Bronchiectasis: still a problem

Etiology and clinical features of children with bronchiectasis in China: A 10-year multicenter retrospective study

INTRODUCTION

The current study aims to investigate the etiology spectrum and the clinical characteristics of bronchiectasis in Chinese children.

METHODS

The study is designed as a multicenter retrospective study. 193 cases were enrolled in 13 centers in China between 2008 and 2017. The inclusive cases must meet the clinical as well as the HRCT criteria. Only if both two radiologists confirmed the diagnosis, the case could be enrolled. The cases that could not provide clinical and imageology data were excluded. The data were entered into the specialized system and then analyzed.

RESULTS

One hundred sixty-nine cases (87%) were found to have the underlying etiology. Post-infective (46%), primary immunodeficiency (14%), and PCD (13%) were the common causes. All cases came from 28 provinces in Mainland China. The median age of symptom onset was 5.8 (2.0, 8.9) years. The median age of diagnosis was 8.4 (4.5, 11.6) years. The main symptoms were cough, sputum expectoration, and fever during the exacerbation. Nineteen percent of patients suffered from limited exercise tolerance. Clubbing was found in 17% of cases. Nearly 30% of patients presented growth limitations. On the HRCT findings, 126 cases had diffused bronchiectasis, and bilateral involvement was found in 94 cases. The lower lobes and right middle lobes were most commonly involved. Approximately 30% of cultures of sputum and bronchoalveolar lavage were positive.

CONCLUSION

A majority of cases could be found the underlying etiology. Post-infective, primary immunodeficiency, and PCD were the most common causes. Some clinical figures might indicate a specific etiology.

Transmission electron microscopy study of suspected primary ciliary dyskinesia patients

Primary ciliary dyskinesia (PCD) is a rare autosomal recessive condition often presenting with chronic respiratory infections in early life. Transmission electron microscopy (TEM) is used to detect ciliary ultrastructural defects. In this study, we aimed to assess ciliary ultrastructural defects using quantitative methods on TEM to identify its diagnostic role in confirming PCD. Nasal samples of 67 patients, including 37 females and 30 males (20.3 ± 10.7 years old), with suspected PCD symptoms were examined by TEM. The most common presentations were bronchiectasis: 26 (38.8%), chronic sinusitis: 23 (34.3%), and recurrent lower respiratory infections: 21 (31.3%). Secondary ciliary dyskinesia, including compound cilia (41.4%) and extra-tubules (44.3%), were the most prevalent TEM finding. Twelve patients (17.9%) had hallmark diagnostic criteria for PCD (class 1) consisting of 11 (16.4%) outer and inner dynein arm (ODA and IDA) defects and only one concurrent IDA defect and microtubular disorganization. Also, 11 patients (16.4%) had probable criteria for PCD (class 2), 26 (38.8%) had other defects, and 18 (26.9%) had normal ciliary ultrastructure. Among our suspected PCD patients, the most common ultrastructural ciliary defects were extra-tubules and compound cilia. However, the most prevalent hallmark diagnostic defect confirming PCD was simultaneous defects of IDA and ODA.

Noncystic fibrosis bronchiectasis in children and adolescents: Follow-up over a decade

BACKGROUND

Noncystic fibrosis bronchiectasis (NCFB) is still considered an "orphan disease" in pediatric age.

OBJECTIVE

The study describes the clinical and functional features, the instrumental, and microbial findings of a large cohort of patients with NCFB, followed in a single tertiary level hospital.

METHODS

Children and adolescents diagnosed with NCFB from January 1, 2010 to December 31, 2019 were included. Data from the diagnosis and during the years of follow-up were recorded retrospectively.

RESULTS

One hundred and thirty-eight patients were enrolled. The most common cause of NCFB was postinfectious (33%), followed by primary ciliary dyskinesia (PCD) (30%), esophageal atresia (EA) (9.5%), and secondary immunodeficiency (9.5%). Chronic cough was the most frequent symptom. The median age of symptoms presentation was 3 years (interquartile age [IQR]: 12-84), with a precocious onset in PCD and EA groups. The median age of CT diagnosis was 9 years for all groups but PCD patients who were diagnosed at older age. Lingula, medium, upper, and lower lobes were more involved in PCD group, while diffuse distribution was observed in the postinfectious one. Microbial exams showed Pseudomonas aeruginosa colonization higher in PCD patients (22%). Despite microbial differences in airways colonization, no difference in respiratory exacerbation rate was recorded among groups. Lung function tests demonstrated the stability of forced expiratory volume in 1 s (FEV1) and forced vital capacity (FVC) over time, except for the secondary immunodeficiency group.

CONCLUSIONS

The role of infections in developed countries should not be underestimated and a major effort to obtain an earlier identification of bronchiectasis should be taken. A prompt diagnosis of NFCB could help to reduce the frequency of exacerbations and improve the stability of lung function over time.

Changing clinical characteristics of non-cystic fibrosis bronchiectasis in children

Background

The prevalence of non-cystic fibrosis (CF) bronchiectasis is increasing in both developed and developing countries in recent years. Although the main features remain similar, etiologies seem to change. Our aim was to evaluate the clinical and laboratory characteristics of our recent non-CF bronchiectasis patients and to compare these with our historical cohort in 2001.

Methods

One hundred four children with non-CF bronchiectasis followed between 2002 and 2019 were enrolled. Age of diagnosis, underlying etiology and microorganisms in sputum culture were recorded. Clinical outcomes were evaluated in terms of lung function tests and annual pulmonary exacerbation rates at presentation and within the last 12 months.

Results

Mean FEV1 and FVC %predicted at presentation improved compared to historical cohort (76.6 ± 17.1 vs. 63.3 ± 22.1 and 76.6 ± 15.1 vs. 67.3 ± 23.1, respectively; p <  0.001). There was a significant decrease in pulmonary exacerbation rate from 6.05 ± 2.88 at presentation to 3.23 ± 2.08 during follow-up (p <  0.0001). In 80.8% of patients, an underlying etiology was identified. There was an increase in primary ciliary dyskinesia (PCD) (32.7% vs. 6.3%; p = 0.001), decrease in idiopathic cases (19.2% vs. 37.8%; p = 0.03) with no change in postinfectious and immunodeficiencies as underlying etiology. Sputum cultures were positive in 77.9% of patients which was 46.9% in the historical cohort (p = 0.001).

Conclusion

Baseline pulmonary function tests were better and distribution of underlying etiology had changed with a remarkable increase in diagnosis of PCD in the recent cohort.

Paediatric and adult bronchiectasis: Specific management with coexisting asthma, COPD, rheumatological disease and inflammatory bowel disease

Bronchiectasis, conventionally defined as irreversible dilatation of the bronchial tree, is generally suspected on a clinical basis and confirmed by means of chest high-resolution computed tomography. Clinical manifestations, including chronic productive cough and endobronchial suppuration with persistent chest infection and inflammation, may deeply affect quality of life, both in children/adolescents and adults. Despite many cases being idiopathic or post-infectious, a number of specific aetiologies have been traditionally associated with bronchiectasis, such as cystic fibrosis (CF), primary ciliary dyskinesia or immunodeficiencies. Nevertheless, bronchiectasis may also develop in patients with bronchial asthma; chronic obstructive pulmonary disease; and, less commonly, rheumatological disorders and inflammatory bowel diseases. Available literature on the development of bronchiectasis in these conditions and on its management is limited, particularly in children. However, bronchiectasis may complicate the clinical course of the underlying condition at any age, and appropriate management requires an integration of multiple skills in a team of complementary experts to provide the most appropriate care to affected children and adolescents. The present review aims at summarizing the current knowledge and available evidence on the management of bronchiectasis in the other conditions mentioned and focuses on the new therapeutic strategies that are emerging as promising tools for improving patients' quality of life.

Challenges of diagnosing and managing bronchiectasis in resource-limited settings: a case study

Bronchiectasis, once an orphan disease is now gaining renewed attention as a significant cause of morbidity and mortality. It is a morphologic term used to describe abnormal, irreversibly dilated and thick-walled bronchi, with many etiologies. The management of bronchiectasis can be challenging because its pathogenetic mechanisms is still evolving. Its diagnosis and management is particularly more demanding especially in resource-limited settings like Nigeria because of delayed diagnosis and improper management with devastating consequences, hence this case study.

Bronchiectasis

Bronchiectasis refers to abnormal dilatation of the bronchi. Airway dilatation can lead to failure of mucus clearance and increased risk of infection. Pathophysiological mechanisms of bronchiectasis include persistent bacterial infections, dysregulated immune responses, impaired mucociliary clearance and airway obstruction. These mechanisms can interact and self-perpetuate, leading over time to impaired lung function. Patients commonly present with productive cough and recurrent chest infections, and the diagnosis of bronchiectasis is based on clinical symptoms and radiological findings. Bronchiectasis can be the result of several different underlying disorders, and identifying the aetiology is crucial to guide management. Treatment is directed at reducing the frequency of exacerbations, improving quality of life and preventing disease progression. Although no therapy is licensed for bronchiectasis by regulatory agencies, evidence supports the effectiveness of airway clearance techniques, antibiotics and mucolytic agents, such as inhaled isotonic or hypertonic saline, in some patients. Bronchiectasis is a disabling disease with an increasing prevalence and can affect individuals of any age. A major challenge is the application of emerging phenotyping and endotyping techniques to identify the patient populations who would most benefit from a specific treatment, with the goal of better targeting existing and emerging treatments and achieving better outcomes.

Evaluation of Noncystic Fibrosis Bronchiectasis Using Clinical and Radiological Scorings in Children

OBJECTIVES

The aim of this study was to evaluate radiological, clinical, and demographic data of patients with noncystic fibrosis bronchiectasis and to compare high-resolution computed tomography (HRCT) scores based on the demographic and clinical characteristics.

MATERIALS AND METHODS

A total of 34 patients (18 male, 16 female) were assessed in terms of age at symptom onset, age at diagnosis, annual attack frequency, cough severity score, physical examination findings, and pulmonary function test results. Modified Bhalla scoring system (B total) and anatomical prevalence degree score (D total) were used for HRCT examination.

RESULTS

There was a strong negative correlation between forced expiratory volume at first second (FEV₁) and bronchial dilatation degree (SBRDIL). There was a moderate negative correlation of FEV₁, forced vital capacity (FVC), and maximum mid-expiratory flow rate (MEF; 25-75) with bronchiectasis degree (EXBRNC), bronchial wall thickness degree (SBWTHICK), and mucus accumulation in the major airways (PMPLA). The B total, D total, EXBRNC, and SBRDIL scores were significantly higher in patients with hemoptysis and sputum. In comparing B and D total scoring systems, B total provided better results in terms of rale, annual exacerbation frequency (AEF), cough severity score (CSS), and FEV₁ values.

CONCLUSION

As it is proved using HRCT, pulmonary function impairment, sputum production, hemoptysis, and increase in AEF strongly correlating with objective HRCT scoring can be accepted as markers for pathological changes due to bronchiectasis.

Inhaled corticosteroids for bronchiectasis

BACKGROUND

Bronchiectasis is being increasingly diagnosed and recognised as an important contributor to chronic lung disease in both adults and children in high- and low-income countries. It is characterised by irreversible dilatation of airways and is generally associated with airway inflammation and chronic bacterial infection. Medical management largely aims to reduce morbidity by controlling the symptoms, reduce exacerbation frequency, improve quality of life and prevent the progression of bronchiectasis. This is an update of a review first published in 2000.

OBJECTIVES

To evaluate the efficacy and safety of inhaled corticosteroids (ICS) in children and adults with stable state bronchiectasis, specifically to assess whether the use of ICS: (1) reduces the severity and frequency of acute respiratory exacerbations; or (2) affects long-term pulmonary function decline.

SEARCH METHODS

We searched the Cochrane Register of Controlled Trials (CENTRAL), the Cochrane Airways Group Register of trials, MEDLINE and Embase databases. We ran the latest literature search in June 2017.

SELECTION CRITERIA

All randomised controlled trials (RCTs) comparing ICS with a placebo or no medication. We included children and adults with clinical or radiographic evidence of bronchiectasis, but excluded people with cystic fibrosis.

DATA COLLECTION AND ANALYSIS

We reviewed search results against predetermined criteria for inclusion. In this update, two independent review authors assessed methodological quality and risk of bias in trials using established criteria and extracted data using standard pro forma. We analysed treatment as 'treatment received' and performed sensitivity analyses.

MAIN RESULTS

The review included seven studies, involving 380 adults. Of the 380 randomised participants, 348 completed the studies.Due to differences in outcomes reported among the seven studies, we could only perform limited meta-analysis for both the short-term ICS use (6 months or less) and the longer-term ICS use (> 6 months).During stable state in the short-term group (ICS for 6 months or less), based on the two studies from which data could be included, there were no significant differences from baseline values in the forced expiratory volume in the first second (FEV1) at the end of the study (mean difference (MD) -0.09, 95% confidence interval (CI) -0.26 to 0.09) and forced vital capacity (FVC) (MD 0.01 L, 95% CI -0.16 to 0.17) in adults on ICS (compared to no ICS). Similarly, we did not find any significant difference in the average exacerbation frequency (MD 0.09, 95% CI -0.61 to 0.79) or health-related quality of life (HRQoL) total scores in adults on ICS when compared with no ICS, though data available were limited. Based on a single non-placebo controlled study from which we could not extract clinical data, there was marginal, though statistically significant improvement in sputum volume and dyspnoea scores on ICS.The single study on long-term outcomes (over 6 months) that examined lung function and other clinical outcomes, showed no significant effect of ICS on any of the outcomes. We could not draw any conclusion on adverse effects due to limited available data.Despite the authors of all seven studies stating they were double-blind, we judged one study (in the short duration ICS) as having a high risk of bias based on blinding, attrition and reporting of outcomes. The GRADE quality of evidence was low for all outcomes (due to non-placebo controlled trial, indirectness and imprecision with small numbers of participants and studies).

AUTHORS' CONCLUSIONS

This updated review indicates that there is insufficient evidence to support the routine use of ICS in adults with stable state bronchiectasis. Further, we cannot draw any conclusion for the use of ICS in adults during an acute exacerbation or in children (for any state), as there were no studies.

Streptococcus pneumoniae and chronic endobronchial infections in childhood

Streptococcus pneumoniae (pneumococcus) is the main cause of bacterial pneumonia worldwide and has been studied extensively in this context. However, its role in chronic endobronchial infections and accompanying lower airway neutrophilic infiltration has received little attention. Severe and recurrent pneumonia are risk factors for chronic suppurative lung disease (CSLD) and bronchiectasis; the latter causes considerable morbidity and, in some populations, premature death in children and adults. Protracted bacterial bronchitis (PBB) is another chronic endobronchial infection associated with substantial morbidity. In some children, PBB may progress to bronchiectasis. Although nontypeable Haemophilus influenzae is the main pathogen in PBB, CSLD and bronchiectasis, pneumococci are isolated commonly from the lower airways of children with these diagnoses. Here we review what is known currently about pneumococci in PBB, CSLD and bronchiectasis, including the importance of pneumococcal nasopharyngeal colonization and how persistence in the lower airways may contribute to the pathogenesis of these chronic pulmonary disorders. Antibiotic treatments, particularly long-term azithromycin therapy, are discussed together with antibiotic resistance and the impact of pneumococcal conjugate vaccines. Important areas requiring further investigation are identified, including immune responses associated with pneumococcal lower airway infection, alone and in combination with other respiratory pathogens, and microarray serotyping to improve detection of carriage and infection by multiple serotypes. Genome wide association studies of pneumococci from the upper and lower airways will help identify virulence and resistance determinants, including potential therapeutic targets and vaccine antigens to treat and prevent endobronchial infections. Much work is needed, but the benefits will be substantial.

The Epidemiology of Chronic Suppurative Lung Disease and Bronchiectasis in Children and Adolescents

In the modern era, the global burden of childhood chronic suppurative lung disease (CSLD) remains poorly captured by the literature. What is clear, however, is that CSLD is essentially a disease of poverty. Disadvantaged children from indigenous and low- and middle-income populations had a substantially higher burden of CSLD, generally infectious in etiology and of a more severe nature, than children in high-income countries. A universal issue was the delay in diagnosis and the inconsistent reporting of clinical features. Importantly, infection-related CSLD is largely preventable. A considerable research and clinical effort is needed to identify modifiable risk factors and socioeconomic determinants of CSLD and provide robust evidence to guide optimal prevention and management strategies. The purpose of this review was to update the international literature on the epidemiology, etiology, and clinical features of pediatric CSLD.

Inhaled non-steroid anti-inflammatories for children and adults with bronchiectasis

BACKGROUND

Chronic neutrophilic inflammation, in both the presence and absence of infection, is a feature of bronchiectasis in adults and children. The anti-inflammatory properties of non-steroid anti-inflammatory drugs (NSAIDs) may be beneficial in reducing airway inflammation, thus potentially improving lung function and quality of life in patients with bronchiectasis.

OBJECTIVES

To evaluate the efficacy of inhaled NSAIDs in the management of non-cystic fibrosis bronchiectasis in children and adults:• during stable bronchiectasis; and• for reduction of:∘ severity and frequency of acute respiratory exacerbations; and∘ long-term pulmonary decline.

SEARCH METHODS

We searched the Cochrane Airways Group Trials Register, which includes reports identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE and the Cumulative Index to Nursing and Allied Health Literature (CINAHL). We also searched the trial registry ClinicalTrials.gov and the World Health Organization (WHO) trial portal. We carried out the latest searches on 22 September 2015.

SELECTION CRITERIA

All randomised controlled trials comparing inhaled NSAIDs versus a control (placebo or usual treatment) in children or adults with bronchiectasis not related to cystic fibrosis.

DATA COLLECTION AND ANALYSIS

We reviewed the results of searches against predetermined criteria for inclusion.

MAIN RESULTS

One small, short-term trial was eligible for inclusion. We included this study of 25 adults with chronic lung disease (only 32% of people included in the trial had bronchiectasis), as the other conditions were linked to development of bronchiectasis, and all were characterised by chronic sputum production. We were not able to obtain separate data for people with a diagnosis of bronchiectasis. We judged that the study was at a high risk of selection bias.The primary outcome (mean difference in control of bronchiectasis severity, quality of life (Qol), cough scores) was not reported in the included study. The single trial in adults reported a significant reduction in sputum production over 14 days for the treatment group (inhaled indomethacin) compared with the placebo group (mean difference (MD) -75.00 g/day; 95% confidence interval (CI) -134.61 to -15.39) and a significant improvement in the Borg Dyspnoea Scale score (MD -1.90, 95% CI -3.15 to -0.65). We noted no significant differences between groups in lung function or blood indices and no reported adverse events.

AUTHORS' CONCLUSIONS

No new studies of adults or children have been conducted since the last version of this review was published. Therefore, final conclusions have not changed. Current evidence is insufficient to support or refute the use of inhaled NSAIDs for the management of bronchiectasis in adults or children. One small trial reported a reduction in sputum production and improved dyspnoea among adults with chronic lung disease who were treated with inhaled indomethacin, indicating that additional studies on the efficacy of NSAIDs for treatment of patients with bronchiectasis are warranted.

Non Cystic Fibrosis Bronchiectasis

Bronchiectasis is a pathological abnormality of the airways in which there is permanent dilatation and thickening of the airways. Precise incidence/prevalence in India is not known. Recent data suggests that about 1 % young children admitted in a hospital with pneumonia may develop bronchiectasis. Due to significant burden of pneumonia in young children in developing countries including India, it may be a significant problem that is possibly under recognized. Causes of bronchiectasis depend on the burden of respiratory infections and availability of the investigations for identification of the underlying cause. Post infectious causes are common in countries where infections are more common; however, since these countries are usually resource constrained and therefore, are not able to appropriately diagnose the other causes, leading to more than real overrepresentation of infections as a cause. In countries with less of infectious illnesses and good diagnostic facilities, malformations of airways, immune deficiency disorders and primary ciliary dyskinesia are common causes of bronchiectasis. High resolution CT scan of chest confirms the diagnosis. Treatment is supportive care and consists of maintenance of nutrition, airway clearance and antibiotics for exacerbations. Medical treatment is successful in the majority.

The relationship between psychological symptoms, lung function and quality of life in children and adolescents with non-cystic fibrosis bronchiectasis

OBJECTIVES

The aim of this study was to evaluate the relationship between psychological symptoms and quality of life (QOL) and clinical variables in a cohort of children and adolescents with non-cystic fibrosis (non-CF) bronchiectasis.

METHODS

Seventy-six patients (aged 8-17years) participated in this study. Questionnaires were used to evaluate the psychological status and QOL of the patients and healthy controls. The patient and control groups were divided into child and adolescent groups to exclude the effect of puberty on psychological status.

RESULTS

No significant difference was found between patient and control groups for mean depression and trait anxiety scores. Only the child-rated physical health QOL scores were significantly lower for patients than the controls. Also, excepting physical health scores in adolescent group, all of the parent-rated QOL scores were significantly lower in both group and total subjects. Regarding determinants of QOL, age of children and FEV1/FVC percent predicted had positive effects, while dyspnea severity and trait anxiety had negative effects, for the sample as a whole.

CONCLUSIONS

Non-CF bronchiectasis is associated with poorer QOL in childhood. The impact of the disease on QOL occurs through both clinical and psychological variables.

Surgical treatment of non-cystic fibrosis bronchiectasis in Brazilian children

PURPOSE

To determine the clinical characteristics of patients submitted to surgical treatment for non-cystic fibrosis (CF) bronchiectasis, the indications for surgery, and the results obtained at a referral facility for pediatric thoracic surgery.

METHODS

Between January 1998 and December 2009, we retrospectively reviewed the medical charts of 109 pediatric patients with non-CF bronchiectasis who underwent surgical treatment. These findings were subsequently analyzed by focusing on postoperative complications and long-term results.

RESULTS

Of the 109 patients undergoing pulmonary resection, the mean age was 7.6 years (ranging from 1 to 15.5 y-o) with male predominance (59 %). The most common procedure was segmentectomy (43 %) followed by left lower lobectomy (38 %). Minor postoperative complications occurred in 36 % of the patients; the most common was transient atelectasis (26 %), followed by air leak (6 %), and postoperative pain (4 %). There was one death within the 30-day postoperative period, but it was unrelated to the procedure. Eighty-three children were followed after discharge, with a mean follow-up period of 667 days. Sixty-five (76 %) patients showed improvement of clinical symptoms after surgery.

CONCLUSIONS

Lung resection for the treatment of non-CF bronchiectasis in children is a safe procedure, with no life-treating morbidity and low mortality. This procedure also leads to significant improvements in symptoms and quality of life.

The evaluation of children with prolonged cough accompanied by American College of Chest Physicians guidelines

INTRODUCTION

In children, coughs lasting longer than 4 weeks are considered to be chronic, with etiological factors varying widely.

OBJECTIVE

This study included children with chronic cough who were followed for 1 year. All cases were evaluated with the guidance of the American College of Chest Physicians (ACCP), and etiological factors were analyzed.

METHODS

The study included 270 children between the ages of 2 months and 14 years. Their presenting symptoms, physical examination findings and laboratory data were recorded. All patients underwent laboratory tests including direct chest X-ray and spirometric measurements. Several patients required additional advanced examinations such as a sweat test, determination of immunoglobulin levels and bronchoscopy. Patients were reevaluated according to ACCP recommendations, and etiological factors were investigated.

RESULTS

The total of 270 patients were included in the study included 43.3% (n=153) females with a mean age of 6.5 ± 2.3 years (7 months to 17 years). After a 1-year follow-up of patients, we determined that the most common etiologic factors were asthma (27%), asthma-like syndrome (15.5%) and gastroesophageal reflux (10%). Other etiological factors included upper airway cough syndrome and protracted bronchitis, respectively.

CONCLUSION

The use of a standardized clinical approach such as the ACCP increases the possibility for fast and accurate diagnosis during the treatment of children with chronic cough, and the use of these guidelines should be required.

Hyper IgM syndrome presenting as chronic suppurative lung disease

The Hyper-immunoglobulin M syndromes (HIGM) are a heterogeneous group of genetic disorders resulting in defects of immunoglobulin class switch recombination. Affected patients show humoral immunodeficiency and high susceptibility to opportunistic infections. Elevated serum IgM levels are the hallmark of the disease, even though in few rare cases they may be in the normal range. Hyper IgM is associated with low to undetectable levels of serum IgG, IgA, and IgE. In some cases, alterations in different genes may be identified. Mutations in five genes have so far been associated to the disease, which can be inherited with an X-linked (CD40 ligand, and nuclear factor-kB essential modulator defects) or an autosomal recessive (CD40, activation-induced cytidine deaminase, and uracil-DNA glycosylase mutation) pattern. The patient herein described presented with recurrent upper and lower respiratory infections and evidence of suppurative lung disease at the conventional chest imaging. The presence of low serum IgG and IgA levels, elevated IgM levels, and a marked reduction of in vivo switched memory B cells led to a clinical and functional diagnosis of HIGM although the genetic cause was not identified.

Azithromycin for Indigenous children with bronchiectasis: study protocol for a multi-centre randomized controlled trial

BACKGROUND

The prevalence of chronic suppurative lung disease (CSLD) and bronchiectasis unrelated to cystic fibrosis (CF) among Indigenous children in Australia, New Zealand and Alaska is very high. Antibiotics are a major component of treatment and are used both on a short or long-term basis. One aim of long-term or maintenance antibiotics is to reduce the frequency of acute pulmonary exacerbations and symptoms. However, there are few studies investigating the efficacy of long-term antibiotic use for CSLD and non-CF bronchiectasis among children. This study tests the hypothesis that azithromycin administered once a week as maintenance antibiotic treatment will reduce the rate of pulmonary exacerbations in Indigenous children with bronchiectasis.

METHODS/DESIGN

We are conducting a multicentre, randomised, double-blind, placebo controlled clinical trial in Australia and New Zealand. Inclusion criteria are: Aboriginal, Torres Strait Islander, Maori or Pacific Island children aged 1 to 8 years, diagnosed with bronchiectasis (or probable bronchiectasis) with no underlying disease identified (such as CF or primary immunodeficiency), and having had at least one episode of pulmonary exacerbation in the last 12 months. After informed consent, children are randomised to receive either azithromycin (30 mg/kg once a week) or placebo (once a week) for 12-24 months from study entry. Primary outcomes are the rate of pulmonary exacerbations and time to pulmonary exacerbation determined by review of patient medical records. Secondary outcomes include length and severity of pulmonary exacerbation episodes, changes in growth, school loss, respiratory symptoms, forced expiratory volume in 1-second (FEV(1); for children ≥6 years), and sputum characteristics. Safety endpoints include serious adverse events. Antibiotic resistance in respiratory bacterial pathogens colonising the nasopharynx is monitored. Data derived from medical records and clinical assessments every 3 to 4 months for up to 24 months from study entry are recorded on standardised forms.

DISCUSSION

Should this trial demonstrate that azithromycin is efficacious in reducing the number of pulmonary exacerbations, it will provide a much-needed rationale for the use of long-term antibiotics in the medical management of bronchiectasis in Indigenous children.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry: ACTRN12610000383066.

Non-cystic fibrosis bronchiectasis

Non-cystic fibrosis (CF) bronchiectasis is said to be a declining problem in developed countries, although its prevalence in indigenous communities in Australia and New Zealand is among the highest reported in the world. Early childhood pneumonia and underlying conditions such as immunodeficiency and primary ciliary dyskinesia need to be considered in the aetiology. A high-resolution computerised tomography scan is the key investigation in children with a chronic wet cough in whom bronchiectasis is suspected. Regardless of the cause, the treatment of bronchiectasis is centred upon facilitating the clearance of airway secretions and the treatment of pulmonary exacerbations. This review aims to provide general paediatricians with an update on the presenting features, investigation and management of non-cystic fibrosis bronchiectasis.

The burden of disease in pediatric non-cystic fibrosis bronchiectasis

BACKGROUND

The burden of disease in children with non-cystic fibrosis (non-CF) bronchiectasis is unknown. Our study aimed to identify the determinants of quality of life (QOL) and parental mental health in this group of patients and their parents and to evaluate the effect of exacerbations on these parameters.

METHODS

Parents of 69 children (median age 7 years) with non-CF bronchiectasis prospectively completed two questionnaires (parent-proxy cough-specific quality of life [PC-QOL] and the Depression, Anxiety, and Stress Scale [DASS]) at stable and exacerbation states. Data on clinical, investigational, and lung function parameters were also collected.

RESULTS

During the stable state, the median interquartile range (IQR) PC-QOL score was 6.5 (5.3-6.9) and the DASS 21-item questionnaire score was 6 (0-20). Being of a young age correlated with a worse QOL (r(5) = 0.242, P = .04) but radiologic extent, lung function, underlying cause, environmental tobacco smoke exposure, and chronic upper-airway disease did not influence these scores. Exacerbations caused significant worsening in the PC-QOL scores (median [IQR], 4.6 [3.8-5.4]; P = .001) and DASS scores (median [IQR], 22 [9-42]; P < .001; 38% with elevated anxiety, 54% with abnormal depression/stress scores during exacerbation). The presence of viral infection, hypoxia, and hospitalization did not influence the exacerbation PC-QOL and DASS scores.

CONCLUSIONS

There is a significant burden of disease, especially during exacerbation, on parents of children with bronchiectasis. Prevention, early detection, and appropriate treatment of exacerbations are likely to reduce psychologic morbidity in this group.

Surgery for bronchiectasis: The effect of morphological types to prognosis

BACKGROUND

Although the incidence has declined over the past years in societies with high socioeconomic status, bronchiectasis is still an important health problem in our country.

AIM

To review and present our cases undergoing surgery for bronchiectasis in the past 12 years and their early and late term postoperative outcomes and our experience in bronchiectasis surgery and the effect of morphological type on the prognosis.

METHODS

The medical records of 62 cases undergoing surgical resection for bronchiectasis in the Clinics of Thoracic and Pediatric Surgery were evaluated retrospectively. The disease was on the left in 33 cases, on the right in 26 and bilateral in three cases. The most common surgical procedure was lobectomy. Forty one patients underwent pneumonectomy, lobectomy and complete resection including bilobectomy. Twenty-one (33.87%) cases underwent incomplete resection, of whom 11 (17.74%) underwent segmentectomy and 10 (16.13%) underwent lobectomy + segmentectomy.

RESULTS

It was found that the rate of being asymptomatic was significantly higher in patients undergoing complete resection compared to those undergoing incomplete resection. Spirometric respiratory function tests were performed to assess the relationship between morphological type and the severity of disease. All parameters of respiratory function were worse in the saccular type and FEV(1)/FVC showed a worse obstructive deterioration in the saccular type compared to the tubular type.

CONCLUSION

The success rate of the procedure increases with complete resection of the involved region. The morphological type is more important than the number and extension of the involved segments in showing the disease severity.

A neglected problem of developing countries: Noncystic fibrosis bronchiectasis

BACKGROUND:

Bronchiectasis has been defined as the abnormal and permanent dilation of the bronchi. It is still an important problem in many developing countries.

AIM:

The aim of this study was to identify the chacteristics and underlying etiology of children followed with the diagnosis of noncystic fibrosis bronchiectasis.

MATERIALS AND METHODS:

Children with bronchiectasis confirmed with high-resolution computed tomography were enrolled into the study. The data of the patients, including symptoms of the disease, age at the onset of symptoms, findings of physical examination, labrotory investigations performed in order to identify the etiology of bronchiectasis, etiology of bronchiectasis if found, radiologic findings and treatment modalities were noted.

RESULTS:

Sixty-six children between 1 and 17 years were included in the study retrospectively. Forty-four of them were males (66.7%) and 22 (33.3%) were females. The most common presenting symptoms were cough (100%) and sputum expectoration (50%). An underlying etiology was identified in 44 (66.7%) of the study subjects. The four most common underlying causes were found as infections (21.2%), asthma (16.7%), aspiration syndromes and/or gastroesophageal reflux disease (9.1%) and immunodeficiency syndromes (7.6%), respectively.

CONCLUSION:

Identifying an underlying etiology will have a significant effect on the management of noncystic fibrosis bronchiectasis. Defining the cause of bronchiectasis may also decrease its incidence, progression and complications.

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.

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.

Bronchiectasis in children: 10-year experience at a single institution

Purpose

Bronchiectasis in children is still one of the most common causes of childhood mortality in developing countries. The aim of this study was to investigate the epidemiological characteristics, clinical features, underlying etiologic factors, and distinct change in the management of patients with bronchiectasis at Asan Medical Center Children's Hospital of Seoul.

Methods

A retrospective study of children diagnosed with bronchiectasis was conducted between January 1999 and December 2008. All patients underwent a comprehensive examination to identify etiologic factors. Data analysis in terms of age at onset, initial presenting symptoms, underlying etiology, distinct change in treatment, distribution of pulmonary involvement on computed tomography (CT), and causative microbiological flora triggering secondary infections was performed.

Results

The median age at the time of the diagnosis of bronchiectasis was 7.6 years (range, 2 months to 18 years). Persistent coughing was the most common symptom. The underlying etiologies identified in 79 patients (85.8%) included bronchiolitis obliterans (32.6%), childhood respiratory infection (20.6%), interstitial lung disease (17.3%), immunodeficiency (8.6%), and primary ciliary dyskinesia (4.3%). In 53 children (67%), the identified cause led to a distinct and individualized change in management. The distribution of CT abnormalities had no correlation with the underlying cause of bronchiectasis.

Conclusions

Selected Korean children with bronchiectasis were reviewed to identify diverse underlying etiologies. All children with bronchiectasis should be comprehensively investigated because identifying underlying causes may have a major impact on their management and prognosis.

A review of 151 cases of pediatric noncystic fibrosis bronchiectasis in a tertiary care center

OBJECTIVE:

This study was conducted to review the etiological factors and diseases associated with pediatric noncystic fibrosis bronchiectasis in a tertiary care center in Saudi Arabia.

MATERIALS AND METHODS:

A retrospective review of all patients with confirmed noncystic fibrosis (Non-CF) bronchiectasis by chest X-ray and/or CT chest in a pulmonary clinic during the period 1993–2005 at a tertiary care center in Riyadh.

RESULTS:

A total of 151 cases were diagnosed as Non-CF bronchiectasis. Seventy-five (49.7%) were male, 76 (50.3%) were female; 148 (98%) are alive and 3 (2%) died. The southwestern regions constituted 72 (50%) of the cases. There was a period of (5 ± 3.2) years between the start of symptoms and diagnosis of bronchiectasis. More than two-thirds of the patients had cough, tachypnea, wheezing, sputum production and failure to thrive. Ninety-one (60%) had associated diseases: Pulmonary diseases in 48 (32%), immunodeficiency in 27 (18%), central nervous system anomalies in 10 (7%), cardiac in 10 (7%) and asthma in 103 (68%) of the patients. Left lower lobe was commonly involved in 114 (76%) patients. Sixty-eight (67%) were found to have sinusitis. More than two-thirds of patients had two or more associated diseases. Forty-nine (32%) developed gastroesophageal reflux. Hemophilus influenza was cultured in 56 (37%), strept pneumoniae in 25 (17%) and pseudomonas aeruginosa in 24 (16%) of the patients. Eighty percent of the patients who had pulmonary function test had abnormal changes. Disease progression was related to development of symptoms before 5 years of age, persistent atelectasis and right lower lobe involvement (P< 0.05).

CONCLUSION:

Non-CF bronchiectasis should be included in the differential diagnosis of recurrent chest infection in Saudi Arabia. Early diagnosis and identification of associated diseases is needed to prevent progression of the disease.

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.

Inhaled non-steroid anti-inflammatories for children and adults with bronchiectasis

BACKGROUND

Chronic neutrophilic inflammation, both in the presence and absence of infection, is a feature of bronchiectasis in adults and children. The anti-inflammatory properties of non-steroid anti-inflammatory drugs (NSAIDs) may be beneficial in reducing airway inflammation and thus potentially improve lung function and quality of life in patients with bronchiectasis.

OBJECTIVES

To evaluate the efficacy of inhaled NSAIDs in the management of non-cystic fibrosis bronchiectasis in children and adults.

SEARCH STRATEGY

We searched the Cochrane Airways Group Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2009, issue 3), MEDLINE, OLDMEDLINE and EMBASE databases. The latest searches were carried out in October 2009

SELECTION CRITERIA

All randomised controlled trials comparing inhaled NSAIDs to a control group (placebo or usual treatment) in children or adults with bronchiectasis not related to cystic fibrosis.

DATA COLLECTION AND ANALYSIS

We reviewed the results of the searches against pre-determined criteria for inclusion.

MAIN RESULTS

One small, short-term trial was eligible for inclusion. We included this study of 25 adults with chronic lung disease (including bronchiectasis) as the other conditions were linked to development of bronchiectasis and all had chronic sputum production.The single trial in adults reported a significant reduction in sputum production over 14 days in the treatment group (inhaled indomethacin) compared to placebo (difference -75.00 g/day; 95% CI -134.61 to -15.39) and a significant improvement in a dyspnoea score (difference -1.90; 95% CI -3.15 to -0.65). There was no significant difference between groups in lung function or blood indices. No adverse events were reported.

AUTHORS' CONCLUSIONS

There is currently insufficient evidence to support or refute the use of inhaled NSAIDs in the management of bronchiectasis in adults or children. One small trial reported a reduction in sputum production and improved dyspnoea in adults with chronic lung disease who were treated with inhaled indomethacin, indicating that further studies on the efficacy of NSAIDs in treating patients with bronchiectasis are warranted.

Singing for children and adults with bronchiectasis

BACKGROUND

Bronchiectasis is a common respiratory disease, especially in developing countries. Its cause varies from chronic infection to rare immune deficiencies. Bronchiectasis can be present with other respiratory diseases, such as chronic obstructive pulmonary disease (COPD). People with bronchiectasis may suffer from chronic cough, fatigue, shortness of breath, chest pain and coughing up blood. Their lung function may decline with time. These can also have a negative impact on their quality of life. Thus, a holistic management is needed to provide treatment and support. Therapies which include breathing manoeuvres, such as singing, may have health benefits for respiratory function and psychological well being.

OBJECTIVES

To evaluate the effects of a singing intervention as a therapy on the quality of life, morbidity, respiratory muscle strength and pulmonary function of children and adults with bronchiectasis.

SEARCH STRATEGY

We searched the Cochrane Airways Group (CAG) trials register, the Cochrane Central Register of Controlled Trials, major allied complementary databases, and clinical trials registers. Professional organisations and individuals were also contacted. CAG performed searches in February, and additional searches were carried out in June 2009.

SELECTION CRITERIA

Randomised controlled trials in which singing (as an intervention) is compared with either a sham intervention or no singing in patients with bronchiectasis.

DATA COLLECTION AND ANALYSIS

Two authors independently reviewed the titles, abstracts and citations to assess potential relevance for full review. No eligible trials were identified and thus no data were available for analysis.

MAIN RESULTS

No meta-analysis could be performed.

AUTHORS' CONCLUSIONS

In the absence of data, we cannot draw any conclusion to support or refute the adoption of singing as an intervention for people with bronchiectasis. Given the simplicity of the potentially beneficial intervention, future randomised controlled trials are required to evaluate singing therapy for people with bronchiectasis.

Exhaled breath condensate MMP-9 levels in children with bronchiectasis

Bronchiectasis (BE) is still an important cause of chronic supurative respiratory diseases in developing countries. Neutrophil-derived proteases such as neutrophil elastase and matrix metalloproteases (MMPs) are implicated in causing airway damage in chronic pulmonary disease. In this study, we aimed to evaluate the MMP-9 and its natural tissue inhibitors of metalloproteinases (TIMP-1) levels utilizing the exhaled breath condensate (EBC) method and their relationship with radiological findings and pulmonary functions in children with BE.Thirty-eight children with BE and 12 healthy children were included: Group 1 (cystic fibrosis [CF] BE), Group 2 (non-CF BE), Group 3 (control group). High-resolution computerized tomography (HRCT) scores were calculated according to the anatomic extent of BE. Pulmonary function tests were performed, and MMP-9 and TIMP-1 levels in EBC were analyzed by ELISA.Exhaled breath condensate MMP-9 level was 48.9 +/- 26.8 ng/ml for Group 1, and for Group 2, 42.8 +/- 18.1 ng/ml; and for Group 3, 30 +/- 3.7 ng/ml. Although no statistically significant difference was found between the Groups 1 and 2, a significant difference was detected between these groups and controls. No statistically significant difference was found in TIMP-1 levels regarding all groups. EBC MMP-9 levels were inversely correlated with pulmonary functions test, and positively with HRCT scores and annual number of pulmonary infections.In conclusion, this study showed that EBC of children with both CF BE and non-CF BE contained higher levels of MMP-9 in comparison to controls. We suggest that EBC MMP-9 level may be a useful marker of airway injury in patients with BE however prospective studies are needed.

Inhaled steroids for bronchiectasis

BACKGROUND

Bronchiectasis is increasingly recognized as a major cause of respiratory morbidity especially in developing countries and in some ethnic populations of affluent countries. It is characterized by irreversible dilatation of airways, generally associated with chronic bacterial infection. Medical management largely aims to reduce morbidity by controlling the symptoms and by preventing the progression of bronchiectasis.

OBJECTIVES

To evaluate the efficacy of inhaled corticosteroids (ICS) in children and adults with bronchiectasis (a) during stable bronchiectasis; and for reducing; (b) the severity and frequency of acute respiratory exacerbations and (c) long term pulmonary decline.

SEARCH STRATEGY

The Cochrane Register of Controlled Trials (CENTRAL), the Cochrane Airways Group Specialized Register Collaboration and Cochrane Airways Group, MEDLINE and EMBASE databases were searched by the Cochrane Airways Group. The latest searches were performed in September 2007.

SELECTION CRITERIA

All randomised controlled trials comparing ICS with a placebo or no medication. Children and adults with clinical or radiographic evidence of bronchiectasis were included, but patients with cystic fibrosis (CF) were excluded.

DATA COLLECTION AND ANALYSIS

Results of searches were reviewed against pre-determined criteria for inclusion.

MAIN RESULTS

There were no paediatric studies. Six adult studies fulfilled the inclusion criteria. Of the 303 randomised, 278 subjects completed the trials. In the short term group (ICS for less then 6 months duration), adults on huge doses of ICS (2g per day of budesonide equivalent) had significantly improved forced expiratory volume in the first second (FEV(1)), forced vital capacity (FVC), Quality of life (QOL) score and sputum volume but no significant difference in peak flow, exacerbations, cough or wheeze, when compared to adults in the control arm (no ICS). When only placebo-controlled studies were included, there were no significant difference between groups in all outcomes examined (spirometry, clinical outcomes of exacerbation or sputum volume etc). The single study on long term outcomes showed no significant effect of inhaled steroids in any of the outcomes.

AUTHORS' CONCLUSIONS

The present review indicates that there is insufficient evidence to recommend the routine use of inhaled steroids in adults with stable state bronchiectasis. While a therapeutic trial may be justified in adults with difficult to control symptoms and in certain subgroups, this has to be balanced with adverse events especially if high doses are used. No recommendation can be made for the use of ICS in adults during an acute exacerbation or in children (for any state) as there were no studies.

Chronic wet cough: Protracted bronchitis, chronic suppurative lung disease and bronchiectasis

The role of persistent and recurrent bacterial infection of the conducting airways (endobronchial infection) in the causation of chronic respiratory symptoms, particularly chronic wet cough, has received very little attention over recent decades other than in the context of cystic fibrosis (CF). This is probably related (at least in part) to the (a) reduction in non-CF bronchiectasis in affluent countries and, (b) intense focus on asthma. In addition failure to characterize endobronchial infections has led to under-recognition and lack of research. The following article describes our current perspective of inter-related endobronchial infections causing chronic wet cough; persistent bacterial bronchitis (PBB), chronic suppurative lung disease (CSLD) and bronchiectasis. In all three conditions, impaired muco-ciliary clearance seems to be the common risk factor that provides organisms the opportunity to colonize the lower airway. Respiratory infections in early childhood would appear to be the most common initiating event but other conditions (e.g., tracheobronchomalacia, neuromuscular disease) increases the risk of bacterial colonization. Clinically these conditions overlap and the eventual diagnosis is evident only with further investigations and long term follow up. However whether these conditions are different conditions or reflect severity as part of a spectrum is yet to be determined. Also misdiagnosis of asthma is common and the diagnostic process is further complicated by the fact that the co-existence of asthma is not uncommon. The principles of managing PBB, CSLD and bronchiectasis are the same. Further work is required to improve recognition, diagnosis and management of these causes of chronic wet cough in children.

Oral non steroid anti-inflammatories for children and adults with bronchiectasis

BACKGROUND

Bronchiectasis is increasing recognised as a co-morbidity in many respiratory illness. Anti inflammatory drugs may reduce the inflammatory cascade and thus reduce symptoms and slow long term pulmonary decline.

OBJECTIVES

To assess the role of non steroid anti inflammatory drugs (NSAIDs) on symptom control and natural history of the disease in children and adults with bronchiectasis.

SEARCH STRATEGY

The Cochrane Central Register of Controlled Trials (CENTRAL), the Cochrane Airways Group Specialised Register, MEDLINE and EMBASE databases were searched by the Cochrane Airways Group up to December 2006.

SELECTION CRITERIA

Only randomised controlled trials were considered. Patients with radiological or clinical evidence of bronchiectasis were included. Patients with Cystic Fibrosis were excluded.

DATA COLLECTION AND ANALYSIS

The titles, abstracts and citations were independently reviewed by two reviewers to assess potential relevance for full review. No eligible trials were identified and thus no data were available for analysis.

MAIN RESULTS

No randomised or controlled trials were found.

AUTHORS' CONCLUSIONS

There are no randomised controlled that examined the effect of oral NSAIDs in patients with bronchiectasis. In view of some benefit shown by inhaled NSAIDs in bronchiectasis, RCTs are clearly needed to study the beneficial effect of oral NSAIDs in patients with bronchiectasis.

Risk factors affecting outcome and morbidity in the surgical management of bronchiectasis

OBJECTIVE

Bronchiectasis continues to be a major cause of morbidity and mortality in developing countries. The purpose of this study was to present the results of our 14 years of surgical experience to re-evaluate our indications for using surgical therapy and to analyze several factors that might affect the outcome and postoperative complications of this disease.

METHOD

Age, sex, etiologic factors, symptoms, the duration of symptoms, radiologic and radionuclide examinations, preoperative evaluation, surgical procedures, postoperative morbidity and mortality, and the follow-up results from 143 patients operated on for bronchiectasis between January 1992 and January 2006, were reviewed retrospectively.

RESULTS

One hundred forty-three patients underwent 148 operations for bronchiectasis. The mean age was 23.4 years. Complete resection was achieved in 118 patients. The morbidity rate was 23.0% and the mortality rate was 1.3%. Postoperatively, 75.9% of the patients were free of symptoms, 15.7% were improved, and 8.2% showed no improvement or were worse. The logistic regression analysis showed that a history of tuberculosis and incomplete resection were independent predictors of the operative result. Moreover, the lack of a preoperative bronchoscopic examination, a forced expiratory volume in 1 second of less than 60% of the predicted value, a history of tuberculosis, and incomplete resection were independent predictors of postoperative complications.

CONCLUSIONS

A history of tuberculosis and incomplete resection were risk factors both for postoperative complications and for a worse operative result. The lack of a preoperative bronchoscopic examination and a low forced expiratory volume in 1 second were risk factors for postoperative complications. Surgery for multiple segments on different lobes should be performed whenever possible.

Influenza vaccine for children and adults with bronchiectasis

BACKGROUND

Bronchiectasis is a major cause of respiratory morbidity especially in developing countries. In affluent countries, bronchiectasis is increasingly recognised in certain subsections of communities (e.g. Aboriginal communities) as well as a coexistent disease/comorbidity and disease modifier in respiratory diseases such as COPD (reported rates of 29-50% in adults). Respiratory exacerbations in people with bronchiectasis are associated with reduced quality of life, accelerated pulmonary decline, hospitalisation and even death. Current recommendations for inactivated influenza vaccination includes adults aged 65 years and over, those in residential care and health care workers and also all adults and children with chronic illness, particularly cardiac and pulmonary diseases.

OBJECTIVES

To evaluate the effectiveness of influenza vaccine as routine management in children and adults with bronchiectasis in (a) reducing the severity and frequency of respiratory exacerbations and (b) pulmonary decline

SEARCH STRATEGY

The Cochrane Register of Controlled Trials (CENTRAL), the Cochrane Airways Group Specialised Register, MEDLINE and EMBASE databases were searched by the Cochrane Airways Group. Pharmaceutical manufacturers of influenza were also contacted. The latest searches were performed in July 2006.

SELECTION CRITERIA

All randomised controlled trials with at least one annual influenza vaccine involving children or adults with bronchiectasis.

DATA COLLECTION AND ANALYSIS

Results of searches were reviewed against pre-determined criteria for inclusion. It was planned that two independent reviewers selected, extracted and assessed data for inclusion.

MAIN RESULTS

No eligible trials were identified and thus no data were available for analysis.

AUTHORS' CONCLUSIONS

There is neither evidence for, nor against, routine annual influenza vaccination for children and adults with bronchiectasis.

Bone Mineral Density in Children with Non-Cystic Fibrosis Bronchiectasis

BACKGROUND

Bronchiectasis presents as a common sequela of several chronic pulmonary diseases. Bone mineral density (BMD) is generally decreased in children with cystic fibrosis (CF). Although children with non-CF bronchiectasis have similar risk factors for osteopenia/osteoporosis, data on BMD in this group of patients are lacking.

OBJECTIVE

To evaluate BMD in children with non-CF bronchiectasis.

METHODS

In this study, we evaluated BMD of the radius and tibia in 32 children (17 girls) with non-CF bronchiectasis and in 23 healthy controls matched for age, sex and pubertal stage by quantitative ultrasound (speed of sound). Daily calcium intake and pulmonary function tests and data about steroid use were noted.

RESULTS

Mean age was 12.5 +/- 4.6 years. Six children (18%) had moderate-to-severe lung disease (FEV(1) <60% predicted). All except 2 children (94%) were receiving inhaled steroids. There was no significant difference in BMD (expressed as z-score) of the radius and tibia between the patient and control groups (tibia z-scores: -0.1 +/- 0.9 vs. -0.8 +/- 0.8 and radius z-scores -1.3 +/- 1.4 vs. -1.0 +/- 0.9 in bronchiectasis patients and controls, respectively, p > 0.05). However, more children with non-CF bronchiectasis had osteopenia (z-scores between -1 and -2 SD) and osteoporosis (z-score <or=2 SD) compared to the control group (62 vs. 30%, p = 0.019). There was a significant correlation between age and radius z-scores (r = -0.365, p = 0.04). There was no correlation between BMD and severity of lung illness, calcium intake or cumulative steroid doses.

CONCLUSION

Osteopenia is more common in children with non-CF bronchiectasis compared to controls and the risk of osteoporosis and osteopenia increases with age.

Pneumococcal vaccines for children and adults with bronchiectasis

BACKGROUND

Bronchiectasis is increasingly recognized as a major cause of respiratory morbidity especially in developing countries. Even in affluent countries, bronchiectasis is increasingly seen in some community subsections (e.g. Aboriginal communities) and occurs as a comorbidity and disease modifier in respiratory diseases such as chronic obstructive pulmonary disease (COPD). Respiratory exacerbations in people with bronchiectasis is associated with reduced quality of life, accelerated pulmonary decline, hospitalisation and even death. Conjugate pneumococcal vaccine is part of the routine infant immunisation schedule in many countries. Current recommendations for additional pneumococcal vaccination include children and adults with chronic suppurative disease.

OBJECTIVES

To evaluate the effectiveness of pneumococcal vaccine as routine management in children and adults with bronchiectasis in (a) reducing the severity and frequency of respiratory exacerbations and (b) pulmonary decline.

SEARCH STRATEGY

The Cochrane Register of Controlled Trials (CENTRAL), the Cochrane Airways Group Specialised Register, MEDLINE and EMBASE databases were searched by the Cochrane Airways Group. Pharmaceutical manufacturers of pneumococcal vaccines were also contacted. The latest searches were performed in October 2006.

SELECTION CRITERIA

All randomised controlled trials that utilised pneumococcal vaccine on children and adults with bronchiectasis. All types of pneumococcal vaccines were included.

DATA COLLECTION AND ANALYSIS

Results of searches were reviewed against pre-determined criteria for inclusion. No eligible trials were identified and thus no data was available for analysis. One small non-randomised controlled trial in children was reported.

MAIN RESULTS

No randomised controlled trials pertaining effectiveness of pneumococcal vaccine as routine management in children and adults with bronchiectasis were found. A benefit in elimination of Strep. pneumoniae in the sputum was found in a non-randomised trial in children but no clinical effect was described.

AUTHORS' CONCLUSIONS

At present, there is a lack of reliable evidence to support or refute the routine use of pneumococcal vaccine as routine management in children and adults with bronchiectasis. Randomised controlled trials examining the efficacy of this intervention using various vaccine types in different age groups are needed. Until further evidence is available, it is recommended that health providers adhere to national guidelines.

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.

Clinical profile of Saudi children with bronchiectasis

OBJECTIVE

This study represents the experience of a tertiary care center in Saudi Arabia on non-cystic fibrosis bronchiectasis.

METHODS

A retrospective review of all patients with confirmed Non-Cystic Fibrosis (Non-CF) bronchiectasis by chest X-ray and or CT chest in a pulmonary clinic for the period 1993-2005 at a tertiary care center in Riyadh.

RESULTS

A0 total of 151 cases were diagnosed as Non-CF bronchiectasis. Siventy-five (49.7%) were males, 76(50.3%) were females. One hundred forty-eight (98%) are alive and 3(2%) died. The southwestern regions constituted 72(50%) of the cases. There is a period (5+/- 3.2) years between the start of symptoms and the diagnosis of bronchiectasis. More than 2/3 of the patients had cough, tachypnea, wheezing, sputum production and failure to thrive. Ninety one (60%) had associated disease: Pulmonary diseases in 48(32%), immunodefficiency in 27(18%), CNS in 18(12%), cardiac in 12(8%) and asthma in 103(68%) of the patients. Left lower lobes were commonly involved in 114(76%) cases. Sixty-eight (67%) were found to have sinusitis. Forty-nine (32%) developed gastroesophgeal reflux (GER). Hemophilus influenza was cultured in 56(37%), Strept pneumoniae in 25(17%) and Pseudomonas aeruginosa in 24(16%) of the patients. 80% of the patients who had pulmonary function test had abnormal changes. Disease progression was related to development of symptoms before 5 years of age, persistent atelectasis and right lower lobe involvement (p<0.05).

CONCLUSION

Non-CF bronchiectasis is a common problem in Saudi Arabia. Early recognition and institution of treatment with proper vaccination of available anti-bacterial and anti-viral vaccines are encouraged to prevent progression of the disease.

Non-cystic-fibrosis bronchiectasis: a perspective from South America

Nowadays, bronchiectasis tends to be considered a rare disease. This is really the case in developed countries, where good standards of living have been prevalent for many decades. But it might not be the case in the developing world, where better sanitary conditions are still needed. This article reviews non-cystic fibrosis bronchiectasis, emphasising differences between developed and developing countries. Diagnostic methods and therapeutic issues are discussed as is the Latin American experience of postviral bronchiectasis.