Contemporary management of bronchiectasis in children

Gastrointestinal factors associated with risk of bronchiectasis in children

OBJECTIVE

To evaluate gastrointestinal (GI) risk factors for bronchiectasis in children. We hypothesized that upper GI tract dysmotility would be associated with increased risk of bronchiectasis.

STUDY DESIGN

Subjects in this retrospective cohort study included those evaluated for persistent pulmonary symptoms in the Aerodigestive Center at Boston Children's Hospital who underwent chest computed tomography (CT) between 2002 and 2019. To determine gastrointestinal predictors of bronchiectasis, baseline characteristics, comorbidities, enteral tube status, medications received, gastroesophageal reflux burden, adequacy of swallow function, esophageal dysmotility, gastric dysmotility, and neutrophil count on bronchoalveolar lavage (BAL) were compared between patients with and without bronchiectasis. Proportions were compared with Fisher's exact test and binary logistic regression with stepwise selection was used for multivariate analysis. ROC analyses were utilized to compare BAL neutrophils and bronchiectasis.

RESULTS

Of 192 subjects, 24% were found to have evidence of bronchiectasis on chest CT at age 7.9 ± 0.5 years. Enteral tubes (OR 5.77, 95% CI 2.25-14.83, p < 0.001) and increased BAL neutrophil count (OR 5.79, 95% CI 1.87-17.94, p = 0.002) were associated with increased risk while neurologic comorbidities were associated with decreased risk (OR 0.24, 95% CI 0.09-0.66, p = 0.006). Gastroesophageal reflux was not found to be a significant risk factor. Neutrophil counts >10% had 72% sensitivity and 60% specificity for identifying bronchiectasis.

CONCLUSIONS

Enteral tubes were associated with significantly increased risk of bronchiectasis but gastroesophageal reflux was not. Providers should consider obtaining chest CT to evaluate for bronchiectasis in children found to have unexplained elevated BAL neutrophil count.

Global research status and trends of bronchiectasis in children from 2003 to 2022: A 20-year bibliometric analysis

Background

This study aims to analyze the research hotspots, evolution, and developing trends in pediatric bronchiectasis over the past 20 years using bibliometric analysis and visualization tools to identify potential new research directions.

Methods

Publications related to bronchiectasis in children were retrieved from the Web of Science Core Collection (WoSCC) database from 2003 to 2022. Knowledge maps were performed through VOSviewer1.6.18 and CiteSpace6.1 R2.

Results

A total of 2,133 publications were searched, while only 1,351 original articles written in English between 2003 and 2022 were incorporated. After removing duplicates, we finally included 1,350 articles published by 6,593 authors from 1,865 institutions in 80 countries/regions in 384 different academic journals with an average citation frequency of 24.91 times. The number of publications shows an extremely obvious binomial growth trend. The majority of publications originated from the United States, Australia, and England. The institutes in Australia, especially Charles Darwin University, published the most articles associated with pediatric bronchiectasis. In addition, Pediatric Pulmonology was the most published journal. In terms of authors, Chang AB was the most productive author, while Gangell CL had the highest average citation frequency. The five keywords that have appeared most frequently during the last two decades were "children," "cystic fibrosis," "bronchiectasis," "ct," and "pulmonary-function." According to keyword analysis, early diagnosis and intervention and optimal long-term pediatric-specific management were the most concerned topics for researchers.

Conclusion

This bibliometric analysis indicates that bronchiectasis in children has drawn increasing attention in the last two decades as its recognition continues to rise, providing scholars in the field with significant information on current topical issues and research frontiers.

EVALUATING THE EFFICACY OF HUMAN BRONCHIECTASISBASED ANTIBIOTIC THERAPY IN THE TREATMENT OF ORANGUTAN RESPIRATORY DISEASE SYNDROME

Unique among apes, orangutans (Pongo spp.) develop a chronic respiratory disease called orangutan respiratory disease syndrome (ORDS). The authors define ORDS as intermittent bacterial infection and chronic inflammation of any region or combination of regions of the respiratory tract, including the sinuses, air sacs, cranial bones, airways, and lung parenchyma. Infection in any of these areas can present acutely but then becomes recurrent, chronic, progressive, and ultimately fatal. The closest model to this disease is cystic fibrosis (CF) in people. We hypothesized that use of a 4-8-wk course of combined oral antibiotics used in the treatment of bronchiectasis in CF patients would lead to prolonged symptomatic and computed tomography (CT) scan improvement in orangutans experiencing early signs of ORDS. Nine adult Bornean orangutans (Pongo pygmaeus, eight males, one female, 18-29 yr of age) diagnosed with early ORDS-like respiratory disease underwent CT scan before initiation of treatment. Each animal received a combined course of azithromycin (400 mg 3/wk, mean 7 mg/kg) and levofloxacin (500 mg PO q24h, mean 8.75 mg/kg) for a period of 4-8 wk. CT scan was repeated 6-14 mon after completion of antibiotic treatment. Pretreatment CT showed that six of nine animals had lower respiratory pathology (airway disease, pneumonia, or both). All six orangutans had concurrent sinusitis, mastoiditis, airsacculitis, or a combination of these conditions. Upper respiratory disease alone was observed in three animals. CT showed improvement or resolution in four of five sinusitis cases, improvement in one of two instances of mastoiditis, resolution in five of six instances of airsacculitis, improvement or resolution in six of six instance of lower airway disease (P = 0.03, 95% CI 0.54-1.0], and resolution in five of five cases of pneumonia. Resolution of pretreatment clinical signs was observed in all nine animals. Two developed signs not present at pretreatment. These results show that combination antibiotic therapy with azithromycin and levofloxacin provides improvement in clinical signs and CT evidence of ORDS-related pathology, resulting in symptom-free status in some animals for up to 33 mon.

Teaching about children with medical complexity: A blueprint for curriculum design

Children with medical complexity make up a small portion of the pediatric population but utilize a large percentage of health care time and spending. The medical needs of children with medical complexity are highly variable and the education of healthcare providers in the care of these children has taken on more significance. Designing curricula and educational innovations related to the care of children with medical complexity can be challenging. Familiarity with the sociocultural theory, the zone of proximal development, Kolb's experiential learning model, and the educational resources that already exist allow for more ease in developing a curriculum that fits the needs of learners who may have a wide range of exposure to children with medical complexity. Flipped classroom models, simulations, asynchronous modules, and home and community experiences are all useful learning modalities to provide a varied and important curriculum. Taking advantage of the knowledge and skills of the many different members of the multi-disciplinary team caring for children with medical complexity is an important educational strategy that provides benefits to the learners and can enhance interprofessional education.

Refining diagnostic criteria for paediatric bronchiectasis using low-dose CT scan

BACKGROUND

There is a current lack of consensus amongst paediatric radiologists and respiratory paediatricians as to the correct CT definition of bronchiectasis in children. Using contemporary low-dose CT, our objectives were to determine the upper limit of normal for broncho-arterial ratio (BAR) in children and to evaluate the effect of age and general anaesthesia.

METHODS

Measurements of 330 broncho-arterial ratios from 51 children (0-19 years) undergoing low-dose CT chest for non-respiratory indications were performed by 3 blinded observers (two radiologists, one respiratory physician) using four different methods. Inter-observer reliability, mean BAR and reference ranges (mean±2SD) were calculated. Correlation between age and BARs were examined. Mean BAR for CT under general anaesthesia and CT awake were compared.

RESULTS

Inter-observer correlation was extremely high for all measurements (0.93-0.97). There was a weak positive correlation between age and BAR in the CT-awake group (r = 0.33, 95%CI: 0.03-0.57; p = 0.031) using the inner-bronchial wall to artery, short-axis measurement. CT under general anaesthesia showed significantly higher BAR compared to CT-awake [mean difference 0.13 (95%CI: 0.05-0.22; p = 0.004)]. For the CT-awake group, the mean BAR was 0.65 (range: 0.42 to 0.89), with no child having a BAR above 0.9.

CONCLUSION

Using a standardised approach, we have shown that a broncho-arterial ratio above 0.9 in children undergoing awake CT is abnormal and suggests airway widening or radiological bronchiectasis. Children undergoing CT under anaesthesia have higher BARs than those undergoing awake CT. A weak positive correlation between broncho-arterial ratio and age was observed, hence, age-adjusted cut-offs for BAR warrant further study.

Care recommendations for the respiratory complications of esophageal atresia-tracheoesophageal fistula

Tracheoesophageal fistula (TEF) with esophageal atresia (EA) is a common congenital anomaly that is associated with significant respiratory morbidity throughout life. The objective of this document is to provide a framework for the diagnosis and management of the respiratory complications that are associated with the condition. As there are no randomized controlled studies on the subject, a group of experts used a modification of the Rand Appropriateness Method to describe the various aspects of the condition in terms of their relative importance, and to rate the available diagnostic methods and therapeutic interventions on the basis of their appropriateness and necessity. Specific recommendations were formulated and reported as Level A, B, and C based on whether they were based on "strong", "moderate" or "weak" agreement. The tracheomalacia that exists in the site of the fistula was considered the main abnormality that predisposes to all other respiratory complications due to airway collapse and impaired clearance of secretions. Aspiration due to impaired airway protection reflexes is the main underlying contributing mechanism. Flexible bronchoscopy is the main diagnostic modality, aided by imaging modalities, especially CT scans of the chest. Noninvasive positive airway pressure support, surgical techniques such as tracheopexy and rarely tracheostomy are required for the management of severe tracheomalacia. Regular long-term follow-up by a multidisciplinary team was considered imperative. Specific templates outlining the elements of the clinical respiratory evaluation according to the patients' age were also developed.

Bronchiectasis in Primary Antibody Deficiencies: A Multidisciplinary Approach

Bronchiectasis, the presence of bronchial wall thickening with airway dilatation, is a particularly challenging complication of primary antibody deficiencies. While susceptibility to infections may be the primary factor leading to the development of bronchiectasis in these patients, the condition may develop in the absence of known infections. Once bronchiectasis is present, the lungs are subject to a progressive cycle involving both infectious and non-infectious factors. If bronchiectasis is not identified or not managed appropriately, the cycle proceeds unchecked and yields advanced and permanent lung damage. Severe symptoms may limit exercise tolerance, require frequent hospitalizations, profoundly impair quality of life (QOL), and lead to early death. This review article focuses on the appropriate identification and management of bronchiectasis in patients with primary antibody deficiencies. The underlying immune deficiency and the bronchiectasis need to be treated from combined immunology and pulmonary perspectives, reflected in this review by experts from both fields. An aggressive multidisciplinary approach may reduce exacerbations and slow the progression of permanent lung damage.