Original Article
Protracted Bacterial Bronchitis in Young Children: Association with Airway Malacia

Presented in part at the annual meeting of the American College of Chest Physicians in Vancouver, Nov 2, 2010. M.K received a Young Investigator Award for her presentation, which was supported by the Stephen Grant Orton Award Fund of the University of Iowa Foundation. The authors declare no conflicts of interest.
https://doi.org/10.1016/j.jpeds.2011.06.049Get rights and content

Objective

To examine associated findings and clinical outcome in young children with prolonged cough, wheeze, and/or noisy breathing in whom high colony counts of potentially pathogenic bacteria were cultured from bronchoalveolar lavage (BAL) during diagnostic flexible fiberoptic bronchoscopy.

Study design

This was a retrospective review of all medical records of children from infancy to 60 months of age seen in our specialty clinic from 1999 to 2009 with protracted cough, wheeze, and/or noisy breathing in whom BAL found ≥104 colony forming units per milliliter of potentially pathogenic bacteria. Children with other major diagnoses were excluded.

Results

With quantitative culture from BAL, ≥104 colony forming units per milliliter of Streptococcus pneumoniae, Haemophilus influenza, or Moraxella catarrhalis, separately or in combination, were found in 70 children. Neutrophilia was present in 87% of BALs. Tracheomalacia, bronchomalacia, or both was present in 52 children (74%). Symptoms were eliminated with antibiotics in all 61 children with follow-up data. Relapse and subsequent successful re-treatment occurred in 43 children.

Conclusions

High colony counts of potentially pathogenic bacteria associated with neutrophilia in the BAL identifies protracted bacterial bronchitis. The predominance of airway malacia in these patients suggests an etiologic role for those airway anomalies. The potential for chronic airway damage from protracted bacterial bronchitis warrants further investigation.

Section snippets

Methods

The diagnostic term chronic purulent bronchitis had customarily been given at our center for children in whom BAL had identified ≥ 104 colony forming units per milliliter (cfu/mL) of specific bacteria judged to be potentially pathogenic as the etiology of symptoms. We therefore first performed a computer search for that diagnostic term during the period from 1999 to 2009 for all patients seen by the Pediatric Allergy & Pulmonary Clinic at the University of Iowa Children’s Hospital.

Results

Seventy patients (20 female, 50 male) met inclusion criteria. All children except 5 had onset of symptoms before the age of 1 year (median, 3 months of age). None of the patients had fever or toxic appearance associated with their respiratory symptoms. The duration of symptoms before being examined by the pediatric allergy and pulmonary physicians at the University of Iowa was at least 1 month, with a range as long as 60 months (median, 5 months). Cough, alone or with other symptoms, was

Discussion

Our findings were consistent with earlier reports that PBB can be a cause of chronic cough in young children. We additionally observed that wheezing and noisy breathing were also associated with PBB. On the basis of our observation of airway malacia in 74% of our patients, we hypothesize that tracheal malacia, bronchial malacia, or both is a predisposing anomaly for PBB. Airway collapse decreases effectiveness of cough and can interfere with normal cephalad mucous flow, an important mechanism

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