Danielle F. Wurzel

Prospective Characterization of Protracted Bacterial Bronchitis in Children

Background Prior studies on protracted bacterial bronchitis (PBB) in children have been retrospective or based on small cohorts. As PBB shares common features with other pediatric conditions, further characterization is needed to improve diagnostic accuracy among clinicians. In this study, we aim to further delineate the clinical and laboratory features of PBB in a larger cohort, with a specific focus on concurrent viral detection. Methods Children with and without PBB (control subjects) undergoing flexible bronchoscopy were prospectively recruited. Basic immune function testing and lymphocyte subset analyses were performed. BAL specimens were processed for cellularity and microbiology. Viruses were identified using polymerase chain reaction (PCR) and bacteria were identified via culture. Results The median age of the 104 children (69% male) with PBB was 19 months (interquartile range [IQR], 12-30 mo). Compared with control subjects, children with PBB were more likely to have attended childcare (OR, 8.43; 95% CI, 2.34-30.46). High rates of wheeze were present in both groups, and tracheobronchomalacia was common. Children with PBB had significantly elevated percentages of neutrophils in the lower airways compared with control subjects, and adenovirus was more likely to be detected in BAL specimens in those with PBB (OR, 6.69; 95% CI, 1.50-29.80). Median CD56 and CD16 natural killer (NK) cell levels in blood were elevated for age in children with PBB (0.7 × 109/L; IQR, 0.5-0.9 cells/L). Conclusions Children with PBB are, typically, very young boys with prolonged wet cough and parent-reported wheeze who have attended childcare. Coupled with elevated NK-cell levels, the association between adenovirus and PBB suggests a likely role of viruses in PBB pathogenesis.

Adenovirus Species C Is Associated With Chronic Suppurative Lung Diseases in Children

Adenovirus species C is commonly detected in the lower airways of children with chronic endobronchial suppuration. Compared with older children, younger children are more likely to have human adenovirus infection and bacterial coinfection of their lower airways.

Respiratory virus detection in nasopharyngeal aspirate versus bronchoalveolar lavage is dependent on virus type in children with chronic respiratory symptoms.

Abstract Background The comparative yield of respiratory virus detection from nasopharyngeal aspirate (NPA) versus bronchoalveolar lavage (BAL) is uncertain. Furthermore, the significance of virus detection and its relationship to lower airway neutrophilic inflammation is poorly studied. Objectives To evaluate the sensitivity, specificity and predictive values of NPA for detecting respiratory viruses in BAL; and to determine the relationship between viruses and lower airway neutrophilia in children with non-acute respiratory illness. Study design 150 paired NPA and BAL samples were obtained from 75 children aged <18 years undergoing flexible bronchoscopy for investigation of chronic respiratory symptoms. Viral studies were performed using polymerase chain reaction (PCR). Cellularity studies were performed on BALs. Diagnostic parameters of NPA compared to BAL and associations between viruses and lower airway %neutrophils were evaluated. Results NPA had a higher yield than BAL for detection of any respiratory virus (52 versus 38, respectively). NPA had a high sensitivity (92%) and low specificity (57%) for detecting HRV in BAL with poor kappa agreement value of 0.398 (95% CI 0.218–0.578, p <0.001). NPA had a fair sensitivity (69%) and good specificity (90.3%) for detecting HAdV on BAL, kappa agreement was 0.561 (95% CI 0.321–0.801, p <0.001). HAdV positivity on NPA, compared to negativity, was independently associated with heightened airway neutrophilia [mean difference (95% CI): 18 (1,35); p =0.042]. Conclusions NPA has a higher yield for respiratory virus detection than BAL, however its diagnostic accuracy is dependent on viral species. Adenovirus positivity is associated with significantly heightened lower airway neutrophilia in children with chronic respiratory symptoms.

Wet cough in children: Infective and inflammatory characteristics in broncho‐alveolar lavage fluid

Wet cough is a common feature of many disease processes affecting children. Our aim was to examine the relationships between cough nature, lower airway infection (bacterial, viral, and viral–bacterial) and severity of neutrophilic airway inflammation. We hypothesized that viral–bacterial co‐infection of the lower airway would be associated with wet cough and heightened neutrophilic airway inflammation. We prospectively recruited 232 children undergoing elective flexible bronchoscopy. Participants were grouped using a cough nature symptom‐based approach, into wet, dry or no cough groups. Broncho‐alveolar lavage (BAL) and clinical data, including presence, nature, and duration of cough and key demographic factors, were collected. Children with wet cough (n = 143) were more likely to have lower airway bacterial infection (OR 2.6, P = 0.001), viral infection (OR 2.04, P = 0.045) and viral–bacterial co‐infection (OR 2.65, P = 0.042) compared to those without wet cough. Wet cough was associated with heightened airway neutrophilia (median 19%) as compared to dry or no cough. Viral–bacterial co‐infection was associated with the highest median %neutrophils (33.5%) compared to bacteria only, virus/es only and no infection (20%, 18%, and 6%, respectively, P < 0.0001). Children with wet cough had higher rates of lower airway infection with bacteria and viruses. Maximal neutrophilic airway inflammation was seen in those with viral–bacterial co‐infection. Cough nature may be a useful indicator of infection and inflammation of the lower airways in children. Pediatr Pulmonol. 2014; 49:561–568.

Paralysis and a perihilar protuberance: an unusual presentation of sarcoidosis in a child.

Sarcoidosis in children can present with extra‐pulmonary manifestations, making diagnosis difficult. We describe a case of sarcoidosis in a child, presenting as a Guillain–Barré‐like illness with the incidental finding of a perihilar mass. We also report the first successful use of the minimally invasive technique of Endobronchial Ultrasound‐Guided Transbronchial Needle Aspiration (EBUS‐TBNA) to delineate the cause of hilar lymphadenopathy in a child. Pediatr Pulmonol. 2009; 44:410–414.

Endobronchial ultrasound in pediatric pulmonology.

Endobronchial ultrasound (EBUS) is a recently introduced technique that has significantly advanced bronchoscopic techniques in adult medicine. Use of ultrasound allows far more accurate localization and sampling of both peripheral pulmonary, as well as mediastinal and hilar lesions. This has led to greater diagnostic success, with a reduced rate of complications. Its performance characteristics in adult populations are equivalent to surgical procedures previously considered gold standard, but it has dramatically reduced morbidity and mortality among patients requiring invasive diagnostic procedures, when compared to surgical approaches. We describe the types of EBUS in clinical use, the method of use, the clinical indications for each procedure, and the potential role for EBUS in pediatric pulmonology. Radial probe EBUS is used in the investigation of peripheral lung lesions and could be adopted in children to achieve accurate biopsy of such lesions. Linear probe EBUS allows minimally invasive biopsy of mediastinal and hilar lesions. It has potentially greater performance characteristics than current biopsy techniques, with no significant complications reported to date. It may be useful in the diagnosis of lymphoma, or neurogenic tumors, as well as many other diseases resulting in mediastinal or hilar lymphadenopathy. EBUS is a minimally invasive technique that allows tissue sampling of peripheral lung lesions, or mediastinal/hilar masses, with a high diagnostic accuracy, and a significantly lower morbidity and mortality than alternative approaches. The indications for and the use of EBUS in pediatric patients is certain to increase in the future. Pediatr Pulmonol. 2009; 44:303–308.

An update on pediatric bronchiectasis

ABSTRACT 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.

A case for early bronchoscopic airway assessment after disc battery ingestion.

Disc battery ingestion in children is becoming increasingly common with the proliferation of small battery‐powered electronic devices. In the case of esophageal impaction, the likelihood and severity of complications are proportionate to the time between ingestion and removal. Tracheo‐esophageal fistulae (TOF) are a recognized complication and can be life‐threatening. We describe an interesting case of disc battery ingestion with delayed recognition of a TOF. We document the tracheal mucosal healing process of a large airway defect and describe the role of bronchoscopy in guiding the timing of surgical intervention. This case highlights the important role of early bronchoscopic assessment in management of these patients. Pediatr Pulmonol. 2014; 49:E72–E74.

No evidence that heliox inhalation therapy improves important outcomes for infants with bronchiolitis: Heliox inhalation therapy outcomes in infant

There was a significant improvement in one secondary outcome, clinical respiratory scores 1 h after the commencement of heliox therapy (Fig. 1). There were no statistically significant additional benefits for primary outcome measures (see next section) or other secondary outcomes measures including gas exchange, respiratory mechanics and clinical respiratory score within the first 24 h of starting helioxand total duration of hospitalisation.

A case for early bronchoscopic airway assessment after disc battery ingestion: Bronchoscopy after Disc Battery Ingestion

Disc battery ingestion in children is becoming increasingly common with the proliferation of small battery‐powered electronic devices. In the case of esophageal impaction, the likelihood and severity of complications are proportionate to the time between ingestion and removal. Tracheo‐esophageal fistulae (TOF) are a recognized complication and can be life‐threatening. We describe an interesting case of disc battery ingestion with delayed recognition of a TOF. We document the tracheal mucosal healing process of a large airway defect and describe the role of bronchoscopy in guiding the timing of surgical intervention. This case highlights the important role of early bronchoscopic assessment in management of these patients. Pediatr Pulmonol. 2014; 49:E72–E74.