Pediatric Bronchiectasis

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René Laennec, inventor of the stethoscope, first described bronchiectasis in 1819 while observing patients with tuberculosis and the sequelae of pneumonia in the pre-antibiotic era. In 1922, Jean Athanase Sicard introduced contrast bronchography, which provided imaging of the destructive changes characteristic of bronchiectasis. The term bronchiectasis is derived from the Greek bronchion, meaning windpipe, and ektasis, meaning stretched. Bronchiectasis is a pathologic term defined by the dilatation of bronchi with destruction of elastic and muscular components of their walls.

Bronchiectasis can be focal or diffuse.  When bronchiectasis occurs locally it often produces recurrent cough and infectious exacerbations.  When it occurs diffusely, the patient will often have additional signs and symptoms of generalized airway obstruction, reduced lung function, and may ultimately progress to respiratory failure.  Bronchiectasis develops as a result of acute or chronic infection or inflammation which may also be associated with an underlying anatomic airway obstruction, or congenital disease. (see Etiology).

Bronchiectasis is more directly the product of obstruction and/or inflammation of the airway, however it is generally the result of an intricate interaction between the host, pathogens and the environment. The obstruction and inflammation may be due to any of the underlying disorders listed above or to infection, including acute tuberculosis, adenovirus, measles, Mycobacteriumavium, or Aspergillus fumigatus.

Mucus clearance is reduced in the setting of bronchiectasis due to airflow limitation, abnormal quantity and quality of mucus produced, and specific bacterial characteristics that contribute to ciliary dyskinesia. Bronchiectasis associated with bronchial obstruction may have a focal distribution distal to the site of obstruction. Bronchiectasis associated with underlying disease is more likely to be diffuse.

Regardless of the etiology, there is an impairment in the mucociliary clearance ability of the lungs, which leads to a diminished ability to clear the airway of the purulent and inflammatory material, which in turn leads to increased bacterial colonization and infection. [1]  Cole proposed a “vicious cycle” of infection and dysregulated airway inflammation, leading to progressive destruction of bronchial walls resulting in dilatation and airflow obstruction. [2]  

Infection leads to recruitment of neutrophils, T lymphocytes, and monocyte-derived cytokines. Multiple studies have evaluated the inflammatory patterns seen in samples from bronchoscopic and sputum analysis.  These studies have found increased interleukin-8 expression, infiltration by neutrophils, T lymphocytes and mucous gland hypertrophy on mucosal biopsies and sputum and bronchoalveolar lavage fluid with increased concentrations of inflammatory mediators such as neutrophil elastase, interleukin-8, tumor necrosis factor-alpha and prostanoids. [3] The release of inflammatory mediators, elastases, and collagenases leads to inflammation and destruction of elastic and muscular components of bronchial walls. In addition, the outward elastic recoil forces of surrounding lung parenchyma exert traction, which causes expansion of airway diameter. Two different types of bronchiectasis are noted: cylindrical, which is presumably more readily reversible if the underlying disorder can be controlled, and saccular, which is less readily reversible even if the underlying disorder is controlled.

These changes may be accompanied by bronchial arterial proliferation, which predisposes to hemoptysis. Hemoptysis may also occur as a result of the dilating airways impinging on the accompanying blood vessels.

Bronchiectasis may result from multiple etiologies including most commonly infection, congenital or genetic disorders, or idiopathic.  A systematic review (12 studies involving 989 children) found 63% had an underlying cause. [4]  Previous pneumonia (19%), primary immunodeficiency (17%), recurrent aspiration, including an inhaled foreign body (10%), and primary ciliary dyskinesia (7%) were implicated most commonly.  It has been estimated that approximately 30% of cases of bronchiectasis are idiopathic. 

Common theory suggests that a single severe acute lower respiratory tract infection or multiple lower respiratory tract infections early in life can lead to bronchiectasis.  More specifically, a correlation has been found between the overall number of pneumonias rather than the site of pneumonia and bronchiectasis. Although, infections remain the most common etiology of bronchiectasis, there has been a reduction in post-infectious bronchiectasis particularly in developed countries due to the widespread use of vaccinations and antibiotics.

All causes share the same pathophysiologic pathway: ineffective pulmonary toilet and chronic or recurrent infection and inflammation.

Common infectious causes include the following:

Infectious:

Congenital/Genetic disorders:

Immune deficiency:

Acquired disorders associated with bronchiectasis include the following:

The true prevalence of bronchiectasis in children has been difficult to determine due to the frequent delay in diagnosis, difference in prevalence among various populations, physician awareness, and the availability of high resolution CT scans as the diagnostic modality of choice.  Current population-based estimates of occurrence are not available. In 1963, Clark estimated an incidence of 1.06 cases per 10,000 population. [6] The incidence of bronchiectasis associated with underlying systemic disease reflects the incidence of the particular disease. The most common genetic disease associated with bronchiectasis is cystic fibrosis (CF). One study estimates that 110,000 people in the United States have bronchiectasis, including adults. [7] The incidence of non-cystic fibrosis bronchiectasis in childhood has been estimated to be approximately 87 cases per million.

In most developed countries, the overall prevalence of childhood bronchiectasis has significantly declined over the last 4 decades.  The reduced incidence is thought to be due to reduced crowding, broader immunization programs, improved hygiene and nutrition, and easier access to medical care.  The exception to this is indigenous populations and disadvantages groups where the prevalence has not decreased as dramatically.   

Callahan and associates reported the incidence among Alaskan Native children in the Yuskon-Kuskokwim region to be about 140 cases per 10,000 population. [8] Redding and colleagues reported the incidence of bronchiectasis in southwest Alaskan Natives is 16 cases per 1,000 population. [9]

 

In developed countries, the frequency is similar to that in the United States with bronchiectasis being more common among indigenous populations and disadvantaged groups.  Similarly to the United States, the most clinically significant cause of bronchiectasis in developed affluent countries is cystic fibrosis.  Throughout the world, bronchiectasis is predominantly associated with non-CF related conditions rather than CF.

The frequency is higher in the developing world, where measles, adenovirus infection, pneumonia, tuberculosis, and HIV infection are all on the rise and are associated with bronchiectasis.

In a study from the United Kingdom that started in 1949, Field studied children with bronchiectasis for almost 2 decades and documented a fall in the annual hospitalization rate for bronchiectasis in 5 British hospitals. During the study period, as broad-spectrum antibiotics became widely available, the hospitalization rate decreased from approximately 48 cases per 10,000 population to 10 cases per 10,000 population. [10]

In New Zealand, Twiss and colleagues reported the incidence of bronchiectasis in children younger than 15 years at 3.7 cases per 100,000 population in 2001-2002. [11] The incidence was highest among Pacific children, at 17.8 cases per 100,000 population. The incidence was 4.8 cases per 100,000 population in Maori children and 1.5 cases per 100,000 in New Zealand overall, compared with 2.4 cases per 100,000 in other Pacific regions. Most New Zealand children with bronchiectasis developed disease in early childhood and had a delayed diagnosis.

Twiss and colleagues noted that the incidence of bronchiectasis in New Zealand children was nearly twice the rate of CF and 7 times that of bronchiectasis in Finland, which is the only other country reporting a childhood national rate. They further noted that in central Australian aborigines, the incidence is 14 cases per 1,000 population, compared with 0.1 cases per 1,000 in Scotland and 4.9 cases per 1,000,000 in Finnish children. [11]

 

Bronchiectasis is more common in patients of Polynesian and Alaskan Native ancestry. Karadag and associates’ study in Turkey suggests possible genetic predisposition in some populations and found that 43% of children with bronchiectasis had parents who were first-degree or second-degree relatives but presumably without any other known underlying disorder. [12]

Morrissey and colleagues found non-CF bronchiectasis to be more common and more virulent in women. The differences may results from inflammatory-immune, environmental, anatomic, or other genetic factors. [13]

 

Overall, the prognosis is good for a child with non-cystic fibrosis bronchiectasis. There is very limited data on the prognosis of non-CF pediatric bronchiectasis, yet with increasing earlier detections and multi-disciplinary management, the lung function in children with bronchiectasis often stabilizes and patients have an overall good prognosis. Many studies have found that while clinical symptoms improve there will likely be persistence of signs of bronchiectasis on CT scan and improvement in lung function tests without complete normalization.

However, the prognosis of non-CF bronchiectasis primarily depends on the underlying cause and whether that etiology is an acute or chronic condition.  The key to a successful outcome is determining whether the cause of the damage is ongoing (e.g., chronic aspiration) and then treating the underlying problem. In the absence of an underlying condition, children with isolated bronchiectasis often have a better prognosis compared to those with more diffuse disease.

Growth of new pulmonary tissue in children proceeds rapidly until about age 6 years and then tapers off through childhood. Injury at an early age may be compensated for in part by growth of normal healthy lung parenchyma in the absence of ongoing damage.

Progressive bronchiectasis from underlying disease (e.g., CF) or ongoing pulmonary insult (e.g., aspiration syndromes) causes a progressive obstructive and, ultimately, respiratory compromise.  In these cases bronchiectasis is an irreversible process associated with progressive and persistent lung damage. The progression of the lung damage that occurs with bronchiectasis is associated with significant morbidity as it usually manifests as recurrent infectious exacerbations and progressive obstructive lung disease.  Respiratory compromise may manifest as dyspnea at rest or with exercise or sleep-disordered breathing. Ultimately, patients may experience chronic hypoxemia, pulmonary hypertension, cor pulmonale, hypercarbia, respiratory failure, and death.

Progressive focal disease may lead to progressive infection with fever and abnormal growth. The area may contribute enough ventilation/perfusion mismatch to cause hypoxemia with exercise. Although not yet proven, infected secretions from the abnormal portion of the lung could spill over to other portions of the lung, causing more widespread infection.

Limited mortality data are available. In Field’s original group, who were studied at the beginning of the antibiotic era, 4% of children with medically treated bronchiectasis died (mostly from infection), and 3% of children who were surgically treated died (many immediately following or as a late result of surgery) in the ensuing two decades. [14]

A poorer prognosis is associated with the presence of asthma, bilateral lung involvement, and saccular bronchiectasis. Akalin and colleagues reported decreased left ventricular function and exercise capacity in bronchiectasis, which has subsequently been found to present late in the disease course. [12]

Many studies have found that while clinical symptoms improve there will likely be persistence of signs of bronchiectasis on CT scan and improvement in lung function tests without complete normalization.

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Kristen N Miller, MD Fellow in Pediatric Pulmonology Medicine, Texas Children’s Hospital, Baylor College of Medicine

Kristen N Miller, MD is a member of the following medical societies: American Academy of Pediatrics

Disclosure: Nothing to disclose.

Marianna M Sockrider, MD, DrPH Associate Professor of Pediatrics, Department of Pediatrics, Baylor College of Medicine

Marianna M Sockrider, MD, DrPH is a member of the following medical societies: American Academy of Pediatrics, American Thoracic Society, Harris County Medical Society, Texas Medical Association

Disclosure: Nothing to disclose.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug

Disclosure: Nothing to disclose.

Charles Callahan, DO Professor, Chief, Department of Pediatrics and Pediatric Pulmonology, Tripler Army Medical Center

Charles Callahan, DO is a member of the following medical societies: American Academy of Pediatrics, American College of Chest Physicians, American College of Osteopathic Pediatricians, American Thoracic Society, Association of Military Surgeons of the US, Christian Medical and Dental Associations

Disclosure: Nothing to disclose.

Girish D Sharma, MD, FCCP, FAAP Professor of Pediatrics, Rush Medical College; Director, Section of Pediatric Pulmonology and Rush Cystic Fibrosis Center, Rush Children’s Hospital, Rush University Medical Center

Girish D Sharma, MD, FCCP, FAAP is a member of the following medical societies: American Academy of Pediatrics, American College of Chest Physicians, American Thoracic Society, Royal College of Physicians of Ireland

Disclosure: Nothing to disclose.

Michael R Bye, MD Professor of Clinical Pediatrics, State University of New York at Buffalo School of Medicine; Attending Physician, Pediatric Pulmonary Division, Women’s and Children’s Hospital of Buffalo

Michael R Bye, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Chest Physicians, American Thoracic Society

Disclosure: Nothing to disclose.

Thomas Scanlin, MD Chief, Division of Pulmonary Medicine and Cystic Fibrosis Center, Department of Pediatrics, Rutgers Robert Wood Johnson Medical School

Thomas Scanlin, MD is a member of the following medical societies: American Association for the Advancement of Science, Society for Pediatric Research, American Society for Biochemistry and Molecular Biology, American Thoracic Society, Society for Pediatric Research

Disclosure: Nothing to disclose.

Charles Callahan, DO Professor, Chief, Department of Pediatrics and Pediatric Pulmonology, Tripler Army Medical Center

Charles Callahan, DO is a member of the following medical societies: American Academy of Pediatrics, American College of Chest Physicians, American College of Osteopathic Pediatricians, American Thoracic Society, Association of Military Surgeons of the US, Christian Medical and Dental Associations

Disclosure: Nothing to disclose.

The authors and editors of Medscape gratefully acknowledge the contributions of previous Pauline Fani, MD, to the and writing of the source article.

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