PURPOSE: We observed infants and young children with sustained periods of noisy breathing, cough, and sometimes wheeze that failed a course of oral corticosteroids as a test for asthma. We report our experience with bronchoscopy and bronchoalveolar lavage in such patients.
METHODS: This was a retrospective review of medical records of children where bronchoalveolar lavage (BAL) found ≥ 10,000 cfu/ml of potentially pathogenic bacteria. Indications for bronchoscopy included noisy breathing, cough, or wheeze where asthma and other diagnoses had been excluded. Ages ranged from infancy to 60 months of age. Exclusion criteria included presence of other major diagnoses.
RESULTS: Seventy patients met criteria for inclusion. While age of onset ranged from birth to 5 years; all but 5 were < 1 year of age. Duration of symptoms prior to being seen by us was > 1 month (median 4 months). Bronchoscopy identified tracheomalacia and/or bronchomalacia in 52 cases (74%). BAL found significant neutrophilia (>7% of the sume of neutrophils and macrophages) in all but 9. Quantitative culture from BAL found ≥ 10^4 colony forming units per milliliter of organisms including Streptococcus pneumoniae in 26, Haemophilus influenza in 40, and Moraxella catarrhalis in 40. Clinical response to amoxicillin/clavulanate or trimethoprim/sulfamethoxazole was successful in eliminating symptoms in 61 cases (79%). Relapse and subsequent successful retreatment occurred in 42.
CONCLUSION:Patients with chronic purulent bronchitis made up a small percentage of all patients presenting with chronic cough or wheeze. While such symptoms are a common presentation for an asthma phenotype that either responds to a course of oral prednisone or has been episodic in nature, these patients had prolonged and unremitting respiratory symptoms. The frequent finding of significant neutrophilia in the BAL associated with high colony counts of potentially pathogenic bacteria indicated the presence of persistent bacterial bronchitis. The predominance of airway malacia in these patients suggest an etiologic role, probably through an adverse effect on mucous clearance.
CLINICAL IMPLICATIONS: The potential for chronic airway damage from chronic purulent bronchitis warrents further investigation.
DISCLOSURE: Michelle Kompare, No Financial Disclosure Information; No Product/Research Disclosure Information