Pediatric Bronchiectasis Clinical Presentation

Non–cystic fibrosis (CF) bronchiectasis in children presents as a wide spectrum of disease severity. Some children have intermittent symptoms of cough and occasional lower respiratory tract infections. Others experience daily cough and produce purulent fetid sputum, requiring frequent hospitalizations for respiratory exacerbations.

The diagnosis should be considered in children with a daily productive cough for longer than 6 weeks. Bronchiectasis should also be considered in children with chronic or persistent cough in whom another diagnosis has been made but who are not responding to therapy. If children with cough respond to antibiotics on a recurrent basis, bronchiectasis should be considered.

Recurrent cough with fetid sputum, hemoptysis, or recurrent pneumonia are important clues to early diagnosis of this disease. Ensure that pneumonia clears on radiography findings; follow-up radiography is indicated 6-8 weeks after the acute infection occurs.

Cough is an almost universal symptom and is frequently described as productive in older children or loose in toddlers and infants. Because small children rarely expectorate, the clinician may observe the child with a loose-sounding cough who swallows after coughing.

Although cough is a cardinal symptom in bronchiectasis, Smyrnios and colleagues concluded that cough is much more common in patients with asthma (24%), gastroesophageal reflux disease (15%), and viral bronchitis (11%) than in patients with bronchiectasis (4%). However, if children with gastroesophageal reflux disease or asthma do not respond to therapy, bronchiectasis should be considered. Furthermore, recurrent aspiration can lead to bronchiectasis, and allergic bronchopulmonary aspergillosis includes bronchiectasis.

Tsao and associates reported that hemoptysis is the second most common symptom of bronchiectasis.^[13]

Underlying conditions

The diagnosis of asthma or reflux-associated lung disease does not preclude bronchiectasis. In fact, bronchiectasis may be a complication of these diseases. An underlying systemic disease or congenital anatomical malformations such as tracheoesophageal fistula or history of foreign body aspiration in conjunction with respiratory symptoms should increase suspicion for bronchiectasis.

Physical examination findings in patients with bronchiectasis may include variable degrees of crackles or coarse rhonchi and clubbing. However, the examination findings may be normal. Lai and colleagues reported crackles and wheezing as the most frequent findings of the physical examination.^[14] An inspiratory "honk" has been described in some children with bronchiectasis, the etiology of which is unclear.

Digital clubbing is reported in 37-51% of patients with bronchiectasis. Edwards and associates found that children with digital clubbing and chest deformity showed significantly higher scores for extent of bronchiectasis, bronchial wall dilatation and thickness, and overall changes based on CT score.^[15]

In Field's 1949 series, clubbing was present in 78 cases (43.7%).^[10] In many of her cases, the clubbing cleared after the affected section of the lung was surgically removed. In medically treated cases, clubbing often improved and, in some cases, disappeared despite persistent bronchographic evidence of bronchiectasis. Although Field concluded that clubbing in the absence of congenital heart disease signifies irreversible bronchiectasis, myriad other entities are now known to cause clubbing.