0
Original Research |

The Burden of Disease in Pediatric Non-Cystic Fibrosis BronchiectasisBurden of Disease in Pediatric Bronchiectasis FREE TO VIEW

Nitin Kapur, PhD; I. Brent Masters, PhD; Peter Newcombe, PhD; Anne B. Chang, PhD
Author and Funding Information

From the Department of Respiratory Medicine and the Queensland Children’s Medical Research Institute (Drs Kapur, Masters, and Chang), Royal Children’s Hospital, Herston, QLD; the School of Social Work and Applied Human Sciences (Dr Newcombe), University of Queensland, Brisbane, QLD; and the Child Health Division, Menzies School of Health Research (Drs Kapur and Chang), Charles Darwin University, Darwin, NT, Australia.

Correspondence to: Nitin Kapur, PhD, Department of Respiratory Medicine, Royal Children’s Hospital, Herston, QLD 4029, Australia; e-mail: dr.nitinkapur@gmail.com


Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (http://www.chestpubs.org/site/misc/reprints.xhtml).

Funding/Support: This research was conducted with support from the Australian National Health and Medical Research Council [Grant 545216] and a grant from the Royal Children’s Hospital Foundation to Dr Chang. Dr Kapur is supported by an Australia and New Zealand Trustees PhD Scholarship, an Endeavour Asia Award, and a Menzies School of Health Research scholarship.


© 2012 American College of Chest Physicians


Chest. 2012;141(4):1018-1024. doi:10.1378/chest.11-0679
Text Size: A A A
Published online

Background:  The burden of disease in children with non-cystic fibrosis (non-CF) bronchiectasis is unknown. Our study aimed to identify the determinants of quality of life (QOL) and parental mental health in this group of patients and their parents and to evaluate the effect of exacerbations on these parameters.

Methods:  Parents of 69 children (median age 7 years) with non-CF bronchiectasis prospectively completed two questionnaires (parent-proxy cough-specific quality of life [PC-QOL] and the Depression, Anxiety, and Stress Scale [DASS]) at stable and exacerbation states. Data on clinical, investigational, and lung function parameters were also collected.

Results:  During the stable state, the median interquartile range (IQR) PC-QOL score was 6.5 (5.3-6.9) and the DASS 21-item questionnaire score was 6 (0-20). Being of a young age correlated with a worse QOL (r5 = 0.242, P = .04) but radiologic extent, lung function, underlying cause, environmental tobacco smoke exposure, and chronic upper-airway disease did not influence these scores. Exacerbations caused significant worsening in the PC-QOL scores (median [IQR], 4.6 [3.8-5.4]; P = .001) and DASS scores (median [IQR], 22 [9-42]; P < .001; 38% with elevated anxiety, 54% with abnormal depression/stress scores during exacerbation). The presence of viral infection, hypoxia, and hospitalization did not influence the exacerbation PC-QOL and DASS scores.

Conclusions:  There is a significant burden of disease, especially during exacerbation, on parents of children with bronchiectasis. Prevention, early detection, and appropriate treatment of exacerbations are likely to reduce psychologic morbidity in this group.

Figures in this Article

Non-cystic fibrosis (non-CF) bronchiectasis continues to be an important cause of respiratory morbidity in both children and adults of developed1 and developing2 countries. Despite its importance, non-CF bronchiectasis remains neglected. Traditionally, outcomes of children with bronchiectasis have been assessed using parameters such as pulmonary function, growth,3 and radiologic extent of bronchiectasis,1 though their correlation with clinical severity may not be ideal.1,4 Since one goal of health care is to improve the quality of life (QOL), this assessment is increasingly used as an important outcome in chronic diseases such as asthma, cystic fibrosis (CF), and COPD.5,6 To our knowledge, there is no published data to date on health-related QOL (HRQOL) in children with non-CF bronchiectasis. Also, in childhood illnesses, the family, and particularly the primary caregiver, may face considerable burden,7,8 causing stress, anxiety, and depression.9 These are important since maternal depression may be an important factor in nonadherence to therapy and morbidity.10,11

As in other chronic pulmonary conditions, pulmonary exacerbations in bronchiectasis impact short- and long-term morbidity,3,12 though this remains underresearched. Recurrent exacerbations (in the preceding year) in adults have been reported to predict poor QOL in stable bronchiectasis,13 though similar pediatric data and data on the acute effect of exacerbation on burden of disease are unavailable. Further, in 15 adults with bronchiectasis, Courtney et al14 reported a significant improvement in QOL scores for people with chronic respiratory conditions after treatment of pulmonary exacerbations. Similar improvements have also been reported with treatment in adolescents with CF,5 but to our knowledge, no data in children with non-CF bronchiectasis exist. In addition to the paucity of quantitative studies addressing the burden of disease on parents of children with bronchiectasis, we know of no studies that have examined acute changes in these parameters for patients with pulmonary exacerbations. The objectives of our prospective study in a cohort of children with non-CF bronchiectasis were (1) to identify the determinants of parent-proxy cough-specific QOL (PC-QOL) and parental mental health (using the Depression, Anxiety, and Stress Scale [DASS] questionnaire)15 during the stable state and (2) to assess the magnitude of changes in these parameters in patients with pulmonary exacerbations.

Study Population

Children (aged < 18 years) with high-resolution CT imaging-based diagnosis of bronchiectasis without CF attending the respiratory clinic at the Royal Children’s Hospital in Brisbane, Queensland, Australia, were prospectively enrolled from February 1, 2008, to January 31, 2010, and followed until July 31, 2010. This was part of a larger prospective cohort study to delineate a validated definition of pulmonary exacerbation in children with non-CF bronchiectasis. Parents were asked to contact the primary investigator (N. K.) when their child was suspected of experiencing an exacerbation. Children were reviewed at the hospital clinic every 3 months and when suspected of experiencing an exacerbation. Information on demographic characteristics, underlying causes, extent of radiologic bronchiectasis, presence of upper-airway disease (middle ear disease, sinusitis, or allergic rhinitis), and environmental tobacco smoke (ETS) exposure were collected at the initial consultation. All children had a sweat chloride level of < 35 mEq/L. Informed parental consent was obtained at the time of enrollment. The Queensland health children’s health services ethics committee approved the study (Number 2008/038).

Each participating parent (primary caregiver for the child) completed two questionnaires (a PC-QOL questionnaire and the Depression, Anxiety, and Stress Scale 21-item questionnaire [DASS-21]) during the stable state and within 72 h of the start of a pulmonary exacerbation. Parent-reported QOL scores were used as a proxy for the QOL of the children. Exacerbation was diagnosed by the treating pediatric pulmonologist based on the Aspen workshop16 definition of pulmonary exacerbation as “a sustained worsening of the patient’s condition from stable state and beyond normal day to day variations that is acute in onset and necessitates a change in regular medication.” In the absence of a validated definition of pulmonary exacerbation in pediatric bronchiectasis (CF or non-CF), we used this definition as the “gold standard.” We have previously used this definition12 in a retrospective study on the clinical features of pulmonary exacerbations in children with non-CF bronchiectasis. The most recent stable-state data related to exacerbation data were included. These events were within 6 months of each other. Blood investigations and airway resistance measurement using the Impulse Oscillometry System (IOS) (Masterscreen-IOS, Jaeger) were performed in each child during the stable state and the exacerbation state. Extended viral screening using a polymerase chain reaction test was also performed on the nasopharyngeal aspirates obtained during each exacerbation (e-Appendix 1).

Scales for Measurement of Burden of Disease

In the absence of any suitable QOL measures for children with non-CF bronchiectasis, we used a validated cough-specific QOL for children,17 since cough-specific QOL scales have been proven valid and useful in adults with bronchiectasis.18 In the youngest children (usually < 6 years), a parent-proxy QOL is usually reported.8,17 The PC-QOL is a validated17 27-item scale with a seven-point Likert-type scale with a minimum important difference of 0.9.19 The PC-QOL is further divided into three subscales: psychologic (11 items), physical (11 items), and social (5 items). Lower scores reflect a worse QOL.

Depression, Anxiety, and Stress Scale 21-Item Questionnaire:

This is a self-reported scale with 21 items measuring three dimensions of emotional distress construct: depression, anxiety, and stress (seven items each).15 Participants respond to each item on a four-point severity scale from 0 (did not apply to me) to 3 (applied to me most of the time), with the past week as the referent period. Scores from the DASS-21 were compared with normative population data,15 and z-scores were calculated. Higher scores indicate worse mental health, and z-scores > 0.5 are considered abnormal,15 corresponding with a depression score of 10, an anxiety score of 7, and a stress score of 14, with respect to normative data.

Statistical Analysis

For the PC-QOL, mean values per child were first calculated for the total score, as well as for each domain (psychologic, physical, and social). For the DASS-21, the sum of the total scores as well as the sum of each domain (depression, anxiety, and stress) were separately calculated. As these data were not normally distributed, results for the whole cohort were expressed as medians and their interquartile range (IQR). Paired data were compared using a Wilcoxon signed rank test when continuous and using conditional logistic regression when categorical. Independent data were compared using a Mann-Whitney U test. Correlations were examined using the Spearman rank signed test. Statistical analysis was performed using SPSS 13.0 software (SPSS Inc). A P value < .05 was considered statistically significant.

Study Population

The demographic profile of the 69 children prospectively enrolled and followed for 900 child-months is presented in Table 1. The PC-QOL scores were available from all 69 children during the stable state and for 64 children during the exacerbation state (four children did not have an exacerbation; one questionnaire was not returned). Three parents declined to respond to the DASS-21, and, thus, data were available from 66 children during the stable state and from 61 children during the exacerbation state. Thirty-one exacerbations (48%) had virus-positive polymerase chain reaction results on the nasopharyngeal aspirates (e-Appendix 1).

Table Graphic Jump Location
Table 1 —General Characteristics of 69 Children Enrolled in the Study

Data are presented as median (interquartile range) or No. (%). ETS = environmental tobacco smoke; HRCT = high-resolution CT; hs-CRP = high-sensitivity C-reactive protein; R5 = resistance at 5 Hz.

Assessment During the Stable State

The median (IQR) PC-QOL scores during the stable state in the 69 children were as follows: total score, 6.5 (5.3-6.9); psychologic, 6.6 (4.8-7); physical, 6.5 (5.7-7); and social, 6.6 (5.5-7). The three subscales of the PC-QOL all correlated highly with one another during the stable state (psychologic with physical, r = 0.724; P < .001; psychologic with social, r = 0.768; P < .001; and physical with social, r = 0.882; P < .001).

The median (IQR) DASS-21 scores during the stable state in the 66 children were as follows: total score, 6 (0-20); depression, 2 (0-6); anxiety, 0 (0-4); and stress, 2 (0-10). When compared with normative data, the median (IQR) z-scores for the three subcomponents were the following: depression, −0.62 (−0.91 to −0.05); anxiety, −0.96 (−0.96 to −0.14), and stress, −1.03 (−1.28 to −0.01). The three subcomponents of the DASS-21 all correlated highly with one another during the stable state (depression with anxiety, r = 0.790; P < .001; depression with stress, r = 0.801; P < .001; and anxiety with stress, r = 0.603; P < .001).

The PC-QOL total score, but not the DASS, was significantly related to older age, but the correlation coefficient was small (Table 2). The PC-QOL was significantly and negatively correlated with the total DASS-21 scores (Table 2). The PC-QOL and DASS scores did not significantly correlate with the time since diagnosis, C-reactive protein, or airway resistance (resistance at 5 Hz, measured on IOS).

Table Graphic Jump Location
Table 2 —Factors Associated With Total PC-QOL and Total DASS-21 Scores During the Stable State

CRP = C-reactive protein; DASS-21 = Depression, Anxiety, and Stress Scale 21-item questionnaire; PC-QOL = parent proxy cough-specific quality of life. See Table 1 legend for expansion of the other abbreviation.

a 

Spearman rank correlation.

There was also no significant difference in the total PC-QOL or DASS-21 scores between children exposed to ETS (PC-QOL median [IQR], 6.25 [4.6-6.7]; DASS-21 median [IQR], 4 [0-26])and those not exposed (PC-QOL median [IQR], 6.6 [5.9-6.9]; P = .26; DASS-21 median [IQR], 6 [0-20]; P = .9). Similarly, no significant difference was seen between children grouped by the extent of radiologic bronchiectasis (unilobar bronchiectasis: PC-QOL median [IQR], 6.53 [4.9-6.9]; DASS-21 median [IQR], 6 [0-18] vs multilobar: PC-QOL median [IQR], 6.4 [5.3-6.9]; P = .78; DASS-21 median [IQR], 6 [0-20]; P = .62). Further, there was no significant difference in the total or any subcomponent PC-QOL or DASS-21 scores based on underlying cause or the presence of chronic upper airway disease (middle ear disease, sinusitis, or allergic rhinitis) (data not shown).

Assessment During Exacerbation State

Pulmonary exacerbation significantly worsened the total PC-QOL scores and all three subscales when compared with stable-state scores (Fig 1). There was no difference in the exacerbation-state PC-QOL total scores between exacerbations caused by viral agents (virus positive: n = 31, median [IQR], 4.4 [3.1-5.3]; virus negative: n = 33, median [IQR], 4.9 [3.4-5.5]; P = .3) or exacerbations requiring hospitalization (requiring hospitalization: n = 32, median [IQR], 4.7 [2.9-5.1]; not requiring hospitalization: n = 32, median [IQR], 4.6 [3.7-5.5]; P = .3). There was also no difference in the score during exacerbation in regard to the extent of radiologic bronchiectasis, underlying cause, or presence of hypoxia during exacerbation (data not shown). Similarly, the DASS-21 total scores and the depression, anxiety, and stress subscores were all significantly worse during an exacerbation than in the stable state (Fig 2, Table 3).

Figure Jump LinkFigure 1. Comparative analysis showing effect of pulmonary exacerbation on PC-QOL total and subcomponent scores. (Empty boxes indicate SS and filled boxes indicate ES.) PC-QOL = parent proxy cough-specific quality of life.Grahic Jump Location
Figure Jump LinkFigure 2. Comparative analysis showing effect of pulmonary exacerbation on DASS-21 total and subcomponent scores. (Empty boxes indicate SS and filled boxes indicate ES.) DASS-21 = Depression, Anxiety, and Stress Scale 21-item questionnaire. See Figure 1 legend for expansion of other abbreviation.Grahic Jump Location
Table Graphic Jump Location
Table 3 —Comparison of DASS-21 Scores Between Stable and Exacerbation State (N = 61 Pairs)

See Table 2 legend for expansion of the abbreviation.

a 

Univariate conditional logistic regression.

There was no difference in the exacerbation-state DASS-21 scores between virus-positive and virus-negative exacerbations (virus positive: n = 30, median [IQR], 15 [8-22.5]; virus negative: n = 31, median [IQR], 8 [3-18.5]; P = .1) or those requiring hospitalization (requiring hospitalization: n = 30, median [IQR], 14 [3-20.5]; not requiring hospitalization: n = 31, median [IQR], 9.5 [4.7-21.5]; P = .8). There was also no difference in the DASS-21 scores in regard to the extent of radiologic bronchiectasis, underlying cause, or presence of hypoxia during exacerbation (data not shown).

To the best of our knowledge, this is the first report on QOL and mental health data (depression, stress, anxiety) reported by caregivers of children with non-CF bronchiectasis. In our prospective cohort of 69 children with non-CF bronchiectasis, parents of younger children with bronchiectasis were more likely to report an impaired QOL, but radiologic extent, baseline lung function, underlying cause, and chronic upper airway disease did not influence the burden of disease scores. A small but important number (12%-15%) of mothers had abnormal scores reflecting anxiety, stress, or depression above population norms. Acute pulmonary exacerbations caused significant worsening in both QOL and DASS scores, with 38% to 54% having scores reflecting abnormal depression, anxiety, and stress. The presence of viral infection and the severity of exacerbation (hospitalized vs nonhospitalized, hypoxia vs no hypoxia) did not influence the QOL and DASS scores during an exacerbation.

In this study to prospectively examine the magnitude of parent-proxy burden of disease in children with non-CF bronchiectasis and its determinants, we found that young age was the only significant factor associated with a worse burden of disease. Factors that govern QOL in adults with bronchiectasis include Pseudomonas aeruginosa infection,20 dyspnea, sputum production,21 and frequency of exacerbations,13 though similar pediatric data are not available. However adult features such as sputum production, sputum bacteriology, and spirometric parameters are of limited use in young children, who cannot perform spirometry and do not expectorate. We had found that lung airway resistance (using spirometry or IOS) contributed little value when defining pulmonary exacerbations of bronchiectasis,22 though as a result of the relatively young cohort, spirometric data were unavailable from nearly half the cohort, limiting assessment of this parameter. In pediatric cohorts with chronic respiratory illness (asthma, CF, chronic cough), studies show that upper airway disease,23 recurrent doctor visits,7 and high frequency of cough24 worsen QOL. In our cohort, radiologic extent, stable-state lung function (measured as airway resistance using IOS), and ETS exposure were not associated with the overall burden of disease measures, a finding similar to those of other pediatric and adult studies.10,20 The correlation coefficient for age and PC-QOL scores was small (0.24), even though statistically significant. Because of the small coefficient and no clear clinical plausibility, we can only speculate on the reasons for this correlation. These reasons may include parental fear of lung disease deterioration when the child becomes older and the effects of sleep deprivation on the young child. It is also possible that the parents of older children are more adjusted to the medical condition than those of younger children.

In adults with bronchiectasis, elevated scores for anxiety and/or depression have been described in ≤ one-third of patients.25 In contrast, the majority of parents of children with bronchiectasis in our cohort were not depressed ( < 15% had DASS z-scores > 0.5) during the stable state. It is possible that this difference could reflect differences in symptoms between pediatric and adult populations. Whereas adult bronchiectasis is considered a disease of chronic cough and sputum production, children with bronchiectasis in the stable state are likely to be minimally symptomatic when treated appropriately for exacerbations.12 However, during pulmonary exacerbations, a high proportion of parents reported significant worsening in the QOL and the psychologic burden of disease. Thus, in addition to data showing that severe exacerbations are associated with accelerated lung function decline,3 our study’s finding supports the contention that reduction of exacerbations should be one of the goals in the treatment of children with non-CF bronchiectasis. Recurrent exacerbations are known to worsen the QOL in adults with bronchiectasis,13 and QOL scores have been shown to improve after treatment of pulmonary exacerbations in adults.14

The DASS-21 is a commonly used tool to measure the variations in emotional state in adults, though there is limited data on parents of children with chronic disease. Data from a cohort of children with chronic cough reported by Marchant et al7 show that the median DASS-21 score was 10 and the median PC-QOL score was 3.38. Both these parameters improved significantly with cessation of cough. In comparison, our cohort in exacerbation had worse DASS scores (median, 22) but better PC-QOL scores (median, 4.6). The differences in age may explain some of these differences (Marchant and colleagues’ cohort was much younger, with a median age of 2.56 years), though it is possible that factors other than cough may be governing the burden of disease in our cohort of children with non-CF bronchiectasis.

A further implication of our findings in the depression, stress, and anxiety scores, particularly during an exacerbation, is that physicians should be cognizant that irrespective of the underlying cause or severity of bronchiectasis, some parents are substantially burdened. Detecting depressive symptoms in the primary caregivers of children is important since depression is reported to influence medication adherence. In a pediatric asthma study, Bartlett and colleagues10 reported maternal depression to be associated with decreased medication adherence and increased ED visits. In 39 children with CF aged 7 to 17 years, parental depression was reported to be an important factor for poor adherence to airway clearance.26 Also, data suggest that addressing the psychosocial aspects early improves functioning and minimizes the parental burden of illness.11

A increase in clinical symptoms such as dyspnea and sputum production is associated with worsening QOL in adults with chronic respiratory illnesses.6,21 Acute events such as pulmonary exacerbations that aggravate symptoms are therefore likely to worsen the QOL. This is especially relevant in light of the fact that recurrent stress is a risk factor for major depression in adults,27 and stressful states such as a pulmonary exacerbation could have a compounding effect on making the parental mental state worse.

In the context of the finding that adult cough-specific QOL determination is valid for adults with bronchiectasis,18 we used the sole validated cough-specific QOL scale for children. There is no QOL scale specific for non-CF bronchiectasis. In adults, the St. George’s Respiratory Questionnaire is often used.21 This questionnaire is not appropriate in our cohort of children, which includes the very young. Because young children are unable to verbally express themselves adequately, it is standard practice for parents to be proxy assessors of their child.8 Although proxy HRQOL measurements have been validated for assessing outcomes in children and adolescents,28 it remains unknown if the use of child QOL scales would have resulted in the similar findings. Of note, in 62 adolescents with CF, Britto and colleagues29 reported that HRQOL scores from children were comparable to their parents’ proxy rating across most domains. Also, the fact that the PC-QOL scores in our cohort during the stable state correlated well with the DASS scores gives further strength to the role of this tool in understanding parental QOL and mental health. The correlation between the DASS and the PC-QOL is not surprising, as we had previously described this finding in the development of the PC-QOL in 190 children.7 In children with chronic cough, parental DASS scores significantly reduced when cough ceased, and the reduction was primarily related to the stress factor. The reasons for this explanation can only be speculated on and have been described in our previous paper.7

In conclusion, our study highlights the need for the treating physician to be sensitive to the emotional distress of parents, thereby addressing this early in the consultative process. This is especially relevant during periods of clinical deterioration, such as an exacerbation that constitutes a psychologically “vulnerable period.” Efforts should also be made for the prevention, early detection, and appropriate treatment of an exacerbation since recurrent stressors, such as exacerbations, could be a risk factor for long-term caregiver depression.

Author contributions: Dr Kapur is the guarantor of the paper, taking responsibility for the integrity of the work as a whole, from inception to published article.

Dr Kapur: contributed to the study concept and design, collected all the data, contributed to the analysis and interpretation of the data, and contributed to the drafting of the article.

Dr Masters: contributed to the drafting of the article.

Dr Newcombe: contributed to the analysis and interpretation of the data and contributed to the drafting of the article.

Dr Chang: contributed to the study concept and design and contributed to the drafting of the article.

Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Role of sponsors: The sponsor had no role in the design of the study, the collection and analysis of the data, or in the preparation of the manuscript.

Other contributions: This work was performed at theRoyal Children’s Hospital, University of Queensland, Brisbane, Queensland, Australia.

Additional information: The e-Appendix can be found in the Online Supplement at http://chestjournal.chestpubs.org/content/141/4/1018/suppl/DC1.

CF

cystic fibrosis

DASS

Depression, Anxiety, and Stress Scale

DASS-21

Depression, Anxiety, and Stress Scale 21-item questionnaire

ETS

environmental tobacco smoke

HRQOL

health-related quality of life

IOS

Impulse Oscillometry System

IQR

interquartile range

non-CF

non-cystic fibrosis

PC-QOL

parent proxy cough-specific quality of life

QOL

quality of life

Santamaria F, Montella S, Camera L, Palumbo C, Greco L, Boner AL. Lung structure abnormalities, but normal lung function in pediatric bronchiectasis. Chest. 2006;1302:480-486 [PubMed] [CrossRef]
 
Karakoc GB, Yilmaz M, Altintas DU, Kendirli SG. Bronchiectasis: Still a problem. Pediatr Pulmonol. 2001;322:175-178 [PubMed]
 
Kapur N, Masters IB, Chang AB. Longitudinal growth and lung function in pediatric non-cystic fibrosis bronchiectasis: What influences lung function stability? Chest. 2010;1381:158-164 [PubMed]
 
Chang AB, Masel JP, Boyce NC, Wheaton G, Torzillo PJ. Non-CF bronchiectasis: Clinical and HRCT evaluation. Pediatr Pulmonol. 2003;356:477-483 [PubMed]
 
Yi MS, Tsevat J, Wilmott RW, Kotagal UR, Britto MT. The impact of treatment of pulmonary exacerbations on the health-related quality of life of patients with cystic fibrosis: does hospitalization make a difference? J Pediatr. 2004;1446:711-718 [PubMed]
 
Voll-Aanerud M, Eagan TM, Plana E, et al. Respiratory symptoms in adults are related to impaired quality of life, regardless of asthma and COPD: results from the European community respiratory health survey. Health Qual Life Outcomes. 2010;8:107 [PubMed]
 
Marchant JM, Newcombe PA, Juniper EF, Sheffield JK, Stathis SL, Chang AB. What is the burden of chronic cough for families? Chest. 2008;1342:303-309 [PubMed]
 
Juniper EF, Guyatt GH, Feeny DH, Ferrie PJ, Griffith LE, Townsend M. Measuring quality of life in the parents of children with asthma. Qual Life Res. 1996;51:27-34 [PubMed]
 
Leão LL, Zhang L, Sousa PL, et al. High prevalence of depression amongst mothers of children with asthma. J Asthma. 2009;464:388-391 [PubMed]
 
Bartlett SJ, Krishnan JA, Riekert KA, Butz AM, Malveaux FJ, Rand CS. Maternal depressive symptoms and adherence to therapy in inner-city children with asthma. Pediatrics. 2004;1132:229-237 [PubMed]
 
Perry CD. Does treating maternal depression improve child health management? The case of pediatric asthma. J Health Econ. 2008;271:157-173 [PubMed]
 
Kapur N, Masters IB, Chang AB. Exacerbations in noncystic fibrosis bronchiectasis: clinical features and investigations. Respir Med. 2009;10311:1681-1687 [PubMed]
 
Wilson CB, Jones PW, O’Leary CJ, Cole PJ, Wilson R. Validation of the St. George’s Respiratory Questionnaire in bronchiectasis. Am J Respir Crit Care Med. 1997;1562 pt 1:536-541 [PubMed]
 
Courtney JM, Kelly MG, Watt A, et al. Quality of life and inflammation in exacerbations of bronchiectasis. Chron Respir Dis. 2008;53:161-168 [PubMed]
 
Lovibond SH, Lovibond PF. Manual for the Depression Anxiety Stress Scales. 1995; Sydney, Australia Psychology Foundation Monograph
 
Rodriguez-Roisin R. Toward a consensus definition for COPD exacerbations. Chest. 2000;1175 suppl 2:398S-401S [PubMed]
 
Newcombe PA, Sheffield JK, Juniper EF, Petsky HL, Willis C, Chang AB. Validation of a parent-proxy quality of life questionnaire for paediatric chronic cough (PC-QOL). Thorax. 2010;659:819-823 [PubMed]
 
Murray MP, Turnbull K, MacQuarrie S, Pentland JL, Hill AT. Validation of the Leicester Cough Questionnaire in non-cystic fibrosis bronchiectasis. Eur Respir J. 2009;341:125-131 [PubMed]
 
Newcombe PA, Sheffield JK, Chang AB. Minimally important change in a parent-proxy quality-of-life questionnaire for pediatric chronic cough. Chest. 2011;1393:576-580 [PubMed]
 
Wilson CB, Jones PW, O’Leary CJ, Hansell DM, Cole PJ, Wilson R. Effect of sputum bacteriology on the quality of life of patients with bronchiectasis. Eur Respir J. 1997;108:1754-1760 [PubMed]
 
Martínez-García MA, Perpiñá-Tordera M, Román-Sánchez P, Soler-Cataluña JJ. Quality-of-life determinants in patients with clinically stable bronchiectasis. Chest. 2005;1282:739-745 [PubMed]
 
Kapur N, Masters IB, Morris PS, Galligan J, Ware R, Chang AB. Defining pulmonary exacerbation in children with non-cystic fibrosis bronchiectasis. Pediatr Pulmonol. 2012;471:68-75 [PubMed]
 
Vandenplas O, Dramaix M, Joos G, et al. The impact of concomitant rhinitis on asthma-related quality of life and asthma control. Allergy. 2010;6510:1290-1297 [PubMed]
 
Petsios KT, Priftis KN, Tsoumakas C, et al. Cough affects quality of life in asthmatic children aged 8-14 more than other asthma symptoms. Allergol Immunopathol (Madr). 2009;372:80-88 [PubMed]
 
O’Leary CJ, Wilson CB, Hansell DM, Cole PJ, Wilson R, Jones PW. Relationship between psychological well-being and lung health status in patients with bronchiectasis. Respir Med. 2002;969:686-692 [PubMed]
 
Smith BA, Modi AC, Quittner AL, Wood BL. Depressive symptoms in children with cystic fibrosis and parents and its effects on adherence to airway clearance. Pediatr Pulmonol. 2010;458:756-763 [PubMed]
 
Patten SB, Wang JL, Williams JV, Lavorato DH, Khaled SM, Bulloch AG. Predictors of the longitudinal course of major depression in a Canadian population sample. Can J Psychiatry. 2010;5510:669-676 [PubMed]
 
Theunissen NC, Vogels TG, Koopman HM, et al. The proxy problem: child report versus parent report in health-related quality of life research. Qual Life Res. 1998;75:387-397 [PubMed]
 
Britto MT, Kotagal UR, Chenier T, Tsevat J, Atherton HD, Wilmott RW. Differences between adolescents’ and parents’ reports of health-related quality of life in cystic fibrosis. Pediatr Pulmonol. 2004;372:165-171 [PubMed]
 

Figures

Figure Jump LinkFigure 1. Comparative analysis showing effect of pulmonary exacerbation on PC-QOL total and subcomponent scores. (Empty boxes indicate SS and filled boxes indicate ES.) PC-QOL = parent proxy cough-specific quality of life.Grahic Jump Location
Figure Jump LinkFigure 2. Comparative analysis showing effect of pulmonary exacerbation on DASS-21 total and subcomponent scores. (Empty boxes indicate SS and filled boxes indicate ES.) DASS-21 = Depression, Anxiety, and Stress Scale 21-item questionnaire. See Figure 1 legend for expansion of other abbreviation.Grahic Jump Location

Tables

Table Graphic Jump Location
Table 1 —General Characteristics of 69 Children Enrolled in the Study

Data are presented as median (interquartile range) or No. (%). ETS = environmental tobacco smoke; HRCT = high-resolution CT; hs-CRP = high-sensitivity C-reactive protein; R5 = resistance at 5 Hz.

Table Graphic Jump Location
Table 2 —Factors Associated With Total PC-QOL and Total DASS-21 Scores During the Stable State

CRP = C-reactive protein; DASS-21 = Depression, Anxiety, and Stress Scale 21-item questionnaire; PC-QOL = parent proxy cough-specific quality of life. See Table 1 legend for expansion of the other abbreviation.

a 

Spearman rank correlation.

Table Graphic Jump Location
Table 3 —Comparison of DASS-21 Scores Between Stable and Exacerbation State (N = 61 Pairs)

See Table 2 legend for expansion of the abbreviation.

a 

Univariate conditional logistic regression.

References

Santamaria F, Montella S, Camera L, Palumbo C, Greco L, Boner AL. Lung structure abnormalities, but normal lung function in pediatric bronchiectasis. Chest. 2006;1302:480-486 [PubMed] [CrossRef]
 
Karakoc GB, Yilmaz M, Altintas DU, Kendirli SG. Bronchiectasis: Still a problem. Pediatr Pulmonol. 2001;322:175-178 [PubMed]
 
Kapur N, Masters IB, Chang AB. Longitudinal growth and lung function in pediatric non-cystic fibrosis bronchiectasis: What influences lung function stability? Chest. 2010;1381:158-164 [PubMed]
 
Chang AB, Masel JP, Boyce NC, Wheaton G, Torzillo PJ. Non-CF bronchiectasis: Clinical and HRCT evaluation. Pediatr Pulmonol. 2003;356:477-483 [PubMed]
 
Yi MS, Tsevat J, Wilmott RW, Kotagal UR, Britto MT. The impact of treatment of pulmonary exacerbations on the health-related quality of life of patients with cystic fibrosis: does hospitalization make a difference? J Pediatr. 2004;1446:711-718 [PubMed]
 
Voll-Aanerud M, Eagan TM, Plana E, et al. Respiratory symptoms in adults are related to impaired quality of life, regardless of asthma and COPD: results from the European community respiratory health survey. Health Qual Life Outcomes. 2010;8:107 [PubMed]
 
Marchant JM, Newcombe PA, Juniper EF, Sheffield JK, Stathis SL, Chang AB. What is the burden of chronic cough for families? Chest. 2008;1342:303-309 [PubMed]
 
Juniper EF, Guyatt GH, Feeny DH, Ferrie PJ, Griffith LE, Townsend M. Measuring quality of life in the parents of children with asthma. Qual Life Res. 1996;51:27-34 [PubMed]
 
Leão LL, Zhang L, Sousa PL, et al. High prevalence of depression amongst mothers of children with asthma. J Asthma. 2009;464:388-391 [PubMed]
 
Bartlett SJ, Krishnan JA, Riekert KA, Butz AM, Malveaux FJ, Rand CS. Maternal depressive symptoms and adherence to therapy in inner-city children with asthma. Pediatrics. 2004;1132:229-237 [PubMed]
 
Perry CD. Does treating maternal depression improve child health management? The case of pediatric asthma. J Health Econ. 2008;271:157-173 [PubMed]
 
Kapur N, Masters IB, Chang AB. Exacerbations in noncystic fibrosis bronchiectasis: clinical features and investigations. Respir Med. 2009;10311:1681-1687 [PubMed]
 
Wilson CB, Jones PW, O’Leary CJ, Cole PJ, Wilson R. Validation of the St. George’s Respiratory Questionnaire in bronchiectasis. Am J Respir Crit Care Med. 1997;1562 pt 1:536-541 [PubMed]
 
Courtney JM, Kelly MG, Watt A, et al. Quality of life and inflammation in exacerbations of bronchiectasis. Chron Respir Dis. 2008;53:161-168 [PubMed]
 
Lovibond SH, Lovibond PF. Manual for the Depression Anxiety Stress Scales. 1995; Sydney, Australia Psychology Foundation Monograph
 
Rodriguez-Roisin R. Toward a consensus definition for COPD exacerbations. Chest. 2000;1175 suppl 2:398S-401S [PubMed]
 
Newcombe PA, Sheffield JK, Juniper EF, Petsky HL, Willis C, Chang AB. Validation of a parent-proxy quality of life questionnaire for paediatric chronic cough (PC-QOL). Thorax. 2010;659:819-823 [PubMed]
 
Murray MP, Turnbull K, MacQuarrie S, Pentland JL, Hill AT. Validation of the Leicester Cough Questionnaire in non-cystic fibrosis bronchiectasis. Eur Respir J. 2009;341:125-131 [PubMed]
 
Newcombe PA, Sheffield JK, Chang AB. Minimally important change in a parent-proxy quality-of-life questionnaire for pediatric chronic cough. Chest. 2011;1393:576-580 [PubMed]
 
Wilson CB, Jones PW, O’Leary CJ, Hansell DM, Cole PJ, Wilson R. Effect of sputum bacteriology on the quality of life of patients with bronchiectasis. Eur Respir J. 1997;108:1754-1760 [PubMed]
 
Martínez-García MA, Perpiñá-Tordera M, Román-Sánchez P, Soler-Cataluña JJ. Quality-of-life determinants in patients with clinically stable bronchiectasis. Chest. 2005;1282:739-745 [PubMed]
 
Kapur N, Masters IB, Morris PS, Galligan J, Ware R, Chang AB. Defining pulmonary exacerbation in children with non-cystic fibrosis bronchiectasis. Pediatr Pulmonol. 2012;471:68-75 [PubMed]
 
Vandenplas O, Dramaix M, Joos G, et al. The impact of concomitant rhinitis on asthma-related quality of life and asthma control. Allergy. 2010;6510:1290-1297 [PubMed]
 
Petsios KT, Priftis KN, Tsoumakas C, et al. Cough affects quality of life in asthmatic children aged 8-14 more than other asthma symptoms. Allergol Immunopathol (Madr). 2009;372:80-88 [PubMed]
 
O’Leary CJ, Wilson CB, Hansell DM, Cole PJ, Wilson R, Jones PW. Relationship between psychological well-being and lung health status in patients with bronchiectasis. Respir Med. 2002;969:686-692 [PubMed]
 
Smith BA, Modi AC, Quittner AL, Wood BL. Depressive symptoms in children with cystic fibrosis and parents and its effects on adherence to airway clearance. Pediatr Pulmonol. 2010;458:756-763 [PubMed]
 
Patten SB, Wang JL, Williams JV, Lavorato DH, Khaled SM, Bulloch AG. Predictors of the longitudinal course of major depression in a Canadian population sample. Can J Psychiatry. 2010;5510:669-676 [PubMed]
 
Theunissen NC, Vogels TG, Koopman HM, et al. The proxy problem: child report versus parent report in health-related quality of life research. Qual Life Res. 1998;75:387-397 [PubMed]
 
Britto MT, Kotagal UR, Chenier T, Tsevat J, Atherton HD, Wilmott RW. Differences between adolescents’ and parents’ reports of health-related quality of life in cystic fibrosis. Pediatr Pulmonol. 2004;372:165-171 [PubMed]
 
NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).
Supporting Data
Online Supplement

Some tools below are only available to our subscribers or users with an online account.

Related Content

Customize your page view by dragging & repositioning the boxes below.

Find Similar Articles
CHEST Journal Articles
  • CHEST Journal
    Print ISSN: 0012-3692
    Online ISSN: 1931-3543