Chronic bronchial sepsis and progressive lung damage

An update on pediatric bronchiectasis

INTRODUCTION

The prevalence and awareness of bronchiectasis not related to cystic fibrosis (CF) is increasing and it is now recognized as a major cause of respiratory morbidity, mortality and healthcare utilization worldwide. The need to elucidate the early origins of bronchiectasis is increasingly appreciated and has been identified as an important research priority. Current treatments for pediatric bronchiectasis are limited to antimicrobials, airway clearance techniques and vaccination. Several new drugs targeting airway inflammation are currently in development. Areas covered: Current management of pediatric bronchiectasis, including discussion on therapeutics, non-pharmacological interventions and preventative and surveillance strategies are covered in this review. We describe selected adult and pediatric data on bronchiectasis treatments and briefly discuss emerging therapeutics in the field. Expert commentary: Despite the burden of disease, the number of studies evaluating potential treatments for bronchiectasis in children is extremely low and substantially disproportionate to that for CF. Research into the interactions between early life respiratory tract infections and the developing immune system in children is likely to reveal risk factors for bronchiectasis development and inform future preventative and therapeutic strategies. Tailoring interventions to childhood bronchiectasis is imperative to halt the disease in its origins and improve adult outcomes.

99mTc-HMPAO labelled white blood cell scintigraphy in the diagnosis and monitoring of response of the therapy in patients with active bronchiectasis

AIM

The aim of this study was to assess the role of labelled leukocyte scintigraphy in the diagnosis and monitorization of response to therapy of patients with active bronchiectasis.

MATERIAL AND METHODS

Twenty patients underwent (99m)Technetium hexamethylpropyleneamine oxime ((99m)Tc-HMPAO) labelled white blood cell (WBC) scintigraphy. A second scintigraphy was performed in 13 patients at 10 day of the treatment. Regional (99m)Tc-HMPAO WBC uptake and radiologic imaging findings (high resolution computed tomography or Chest X-Ray) in the lungs were classified into 3 categories in 6 lung areas. scintigraphic, radiological and clinical disease scores were calculated for all patients.

RESULTS

An abnormal accumulation was visually observed in 19 of 20 patients on the pre-treatment scans, the scintigraphy showing 95% sensitivity. A significant difference was found between early and late ratios (P=0.001) in the pre-treatment scans. The infected areas revealed a significant decrease in uptake ratios on the post-treatment scans compared to the pre-treatment scans (P=0.001). However, no significant correlation was determined between clinical and radiological scores, clinical and scintigraphic scores and also between scintigraphic and radiological scores (P ≥ 0.05).

CONCLUSIONS

(99m)Tc-HMPAO WBC scintigraphy may be a useful tool to evaluate response to therapy in patients with active bronchiectasis.

Study of auditory function in children with chronic lung diseases

OBJECTIVE

Chronic hypoxia has an evident effect on cochlear function and hearing sensitivity. Otoacoustic emissions' testing is efficient in detecting subtle cochlear dysfunction. This cross sectional study was designed to assess the cochlear function in children with chronic lung diseases who were exposed to prolonged hypoxia and prolonged use of ototoxic drugs (as aminoglycosides) using basic audiological evaluation and transient evoked otoacoustic emissions testing.

METHODS

The study was carried out on 30 Egyptian children with chronic lung disease recruited from the Pediatric Chest Clinic, Children's hospital, Ain Shams University. Twenty normal children were included as control.

RESULTS

Six patients (20%) showed abnormal otoacoustic emissions. A significant effect of hypoxia on otoacoustic emissions findings was found (P<0.05). However, there was no significant effect of inhaled aminoglycosides on auditory functions whether pure tone audiometry, speech audiometry and transient evoked otoacoustic emissions testing.

CONCLUSIONS

Children with chronic lung diseases are liable to cochlear dysfunction due to prolonged hypoxia. Inhaled aminoglycosides in chronic lung diseases is relatively safe on auditory functions.

Bronchodilator response to inhaled beta-2 agonist and anticholinergic drugs in patients with bronchiectasis

OBJECTIVE

An increase in incidence of reversible airflow obstruction and bronchial hyperresponsiveness occurs in patients with bronchiectasis. We conducted a study to assess the efficacy of bronchodilators in the treatment of bronchiectasis.

METHODOLOGY

Twenty-four patients with confirmed bronchiectasis were studied. Each patient inhaled fenoterol 400 microg administered by metered dose inhaler via a spacer after a baseline lung function and a lung function test was repeated 30 min later. This was followed by a second dose of fenoterol 5 mg via nebulizer and another lung function test 30 min later. A repeat study was done at least 24 h later with ipratropium bromide 40 microg by metered dose inhaler and 500 microg by a nebulizer.

RESULTS

The results showed a significant improvement from baselines (mean percentage change +/- SD) of peak expiratory flow rate (PEF) by 8.5 +/- 8.72% and 15.3 +/- 11.63%, forced expiratory volume in 1 s (FEV1) by 8.77 +/- 9.69% and 10.2 +/- 12.2% and forced vital capacity (FVC) by 10.25 +/- 11.61% and 10.09 +/- 10.88% after low- and high-dose fenoterol, respectively. The improvements after low- and high-dose ipratropium bromide for PEE FEV1 and FVC were 9.89 +/- 9.35% and 14.39 +/- 12.82%, 9.38 +/- 10.41% and 13.52 +/- 17.09%, and 8.03 +/- 10.85% and 9.63 +/- 13.85%, respectively. Eleven patients (45.8%) responded to one or both bronchodilators significantly (> 15% improvement in FEV1). Five patients (20%) responded to both, three (12%) to fenoterol alone and another three (12%) to ipratropium bromide alone.

CONCLUSION

There is significant bronchodilator response in a subset of patients with bronchiectasis and patients with bronchiectasis should therefore undergo bronchodilator testing. Skin prick testing against a panel of nine allergens done on each individual yielded a positive result in 13 patients (54.2%).

Treatment of idiopathic bronchiectasis with aerosolized recombinant human DNase I. rhDNase Study Group

STUDY OBJECTIVE

To study the safety and efficacy of aerosolized recombinant human DNase I in the treatment of idiopathic bronchiectasis.

DESIGN

Double-blind, randomized, placebo-controlled, multicenter study.

POPULATIONS

Three hundred forty-nine adult outpatients in stable condition with idiopathic bronchiectasis from 23 centers in North America, Great Britain, and Ireland.

INTERVENTIONS AND MEASUREMENTS

Study patients received aerosolized rhDNase or placebo twice daily for 24 weeks. Primary end points were incidence of pulmonary exacerbations and mean percent change in FEV1 from baseline over the treatment period.

RESULTS

Pulmonary exacerbations were more frequent and FEV1 decline was greater in patients who received rhDNase compared with placebo during this 24-week trial.

CONCLUSIONS

rhDNase was ineffective and potentially harmful in this group of adult outpatients in stable condition with idiopathic bronchiectasis. This contrasts with previously published results that demonstrated efficacy of rhDNase in patients with cystic fibrosis bronchiectasis.

Sputum sol phase proteins and elastase activity in patients with clinically stable bronchiectasis

BACKGROUND

Inflammatory and proteolytic activity occurs in sputum from patients with stable purulent bronchiectasis and has been proposed as the main pathogenetic mechanism of the disease. This study was designed to define further the role of inflammation and proteolysis in bronchiectasis.

METHODS

Neutrophil elastase activity, sputum concentrations of the serum derived inhibitors alpha 1 antiproteinase and alpha 2 macroglobulin, and the sputum to serum ratios of albumin and C reactive protein concentration were measured in 26 patients with bronchiectasis.

RESULTS

Free elastase activity was found in 15 sputum samples. A trend to higher proteolytic and inflammatory activity was found between mucoid and purulent sputum samples, suggesting that inflammatory and proteolytic activities are related to the macroscopic degree of purulence. Purulent sputum had a high sputum to serum ratio of C reactive protein, suggesting local production or active transport of this protein into bronchial secretions. C reactive protein was more sensitive than albumin in detecting a higher degree of inflammation in elastase positive samples.

CONCLUSION

The finding of greater concentrations of alpha 2 macroglobulin in purulent and elastase positive samples than in mucopurulent, mucoid and elastase negative sputum samples suggests that this inhibitor may have a role in the proteolysis-antiproteolysis balance in bronchial secretions.

Inhaled steroids in patients with bronchiectasis

The effect of inhaled beclomethasone diproprionate (1500 micrograms day-1) on symptoms, pulmonary function and sputum production was examined in a double-blind, placebo-controlled, cross-over study in 20 patients with bronchiectasis. An 18% reduction in daily sputum production (P less than 0.003) was observed on treatment with inhaled steroid compared to placebo. A small, significant, improvement in morning peak expiratory flow rate (P less than 0.03) and forced expiratory volume in 1 s (P less than 0.03) was seen but the absolute changes are unlikely to be of clinical importance. Symptom scores for cough improved significantly (P less than 0.02). Inhaled steroids may have a role in the management of bronchiectasis by reducing cough and sputum production.

Systemic effects of inflammation in bronchiectasis

A group of bronchiectatic subjects in the clinically stable state were studied for systemic evidence of inflammation. The following parameters were evaluated: body weight, serum albumin, serum globulin, serum alpha 1-antitrypsin (alpha 1 AT) and peripheral white cell count. For serum albumin and globulin, comparison was made between subjects with bronchiectasis and control subjects with no known pulmonary disease matched for sex and age, and for serum alpha 1 AT and peripheral white cell count, matched for smoking habit as well. The bronchiectatic subjects showed systemic effects of inflammation as indicated by lower body weight and serum albumin (P less than 0.01), higher serum globulin (P less than 0.001), serum alpha 1 AT (P less than 0.05) and total leucocyte count (P less than 0.05). Differential white cell count showed that the elevation was distributed in most cell types. Correlation matrix was done for the above systemic parameters and indices of airway inflammation including sputum volume, purulence, and polymorph count and FEV1. There was an inverse correlation between total peripheral WBC count and FEV1 in percentage of predicted (P less than 0.01), and a positive correlation between sputum purulence and sputum polymorph score (P less than 0.05). This suggests that host peripheral leucocyte response may be a factor in the determination of lung function.

Persistent or recurrent pneumonia in Saudi children seen at King Khalid University Hospital, Riyadh: clinical profile and some predisposing factors

Children with persistent or recurrent pneumonia without an apparent cause constitute an important clinical category with much morbidity and mortality and can be perplexing and frustrating to the treating physician and the parents. To identify the clinical profile and predisposing factors in this group of patients, 18 Saudi children were studied. Their ages ranged from 3 months to 12 years (mean age 5.7 years) with male preponderance--12 boys and 6 girls (M:F ratio 2:1). About 44.4% had immune and inherited metabolic disorders. Anatomical abnormalities were found in four (22.2%). Two had measles as a predisposing factor. None had tuberculosis or pertussis. One child each had pulmonary candidiasis and laryngeal papilloma, probably contracted from their mothers as congenital infections. Though the pattern seems to follow that found in developed countries, it is noteworthy that cystic fibrosis was not identified in any of our patients.

Effect of short and long term antibiotic response on lung function in bronchiectasis

In a study designed to show whether purulent bronchial secretions damage the lung reversibly or irreversibly, 18 patients with bronchiectasis underwent lung function tests before and after two weeks' antibiotic treatment to convert their sputum from purulent to mucoid, and 10 of them also after four months' treatment. After two weeks FEV1, forced vital capacity, vital capacity, functional residual capacity, and total lung capacity showed small but statistically significant (though not clinically useful) improvements. In the 10 patients studied after four months only FVC (of the four indices with significant improvements at two weeks in this group) was still higher than before treatment. These results contrast with those of an earlier study, in which large acute changes were found, perhaps because of differences in the patients studied. It is concluded that the absence of major changes in lung function points to physiological abnormality that is largely irreversible in these patients with chronic bronchial sepsis.

Short term response of patients with bronchiectasis to treatment with amoxycillin given in standard or high doses orally or by inhalation

The effect of three amoxycillin treatment regimens on purulent secretions of patients with bronchiectasis has been studied. On the basis of information recorded on a diary card the patients were divided into three groups, according to the usual nature of their secretions: seven who produced mucoid sputum, which occasionally became purulent; seven whose secretions were usually mucopurulent but occasionally purulent; and 19 whose secretions were persistently purulent. Treatment with capsules of amoxycillin in a dosage of 250 mg three times a day resulted in clearance of purulent secretions in patients of the mucoid group when they were treated for a clinical exacerbation. The sputum remained clear in these patients for long periods before a further exacerbation (median 6 1/2, range 1-11 months). The mucopurulent-purulent group also responded to this dosage but sputum purulence returned more rapidly (median 9, range 4-31 days). Only three of the 19 (17%) patients with persistently purulent secretions showed a macroscopic response to this dosage, whereas seven (60%) of 12 patients who received the higher dosage (3 g sachets twice a day) responded. Among the failures, some responded to nebulised amoxycillin, suggesting that higher levels of amoxycillin in secretions are required in these patients. Macroscopic clearance of purulent secretions was finally achieved in most of the patients studied. The response was not always predictable from the results of sputum culture. Clearance of secretions by antibiotics was also identified by the patients, using a diary card score. Improvements in well being and in symptoms were noticed even in the group who usually produced mucopurulent and purulent secretions even though they appeared to be clinically stable before treatment.

How useful is computed tomography in the diagnosis and assessment of bronchiectasis?

A study was performed to determine the value of computed tomography (CT) in the diagnosis and assessment of cylindrical and mild varicose bronchiectasis. Fifteen patients, in whom bronchography had shown such bronchiectasis in 34 of 73 lobes that could be assessed, were examined by CT. A control group of 12 subjects in whom there was no clinical or plain radiographic suspicion of bronchiectasis was also studied. Computed tomography (CT) was considered to show bronchiectasis in 28 lobes, 27 of which were bronchiectatic as shown by bronchography. Of 45 lobes where CT was not thought to show bronchiectasis, bronchography demonstrated 38 normal and seven bronchiectatic lobes. All lobes in the control group were interpreted as normal. Using bronchography as the definitive investigation for cylindrical or mild varicose bronchiectasis, CT has a sensitivity of 79% and a specificity of 99% in the diagnosis of the disease. The high specificity indicates that a diagnosis of cylindrical or mild varicose bronchiectasis by CT is reliable but CT is too insensitive to be used as a screening test.