Bronchiectasis

Imaging in non-cystic fibrosis bronchiectasis and current limitations

Non-cystic fibrosis bronchiectasis represents a heterogenous spectrum of disorders characterised by an abnormal and permanent dilatation of the bronchial tree associated with respiratory symptoms. To date, diagnosis relies on computed tomography (CT) evidence of dilated airways. Nevertheless, definite radiological criteria and standardised CT protocols are still to be defined. Although largely used, current radiological scoring systems have shown substantial drawbacks, mostly failing to correlate morphological abnormalities with clinical and prognostic data. In limited cases, bronchiectasis morphology and distribution, along with associated CT features, enable radiologists to confidently suggest an underlying cause. Quantitative imaging analyses have shown a potential to overcome the limitations of the current radiological criteria, but their application is still limited to a research setting.

In the present review, we discuss the role of imaging and its current limitations in non-cystic fibrosis bronchiectasis. The potential of automatic quantitative approaches and artificial intelligence in such a context will be also mentioned.

Atypical presentation of cystic fibrosis at 70 years of age

Cystic fibrosis (CF) is an autosomal recessive condition, mostly diagnosed in infancy. It is uncommon for adults to be diagnosed with CF, especially after the age of 65. Individuals, who are diagnosed later in life, usually have milder disease and single organ involvement which can be challenging for clinicians to diagnose. Adult CF patients are more likely to be pancreatic sufficient. They have predominantly upper lobe bronchiectasis, lower incidence of Pseudomonas aeruginosa compared with Staphylococcus aureus and are more likely to have mutations other than ΔF508.

Airway Malformations and Bronchiectasis: A Pediatric Study

Congenital airway malformations are most often identified in early childhood. The development of bronchiectasis in association with malformations of the lower airway has been described, particularly among adult patients. The coexistence in a pediatric population of these conditions is not well described. This study was conducted to identify whether younger patients with airway malformations commonly develop bronchiectasis. International Classification of Diseases, Ninth revision (ICD-9 codes) were defined for airway anomalies and bronchiectasis. The electronic medical records system of a children's hospital was then searched for the number of patients with upper airway anomalies with or without bronchiectasis. The airway database was then cross referenced with the ICD codes for bronchiectasis to identify patients with both conditions. There were 844 patients with airway anomalies and 117 with bronchiectasis in the electronic system during the time period of August 1, 2009 to September 30, 2014. There was only 3 patients identified with both bronchiectasis and airway anomalies. The coexistence of bronchiectasis is low among the pediatric population with upper airway anomalies studied. This would suggest that the children with airway anomalies have been treated with strategies that are effective in the prevention of recurrent lower respiratory tract infection. Further study may be done to define the effectiveness of various strategies in preventing aspiration and lower respiratory tract infection. In addition, this methodologic technique utilizing database integrative platforms is useful in the identification of patients for further study and to identify the coexistence of pediatric conditions.

Pharmacotherapeutic strategies for treating bronchiectasis in pediatric patients

INTRODUCTION

The social and medical costs of bronchiectasis in children are becoming considerable due to its increasing prevalence. Early identification and intensive treatment of bronchiectasis are needed to decrease the morbidity and mortality associated with bronchiectasis in children.

AREAS COVERED

This review presents the current pharmacotherapeutic strategies for treating bronchiectasis in children with a focus on non-cystic fibrosis bronchiectasis.

EXPERT OPINION

Evidence for the effectiveness of diverse treatment strategies in bronchiectasis is lacking, particularly in children, although the disease burden is substantial for bronchiectasis. Most treatment strategies for non-cystic fibrosis bronchiectasis in children have been extrapolated from those in adults with bronchiectasis or children with cystic fibrosis. Antibiotics combined with an active airway clearance therapy via the inhalation of mucoactive agents can stabilize bronchiectasis. The timely and intensive administration of antibiotics during acute exacerbation of bronchiectasis is essential to prevent its progression in children. To suppress the bacterial loads in the airway, systemic or inhaled antibiotics can be administered intermittently or continuously. However, studies on these protocols, including the appropriate duration and effective dosages are lacking. Long-term administration of azithromycin for 12-24 months may reduce the exacerbation frequency with the increased carriage rate of azithromycin-resistant bacteria.

Clinical characteristics and etiologies of bronchiectasis in Korean children: A multicenter retrospective study

BACKGROUND

Bronchiectasis is a chronic pulmonary disease characterized by progressive and irreversible bronchial dilatation. The aim of the present study was to investigate the etiologies and clinical features of bronchiectasis in Korean children.

METHODS

We performed a retrospective review of the medical records for children diagnosed with bronchiectasis between 2000 and 2017 at 28 secondary or tertiary hospitals in South Korea.

RESULTS

A total of 387 cases were enrolled. The mean age at diagnosis was 9.2 ± 5.1 years and 53.5% of the patients were boys. The most common underlying cause of bronchiectasis was preexisting respiratory infection (55.3%), post-infectious bronchiolitis obliterans (14.3%), pulmonary tuberculosis (12.3%), and heart diseases (5.6%). Common initial presenting symptoms included chronic cough (68.0%), recurrent pneumonia (36.4%), fever (31.1%), and dyspnea (19.7%). The most predominantly involved lesions were left lower lobe (53.9%), right lower lobe (47.1%) and right middle lobe (40.2%). No significant difference was observed in the distribution of these involved lesions by etiology. The forced expiratory volume in 1 s (FEV₁) levels were lowest in cases with interstitial lung disease-associated bronchiectasis, followed by those with recurrent aspiration and primary immunodeficiency.

CONCLUSIONS

Bronchiectasis should be strongly considered in children with chronic cough and recurrent pneumonia. Long-term follow-up studies on pediatric bronchiectasis are needed to further clarify the prognosis and reduce the disease burden in these patients.

The Lung in Primary Immunodeficiencies: New Concepts in Infection and Inflammation

Immunoglobulin replacement therapy (IGRT) has contributed critically to the management of primary antibody deficiencies (PAD) and the decrease in pneumonia rate. However, despite adequate IGRT and improved prognosis, patients with PAD continue to experience recurrent respiratory tract infections, leading to bronchiectasis and continuing decline in lung function with a severe impact on their quality of life. Moreover, non-infectious inflammatory and interstitial lung complications, such as granulomatous-lymphocytic interstitial lung disease, contribute substantially to the overall morbidity of PAD. These conditions develop much more often than appreciated and represent a major therapeutic challenge. Therefore, a regular assessment of the structural and functional condition of the lung and the upper airways with appropriate treatment is required to minimize the deterioration of lung function. This work summarizes the knowledge on lung complications in PAD and discusses the currently available diagnostic tools and treatment options.

Beyond bronchitis: a review of the congenital and acquired abnormalities of the bronchus

Anomalies of the bronchus can be both congenital and acquired. Several different congenital aberrations of the bronchial anatomy are commonly encountered including tracheal bronchus, accessory cardiac bronchus, and bronchial agenesis/aplasia/hypoplasia. In addition, Williams-Campbell syndrome and cystic fibrosis are two other congenital conditions that result in bronchial pathology. Acquired pathology affecting the bronchi can typically be divided into three broad categories of bronchial disease: bronchial wall thickening, dilatation/bronchiectasis, and obstruction/stenosis. Bronchial wall thickening is the common final response of the airways to irritants, which cause the bronchi to become swollen and inflamed. Bronchiectasis/bronchial dilatation can develop in response to many aetiologies, including acquired conditions such as infection, pulmonary fibrosis, recurrent or chronic aspiration, as well as because of congenital conditions such as cystic fibrosis. The causes of obstruction and stenosis are varied and include foreign body aspiration, acute aspiration, tracheobronchomalacia, excessive dynamic airway collapse, neoplasm, granulomatous disease, broncholithiasis, and asthma. Knowledge of normal bronchial anatomy and its congenital variants is essential for any practicing radiologist. It is the role of the radiologist to identify common imaging patterns associated with the various categories of bronchial disease and provide the ordering clinician a useful differential diagnosis tailored to the patient’s clinical history and imaging findings.

Teaching Points

• Bronchial disorders are both congenital and acquired in aetiology.

• Bronchial disease can be divided by imaging appearance: wall thickening, dilatation, or obstruction.

• Bronchial wall thickening is the common final response of the airways to irritants.

• Imaging patterns must be recognised and the differential diagnosis tailored for patient management.

A Delphi study of pharmacotherapy for noncystic fibrosis bronchiectasis

BACKGROUND

Presently, there are no medications approved by regulatory bodies for the treatment of noncystic fibrosis bronchiectasis (NCFB). In addition, most techniques/devices to enhance mucociliary clearance in NCFB have not been rigorously evaluated. Therefore, we performed a Delphi study of clinical experts concerning the treatment of NCFB.

METHODS

Ten individuals with extensive experience with NCFB participated. Questions were posed concerning pharmacotherapy and mucocilary clearance techniques for NCFB. Iterative questioning and feedback from previous responses were used with an aim to reach consensus. Consensus was defined as ≥70% agreement of the experts.

RESULTS

The experts reached consensus concerning several issues including: (1) 10 to 14 days duration of antibiotics for exacerbations of NCFB, (2) Combination antibiotics should not be given for acute exacerbations of NCFB regardless of history of pseudomonas colonization, (3) some type of airway clearance technique should be used for stable NCFB, (4) recommended treatment end points for NCFB include sputum volume, sputum color and exacerbation frequency and (5) recombinant DNA-ase and inhaled corticosteroids should not be routinely used for NCFB. There was some inconsistency in expert responses between the 2 rounds of questions, suggesting that even NCFB experts do not have a completely consistent approach to treatment.

CONCLUSIONS

NCFB experts reached consensus on several treatment issues. In the absence of rigorous medical evidence, these data supply support for these approaches. Several questions posed to the experts did not reach consensus. We would classify these issues as "controversial" and suggest that they are important areas for future research.