New Zealand national incidence of bronchiectasis "too high" for a developed country

The role of macrolides in childhood non-cystic fibrosis-related bronchiectasis

Non-cystic fibrosis-related bronchiectasis is a chronic inflammatory lung disease, which is regarded as an “orphan” lung disease, with little research devoted to the study of this condition. Bronchiectasis results in impaired quality of life and mortality if left untreated. The tools available in the armamentarium for the management of bronchiectasis entail antibiotic therapy traditionally used to treat exacerbations, stratagems to improve mucociliary clearance, and avoidance of toxins. Macrolides have been known for the last two decades to have not only anti-bacterial effects but immunomodulatory properties as well. In cystic fibrosis, the use of macrolides is well documented in subjects colonized with Pseudomonas aeruginosa, to improve quality of life and lung function. There is currently emerging evidence to suggest the benefit of macrolides in subjects not colonized with Pseudomonas aeruginosa. This beneficial effect has been less explored in the context of bronchiectasis from other causes. The purpose of this paper is to review the current literature on the use of macrolides in non-cystic fibrosis related bronchiectasis in paediatrics.

Risk factors for morbidity and death in non-cystic fibrosis bronchiectasis: a retrospective cross-sectional analysis of CT diagnosed bronchiectatic patients

INTRODUCTION

There is a relative lack of information about the death rate and morbidity of non-cystic fibrosis bronchiectasis and most studies are limited due to referral bias. We wanted to assess death rate and morbidity in those patients at our hospital.

METHODS

Adult patients seen at our department between June 2006 and November 2009 were recruited if the key string "bronchiect-" was mentioned in electronic clinical records and if chest CT imaging was available. Clinical records of all patients with confirmed radiologic diagnosis of bronchiectasis were reviewed and clinical characteristics were analyzed.

RESULTS

539 patients with a radiographic diagnosis of non-cystic fibrosis bronchiectasis were identified in a retrospective cross-sectional analysis giving a prevalence of 2.6% in our hospital population. A wide range of etiologies was found with idiopathic bronchiectasis in 26%. In the 41 months interval, 57 patients (10.6%) died. We found a median exacerbation rate of 1.94 per year. Bacterial colonization status was associated with more deaths, exacerbation rate, symptoms and reduced pulmonary function. Pulmonary hypertension was found in 48% of our patients.

CONCLUSIONS

We evaluated a large non-cystic fibrosis bronchiectasis population, and provided new epidemiological data on associations between clinical characteristics and deaths and morbidity in these patients.

Bronchiectasis--diagnosis and treatment

BACKGROUND

Radiologically evident bronchiectasis is seen in 30% to 50% of patients with advanced chronic obstructive pulmonary disease (COPD). As COPD is now becoming more common around the world, bronchiectasis is as well.

METHODS

We review pertinent articles published before May 2011 that were retrieved by a selective PubMed search.

RESULTS

The principles of treatment of bronchiectasis in patients who do not have cystic fibrosis ("non-CF bronchiectasis") are derived from the treatment of other diseases: secretolytic and anti-infectious treatment are given as in cystic fibrosis, while anti-obstructive treatment is given as in COPD. The few randomized trials of treatment for non-CF bronchiectasis that have been completed to date do not permit the formulation of any evidence-based recommendations. Many potential treatments are now under evaluation. Hypertonic saline is often used because of its demonstrated benefit in CF, even though no benefit has yet been shown for non-CF bronchiectasis. Phase II trials of inhaled mannitol have yielded promising results, leading to phase III trials that are now underway. There may be a future role for inhaled antibiotics, particularly in patients colonized with Gram-negative pathogens. Inhaled tobramycin and colistin are well established in clinical practice, though not approved for non-CF bronchiectasis; clinical trials of aztreonam, ciprofloxacin, and gentamicin are ongoing. Macrolides seem to bring an additional benefit, though the studies that documented this involved only small numbers of patients. Long-term treatment with inhaled antibiotics and/or macrolides is indicated only if a benefit is seen within three months of the start of treatment (less sputum, no exacerbations).

CONCLUSION

A national registry of patients with bronchiectasis should be established to help us gain better knowledge of its prognostic factors and treatment options.

Pathogenesis of bronchiectasis

Non-cystic fibrosis bronchiectasis is a heterogeneous condition and its pathogenesis is still not well defined. A combination of a defect in host defense and bacterial infection allows microbial colonization of the airways resulting in chronic inflammation and lung damage. An ongoing cycle of infection and inflammation may be established. Typically, the walls of the small airway are infiltrated by inflammatory cells causing obstruction whilst mediators, such as proteases released predominantly by neutrophils, damage the large airways resulting in bronchial dilatation. Adjacent parenchyma is also involved in the inflammation. Lung function testing generally demonstrates mild to moderate airflow obstruction that progresses over time. There are a large number of different aetiologic factors associated with bronchiectasis. A variety of different microbial pathogens is involved and they change as disease progresses.

Differences and similarities in non-cystic fibrosis bronchiectasis between developing and affluent countries

Non-CF bronchiectasis remains a major cause of morbidity not only in developing countries but in some indigenous groups of affluent countries. Although there is a decline in the prevalence and incidence in developed countries, recent studies in indigenous populations report higher prevalence. Due to the lack of such data, epidemiological studies are required to find the incidence and prevalence in developing countries. Although the main characteristics of bronchiectasis are similar in developing and affluent countries, underlying aetiology, nutritional status, frequency of exacerbations and severity of the disease are different. Delay of diagnosis is surprisingly similar in the affluent and developing countries possibly due to different reasons. Long-term studies are needed for evidence based management of the disease. Successful management and prevention of bronchiectasis require a multidisciplinary approach, while the lack of resources is still a major problem in the developing countries.

Airway microbiology and host defences in paediatric non-CF bronchiectasis

Bronchiectasis in children without cystic fibrosis is most common in socioeconomically disadvantaged communities. Recurrent pneumonia in early childhood and defective pulmonary defences are important risk factors. These help establish a 'vicious cycle' of impaired mucociliary clearance, infection, airway inflammation and progressive lung injury. Haemophilus influenzae, Streptococcus pneumoniae, Moraxella catarrhalis and Pseudomonas aeruginosa are the main infecting pathogens. H. influenzae predominates across all ages, while P. aeruginosa is found in older children with advanced disease. It is uncertain whether viruses and upper airway commensal bacteria play an important aetiological role. Overall, the microbiological data are limited however and there are difficulties obtaining reliable respiratory specimens from young children. Bronchiectasis is a complex disorder resulting from susceptibility to pulmonary infection and poorly regulated respiratory innate and adaptive immunity. Airway inflammatory responses are excessive and persist, even once infection is cleared. Improved specimen collection, molecular techniques and biomarkers are needed to enhance management.

Diagnosing and preventing chronic suppurative lung disease (CSLD) and bronchiectasis

Current diagnostic labelling of childhood bronchiectasis by radiology has substantial limitations. These include the requirement for two high resolution computerised tomography [HRCT] scans (with associated adversity of radiation) if criteria is adhered to, adoption of radiological criteria for children from adult data, relatively high occurrence of false negative, and to a smaller extent false positive, in conventional HRCT scans when compared to multi-detector CT scans, determination of irreversible airway dilatation, and absence of normative data on broncho-arterial ratio in children. A paradigm presenting a spectrum related to airway bacteria, with associated degradation and inflammation products causing airway damage if untreated, entails protracted bacterial bronchitis (at the mild end) to irreversible airway dilatation with cystic formation as determined by HRCT (at the severe end of the spectrum). Increasing evidence suggests that progression of airway damage can be limited by intensive treatment, even in those predestined to have bronchiectasis (eg immune deficiency). Treatment is aimed at achieving a cure in those at the milder end of the spectrum to limiting further deterioration in those with severe 'irreversible' radiological bronchiectasis.

Do New Zealand children with non-cystic fibrosis bronchiectasis show disease progression?

BACKGROUND

There is minimal literature available on the long-term outcome of pediatric non-cystic fibrosis (CF) bronchiectasis.

AIM

To document 5-year outcomes of children with chest computerized tomography (CT) scan diagnosed bronchiectasis from a tertiary New Zealand (NZ) respiratory clinic.

METHODS

Review of a clinical database identified 91 children. Demographics, clinical data, lung function, chest X-ray (CXR), sputum, presumed etiology, admission data, and the NZ deprivation index (NZDep) were collected. Univariate and multivariate regression were used to correlate clinical findings with lung function data and CXR scores using the Brasfield Scoring System.

RESULTS

Of the 91 children, 53 (59%) were Pacific Island, 22 (24%) Maori, 14 (15%) European, and 2 (2%) Other. The median follow-up period was 6.7 years (range 5.0-15.3 years) and median age at diagnosis was 7.3 years (range 11 months-16 years). Lung function data (n = 64) showed a mean decline of -1.6% predicted/year. In 30 children lung function declined (mean FEV(1) -4.4% predicted/year, range 1-17%), remained stable in 13 and improved in 21 children (mean FEV(1) of +3% predicted/year, range 1-15%). Reduced lung function was associated with male gender, chronic Haemophilus influenzae infection, longevity of disease, and Maori and Pacific Island ethnicity. There was a significant correlation with FEV(1) and CXR score at beginning (n = 47, r = 0.45, P = 0.001) and end (n = 26, r = 0.59, P = 0.002) of the follow-up period. The only variable consistently related to CXR score was chronic Haemophilus influenzae infection occurring in 27 (30%) (r(2)  = 0.52, P = <0.0001). Only four children were chronically infected with Pseudomonas species. Six children died.

CONCLUSION

In our experience despite management in a tertiary multidisciplinary bronchiectasis clinic, progression of lung disease continues in a group of children and young adults.

Chronic suppurative lung disease and bronchiectasis in children and adults in Australia and New Zealand

Consensus recommendations for managing chronic suppurative lung disease (CSLD) and bronchiectasis, based on systematic reviews, were developed for Australian and New Zealand children and adults during a multidisciplinary workshop. The diagnosis of bronchiectasis requires a high-resolution computed tomography scan of the chest. People with symptoms of bronchiectasis, but non-diagnostic scans, have CSLD, which may progress to radiological bronchiectasis. CSLD/bronchiectasis is suspected when chronic wet cough persists beyond 8 weeks. Initial assessment requires specialist expertise. Specialist referral is also required for children who have either two or more episodes of chronic (> 4 weeks) wet cough per year that respond to antibiotics, or chest radiographic abnormalities persisting for at least 6 weeks after appropriate therapy. Intensive treatment seeks to improve symptom control, reduce frequency of acute pulmonary exacerbations, preserve lung function, and maintain a good quality of life. Antibiotic selection for acute infective episodes is based on results of lower airway culture, local antibiotic susceptibility patterns, clinical severity and patient tolerance. Patients whose condition does not respond promptly or adequately to oral antibiotics are hospitalised for more intensive treatments, including intravenous antibiotics. Ongoing treatment requires regular and coordinated primary health care and specialist review, including monitoring for complications and comorbidities. Chest physiotherapy and regular exercise should be encouraged, nutrition optimised, environmental pollutants (including tobacco smoke) avoided, and vaccines administered according to national immunisation schedules. Individualised long-term use of oral or nebulised antibiotics, corticosteroids, bronchodilators and mucoactive agents may provide a benefit, but are not recommended routinely.

Respiratory infections in Tamariki (children) and Taitamariki (young people) Māori, New Zealand

The Māori population is young, with 53% aged less than 25 years and with a higher prevalence of both acute (bronchiolitis, pneumonia, pertussis, tuberculosis) and chronic (bronchiectasis) respiratory tract infections than non-Māori. Environmental, economic and poorer access to health promotion programmes and health care rather than specific or genetic underlying disorders appear to contribute to this burden. While new initiatives are needed, we can do better with current public health programmes and building on regional initiatives that have already proven successful.

The challenge of providing child health care in the indigenous population of New Zealand

This paper defines who is Maori, and traditional Maori attitudes to health and children. It notes the differing levels of engagement of Maori with their culture and the reliance of most Maori on Non Maori practitioners for their medical services. Three relatively common paediatric problems are then used to illustrate the challenges of neither underplaying nor overplaying environmental factors in working with Maori families. The key role of the word respect in working towards positive encounters with Maori is emphasized.

Resolution of extensive severe bronchiectasis in an infant

Bronchiectasis is, by definition, an irreversible condition. Following recent reports of reversible bronchiectasis in children, it has been suggested that the definition be broadened to include pre-bronchiectasis and transitional reversible states. We describe the case of a young infant who had extensive, severe bronchiectasis of unknown etiology that resolved following prolonged treatment with antibiotics and a tapering course of oral steroids. We suggest that the prolonged treatment may have played a role, perhaps by eradicating infection and thus enabling regeneration of bronchial anatomy.

A bronchiectatic patient's risk of pneumonia and prognosis

The objective of this study was to define the morbidity and mortality of bronchiectatic patients. All records from the years 1993-2004 of patients with asthma, chronic obstructive pulmonary disease (COPD) and bronchiectasis as the primary diagnosis were extracted from the Finnish Hospital Discharge Register. The data of these patients' deaths until the end of the year 2004 were acquired from Statistics Finland. These materials were analyzed in order to find each bronchiectatic patient of this period an asthma or COPD control subject who was of the same age and sex and had also been hospitalized in the same year. Their numbers of pneumonia and prognoses were compared with each other during the study period. 59.4% of all bronchiectasis treatment periods in absolute numbers were for people aged 65 years or over. The occurrence of pneumonia in bronchiectatic patients was 1.03 (95% CI 0.82-1.24) per follow-up year, while the corresponding rate in the COPD control subjects was 1.22 (95% CI 0.92-1.53) and in the asthma control subjects 0.38 (95% CI 0.22-0.54). The mean survival times for the bronchiectatic patients were 8.33 (95% CI 8.16-8.50), for the COPD control subjects 6.26 (95% CI 6.07-6.45) and for the asthma patients 8.93 (95% CI 8.76-9.10) years. Bronchiectasis-related hospitalization in Finland is primarily focused on aged people. A bronchiectatic patient has a higher risk of pneumonia and a worse prognosis than an asthmatic, while the situation is opposite when compared to a COPD patient.

Longitudinal growth and lung function in pediatric non-cystic fibrosis bronchiectasis: what influences lung function stability?

BACKGROUND

Longitudinal FEV(1) data in children with non-cystic fibrosis (non-CF) bronchiectasis (BE) are contradictory, and there are no multifactor data on the evolution of lung function and growth in this group. We longitudinally reviewed lung function and growth in children with non-CF BE and explored biologically plausible factors associated with changes in these parameters over time.

METHODS

Fifty-two children with > or = 3 years of lung function data were retrospectively reviewed. Changes in annual anthropometry and spirometry at year 3 and year 5 from baseline were analyzed. The impact of sex, age, cause, baseline FEV(1), exacerbation frequency, radiologic extent, socioeconomic status, environmental tobacco smoke exposure, and period of diagnosis was evaluated.

RESULTS

Over 3 years, the group mean forced expiratory flow midexpiratory phase percent predicted and BMI z-score improved by 3.01 (P = .04; 95% CI, 0.14-5.86) and 0.089 (P = .01; 95% CI, 0.02-0.15) per annum, respectively. FEV(1)% predicted, FVC% predicted, and height z-score all showed nonsignificant improvement. Over 5 years, there was improvement in FVC% predicted (slope 1.74; P = .001) annually, but only minor improvement in other parameters. Children with immunodeficiency and those with low baseline FEV(1) had significantly lower BMI at diagnosis. Frequency of hospitalized exacerbation and low baseline FEV(1) were the only significant predictors of change in FEV(1) over 3 years. Decline in FEV(1)% predicted was large (but nonsignificant) for each additional year in age of diagnosis.

CONCLUSIONS

Spirometric and anthropometric parameters in children with non-CF BE remain stable over a 3- to 5-year follow-up period once appropriate therapy is instituted. Severe exacerbations result in accelerated lung function decline. Increased medical cognizance of children with chronic moist cough is needed for early diagnosis, better management, and improving overall outcome in BE.

Chronic respiratory symptoms and diseases among indigenous children

Children from Indigenous populations experience more frequent, severe, and recurrent lower respiratory infections as infants and toddlers. The consequences of these infections are chronic lung disorders manifested by recurrent wheezing and chronic productive cough. These symptoms are aggravated more frequently by active and passive tobacco smoke exposure among Indigenous groups. Therapies for these symptoms, although not specific to children of Indigenous origins, are described as is the evidence for their use.

The pathophysiology of bronchiectasis

Bronchiectasis is defined by permanent and abnormal widening of the bronchi. This process occurs in the context of chronic airway infection and inflammation. It is usually diagnosed using computed tomography scanning to visualize the larger bronchi. Bronchiectasis is also characterized by mild to moderate airflow obstruction. This review will describe the pathophysiology of noncystic fibrosis bronchiectasis. Studies have demonstrated that the small airways in bronchiectasis are obstructed from an inflammatory infiltrate in the wall. As most of the bronchial tree is composed of small airways, the net effect is obstruction. The bronchial wall is typically thickened by an inflammatory infiltrate of lymphocytes and macrophages which may form lymphoid follicles. It has recently been demonstrated that patients with bronchiectasis have a progressive decline in lung function. There are a large number of etiologic risk factors associated with bronchiectasis. As there is generally a long-term retrospective history, it may be difficult to determine the exact role of such factors in the pathogenesis. Extremes of age and smoking/chronic obstructive pulmonary disease may be important considerations. There are a variety of different pathogens involved in bronchiectasis, but a common finding despite the presence of purulent sputum is failure to identify any pathogenic microorganisms. The bacterial flora appears to change with progression of disease.

Regulation of immunity in bronchiectasis

Bronchiectasis is a chronic, progressive lung disease where there is irreversible, abnormal dilatation of one or more bronchi, with chronic airway inflammation, associated chronic cough and sputum production, recurrent chest infections, and airflow obstruction. As such it is essentially a pathological endpoint with several underlying causes. Allergic bronchopulmonary aspergillosis (ABPA) is an important cause of bronchiectasis and aspergillus related lung disease sometimes complicates established bronchiectasis. A diagnosis of bronchiectasis is made clinically and confirmed with high-resolution computed tomography (HRCT) of the thorax. Progressive lung damage results from a 'vicious cycle' of recurrent bacterial infection and a poorly regulated inflammatory response. There appear to be two stages to the disease process: the initial insult that sets off the disease and then the ongoing, inflammatory process encompassing recurrent infection and progressive lung damage. Abnormalities in innate and adaptive immunity may predispose to bronchiectasis at both stages. Recent immunogenetic evidence suggests that there may be a link between the level of natural killer (NK) cell activation and disease susceptibility, implicating a predisposing role for innate immune mechanisms. A role for adaptive immune mechanisms is suggested by the genetic association of HLA-DR1, DQ5 with increased susceptibility to idiopathic bronchiectasis.

Establishment of a web-based registry for rare (orphan) pediatric lung diseases in the United Kingdom: the BPOLD registry

BACKGROUND

Children with orphan lung diseases (defined as a prevalence of <1 in 2000) receive suboptimal care due to a lack of understanding of pathophysiology and management.

AIM

To develop a low cost, multidisease, web-based registry for children with rare lung diseases.

METHODS

The British Pediatric Orphan Lung Disease (BPOLD) electronic registry was established to provide a web-based method for recording monthly incidence data on nine rare pediatric respiratory diseases (www.bpold.co.uk). An email reporting system was developed which required clinicians to input a username and password to respond following a monthly email reminder. The initial reporting rate was poor despite many registrants. The method for reporting was subsequently streamlined enabling reporting to be done via email by a single mouse-click. A follow-up email, with consent forms as attachments, was automatically sent to positive respondents, with negative responses recorded directly to the database. Non-responders receive a reminder email after 2 weeks.

RESULTS

Initially 101 respiratory clinicians registered via the BPOLD site, responding 162 times over 17 months. In the 12 months following redevelopment (total 12 monthly group emails) 143 of 222 BPRS members (64%) have provided 1,001 responses. Forty-eight clinicians (34% of responders) have responded to 10-12 group emails, with the next highest total being those responding to one only. One hundred fifty-eight cases of orphan lung disease have been identified.

CONCLUSIONS

We have demonstrated the successful establishment of a low cost, web-based registry for children with rare lung diseases. There is an urgent need for European and International collaboration with the establishment of electronic registries for children with rare diseases, if the inequities of health care are to be addressed. A web-based approach, similar to the one we have developed, will enable this.

Infections in chronic lung diseases

Chronic lung diseases are prevalent worldwide and cause significant mortality and suffering. This article discusses infections that occur in three chronic lung diseases: chronic obstructive pulmonary disease, bronchiectasis, and cystic fibrosis. Rather than discussing the role of infections as etiology of these diseases, this article focuses on infections that occur in the background of established chronic lung disease.

Risk factors for respiratory syncytial virus bronchiolitis hospital admission in New Zealand

This study assessed risk factors for respiratory syncytial virus (RSV) hospitalization and disease severity in Wellington, New Zealand. During the southern hemisphere winter months of 2003--2005, 230 infants aged < 24 months hospitalized with bronchiolitis were recruited. RSV was indentified in 141 (61%) infants. Comparison with data from all live hospital births from the same region (2003--2005) revealed three independent risk factors for RSV hospitalization: birth between February and July [adjusted risk ratio (aRR) 1.62, 95% confidence interval (CI) 1.5-2.29], gestation <37 weeks (aRR 2.29, 95% CI 1.48-3.56) and Māori ethnicity (aRR 3.64, 95% CI 2.27-5.85), or Pacific ethnicity (aRR 3.60, 95% CI 2.14-6.06). The high risk for Māori and Pacific infants was only partially accounted for by other known risk factors. This work highlights the importance of RSV disease in indigenous and minority populations, and identifies the need for further research to develop public health measures that can reduce health disparities.

Bronchiectasis in Children with Recurrent Pneumonia: An Immunopathological Damage Associated with Secondary Ciliary Dysmotility

The aim of this study is to assess ciliary motion patterns in children with bronchiectasis unrelated to cystic fibrosis or primary ciliary dyskinesia. In 51 children with recurrent pneumonia, high resolution computed tomography (HRCT) was carried out to detect and score bronchiectasis. Moreover, ciliary ultrastructure, beat frequency and motion pattern were evaluated and compared to those observed in 30 healthy children. Bronchiectasis at HRCT was found in 31/51 children. Ciliary dysmotility was found in 20/31 children with bronchiectasis (64.5%). Overall, ciliary dysmotility was found in 39/51 patients (76.5%). Ciliary dysmotility showed a significant correlation with the HRCT score (p=0.02). Absent motion in some fields was found in 44/51 patients (86.3%) and this also showed significant correlation with the HRCT score (p=0.005). The specificity and sensitivity of ciliary dysmotility as an indicator of bronchiectasis was 74.3% and 83.3% respectively. The positive predictive value was 93.5%, and negative predictive value was 50%. Ciliary dysmotility, in children with recurrent airways infections, correlates with the presence and severity of bronchiectasis. Whether ciliary dysmotility is a cause or a consequence of anatomical lesion is a matter of speculation. Very likely there is an amplification and self-maintaining mechanism between the two events which may lead to more serious disease.

Beyond counting cases: public health impacts of national Paediatric Surveillance Units

Paediatric Surveillance Units (PSUs) have been established in 14 countries and facilitate national, prospective, active surveillance for a range of conditions, with monthly reporting by child health specialists. The International Network of Paediatric Surveillance Units (INoPSU) was established in 1998 and facilitates international collaboration among member PSUs and allows for sharing of resources, simultaneous data collection and hence comparison of data from different geographical regions. The impact of data collected by PSUs, both individually and collectively as members of INoPSU, on public health outcomes, clinical care and research is described.

Association between inflammatory markers in induced sputum and clinical characteristics in children with non-cystic fibrosis bronchiectasis

To study clinical, radiological and laboratory features of children with non-cystic fibrosis (non-CF) bronchiectasis (BE) and the association between symptom scores, spirometry, high-resolution computed tomography (HRCT) findings and inflammatory markers in induced sputum in these children. Twenty-seven children with steady-state non-CF BE were cross-sectionally evaluated by symptom scores, pulmonary function tests, anatomic extension and severity scores of BE in HRCT and tumor necrosis factor-alpha (TNF-alpha) and interleukin-8 (IL-8) levels in induced sputum. There were 16 girls and 11 boys. Median (interquartile range) age of study group was 11.4 (9.5-13.6) years, follow-up duration was 3.5 (2-6.5) years and symptom scores were 4 (3-6). Pulmonary function tests revealed FEV(1) of 82%pred (72-93), FVC of 82%pred (74-92), and FEF(25-75%) of 82%pred (68-95). According to anatomic extent of BE on HRCT; 2 patients had mild, 4 had moderate and 21 had severe BE. Based on severity scores of HRCT; 10 patients had mild, 10 had moderate and 7 had severe BE. Neutrophils consisted 29.9% (14.9-53.7) of the total leucocytes in induced sputum samples. Sputum concentration of TNF-alpha was 58 pg/ml (9.2-302) while IL-8 concentration was 2.7 ng/ml (1.7-2.8). Symptom scores correlated with FEV(1) and sputum IL-8 levels (r=-0.49, r=0.67, P<0.05). There was a significant correlation between HRCT severity scores and symptoms, FEV(1), sputum IL-8 and TNF-alpha levels (r=0.64, r=-0.68, r=0.41, r=0.41, respectively, P<0.05). In children BE is associated with ongoing inflammation. This inflammation can be reliably monitored by radiological scores, spirometry, as well as sputum inflammatory markers. Follow-up of children with BE using these clinical tools may improve patient care.

Paediatric bronchiectasis in Europe: what now and where next?

Bronchiectasis has been defined as the abnormal and permanent dilation of bronchi. It has a variety of causes and has traditionally been viewed as a condition that is irreversible, often progressive and associated with significant morbidity and mortality. In the past, patients had relatively advanced disease by the time the diagnosis was established. By using high-resolution computed tomography (HRCT) scanning of the chest, the potential now exists for the much earlier detection and treatment of children with lesser degrees of bronchial dilation and bronchial wall thickening than was previously possible. In some, the HRCT changes have been seen to improve or completely resolve. This calls into question exactly what now should be termed bronchiectasis and how the parents of children with such HRCT findings should be counselled about the likely prognosis and the necessary or desirable treatment options.

Outcomes in children treated for persistent bacterial bronchitis

BACKGROUND

Persistent bacterial bronchitis (PBB) seems to be under-recognised and often misdiagnosed as asthma. In the absence of published data relating to the management and outcomes in this patient group, a review of the outcomes of patients with PBB attending a paediatric respiratory clinic was undertaken.

METHODS

A retrospective chart review was undertaken of 81 patients in whom a diagnosis of PBB had been made. Diagnosis was based on the standard criterion of a persistent, wet cough for >1 month that resolves with appropriate antibiotic treatment.

RESULTS

The most common reason for referral was a persistent cough or difficult asthma. In most of the patients, symptoms started before the age of 2 years, and had been present for >1 year in 59% of patients. At referral, 59% of patients were receiving asthma treatment and 11% antibiotics. Haemophilus influenzae and Streptococcus pneumoniae were the most commonly isolated organisms. Over half of the patients were completely symptom free after two courses of antibiotics. Only 13% of patients required > or =6 courses of antibiotics.

CONCLUSION

PBB is often misdiagnosed as asthma, although the two conditions may coexist. In addition to eliminating a persistent cough, treatment may also prevent progression to bronchiectasis. Further research relating to both diagnosis and treatment is urgently required.

Bronchiectasis

Bronchiectasis is generally classified into cystic fibrosis and non-cystic fibrosis bronchiectasis. This review article describes non-cystic fibrosis bronchiectasis in adults. Bronchiectasis can be considered a heterogeneous condition characterized by irreversible airway dilatation with chronic bronchial infection/inflammation. It remains a common condition and is a major cause of respiratory morbidity. Many factors are associated with bronchiectasis, but most commonly patients will have idiopathic disease. Important clinical findings include chronic productive cough, rhinosinusitis, fatigue and bi-basal crackles. Patients have usually had symptoms for many years. Diagnosis is confirmed by high-resolution computed tomography scanning using standardized criteria. Spirometry shows moderate airflow obstruction and there is a high prevalence of bronchial hyperreactivity. The most common pathogens are non-typeable Haemophilus influenzae and Pseudomonas aeruginosa. There may be considerable overlap with other chronic airway diseases. Treatment regimens are still not well defined. Patients tend to have ongoing symptoms and decline in respiratory function despite treatment.

Longitudinal pulmonary function of childhood bronchiectasis and comparison with cystic fibrosis

BACKGROUND

Little has been published on the progression of non-cystic fibrosis bronchiectasis (BX), especially in childhood. Data are needed for prognosis and evaluation of the effectiveness of treatments. A study was undertaken to evaluate the change in lung function over time in children with BX, and to consider covariates and compare them with the local cystic fibrosis (CF) population.

METHODS

Children with BX or CF and > or =3 calendar years of lung function data were identified from hospital clinics. Diagnosis was made by high resolution CT scans, sweat tests, and genetic studies. Lung function performed on a single plethysmograph between 6 and 15 years of age and > or =6 weeks after diagnosis was analysed longitudinally (linear mixed model). The impact of reference equation and "best annual" versus "all data" approaches were evaluated.

RESULTS

There were 44 children in each of the BX and CF groups with an overall mean 5.7 calendar years follow up data. The estimated forced expiratory volume in 1 second (FEV(1)) in the BX group had an intercept of 68% predicted (Polgar) at 10 years of age which fell at a rate of 1.9% per annum using "best annual" data compared with 63% and 0.9% using "all data". Those with post-infectious BX or chronic Haemophilus influenzae infection had more severe disease. In CF the FEV(1) ("best annual") intercept was 85% predicted with a slope of -2.9% per annum. The choice of reference equation affected the magnitude of the result but not the conclusions.

CONCLUSION

Children with BX have significant airway obstruction which deteriorates over time, regardless of analysis strategy or reference. Effective interventions are needed to prevent significant morbidity and adult mortality.

Investigation and management of suppurative cough in pre-school children

Suppurative cough can be defined as a cough where purulent sputum is produced. Chronic suppurative cough may be associated with the destruction of the bronchial wall (bronchiectasis). As mild forms of the disease are not associated with respiratory limitation or failure to thrive, such children may not present for investigation and therefore the true incidence of suppurative cough is difficult to gauge. Chronic suppurative cough remains an important health problem in developing countries and some indigenous populations of developed countries. The purpose of this review is to present the appropriate investigations and evaluate the evidence for current management strategies in children with suppurative cough. To accomplish this, a brief discussion on the aetiology of suppurative cough in childhood is presented. The most commonly identifiable cause of suppurative cough is cystic fibrosis. A detailed discussion on cystic fibrosis is beyond the scope of this review. Other causes of chronic suppurative cough in pre-school children may be classified according to congenital malformations of the airway, immunodeficiency, ciliary dysfunction and, unusually, acquired causes. Microbiology of sputum culture or bronchoalveolar lavage, assessment of immune function, the role of exhaled nitric oxide and ciliary studies, and medical imaging are discussed in detail. One can conclude that the evidence for management strategies for children with suppurative cough is, at best, level 3 evidence, i.e. non-randomised, controlled or cohort studies.

Atopy in Patients with Bronchiectasis: More than Coincidence

Bronchiectasis is common in developing countries, but its precise underlying mechanism can be detected in only about 40% of the cases. The studies reporting the frequency of atopy and its relation to radiological findings and lung function in bronchiectasis are limited in number, and the results are controversial. The present study was designed to investigate the relationship between atopy and bronchiectasis by means of high resolution computed tomography (HRCT) and pulmonary function tests. Skin prick test, HRCT and pulmonary function tests, including spirometric values of forced expiratory volume in one second (FEV1), FEV1/FVC (forced vital capacity) ratio were performed in 121 bronchiectatic patients of unknown etiology and in 68 healthy controls. Atopy and HRCT scores for the severity of atopy and extent of bronchiectasis respectively were determined for each patient. The rate of atopy (48.8% vs 11.8%) and mean atopy score (14.3 +/- 10.1 mm vs 5.5 +/- 2.1 mm) were significantly higher in patients with bronchiectasis than those in controls. Atopic patients had significantly worse spirometric values and more extended bronchiectasis than non-atopics. There is a significant correlation between atopy and HRCT scores (r = 0.54, p < 0.001), indicating that the more severe atopy is the more extended bronchiectasis. In conclusion, we suggest that the rate of atopy is higher in bronchiectatic patients than that in healthy controls. Bronchiectatic patients with atopy have lower spirometric values and higher HRCT scores. Atopy might be considered as a deteriorating and/or a causative or contributing factor for development of bronchiectasis.