Pediatric Bronchitis Clinical Presentation

Acute bronchitis begins as a respiratory tract infection that manifests as the common cold. Symptoms often include coryza, malaise, chills, slight fever, sore throat, and back and muscle pain.

The cough in these children is usually accompanied by a nasal discharge. The discharge is watery at first, then after several days becomes thicker and colored or opaque. It then becomes clear again and has a mucoid watery consistency before it spontaneously resolves within 7-10 days. Purulent nasal discharge is common with viral respiratory pathogens and, by itself, does not imply bacterial infection.

Initially, the cough is dry and may be harsh or raspy sounding. The cough then loosens and becomes productive. Children younger than 5 years rarely expectorate. In this age group, sputum is usually seen in vomitus (ie, posttussive emesis). Parents frequently note a rattling sound in the chest. Hemoptysis, a burning discomfort in the chest, and dyspnea may be present.

Brunton et al noted that adult patients with chronic bronchitis have a history of persistent cough that produces yellow, white, or greenish sputum on most days for at least 3 months of the year and for more than 2 consecutive years.^[18] Wheezing and reports of breathlessness are also common. Pulmonary function testing in these adult patients reveals irreversible reduction in maximal airflow velocity.

Lungs may sound normal. Crackles, rhonchi, or large airway wheezing, if any, tend to be scattered and bilateral. The pharynx may be injected.

Recurrent episodes of acute or chronic infectious bronchitis are unusual in children and should alert the clinician to the likelihood of asthma. Bronchitis is often repeatedly diagnosed in children in whom asthma has remained undiagnosed for many years.

Similarly, a family history of asthma in parents or siblings may be masked within a history of “recurrent bronchitis.” The diagnosis of "asthmatic bronchitis" or "wheezy bronchitis" is simply asthma.

Recurrent episodes of acute or chronic bronchitis may be associated with immunodeficiency. Stiehm identifies the 4 most common immunodeficiencies in pediatric patients^[19] :

· Transient hypogammaglobulinemia of infancy (THI)

· Immunoglobulin G (IgG) subclass deficiency

· Impaired polysaccharide responsiveness (partial antibody deficiency)

· Selective IgA deficiency (IgAD)

A summary of immunodeficiency registries in 4 countries listed IgAD in 27.5% of the patients, IgG subclass deficiency in 4.8%, and THI in 2.3%. Patients typically have normal cellular immune systems, phagocyte function, and complement levels. All 4 immunodeficiency states are characterized by recurrent bacterial respiratory infections, such as purulent rhinitis, sinusitis, otitis, and bronchitis. Some patients with selective immunodeficiency may benefit from the use of intravenous immunoglobulin (IVIG), and the long-term prognosis is generally excellent.

Ozkan studied immunoglobulin A (IgA) and IgG deficiency in children who presented with recurrent sinopulmonary infection^[20] and found that the overall frequency of antibody defects was 19.1%. IgA deficiency was observed in 9.3%, IgG subclass deficiency was observed in 8.4%, and both IgA and IgG subclass deficiencies were observed in 1.4%. The prevalence of IgA and/or IgG subclass deficiency was 25% in patients with recurrent upper respiratory tract infections, 22% in patients with recurrent pulmonary infections, and 12.3% in patients with recurrent bronchiolitis.

Common variable immunodeficiency is the most frequent of the primary hypogammaglobulinemias. In a Finnish study by Kainulainen et al of patients with common variable immunodeficiency receiving immunoglobulin replacement therapy,^[21] sinopulmonary infections were the most common clinical presentation: 66% had recurrent pneumonia, 60% had recurrent maxillary sinusitis, and 45% had recurrent bronchitis.

In the Kainulainen study, the mean interval from the time of onset of symptoms to diagnosis was 8 years. Evidence of chronic lung damage was noted in 17% of patients at the time of diagnosis, highlighting the importance of early recognition in the prevention of chronic pulmonary sequelae.

To improve the recognition of common variable immunodeficiency, the authors suggest consideration of this condition in patients with recurrent sinopulmonary infection. In addition to a low serum IgG concentration, measurement of specific antibody production is recommended to establish the diagnosis.