed June 20, 2009 Available at:http://www.msnbc.msn.com/id/28628924.
 
Neighmond P. Clearing things up: Vicks' effectiveness in kids.Accessed June 20, 2009 Available at:http://www.npr.org/templates/story/story.php?storyId=99361709.
 
Biank Fasig J. P&G's Vicks subject of safety study.Accessed June 20, 2009 Available at:http://cincinnati.bizjournals.com/cincinnati/stories/2009/01/12/daily23.html.
 
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