History
Non-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 (chronic cough) for longer than 4 weeks. The cough 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. 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 responsive 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. Tsao and associates reported that hemoptysis is the second most common symptom of bronchiectasis. [18] The frequency of hemoptysis varies and become more common as bronchiectasis progresses due to the increasing diameter of the bronchial artery. Other common symptoms and signs include: exertional dyspnea, recurrent wheezing, digital clubbing, and recurrent lung infections.
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. [26]
Acute exacerbations of bronchiectasis are defined by symptomatic changes, including increased thick sputum production with change in color, shortness of breath, pleuritic chest pain, and generalized malaise. The patient may or may not have fever or chills.
During history taking, those suspected of having bronchiectasis should be screened for any underlying conditions. In addition to detecting co-morbidities, clinicians should investigate for exposures to tobacco smoke or other pollutants and for modifiable exacerbating factors.
Physical Examination
Physical examination findings in patients with bronchiectasis may include variable degrees of crackles or coarse rhonchi and digital clubbing. However, the lung exam may be normal. Crackles and wheezing rank among the most frequent findings of the physical examination. [27] An inspiratory "honk" has been described in some children with bronchiectasis, the etiology of which is unclear. Recurrent wheezing may be present even without the presence of asthma. Chest deformity described as increased anterior-posterior diameter, appearance of hyperinflation and presence of Harrison's sulci can be present. Additionally, chest pain, dyspnea and growth failure or failure to thrive have often been reported.
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. [23] In Field's 1949 series, clubbing was present in 78 cases (43.7%). [11] In many of her cases, the clubbing cleared after the affected section of the lung was surgically removed. The high frequency of this finding has been replicated in multiple studies. 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, a myriad other entities are now known to cause clubbing.
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Posteroanterior chest radiograph of a child with bronchiectasis due to chronic aspiration.
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CT scan of the chest of a child with bronchiectasis due to chronic aspiration.
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Chest radiograph of a child with severe adenoviral pneumonia as an infant. The child has persistent symptoms of cough, congestion, and wheezing.
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Bronchoscopic bronchogram of the left lower lobe on a patient with history of adenoviral pneumonia, demonstrating cylindrical and varicose types of bronchiectasis.
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Bronchoscopic bronchogram of the right upper lobe of a patient with a history of adenoviral pneumonia, demonstrating saccular bronchiectasis.
