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Faverio P, Franco G, Landoni V, Nadalin M, Negri D, Tagliabue A, Acone F, Cattaneo F, Cipolla F, Vimercati C, Aliberti S, Biondi A, Luppi F. Therapeutic Management of Bronchiectasis in Children and Adolescents: A Concise Narrative Review. J Clin Med 2024; 13:4757. [PMID: 39200899 PMCID: PMC11355200 DOI: 10.3390/jcm13164757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2024] [Revised: 08/07/2024] [Accepted: 08/08/2024] [Indexed: 09/02/2024] Open
Abstract
Introduction: Bronchiectasis, characterized by airway dilation, mucus hypersecretion, and recurrent exacerbations, is increasingly recognized in children and adolescents. Recent guidelines from the European Respiratory Society (ERS) and Thoracic Society of Australia and New Zealand (TSANZ) emphasize early diagnosis and optimized management. This review explores therapeutic strategies for pediatric bronchiectasis. Materials and methods: Our review involved a comprehensive search of English-language literature in the PubMed and EMBASE databases until December 2023, focusing on observational studies, interventions, reviews, and guidelines in pediatric bronchiectasis. Results: Management strategies encompass airway clearance techniques, mucoactive agents, pulmonary rehabilitation, bronchodilators and inhaled corticosteroids tailored to individual needs and age-appropriate techniques. Antibiotics play key roles in preventing exacerbations, eradicating pathogens, and managing acute exacerbations, which are guided by culture sensitivities and symptoms. Long-term antibiotic prophylaxis, particularly macrolides, aims to reduce exacerbations, although concerns about antibiotic resistance persist. Vaccinations, including pneumococcal and influenza vaccines, are crucial for preventing infections and complications. Surgery and lung transplantation are reserved to severe, refractory cases after failure of medical therapies. Conclusions: The optimal management of pediatric bronchiectasis requires a multidisciplinary approach, including physiotherapy, pharmacotherapy, and vaccinations, tailored to individual needs and guided by evidence-based guidelines. Further research is needed to refine diagnostic and therapeutic strategies and improve outcomes for affected children and adolescents.
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Affiliation(s)
- Paola Faverio
- School of Medicine and Surgery, University of Milano-Bicocca, 20854 Monza, Italy; (G.F.); (V.L.); (M.N.); (D.N.); (A.T.); (F.A.); (F.C.); (F.C.); (C.V.); (A.B.); (F.L.)
- Respiratory Unit, Fondazione IRCCS San Gerardo dei Tintori, 20900 Monza, Italy
| | - Giovanni Franco
- School of Medicine and Surgery, University of Milano-Bicocca, 20854 Monza, Italy; (G.F.); (V.L.); (M.N.); (D.N.); (A.T.); (F.A.); (F.C.); (F.C.); (C.V.); (A.B.); (F.L.)
- Respiratory Unit, Fondazione IRCCS San Gerardo dei Tintori, 20900 Monza, Italy
| | - Valentina Landoni
- School of Medicine and Surgery, University of Milano-Bicocca, 20854 Monza, Italy; (G.F.); (V.L.); (M.N.); (D.N.); (A.T.); (F.A.); (F.C.); (F.C.); (C.V.); (A.B.); (F.L.)
- Respiratory Unit, Fondazione IRCCS San Gerardo dei Tintori, 20900 Monza, Italy
| | - Marta Nadalin
- School of Medicine and Surgery, University of Milano-Bicocca, 20854 Monza, Italy; (G.F.); (V.L.); (M.N.); (D.N.); (A.T.); (F.A.); (F.C.); (F.C.); (C.V.); (A.B.); (F.L.)
- Respiratory Unit, Fondazione IRCCS San Gerardo dei Tintori, 20900 Monza, Italy
| | - Davide Negri
- School of Medicine and Surgery, University of Milano-Bicocca, 20854 Monza, Italy; (G.F.); (V.L.); (M.N.); (D.N.); (A.T.); (F.A.); (F.C.); (F.C.); (C.V.); (A.B.); (F.L.)
- Respiratory Unit, Fondazione IRCCS San Gerardo dei Tintori, 20900 Monza, Italy
| | - Alessandro Tagliabue
- School of Medicine and Surgery, University of Milano-Bicocca, 20854 Monza, Italy; (G.F.); (V.L.); (M.N.); (D.N.); (A.T.); (F.A.); (F.C.); (F.C.); (C.V.); (A.B.); (F.L.)
- Respiratory Unit, Fondazione IRCCS San Gerardo dei Tintori, 20900 Monza, Italy
| | - Federica Acone
- School of Medicine and Surgery, University of Milano-Bicocca, 20854 Monza, Italy; (G.F.); (V.L.); (M.N.); (D.N.); (A.T.); (F.A.); (F.C.); (F.C.); (C.V.); (A.B.); (F.L.)
- Pediatrics, Fondazione IRCCS San Gerardo dei Tintori, 20900 Monza, Italy
| | - Francesca Cattaneo
- School of Medicine and Surgery, University of Milano-Bicocca, 20854 Monza, Italy; (G.F.); (V.L.); (M.N.); (D.N.); (A.T.); (F.A.); (F.C.); (F.C.); (C.V.); (A.B.); (F.L.)
- Pediatrics, Fondazione IRCCS San Gerardo dei Tintori, 20900 Monza, Italy
| | - Filippo Cipolla
- School of Medicine and Surgery, University of Milano-Bicocca, 20854 Monza, Italy; (G.F.); (V.L.); (M.N.); (D.N.); (A.T.); (F.A.); (F.C.); (F.C.); (C.V.); (A.B.); (F.L.)
- Pediatrics, Fondazione IRCCS San Gerardo dei Tintori, 20900 Monza, Italy
| | - Chiara Vimercati
- School of Medicine and Surgery, University of Milano-Bicocca, 20854 Monza, Italy; (G.F.); (V.L.); (M.N.); (D.N.); (A.T.); (F.A.); (F.C.); (F.C.); (C.V.); (A.B.); (F.L.)
- Pediatrics, Fondazione IRCCS San Gerardo dei Tintori, 20900 Monza, Italy
| | - Stefano Aliberti
- Department of Biomedical Sciences, Humanitas University, 20072 Pieve Emanuele, Italy;
- Respiratory Unit, IRCCS Humanitas Research Hospital, 20089 Rozzano, Italy
| | - Andrea Biondi
- School of Medicine and Surgery, University of Milano-Bicocca, 20854 Monza, Italy; (G.F.); (V.L.); (M.N.); (D.N.); (A.T.); (F.A.); (F.C.); (F.C.); (C.V.); (A.B.); (F.L.)
- Pediatrics, Fondazione IRCCS San Gerardo dei Tintori, 20900 Monza, Italy
| | - Fabrizio Luppi
- School of Medicine and Surgery, University of Milano-Bicocca, 20854 Monza, Italy; (G.F.); (V.L.); (M.N.); (D.N.); (A.T.); (F.A.); (F.C.); (F.C.); (C.V.); (A.B.); (F.L.)
- Respiratory Unit, Fondazione IRCCS San Gerardo dei Tintori, 20900 Monza, Italy
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De Angelis A, Johnson ED, Sutharsan S, Aliberti S. Exacerbations of bronchiectasis. Eur Respir Rev 2024; 33:240085. [PMID: 39048130 PMCID: PMC11267293 DOI: 10.1183/16000617.0085-2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2024] [Accepted: 05/28/2024] [Indexed: 07/27/2024] Open
Abstract
Bronchiectasis presents a significant challenge due to its rising prevalence, associated economic burden and clinical heterogeneity. This review synthesises contemporary understanding and literature of bronchiectasis exacerbations, addressing the transition from stable state to exacerbations, underlining the importance of early and precise recognition, rigorous severity assessment, prompt treatment, and prevention measures, as well as emphasising the need for strategies to assess and improve early and long-term patient outcomes. The review highlights the interplay between stable state phases and exacerbations in bronchiectasis, introducing the concept of "exogenous and endogenous changes in airways homeostasis" and the "adapted island model" with a particular focus on "frequent exacerbators", a group of patients associated with specific clinical characteristics and worse outcomes. The pathophysiology of exacerbations is explored through the lens of microbial and nonmicrobial triggers and the presence and the activity of comorbidities, elaborating on the impact of both exogenous insults, such as infections and pollution, and endogenous factors such as inflammatory endotypes. Finally, the review proposes a multidisciplinary approach to care, integrating advancements in precision medicine and biomarker research, paving the way for tailored treatments that challenge the traditional antibiotic paradigm.
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Affiliation(s)
- Alessandro De Angelis
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- IRCCS Humanitas Research Hospital, Respiratory Unit, Milan, Italy
| | - Emma D Johnson
- University of Dundee, Ninewells Hospital and Medical School, Dundee, UK
| | - Sivagurunathan Sutharsan
- Division of Cystic Fibrosis, Department of Pulmonary Medicine, University Medicine Essen -Ruhrlandklinik, University of Duisburg-Essen, Essen, Germany
| | - Stefano Aliberti
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- IRCCS Humanitas Research Hospital, Respiratory Unit, Milan, Italy
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Gallucci M, Candela E, Di Palmo E, Miniaci A, Pession A. Non-Cystic Fibrosis Bronchiectasis in Pediatric Age: A Case Series in a Metropolitan Area of Northern Italy. CHILDREN 2022; 9:children9091420. [PMID: 36138729 PMCID: PMC9497485 DOI: 10.3390/children9091420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 09/12/2022] [Accepted: 09/17/2022] [Indexed: 11/24/2022]
Abstract
Non-cystic fibrosis bronchiectasis is an emergent disease characterized by endobronchial suppuration, dilated airways with neutrophilic inflammation and chronic wet cough due to recurrent lower airway infections. A regular clinical follow-up and adequate management of exacerbations are essential to reduce symptoms and the worsening of lung injury. We report a retrospective study comprising 15 children and adolescents with NCFB followed in our hospital center of pediatric pulmonology. We retrospectively analyzed the main comorbidities associated with the presence of NCFB, the radiological aspect associated with the different etiologies and the therapeutic approach used. We also emphasized the importance of an effective preventive strategy to reduce and prevent pulmonary exacerbations.
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Affiliation(s)
- Marcella Gallucci
- Pediatric Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Egidio Candela
- Specialty School of Pediatrics, Alma Mater Studiorum, University of Bologna, 40126 Bologna, Italy
- Correspondence: or ; Tel.: +39-3473878582
| | - Emanuela Di Palmo
- Pediatric Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Angela Miniaci
- Pediatric Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Andrea Pession
- Pediatric Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
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Staphylococcus aureus in Non-Cystic Fibrosis Bronchiectasis: Prevalence and Genomic Basis of High Inoculum Beta-Lactam Resistance. Ann Am Thorac Soc 2022; 19:1285-1293. [PMID: 35213810 DOI: 10.1513/annalsats.202108-965oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Rationale The pathobiology of Staphylococcus aureus in non-cystic fibrosis bronchiectasis (nCFB) is poorly defined. When present at high density or "inoculum", some methicillin-sensitive S. aureus (MSSA) can inefficiently degrade anti-Staphylococcal beta-lactam antibiotics via BlaZ penicillinases (termed, the inoculum effect). Given the high burden of organisms in bronchiectatic airways, this is particularly relevant. Objectives Drawing from a prospectively-collected biobank, we sought to understand the prevalence, natural history, potential for transmission, and antibiotic resistance profiles amongst nCFB-derived MSSA isolates. Methods All individuals attending a regional consultancy nCFB clinic with sputum collected between 1981-2017 were considered, and those with ≥1 S. aureus-positive culture comprised the cohort. Each individual's most recent biobank isolate was subjected to whole genome sequencing (including the blaZ gene), antibacterial susceptibility testing, and comparative beta-lactam testing at standard (5 x 105CFU/mL) and high (5 x 107CFU/mL) inoculum to assess for the inoculum, and pronounced inoculum effect (IE and pIE, respectively). Results Seventy-four of 209 (35.4%) individuals had ≥1 sputum sample(s) with S. aureus (68 MSSA, 6 MRSA). Those with S. aureus infection were more likely to be female. Amongst 60/74 MSSA isolates subjected to WGS, no evidence of transmission was identified, although specific MLST types were prevalent including ST-1, ST-15, ST-30, and ST-45. Antibiotic resistance was uncommon except for macrolides (~20%). Amongst the 60 MSSA, prevalence of IE and pIE, respectively, were observed to be drug specific; meropenem (0%, 0%), cefepime (3%, 5%), ceftazidime (8%, 0%), cloxacillin (12%, 0%), cefazolin (23%, 0%) and piperacillin-tazobactam (37%, 17%). The cefazolin IE associated with blaZ type A (p<0.01) and ST-30 (p<0.01), whereas the piperacillin-tazobactam IE associated with type C blaZ (p<0.001) and ST-15 (p<0.05). Conclusions S. aureus infection was common, although no evidence of transmission was apparent in our nCFB cohort. While routine susceptibility testing did not identify significant resistance, inoculum-related resistance was found to be relevant for commonly used nCFB antibiotics including cefazolin and piperacillin-tazobactam. Given previous associations between IEs and negative patient outcomes, further work is warranted to understand how this phenotype impacts nCFB disease progression.
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Vidaillac C, Chotirmall SH. Pseudomonas aeruginosa in bronchiectasis: infection, inflammation, and therapies. Expert Rev Respir Med 2021; 15:649-662. [PMID: 33736539 DOI: 10.1080/17476348.2021.1906225] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Introduction: Bronchiectasis is a chronic endobronchial suppurative disease characterized by irreversibly dilated bronchi damaged by repeated polymicrobial infections and predominantly, neutrophilic airway inflammation. Some consider bronchiectasis a syndromic consequence of several different causes whilst others view it as an individual disease entity. In most patients, identifying an underlying cause remains challenging. The acquisition and colonization of affected airways by Pseudomonas aeruginosa represent a critical and adverse clinical consequence for its progression and management.Areas covered: In this review, we outline clinical and pre-clinical peer-reviewed research published in the last 5 years, focusing on the pathogenesis of bronchiectasis and the role of P. aeruginosa and its virulence in shaping host inflammatory and immune responses in the airway. We further detail its role in airway infection, the lung microbiome, and address therapeutic options in bronchiectasis.Expert opinion: P. aeruginosa represents a key pulmonary pathogen in bronchiectasis that causes acute and/or chronic airway infection. Eradication can prevent adverse clinical consequence and/or disease progression. Novel therapeutic strategies are emerging and include combination-based approaches. Addressing airway infection caused by P. aeruginosa in bronchiectasis is necessary to prevent airway damage, loss of lung function and exacerbations, all of which contribute to adverse clinical outcome.
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Affiliation(s)
- Celine Vidaillac
- Oxford University Clinical Research Unit, University of Oxford, Ho Chi Minh City, Vietnam.,Center for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Sanjay H Chotirmall
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
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