Pediatric Bronchiectasis Clinical Presentation

Updated: Jan 23, 2017
  • Author: Kristen N Miller, MD; Chief Editor: Girish D Sharma, MD, FCCP, FAAP  more...
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Presentation

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. [13] 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. [15]

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.

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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. Lai and colleagues reported crackles and wheezing as the most frequent findings of the physical examination. [16] 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.  There can also be the presence of growth failure.

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. [14]    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, a myriad other entities are now known to cause clubbing.

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Complications

Complications that can develop solely from bronchiectasis range from mild such as focal atelectasis to severely life threatening such as massive hemoptysis.  Other complications associated with disease progression are noted in the Prognosis section and consist of heart related morbidity and respiratory failure. In those with more diffuse involvement, significant impairment in lung function may affect physical activity and quality of life.

Additional morbidity occurs from side effects of medications used in the management of bronchiectasis, predominantly related to the well-documented side effects of antibiotics.

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