Pediatric Bronchitis Workup

Updated: Dec 19, 2016
  • Author: Patrick L Carolan, MD; Chief Editor: Girish D Sharma, MD, FCCP, FAAP  more...
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Workup

Approach Considerations

For maximal cost-effectiveness, diagnostic laboratory tests for bronchitis should be performed in a stepwise manner. Patients with uncomplicated acute respiratory illness who are cared for in an outpatient setting need little, if any, laboratory evaluation.

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Testing in Hospitalized Children

For hospitalized children, serum C-reactive protein screen, respiratory culture, rapid diagnostic studies, and serum cold agglutinin testing (at the appropriate age) help to classify whether the infection is caused by bacteria, atypical pathogens (eg, Chlamydia pneumoniae, Mycoplasma pneumoniae), or viruses. Obtain a blood or sputum culture if antibiotic therapy is under consideration.

For the child admitted to the hospital with a possible chlamydial, mycoplasmal, or viral lower respiratory tract infection for which specific therapy is considered, test nasopharyngeal secretions for these pathogens, using antigen or polymerase chain reaction testing for Chlamydia species and respiratory syncytial, parainfluenza, and influenza viruses or viral culture. Results will guide appropriate antimicrobial selection.

For the child who has been intubated, collect a specimen of deep respiratory secretions for Gram stain, chlamydial and viral antigen assays, and bacterial and viral cultures.

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Asthma Testing

A clinical response to daily high-dose oral corticosteroids may be considered as a diagnostic and therapeutic trial to confirm asthma. Evidence of reversible airflow obstruction revealed by pulmonary function testing confirms the diagnosis of asthma.

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Cystic Fibrosis Testing

Many states are now using tests for immunoreactive trypsinogen (IRT) coupled with cystic fibrosis transmembrane receptor (CFTR) mutational analyses in newborn screening programs. In newborns with positive results, sweat testing is required to diagnose or rule out cystic fibrosis.

In the United States, sweat chloride analysis using pilocarpine iontophoresis is typically conducted at accredited or affiliated pediatric cystic fibrosis centers. According to recommendations from the US Cystic Fibrosis Foundation (CFF) and the European Cystic Fibrosis Society (ECFS), sweat chloride results for infants aged 6 months or younger are classified as normal (chloride levels ≤29 mmol/L), abnormal (chloride levels ≥60 mmol/L), or intermediate/equivocal (chloride levels 30–59 mmol/L). If results fall within the intermediate/equivocal diagnosis range, the CFF recommends a repeat sweat test within 2 months.

Additional testing may include comprehensive CFTR analysis, fecal elastase evaluation, and pulmonary cultures. [28] Although the sensitivity of newborn screening is high, sweat chloride testing may also be pursued for infants or children with recurrent respiratory infection, chronic diarrhea, or failure to thrive who had negative newborn screening results for cystic fibrosis.

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Immunodeficiency Testing

For children in whom immunodeficiency is suspected, measurement of total serum immunoglobulins, immunoglobulin G (IgG) subclasses, and specific antibody production is recommended to establish the diagnosis.

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Chest Radiography

Chest radiography is typically not warranted but, if obtained, appears normal in most patients with uncomplicated bronchitis. Abnormal findings are minimal and may include atelectasis, hyperinflation, and peribronchial thickening. Focal consolidation is not usually present. These findings are similar to the radiographic findings in patients with asthma. Radiographic findings may help exclude other diseases or complications, particularly when abnormalities in either vital signs or pulse oximetry findings are present.

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Pulmonary Function Testing

Pulmonary function tests may show airflow obstruction that is reversible with bronchodilators. Bronchial challenge, such as with exercise or with histamine or methacholine exposure, may demonstrate the airway hyperreactivity characteristic of asthma.

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Bronchoscopy

On fiberoptic bronchoscopy, a diagnosis of chronic bronchitis is suggested if the airways appear erythematous and friable. Bronchoalveolar lavage may be useful in establishing an infectious cause. Bronchoalveolar lavage may reveal numerous monocytic or polymorphonuclear inflammatory cells. In children with chronic aspiration of gastric contents, lipids may be present within macrophages.

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