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Bronchitis in Children

Authors:
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Bronchitis in Children
Christian Peiser
Department for Pediatric Pneumology and Immunology,
Charité, Medical University Berlin,
Germany
1. Introduction
For a paediatrician, children with bronchitis are part of the daily work. Infections of the
respiratory system are the most common reason for children presenting at the doctor´s
practice. Almost all infants and younger school children become sick several times a year
with a bronchitis. In most cases with the beginning of day nursery or nursery school there is
an abrupt accumulation and many parents have the feeling that their child is permanently
ill. That bronchitis occurs much more frequently in winter than in summer, as everyone
knows from personal experience. The cold air outside and the dry heated air indoors,
increases the vulnerability of the mucosa for pathogens. Whether the clinical course of a
bronchitis is uncomplicated or associated with a bronchial obstruction, is partly caused by
the genetic predisposition of the child. Depending on family history of bronchial asthma
and allergies, the risk may be increased many times over. The health damage due to
exposure to tobacco smoke is a major point which should not be underestimated.
The following pages describe in the form of a brief overview symptoms and signs of
bronchitis in children. The different types and stages of bronchitis are shown. The most
common viruses that cause bronchitis are described, in particular the respiratory syncytial
virus. One chapter deals with bronchopulmonary dysplasia, an important risk factor for
bronchitis in children. Furthermore, some important differential diagnoses are presented,
which can become manifest with the typical symptoms of a bronchitis. The laboratory
diagnosis with the aim of differentiating between viral and bacterial bronchitis is discussed.
Finally, therapeutic options are mentioned.
2. Signs and symptoms of bronchitis in children
2.1 Cough
The main symptom of bronchitis is a cough. At the beginning of the disease it tends to be
dry and unproductive. With increasing production of secretion the mucus becomes less
viscous, which makes coughing more effective. Some children have such severe coughing
attacks that vomiting can be induced. An adequate supply of volume and inhalation therapy
with 0.9% NaCl can help to make the mucus more fluid, enabling it to be brought up more
easily by coughing. There are medications, usually in the form of so-called cough syrups,
which will also assist mucolytic activity. After regression of an acute bronchitis, an
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unpleasant dry cough can still remain for several days or weeks. This is caused by a
transient hyperreactivity of the bronchial system due to the infection-induced inflammation.
2.2 Tachypnoea and dyspnoea
If secreted mucus, an oedema of the bronchial mucosa or a spasm of the bronchial
musculature induce bronchial obstruction, tachypnoea and dyspnoea may belong to the
acute disorders. Typical clinical signs for dyspnoea are movement of the nostrils, inter- or
subcostal retractions, use of accessory respiratory muscles, an upright upper body position,
and in the auscultation wheezing and sometimes also rales. In this situation inhalation
therapy with bronchodilatatory agents and the systemic administration of steroids may be
helpful. Because the expiration is more difficult that the inspiration, an emphysema may be
formed due to air trapping. Children with respiratory distress may become anxious and
excited, which makes the situation worse. The excitement and anxiety of the parents may
also be transferred to the child. In the case of severe respiratory distress, the oxygen
saturation in the blood may decrease critically, making oxygen substitution necessary.
Measurement of vital parameters and blood gas analyses are standard procedures. The
suctioning of secretions and mucus, or the application of respiratory supportive procedures,
such as CPAP or intubation and ventilation, should be made immediately possible.
2.3 Pain
Pain in the context of bronchitis can be caused by an inflammatory involvement of the
trachea or pleura. In the case of retrosternal pain during coughing, a tracheitis is most
probable. Respiratory-dependent, especially in deep inspiration increasing pain, which is
localized more laterally in one or both sides of the chest, makes a pleuritis more probable.
Especially the dry chafing of inflamed visceral pleura and parietal pleura against each other
is very painful. If the child develops shallow breathing to avoid the pain, an insufficient
ventilation of the lung may result with the increased risk of a secondary bacterial infection.
For this reason, an appropriate analgesia is strongly recommended.
2.4 Fever
Fever is a general clinical sign, which may occur in any infection, including one of the
respiratory system. The increase of body temperature is a non-specific symptom and can
range from low-grade fever up to hyperpyrexia with acute physical stress for the child. In
the case of an infection of the upper respiratory tract, additionally clinical signs (in addition
to the cough, tachydyspnea, pain and fever) are sniffing (rhinitis), a sore throat (pharyngitis)
and earache (otitis media). Furthermore, swollen and aching cervical lymph nodes are a
common local response to the inflammation process.
3. Different types of bronchitis in children
3.1 Acute, complicated, chronic, recurrent
The average duration of an acute bronchitis is about 1 week with the range from ½ week up
to 2 weeks. Afterwards a nervous cough may remain for several days or a few weeks. The
acute bronchitis has a very high rate of complete recovery; the prognosis is very good. An
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exception is an acute bronchitis caused by adenovirus; in this case complications in the
clinical course or a chronification of the bronchitis are described.
If the symptoms and signs of an acute bronchitis persist for 4 – 6 weeks, we call it compli-
cated bronchitis. If an acute bronchitis is followed by another one, they can be taken for a
complicated bronchitis by mistake. Approximately 20% of acute bronchitis has a complica-
ted course. One possible complication is the secondary bacterial superinfection of a primary
viral infection. In this case the child needs to be treated with antibiotics. Another possible
complication is the transition from bronchitis into bronchopneumonia. In many cases this is
detectable by pulmonary auscultation, but to confirm the diagnosis, a chest X-ray is
necessary. A primary bacterial bronchitis usually presents clinically as a complicated
bronchitis.
Signs and symptoms of a bronchitis persisting for more than 3 months are called chronic
bronchitis.
If children repeat lots of acute bronchitis over months, it is called recurrent bronchitis.
Mainly children in day nursery or nursery school are affected quite often, because the risk of
infection is particularly high there. In the cold seasons bronchitis occurs more frequently
compared to the warm seasons.
3.2 Non-obstructive or obstructive
Bronchitis can be associated more or less with bronchial obstruction. The risk of an
obstruction depends on the lumen of the inflamed bronchus; the smaller the lumen, the
more likely is a clinically relevant obstruction. For this reason, the terms “obstructive
bronchitis” and “bronchiolitis” were sometimes used as synonyms. Bronchial obstruction
can be caused by the following pathophysiological alterations:
1. The smooth muscles of the bronchus get contracted, which can lead to an acute
shortness of breath.
2. The mucosa of the respiratory epithelium is swollen due to the inflammation, which
narrows the bronchial lumen.
3. The increased production of mucus clogs the lumen as well. Furthermore, due to the
inflammation in the respiratory epithelium, the function of the cilia is reduced, and
mucus cannot be transported adequately.
Auscultation of the lung shows wheezing. A so-called silent lung is typical for a severe
bronchial obstruction with air trapping and emphysema. In this case the resting expiratory
position is shifted to the inspiration, what may create a circulus vitiosus.
3.3 Non-allergic or allergic
Bronchitis is an inflammatory disease of the bronchial mucosa. In most cases the
inflammation is caused by an infection. Also allergens may cause an acute or chronic
bronchitis, they act mostly as a trigger. The presence of one or more allergies increases the
statistical risk for the development of bronchial asthma. Relevant inhalation allergens are
dust mites, animal dander, mould fungus and pollen.
As their zoological name "Dermatophagoides" indicates, dust mites feed on epithelia from
the skin, of which one person loses about 1.5 grams per day. They are, depending on the
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446
type, 0.1 - 0.5 mm in size and they live in normal house dust. They are found in carpets,
curtains, upholstered furniture, mattresses, duvets and pillows, stuffed animals etc. The
allergen comes from the faeces of the mites. In order to avoid exposure, the following
protections should be carried out: the use of an encasing such as a mattress cover, monthly
washing of duvets and pillows, occasional freezing of soft toys at -20 °C, followed by
rinsing, no long carpets, regular vacuuming and avoidance of dust turbulence.
With regard to animal dander, those species which are most relevant and which human
beings have close contact with are especially dogs, cats, guinea pigs, hamsters, horses and
birds. The allergen concentration varies within a species, depending on the breed. For this
reason it could happen that someone tolerates contact with one cat very well, whereas
contact with another cat induces an acute bronchial obstruction. In the case of a clinically
relevant allergy against an animal, the contact should be avoided.
The spores of mould fungus can also cause an allergic reaction, like bronchial
hyperreactivity or bronchial obstruction. If at home the walls are infested with mould
fungus, the house has to be renovated.
Among the pollen, early flowering plants (birch, alder, hazel, willow) and grasses are most
relevant. The occurrence of pollen-induced disorders, namely rhinoconjunctivitis and
bronchial asthma, are strongly season-dependent and time-limited. On the basis of cross-
reactions, for example between birch pollen and apple, in the case of an allergy against birch
pollen, an allergic reaction against apple in the form of an oral allergy syndrome may occur.
In the case of pollen, allergen avoidance is almost impossible. In order to reduce the
intensity of pollen-induced allergy symptoms, desensitization is recommended.
3.4 Special forms: Bronchitis fibroplastica, bronchioloitis obliterans
A special form of bronchitis in childhood is the bronchitis fibroplastica. Older synonyms are
fibrinous bronchitis, pseudomembranous bronchitis or Hoffmann’s bronchitis. It is
characterized by obstruction of the bronchi, usually a lobe or segment, consisting of mucin,
which forms large endobronchial casts of rubber-like consistency. Pre-existing pathological
conditions, such as bronchial asthma or cystic fibrosis, which are attended by hypersecretion
of viscous mucus, may act as triggers. Childhood tuberculosis or primary immunodeficiency
seem to be associated with a higher incidence of bronchitis fibroplastica as well. However,
exact epidemiological data are still missing. Main symptoms are a cough and dyspnoea, and
sometimes pleuritic pain and fever occur. In pulmonary auscultation over the affected area
of the lung the breath is quiet or absent; sometimes wheezing or rales can be heard. X-rays
of the chest typically show an atelectatic area next to an emphysematic one. The therapy
consists in the prompt removal of the sticky casts consisting of mucin via rigid
bronchoscopy. If they are not removable, administration of N-acetylcysteine or DNase may
be helpful. If a child without known pre-existing diseases falls ill with bronchitis fibro-
plastica, additional diagnostic investigations should be carried out: sweat tests, tuberculin
tests, allergy tests.
Another special form of bronchitis in children is the bronchiolitis obliterans. An inflammation
of the small airways induces a pathologic tissue remodelling with granulations, which obstruct
the lumen of the bronchioles. This process may be triggered by infections, inhalation of toxic
agents, autoimmune diseases or a chronic rejection after lung transplantation. In the group of
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long-term survivors after lung transplantation, bronchioltis obliterans is the most frequent
cause of death. The clinical signs and symptoms are quite unspecific: a cough and reduced
general condition. In pulmonary auscultation the breath is quiet and rales can be heard. The X-
ray of the chest eventually shows some infiltration or it looks normal. The disease may begin
rapidly or slowly and the clinical course may be progressive or stable. Therapeutic options are
a high-dose glucocorticoid administration, and in the case of lung transplantation, an increase
in the dosage of the immunosuppressive medication.
4. Different stages of bronchitis in children
4.1 Bronchial hyperreactivity
Bronchial hyperreactivity is a chronic inflammation of the bronchial mucosa with recurrent
bronchial obstruction, which may be triggered by infections, allergens or nonspecific
stimuli, such as cold air, physical or even emotional stress. The inflammatory activity causes
a swelling of the bronchial mucosa with a reduction of the bronchial lumen consecutively.
The smaller the lumens are physiologically, such as in infants, the more relevant is its
reduction regarding clinical symptoms. Furthermore, inflammation of the bronchial mucosa
increases the vulnerability to viruses or bacteria.
To make the diagnosis “bronchial hyperreactivity”, an accurate and detailed medical history
is the most important step. Additionally, measurement of the lung function may confirm the
diagnosis, in particular in the case of a reduced flow in the smaller airways; after
administration of a beta-sympathomimetic via inhalation the bronchial obstruction should
be reversible, at least partly. The lung function test can be carried out with children who are
old enough to participate actively. Furthermore, measurement of the NO-exhalation may be
useful to monitor the amount of bronchial inflammation. In some cases it may be helpful to
carry out a bronchial provocation test via inhalation of methacholine, histamine or
carbachol. Of course, all emergency tools have to be available.
4.2 Bronchitis
Bronchitis is a clinically apparent inflammation of the bronchi, triggered by a bronchial
hyprerreactivity, by viruses or bacteria or by allergens. The symptoms (cough, tachypnoea
and dyspnoea, pain, fever), the different courses (acute, complicated, chronic, recurrent) and
different forms (non-obstructive, obstructive) have been described.
4.3 Bronchiolitis
Bronchiolitis is an inflammation of the smallest bronchi and bronchioles. Due to the small
lumens of these airways, swelling of bronchial mucosa may induce severe obstruction quite
rapidly, in most cases associated with pulmonary hyperinflation. This can lead to the
phenomenon of the so-called silent obstruction, that means barely wheezing, humming or
whistling, but fine bubble rales at the end of inspiration. Bronchiolitis is a typical disease of
infancy, the age peak is between 4 and 6 months.
4.4 Bronchopneumonia
Bronchopneumonia is a possible course of a complicated bronchitis. Whereas a primary
pneumonia normally is localized to one segment or lobe of the lung, in the case of a
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bronchopneumonia there is a disseminated inflammation from the bronchi down to the
alveoli.
4.5 Bronchial asthma
Bronchial asthma is a disease with chronic inflammation of the respiratory system with
bronchial hyperreactivity and variable airway obstructions. In many children and
adolescents we find a positive family history for asthma and/or allergies. The restriction of
the air flow, mainly during the expiration, is caused by spastic contraction of the smooth
muscle in the bronchial wall, oedematous swelling of the bronchial mucosa and
hypersecretion of viscous mucus. In addition to these pathological mechanisms, a tissue
remodelling may take place after bronchial asthma over several years, which makes the
airways less elastic. In most cases patients have an allergic bronchial asthma; case of non-
allergic asthma and mixed forms are possible as well.
Criteria for the diagnosis of bronchial asthma in children and adolescents are a relative
forced ventilation capacity (FEV1/VK) < 75% of age- and gender-related norm and a 15 %
increase with prolonged expiratory time, or after inhalation of a short-acting beta-
sympathomimetic. A further criterion is a decrease in respiratory resistance (R) > 50% of
baseline after inhalation of a short-acting beta-sympathomimetic. If the lung function
measurement shows a normal result, but the clinical history is typically for bronchial
asthma, then a circadian variability of the measured peak expiratory flow (PEF) > 20%
confirms the diagnosis. If the doctor is still in doubt with the diagnosis, a provocation test
(for example physical stress or inhalation of metacholine) may be helpful to make the right
diagnosis.
The therapy of bronchial asthma is successful if clinical signs and symptoms of the disease
are under control, so that the affected children or adolescents feel free from disorders if they
are able to partake in sport without any restriction, if there are no side effects of the
medications and if no long-term injury will occur. Taken together, if the children or
adolescents just have a normal life with this chronic disease. Parts of the therapy are
prevention (for example not smoking, either actively or passively, avoidance of allergens, if
possible), general procedures (for example participation on training courses of instruction,
doing sports, doing physiotherapy), pharmacotherapy and rehabilitation, if it is required.
The prescription of drugs should be carried out in accordance with an algorithm, which has
various steps depending on the severity of the bronchial asthma and gives the opportunity
to step up or step down. Standard drugs in pharmacotherapy of bronchial asthma are low-
dose inhaled glucocorticoids and orally administered leukotriene antagonists (additionally
or alternatively) for long-term therapy, as well as inhaled short-acting beta-sympatho-
mimetics for acute therapy. Because of this treatment, severe asthma attacks have become
very rare incidents.
5. Common viruses causing bronchitis in children
Acute bronchitis is almost (in approximately 90%) induced by viruses. The most common
ones are respiratory syncytial, parainfluenza-, influenza-, adeno-, rhino-, metapneumo- and
human bocavirus. Acute bronchitis, which is induced by bacteria primary, is rare (approxi-
mately 10%). In 15% of viral bronchitis a secondary bacterial infection will happen.
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5.1 Respiratory syncytial virus (RSV)
It is a member of the family of paramyxoviridae, has a single-stranded RNA and is
enveloped. We distinguish two serological groups A and B from each other. The
pathogenicity of the virus depends crucially on two glycoproteins on the viral surface:
glycoprotein G enables the docking with the host cell, such as pneumocytes, glycoprotein F
is responsible for the endocytosis into the cell. The fact that the affected cell undergoes a
fusion with neighbouring cells and form syncytia has given the virus its name. Further
details of incubation time, infection and clinical signs and symptoms are in the section
"Characteristics of RSV infection."
5.2 Parainfluenzavirus
It belongs to the family of paramyxoviridae, has a single-stranded RNA and an envelope. It
is (in contrast to the influenza viruses) genetically stable. There are 4 different types. The
transmission of the virus proceeds via droplet or smear infection. The incubation period is
3 - 6 days. At the age of 2 years, almost all children have been sick at least once with a
parainfluenza infection. In infancy and early childhood parainfluenza virus causes an acute
laryngotracheobronchitis with typical croup symptoms.
5.3 Influenzavirus
It is assigned to the family of orthomyxoviridae. It is divided into the 3 types A, B and C, of
which A and B are most relevant for infections of humans. The genome of influenza viruses
type A and B consists of eight single-stranded RNA segments. This creates a high genetic
variability of antigenic drift and antigenic shift, in the case of a dual infection. The eight
RNA segments contain the genetic information for 11 proteins, of which one is the
neuraminidase. Transmission paths of the virus are aerosols and saliva, as well as contact
with contaminated surfaces. The incubation period is 1 - 4 days. Typically we see a high
incidence of influenza during the winter months. The epidemic often has its origin in the
nursery, kindergarten or school. Because of the high contagiosity, pandemics with high
lethality may occur, recently caused by the H1N1 subtype, the so-called "swine flu". In
contrast to the common cold, the clinical course of the influenza infection is characterized by
significantly reduced general condition, high fever and a much higher complication rate.
Children with a disease of the respiratory tract, a heart failure or a deficiency of the immune
system have an especially high risk for severe complications. The diagnosis of influenza can
be made with a rapid test (usually an Elisa) or by RT-PCR, which is more sensitive and
specific, from a nasal or throat swab or corresponding rinse water.
In the case of a severe or complicated clinical course, treatment with an antiviral compound
is indicated. In childhood, the neuraminidase inhibitors oseltamivir (oral administration,
approved from the first year of life) and zanamivir (inhalation, approved from the fifth year
of life) are used. Safety studies were carried out in order to extend the approval of
oseltamivir on the first year of life. The vaccination against influenza provides the best
protection. Because of the high genetic variability of the virus, the vaccination has to be
repeated each year with a current antigen mixture. In addition to the self-protection, the
collective protection is of great importance.
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5.4 Adenovirus
It is a member of the family of adenoviridae. It is a double-stranded DNA virus with a
strong environmental resistance. More than 50 serotypes with various clinical manifesta-
tions have been identified so far. The transmission proceeds via droplet or smear infection.
The incubation time is between 2 and 10 days. Most adenovirus-induced diseases occur in
the age between 6 months and 5 years, usually in the form of a common cold. However, it
can lead to complicated clinical courses with severe obstruction, pneumonia or persistent
bronchial hyperreactivity for months.
5.5 Rhinovirus
It belongs to the family of picornaviridae, the RNA is single stranded. We know about
100 subtypes; the genetic variability is large. Rhinovirus is transmitted primarily via aerosol.
The incubation period is 2 - 5 days. In the first years of life, the incidence of infection with
the virus is around 1 - 2 times per year. Whereas in adults rhinovirus infections usually
cause a common cold, in infants and small children obstructive bronchitis appear quite
often.
5.6 Metapneumovirus
It is a member of the paramyxoviridae, a RNA virus and enveloped. We know 2 subtypes
A and B, each with two sub-groups A1 and A2, as well as B1 and B2. Droplet and smear
infections are the transmission paths. Incubation time is 4 – 6 days. During the first year of
life about one quarter of infants become infected with the metapneumovirus; by the time
children start school, almost everyone has had an infection with this ubiquitous virus. Most
prevalent symptoms are rhinitis and bronchitis.
5.7 Human bocavirus
The human bocavirus was discovered only in 2005. It belongs to the Parvoviridae family
and has a single-stranded DNA. The transmission of the virus proceeds via droplet or smear
infection. Accurate epidemiological data are yet to be collected. Clinically, acute respiratory
symptoms are most relevant.
6. Characteristics of RSV infection in children
6.1 Risk factors
An RSV infection, which occurs in infancy, may have a severe clinical course. Not only in
infancy, but until the age of 5 years, RSV infection may cause disorders of clinical relevance.
The majority of children undergo one or more RSV infections during the first 2 years of life,
usually without a severe or complicated course. Risk factors for a severe or complicated
clinical course are small, narrow airways (this is the reason why infants suffer worse than
older children). Boys are affected slightly more often than girls. Another risk factor, which
should not be underestimated, is the exposure to tobacco smoke. Furthermore, the family
history to allergies has an adverse influence. Pre-term birth or chronic diseases of the lung
increase the risk for a complicated course of a RSV infection considerably. We see a seasonal
accumulation with endemic-like clusters of RSV infections during the cold autumn and
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winter months. The transmission occurs by droplet and smear infection. The incubation time
is at 3 - 6 days.
6.2 Severity of the clinical course
If the RS virus affects the respiratory epithelium of the smallest bronchi and bronchioles
with desquamation of the epithelial cells and oedema of the mucosa, the main symptom is
bronchial obstruction. Distal to an obstructed airway, atelectatic areas may be formed, next
to emphysematic areas. If this causes a mismatch between ventilation and perfusion, the
main symptom is tachydyspnoea with partial or even global respiratory insufficiency. In
this case, the infant needs to get hospitalized for oxygen substitution and, if necessary, with
respiratory support or even mechanical ventilation. An additional reason for hospitalization
is the risk, especially in very young infants, of apnoea and death due to apnoea.
6.3 Diagnosis
The diagnosis can be carried out using a rapid test, which is based on the
immunofluorescence method. The inflammation parameters in the blood are only slightly
increased. The X-ray of the chest often shows diffuse infiltrations of the lung and a partial
reduction of the transmission due to emphysema.
6.4 Limitation of therapeutic options
The therapeutic options are very limited. Because the replication of the RS virus takes place
inside the epithelial cells of the lung, bronchodilatatory agents show no positive effect.
Treatment with steroids has no effect as well, what is confirmed by meta-analysis. An
antiviral therapy with the nucleoside analogue ribavirin is not recommended for the
following reasons: firstly, there seems to be no relevant effect; secondly, it is teratogenic and
has to be administered via aerosol, which could lead to an exposure of pregnant women
who are in contact to the child. There is only one agent with a small, but significant benefit
in the case of an RSV bronchitis or bronchiolitis; it is the leukotriene receptor antagonist
montelukast. Additionally, supportive therapy, such as inhalation with 0.9% NaCl or
decongestant nose drops may be helpful.
6.5 Indications for palivizumab
Palivizumab is a monoclonal antibody against the RS virus. It can be used for passive
immunization. It binds to the glycoprotein F, the fusion protein, and thereby prevents the
virus entering the cell. During the months with high incidence of RSV infections,
palivizumab has to be injected every 4 weeks. Palivizumab is indicated for significant
prematurity, bronchopulmonary dysplasia and hemodynamic relevant congenital heart
failures. The prophylactic immunization with palivizumab reduces severity and duration of
the disease significantly; the hospitalization frequency is halved.
6.6 Recent research on an active immunization
Previous research on an active vaccine, already carried out in the 1960s, was not successful.
Currently there are new research activities in this area. A life vaccine against RSV and PIV3
(parainfluenza virus type 3) is in phase 1 / 2 study.
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7. Bronchopulmonary dysplasia as a risk factor for bronchitis in children
7.1 Definition and pathophysiology
Today bronchopulmonary dysplasia (BPD) is more relevant than ever. Because of the major
advances in neonatology with high survival rates of extremely immature preterm infants,
there is an increase of diseases and complications, which are typically associated with
prematurity, like BPD. If very preterm infants are born, their lungs are not completely
developed, neither structurally nor functionally, especially with respect to the synthesis of
surfactant. Because of the respiration prior to maturity, the lung tissue undergoes a fibrotic
remodelling process of the alveoli. Prenatal and postnatal factors, such as inflammation,
infection, hyperoxia and mechanical ventilation, have an additional adverse effect.
Because the morphological alterations are not visible and the radiological ones do not
correlate well with the clinical severity, the BPD is defined by the duration of oxygen
supplementation for longer than 28 days. Depending on the amount of oxygen supplemen-
tation and the requirement of breathing support, we distinguish mild, moderate and severe
BPD.
7.2 Prophylaxis and therapy
The following prophylactic procedures may reduce the severity of BPD: the prenatal anti-
inflammatory treatment via administration of beta-dexamethasone to the mother, the so-
called “lung maturation”, is standard. The application of surfactant as soon as possible is
very important. A patent ductus arteriosus with hemodynamic relevance should be treated
early, if possible pharmacologically, if necessary via ligature. A protective effect of vitamin
A has been demonstrated, although the effect is only minor.
Therapeutic procedures are avoidance of hyperoxia, moderate infusion or even forced
diuresis. high-caloric nutrition, gentle ventilation mode, physiotherapy, and in very rare
cases, the postnatal application of corticosteroids.
7.3 Prognosis
The BPD also affects the future life of the children: they suffer more frequently with
bronchial hyperreactivity and asthma, they have an increased risk for the incidence of
respiratory infections, and in the first year of life they are more often hospitalized for acute
respiratory problems. Even if they have no symptoms, the measurement of lung function
will show worse values.
8. Differential diagnoses of bronchitis in children
8.1 Croup
In distinction from the original diphtheritic croup (which has become very rare thanks to the
vaccination), the common croup is a subglottic laryngitis with an inflammatory oedema of
the mucosa in the context of a viral infection of the respiratory system. The main prevalence
is at the age between 6 months and 6 years. Typically in the late evening or during the night
in the cold winter, the affected infants and children get an acute attack with a barking
cough, hoarseness, inspiratory stridor and dyspnoea. We divide the croup into 4 different
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degrees of severity, from just cough and hoarseness without dyspnoea to dramatic
dyspnoea with the feeling of combustion.
What are the urgent measures in the case of a croup attack? The first step is to reassure the
anxious and excited child. It should be kept in an upright position, in order to allow the use
of the thoracal muscles for breathing. The child should be brought into the fresh and cold
air, which may reduce the swelling of the respiratory mucosa. If available, a glucocorticoid
suppository can be administered by the parents. Prophylactically, a moistening of the air
indoors is recommended. In many cases of a moderate croup episode, these easy measures
may stabilize the situation, that the parents are able to manage it at home without any
professional help. However, in severe cases or in any cases of doubt, the ambulance should
be called immediately. The emergency doctor can initiate an inhalation with adrenaline, an
oxygen supplementation and an intravenous application of a glucocorticoid. If necessary,
the child can be hospitalized and monitored via pulse oximetry. In very rare cases, the
sedation of a child (for example with chloral hydrate) is unavoidable. In extreme severe and
complicated clinical courses, the treatment of the child at an intensive care unit is
recommended.
In the extremely rare case of a diphtheritic croup, the treatment with diphtheria antitoxin
has to start immediately. Also extremely rare (thanks to the haemophilus vaccination), a
bacterial epiglottitis occurs. But because of its rarity, the risk of misinterpretation as a
normal croup is quite high. In contrast to the croup, the epiglottitis usually is associated
with high fever, a very poor general condition, a septic clinical course, an increased
salivation and dysphagia. An epiglottis is always a peracute emergency. Inspection of the
pharynx using a spatula is strictly contraindicated, because the slightest mechanical
provocation can induce a complete occlusion of the epiglottis without any possibility for an
intubation. Then only cricothyrotomy or tracheostomy can be carried out, to save the life of
the child.
8.2 Aspiration
Aspiration of gastric juice or of a foreign body causes coughing. Common foreign bodies are
small pieces of an apple or a carrot, half or whole peanuts and all sorts of small parts made
of plastic or metal, quite often from the toys, the child has played with. We distinguish
between the acute and the chronic foreign body aspiration.
In the case of an acute aspiration the child has an abrupt coughing attack and dyspnoea.
Because the beginning of the right main bronchus from the trachea is angulated to a lesser
extent compared with the left one, it is preferentially affected. Over the affected side the
breath is quiet and wheezing can be heard. Radiologically, a mediastinal shift to the healthy
side can be seen.
In contrast to an acute aspiration, which is associated with an abrupt coughing attack and
dyspnoea, in the case of a chronic aspiration the clinical symptoms are milder and less
severe. In most cases the foreign body is smaller compared to those of an acute aspiration, so
that it can slide into a segmental bronchus, settle there and maintain an inflammatory
response, which occurs as a chronic cough. This is the reason why chronic aspirations quite
often get misinterpreted as a chronic bronchitis of infectious or allergic origin.
Lung Diseases – Selected State of the Art Reviews
454
For treatment the bronchoscopical removal of the foreign body is necessary, almost always
in the form of a rigid bronchoscopy.
8.3 Tuberculosis
In the case of a chronic cough it is important to take the possibility of a pulmonary
tuberculosis as a differential diagnosis into account, especially in children who come from
high-incidence countries, or if they have had or still have close contact with people coming
from such areas. The mycobacterium tuberculosis is transmitted via the aerosols, which
comes from coughing people with an open pulmonary tuberculosis. Children are generally
less contagious, even if they have an open pulmonary tuberculosis, because there are only a
few bacteria in the sputum. This phenomenon is called paucibacillary tuberculosis.
At the slightest suspicion of a tuberculosis infection, an appropriate diagnostic investigation
has to be made: next to an accurate medical history and physical examination,
immunological tests have to be carried out. These are an intracutanously applied tuberculin
test and an IGRA (interferon-gamma release assay) from the blood. The combination of both
tests results in an optimal specifity. Additionally, an X-ray from the chest at two levels
belongs to the standard diagnostic. The microscopical and microbiological analysis is made
from induced sputum or from gastric juice, because children younger than 10 years usually
are not able to give sputum spontaneously.
If, in the case of an exposure to tuberculosis, all diagnostic investigations have a negative
result, a chemoprophylaxis with isoniazid for 3 months is recommended. If the
immunological tests are positive, but the clinical course, the X-ray and the analysis of
induced sputum or gastric juice show normal results, then a preventive chemotherapy with
either isoniazid as monotherapy for 9 months or alternatively with isoniazid and rifampicin
as dual therapy for 4 months should be carried out. If a child has signs or symptoms of a
tuberculosis, if pulmonary or extra-pulmonary, a combination therapy with at least 3 tuber-
culostatic drugs has to be initiated, for example with isoniazid, rifampicin and
pyrazinamide. In most cases, after 2 months of treatment the medication can be reduced to
an isoniazid/rifampicin - dual therapy. The total duration of the treatment depends on the
clinical course and the severity of complication and is at least 6 months. Of course the choice
of the tuberculostatic drugs has to be adjusted to possible resistances.
8.4 Cystic fibrosis (CF)
If infants have recurrent obstructive bronchitis with a chronic cough and problems to
dissolve the mucus, one differential diagnosis, which has to be taken into account, is CF.
Even though it is a rare disease, it is still one of the most common hereditary diseases. The
mode of inheritance is autosomal recessive and caused by a mutation in the CFTR (cystic
fibrosis transmembrane conductance regulator) - gene, which encodes a chloride ion
channel. More than 1500 mutations have been known. The mutation deltaF508 describes the
deletion of 3 base pairs, what causes the lack of phenylalanine at position 508 of the protein
chain, and is with 70% by far the most frequent one. Depending on the amount of the CFTR
defect, there are milder and more severe clinical courses of the disease. Due to the
dysfunction of the chloride ion channel, the epithelial fluid film becomes hyperosmolar and
the produced mucus gets dyscrinic.
Bronchitis in Children 455
The clinical course is characterized by this problem. Shortly after birth, due to the viscous
intestinal secretion, a meconium ileus can be the first complication of a CF. The same
problem may occur in later life as distal intestinal obstruction syndrome (DIOS). The most
important focus in the progress of the CF is the respiratory system. The viscous sputum
cannot be mobilized and brought out adequately, what gives bacteria a good medium for
colonization, unfortunately quite often with mucoid pseudomonas aeruginosa and other
multi-resistant bacteria. Also pulmonary mycoses (for example an aspergillosis) may occur.
These permanent inflammatory processes lead to an irreversible tissue remodelling of the
respiratory tract. At the end, atelectatic areaes and emphysematic bullae, insufficient for
ventilation or diffusion, replace the normal tissue. Haemoptysis and pneumothoraces are
dreaded complications. About 90% of all patients with CF develop an exocrine pancreatic
insufficiency with the consequence of an inadequate intestinal absorption of proteins, fats
and fat-soluble vitamins, which leads to dystrophy of the affected patients. With further
progress of the disease, an endocrine pancreatic insufficiency may occur, which is why
about 15% of all patients with CF develop an insulin-dependent diabetes mellitus.
Therapeutical tools are the removal of bronchial secretions by autogenic drainage,
physiotherapy, inhalations, mucolysis and ample fluid intake, the antibacterial treatment by
intravenous antibiotics, the stimulation of the digestion by dietary fibre enriched food and
physical activity, the improvement of the intestinal absorption by replacement of enzymes
(porcine pancreas powder) and substitution of vitamins, and the counteraction of dystrophy
by high-caloric nutrition.
In the most patients with CF, the life limiting factor is the global respiratory insufficiency.
Often, lung transplantation is the only life-prolonging option. Because of the enormous
medical progress, especially in the development of new antibiotics, the life expectancy of
people with CF increases steadily and rapidly. CF as a disease which occurs exclusively in
childhood is part of medical history.
8.5 Primary ciliary dyskinesis
A primary ciliary dyskinesis often causes recurrent bronchitis. It is a genetically determined
(usually autosomal recessive) disorder of the respiratory ciliated epithelium and other
ciliated cells, resulting in a reduction in mucociliary clearance. Typical clinical symptoms are
chronic rhinitis and sinusitis with much secretion, chronic bronchitis with a productive
cough and recurrent pneumonia. Additional possible abnormalities are the formation of a
hydrocephalus (due to the lack of ciliary motility of the ependymal cells), infertility in male
(due to the lack of motility of the sperms) and in female patients (due to the lack of motility
of the cilia of the fallopian tube) or a situs inversus (due to the absence of a directed cilia
beat during the embryogenesis). A situs inversus occurs in 50% of the patients who are
affected by the primary ciliary dyskinesis and it is called Kartagener's syndrome. In the
diagnostic investigation of the primary ciliary dyskinesis the measurement of exhaled NO
and the analysis of the ciliary function using a light microscope are purposeful tools. For
confirmation of the diagnosis, an analysis via an electron microscope is needed. Therapeutic
options are physiotherapy, inhalation and antibiotic treatment in the case of bacterial
infections.
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456
8.6 Vocal cord dysfunction
The vocal cord dysfunction (VCD) is a functional disorder with an acute spasm of the vocal
cords. In most cases school children are affected. A VCD attack can range from a mild
dyspnoea to the feeling of suffocation. Fortunately, such episodes are not life threatening,
because despite the vocal cord spasm a small air gap still remains. Possible triggers for a
VCD attack are coughing, physical exertion, inhalation of cigarette smoke or reflux of gastric
juice, postnasal drip syndrome and general stress.
8.7 Gastroesophageal reflux
In the case of a recurrent or chronic cough, of course at first everybody thinks of a disease of
the respiratory system. However, a gastroesophageal reflux may also cause such symptoms.
Especially in the first months of life, chyme and gastric juice can flow back into the
oesophagus and induce an inflammation of the mucosa there. Clinical symptoms may be
heartburn, regurgitation, vomiting, feeding problems and finally dystrophia. Further
symptoms may be a cough, hoarseness, bronchial obstruction, episodes with apnoea and
cyanosis, as well as pneumonia due to aspiration. In order to avoid the gastroesophageal
reflux in infants, the nutrition can be thickened and the feeding portions can be reduced by
increasing the feeding frequency. In addition, the upper body should be slightly elevated.
Potential drugs are antacids or proton pump blockers.
9. Inflammation parameters in the case of bronchitis in children
9.1 C-reactive protein (CRP)
CRP is an annular pentamer with sub-units composed of 206 amino acids each. It is
synthesized in the liver and then secreted into the blood. Its concentration in the blood
increases within 6 to 48 h in the case of any systemic inflammation. That can be an infectious
disease, an immune reaction of non-infectious etiology or large tissue damage. Thus, CRP is
an unspecific marker for inflammation and its increase starts with delay. Depending on the
laboratory, a plasma concentration up to 0.1 - 1 mg/dl is in the normal range.
Concentrations between 1 – 10 mg/dl are typical for mild to moderate concentrations,
> 10 mg/dl for severe inflammation. Because of the reasonably long half-life of
approximately 24 h, CRP is ideal for the follow-up monitoring of an inflammatory process
which can help to evaluate the effectiveness of a treatment.
9.2 Interleukin-6 (IL-6)
IL-6 is a proinflammatory cytokine consisting of 184 amino acids. It is released primarily by
monocytes, but also by T-lymphocytes, as well as endothelial and epithelial cells. Infections,
non-infectious immunological reactions, tissue hypoxia and trauma induce the release of
IL-6 within 6 h. Thus, IL-6 is an unspecific marker for various forms of inflammation as well,
but its increase starts much faster. Depending on the laboratory, a plasma concentration up
to 10 – 50 ng/l is in the normal range. The half-life in the blood is just a few minutes.
Because of this very short half-life, the kinetics shows a narrow peak with the risk of false
negative results in the case of measurements outside this peak.
Bronchitis in Children 457
9.3 Complete blood count (CBC)
The CBC may also be helpful in the diagnosis of an inflammation. High increases in the
amount of the leucocytes occur in bacterial infections, but also in other inflammatory
processes. Like CRP and IL-6, CBC is a non-specific marker of general inflammation. The
increase of the leucocytes needs several hours and starts a little bit earlier than the increase
of the CRP level. The standard value of the amount of leucocytes depends on the age of life:
for adults 4 - 10 / nl, for school children 5 - 15 / nl, for small children 6 - 17,5 / nl and for
newborns even 9 - 30 / nl are physiological. The differential blood count shows a reactive
shift to the immature leucocytes, because their reinforced presence in the peripheral blood
induces an enhanced release of still premature leucocytes from the bone marrow.
9.4 Erythrocyte sedimentation rate (ESR)
The ESR is a very non-specific marker for any kind of inflammation. The pathophysiological
mechanisms, which lead to a higher ESR, are as follows: in the case of an inflammatory
condition, erythrocytes form aggregates, which have a lower flow resistance compared to
the sum of each separate erythrocyte. Furthermore, higher concentrations of acute phase
proteins (like CRP), of fibrinogen or of immunoglobulins in the plasma, increase the ESR. It
takes several weeks, after an inflammation has taken place, until an increased ESR gets
normalized again. Standard value for boys or male adolescents is a sedimentation of 15 mm
during 1 h, for girls or female adolescents 20 mm during 1 h.
9.5 Procalcitonin (PCT)
PCT is a protein which is constructed from 116 amino acids. It is produced mainly in the
parafollicular C cells of the thyroid gland and in various neuroendocrine cells. Under
physiological conditions, it acts as a prohormone of calcitonin. It is known that the release of
PCT increases in the case of an infection, which is caused by bacterials, fungi or parasites. In
this special condition, PCT is secreted predominantly in cells other the thyroid gland,
including leukocytes, adipocytes, myocytes and hepatocytes. Stimuli for the synthesis of
PCT in these cells are bacterial endotoxins (lipopolysaccharides = LPS) and cytokines
(Interleukin - 1 beta, tumour necrosis factor - alpha). The pathophysiological significance of
PCT increase has not yet been clarified. Anyway, there is no effect on the thyroid gland.
The PCT level in the blood increases within 3 h after stimulation by endotoxins or cytokines.
The maximum of the PCT level is reached after 8 – 24 h and will be stable for another 24 h.
Then the PCT amount will decrease again with a quite long half-life of 20 – 24 h. In healthy
individuals, the physiological PCT level is < 0.5 µg/l. Values from 0.5 to 2.0 µg/l are
associated with a mild respective moderate systemic infection, values from 2.0 to 10.0 µg/l
with a severe systemic infection and values > 10.0 µg/l are in the majority of cases a sign of
a sepsis. The amount of PCT correlates with the severity of the infectious disease and the
mortality rate. In other very severe diseases, such as multiple trauma, large-scale burning,
cardiogenic shock or multiple organ failure, the PCT level increases as well.
PCT remains nearly unaffected in the case of a localized, a viral, an autoimmunological or
an allergic inflammation. For this reason it is an excellent marker for the rapid
differentiation between viral and bacterial systemic (= antibiotic-requiring) infections.
Lung Diseases – Selected State of the Art Reviews
458
Furthermore, PCT is well suited for the monitoring of the course of a systemic bacterial
infection.
A big advantage of PCT, compared to CRP, CBC and ESR, is its much faster increase, which
allows a very early detection of a systemic bacterial infection. Moreover, its predictive value
for prediction of sepsis with 0.93 is much better than that of CRP, which is only 0.68.
Furthermore, the interference by a therapy with steroids is much lower. One advantage
compared to IL-6 is the better biological stability with a much longer half-life, what reduces
the risk of false negative results. Additionally, in contrast to IL-6, autoimmunological
inflammations do not interfere with PCT.
The measurement of the PCT level in patients with a febrile infection may be helpful to
decide whether or not a patient needs an antibiotic treatment. In a clinical study it has been
shown that by using a simple algorithm, the knowledge of the PCT level could reduce the
administration of antibiotics from 80% previously to 44%.
On the one hand one wants to avoid the “treatment” of a viral infection with antibiotics, on
the other hand one wants to assure the start of a required antibiotic therapy in time.
Especially newborns and young infants may undergo fulminant clinical courses in the form
of severe sepsis, for which reason this age group is very critical, and it is not acceptable to
delay the start of an antibiotic treatment. Generally, it seems to be useful to give the
measurement of PCT a higher priority than is currently given.
10. Therapeutic concepts for bronchitis in children - pro and contra
In general, a bronchitis may be treated symptomatically, because in most cases it is caused
by an viral infection, and there exists no specific treatment. But the importance of the so-
called household remedies should not be underestimated: an adequate fluid intake and
inhalation of 0.9% NaCl may help to keep the bronchial mucosa moist and to liquefy the
mucus. Sage drops may reduce the tussive irritation. The inhalation of essential oils, which
are suitable for children, may also help to reduce discomfort, but it should be noted that
there is a small risk of sensitization. In addition, there are a number of drugs (some are
available in the pharmacy without prescription, some have to be prescribed), which have a
reasonably proficient efficacy.
10.1 Sympathomimetic
For the treatment of an acute bronchial obstruction beta 2 - agonists are used, which have a
selective effect on the respiratory system, in order to minimize beta 1 – receptor - mediated
adverse effects on the heart. The binding of the drug to its receptor activates the adenylyl
cyclase whereby ATP is converted to cAMP. That leads to a relaxation of the smooth
musculature via a reduction in calcium ion concentration in the cells, and it leads to an
inhibition of the release of mediators from mast cells. Generally, short-acting beta 2 -
agonists, such as salbutamol, are used. In most cases salbutamol is applied in the form of
inhalation, the common dosage is about ½ drop per kg body weight in about 2 ml 0.9%
NaCl, administered with an ultrasonic nebulizer. Alternatively, especially en route,
1 – 2 puffs of a spray via a spacer can be used. The frequency of inhalation depends on the
severity of bronchial obstruction. 3 - 6 applications in 24 hours are an average frequency
Bronchitis in Children 459
during an acute obstructive bronchitis, but it can be increased, if necessary. The oral
administration of salbutamol is possible, but because of a lower efficacy and an increase of
adverse effects due to a higher intake into the blood this is not recommended as a first
choice. Common adverse effects are restlessness, heart palpitations and shakiness. These
symptoms are induced by an increased sympathetic activity and can be reduced by
reduction of the single dosage or the frequency of administration. In pregnant female
adolescents, salbutamol can induces tocolysis via the beta 2 - receptor.
10.2 Anticholinergic
Anticholinergics inhibit acetylcholine due to competition on the muscarinic acetylcholine
receptors and antagonize its bronchoconstrictive effect. They were applicated via inhalation.
In comparison to the sympathomimetics, their effect is weaker and occurs with a delay.
Ipratropium bromide is used most frequently, usually in addition to a beta 2 - agonist, if the
sympathomimetic effect is not sufficient. Possible side effects include dry mouth, a bitter
taste, tachycardia and arterial hypertension.
10.3 Methylxanthine
The exact mechanism of action of methylxanthines, such as theophylline, is not fully known.
Several different mokecularbiological pathways seem to be involved: methylxanthines
inhibit the phosphodiesterase, increase intracellular cAMP and antagonize effects on the
adenosine receptors. Due to these mechanisms, methylxanthines have bronchodilatatory
and anti-inflammatory effects and they stimulate the respiratory centre in the brain stem.
They are rarely used, mainly as reserve medication for severe asthma - attacks. Theophylline
is then usually given as a continuous infusion. The side effects can be serious: tachycardia,
extrasystoles, arterial hypertension, restlessness, insomnia, gastrointestinal disorders or
increased diuresis.
10.4 Glucocorticoid
Glucocorticoids induce the secretion of lipocortin, a glycoprotein which inhibits the
phospholipase A2 and thereby reduces the release of arachidonic acid. Due to this
mechanism, the cyclooxygenase pathway produces less prostaglandins and the
lipoxygenase pathway less leukotrienes. Several cytokines, particularly interleukin-1,
interleukin-2 and tumour necrosis factor – alpha, are produced in a reduced amount as well.
In the peripheral blood the number of monocytes is decreased and also their bactericidal
and chemotactic effects, as well as their migration are reduced. All these changes have a
non-specific anti-inflammatory effect. Depending on the half-life, glucocorticoids are
divided into short-acting (for example cortisone and cortisol), medium-acting (for example
prednisone, prednisolone and methyl prednisolone) and long-acting (for example
dexamethasone) substances. The systematic administration of glucocorticoids over a short
time period may be necessary in the case of an acute severe bronchial obstruction. In infants
and young children the application can be carried out in the form of a suppository, which
can be done at home by the parents. If a child with an acute severe bronchial obstruction is
brought into the emergency room, the intravenous application is part of the standard
therapy. The long-term treatment with a glucocoticoid should be done topically, that is via
Lung Diseases – Selected State of the Art Reviews
460
inhalation. Commonly used corticosteroids for an inhalation therapy are budesonide,
beclomethasone and fluticasone. The dosages are here in the microgram range; that means,
they are by a factor of 100 – 1000 lower than the systemically given dosages. Thereby any
side effects are reduced to a minimum. Parents who are afraid of the possible adverse effects
of corticoids from long-term treatment should have an informative consultation. If they have
the relevant knowledge, then their worries should be placated. If there are local side effects ,
for example the development of an oral thrush these can arise after inhalation if the mouth
is not rinsed with water.
10.5 Leukotriene antagonist
Leukotrienes, products of the arachidonic acid metabolism, are synthesized in mast cells,
macrophages, eosinophils and basophils. They have a very strong bronchoconstrictive effect
(1000-fold more potent than histamine), induce an oedema of the bronchial mucus via
increasing the capillary permeability and increase the production of mucus. Additionally,
leukotrienes have a chemotactic influence on inflammatory cells, especially the eosinophils,
which sensitizes the nerve fibres occurring in the respiratory tract, resulting in a bronchial
hyperreactivity. The most common leukotriene antagonist is montelukast. Because its
structure is similar to the leukotriene D4, it acts as a selective competitor at the receptor
without the effects mentioned above. Montelukast is used as a long-term anti-inflammatory
therapy, often in combination with a topical corticosteroid. Montelukast is administered
orally in the evening. The adverse effects that may occur include headache and abdominal
pain.
10.6 Mucolytic
Mucolytic respective secretolytic drugs are expectorants. In contrast to secretomotoric
drugs, which increase the activity of the ciliated epithelium, expectorants should cause a
liquefaction of the bronchial mucus to make it easier to cough it up. Among the mucolytics
are acetylcysteine, bromhexin and ambroxol. Acetylcysteine cleaves the disulfide bonds of
the mucopolysaccharides. Furthermore, it has an anti-inflammatory effect due to catching
free radicals with its reactive SH group. Bromhexin activates enzymes, which cleave the
molecules of the mucus and stimulate the glandular cells to increase the mucus production,
reduce the viscosity. Ambroxol is a metabolite of bromhexin. In addition to the effects of
bromhexin, it stimulates the synthesis of surfacant. Some herbal substances, such as ivy, also
belong to mucolytic drugs. Generally, the therapeutic significance of all these so-called
cough syrups should not be overestimated. It is much more important that the children
drink enough and make inhalations.
10.7 Antitussive
Antitussives reduce the cough by acting on the brain stem. Opiates, like codeine,
dihydrocodeine, hydrocodone or noscapine, are the most common drugs against tussive
irritation. There are newer substances, such as pentoxiverin, which have the advantage of
lacking a sedative effect or an addiction potential. Pentoxiverin is an agonist at the sigma
receptor and also acts antagonistically at the muscarinic M1 receptor. Potential side effects
are nausea, vomiting and diarrhoea. It is contraindicated in children younger than 2 years
Bronchitis in Children 461
because a depressant effect on the respiration cannot be excluded, and in pregnant women
because there are no sufficient safety data. However, in childhood antitussives, these should
be prescribed only in rare cases with a non-productive cough. Otherwise, if a productive
cough is inhibited, the mucus remains in the airways, increasing the risk of secondary
bacterial infections with bronchopneumonia.
10.8 Antibiotic
In the case of a bacterial infection treatment with antibiotics is recommended. The choice of
the appropriate antibiotic depends on the age of the child, because in different age groups
there are different spectra of bacteria. After receiving the antibiogram, the antibiotic therapy
can be specified in accordance to sensitivities and resistances of the bacterium. Between
community-acquired and nosocomial infections, bacterial spectra differ as well. Sometimes
it is not possible to distinguish between a viral and a bacterial infection, since the clinical
course and the blood parameters can be quite similar. In this situation it may be that a child
will be treated with an antibiotic, although it is just a viral infection with high fever.
10.9 Oxygen supplementation
In the case of severe bronchial obstruction with spasms of the bronchial musculature, with
oedema of the bronchial mucosa and production of viscous secretions, ventilation in the
airways and diffusion in the alveoli may be disturbed. This can cause a partial (hypoxia,
normocapnia) or global (hypoxia, hypercapnia) respiratory insufficiency. If the
transcutanously measured oxygen saturation in the blood is too low, the supplementation of
oxygen is necessary. Usually the oxygen is supplied via nasal prongs. If small children do
not tolerate nasal prongs, a mask can be placed in front of the face, especially during sleep.
In the treatment of premature infants with a respiratory distress syndrome, we have
different procedures, because there the toxic effect of oxygen on the immature organs has to
be taken into account. Complications caused by oxygen can be BPD, the retinopathy of
prematurity and an apoptosis-mediated neurodegeneration. The monitoring of the
premature infants should contain a capnometric analysis next to the measurement of the
oxygen saturation.
10.10 Physiotherapy
Physiotherapy is required in the case of chronic diseases of the respiratory system (for
example cystic fibrosis or primary ciliary dyskinesis), but also in the case of acute
pneumological problems (for example the formation of an atelectasis as a complication of
pneumonia). The aims of physiotherapy are to attain effective ventilation of all lung sections
and an effective drainage of secretion.
10.11 Nasal drops
0.9% NaCl - nose drops are used to moisten and clean the nasal mucosa. Decongestant nose
drops (dependent on age 0.25%, 0.5% or 1% xylometazoline) should be given, if the
eustachian tube is swollen in response to an infection of the upper airways, in order to
guarantee the ventilation of the middle ear. These nose drops should not be given for longer
Lung Diseases – Selected State of the Art Reviews
462
than 7 days, otherwise they could lead to an irreversible damage of the mucosa. A stuffy
nose is not a good reason for the application of decongestant nose drops. Depending on the
age of the child, a nose spray may be used instead of nose drops.
11. References
Brodzinski H, Ruddy RM. (2009). Review of new and newly discovered respiratory tract
viruses in children. Pediatr Emerg Care, 25 (5), 51-63, ISSN 0749-5161
Bundesärztekammer (BÄK), Kassenärztliche Bundesvereinigung (KBV), Arbeitsge-
meinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften (AWMF).
(2011). Nationale VersorgungsLeitlinie Asthma – Kurzfassung, 2. Auflage. Version 1.3,
available from: http://www.versorgungsleitlinien.de/themen/asthma
Deutsche Gesellschaft für Pädiatrische Infektiologie (DGPI) e. V. (2009). DGPI Handbuch,
Infektionen bei Kindern und Jugendlichen, Thieme-Verlag, ISBN 978-3-13-144715-9,
Stuttgart
Deis JN, Creech CB, Estrada CM, Abramo TJ. (2010). Procalcitonin as a marker of severe
bacterial infection in children in the emergency department. Pediatr Emerg Care, 26
(1), 51-63, ISSN 0749-5161
Global Initiative for Asthma (GINA). (2010). Global Strategy for Asthma Management and
Prevention, available from: http://www.ginasthma.org
Mitchell I. (2009). Treatment of RSV bronchiolitis: drugs, antibiotics. Pediatr Respir Rev, 10
Suppl 1, 14-15, ISSN 1526-0542
Ramanuja S, Kelkar PS. (2010). The approach to pediatric cough. Ann Allergy Asthma
Immunol, 105 (1), 3-8
Rieger C, von der Hardt H, Sennhauser FH, Wahn U, Zach M (Eds.). (2004). Pädiatrische
Pneumologie, Springer-Verlag, ISBN 3-540-43627-8, Berlin
Wainwright C. (2009). Acute viral bronchiolitis in children – a very common condition with
few therapeutic options. Pediatr Respir Rev, 11, 39-45, ISSN 1526-0542
Article
Background Acute bronchitis is one of the most common pediatric diseases. In addition to conventional therapies, a frequent use of complementary and alternative medicine (CAM) has been stated. Anthroposophic medicine (AM) is one of the most practiced complementary and integrative medicine (CIM) approaches in Central Europe but hitherto no consensus-based clinical recommendations or guidelines are available. Therefore, a consensus-based recommendation leading to an informed and reasonable use of AM in the treatment of acute bronchitis in pediatrics was developed. Methods A total of 61 physicians in Germany with expertise in the field of anthroposophic pediatrics was invited to complete an online multistep Delphi process. Two independent reviewers quantitatively and qualitatively evaluated the results. The survey was completed when >75 % consensus was achieved. Results The clinical recommendation comprises 15 subitems related to treatment as well as clinical and psychosocial aspects. All items reached strong consensus (>90 %; N = 9) or consensus (75–90 %; N = 6). Conclusion The comprehensive clinical recommendation creates a scientific base for the anthroposophic integrative treatment of acute bronchitis in children in Germany. It will make the anthroposophic approach more applicable, understandable and comparable to a wider public of physicians and other health professionals in Germany.
Article
RSV bronchiolitis is one of the most common reasons for hospital admission and for visits to emergency departments for children, and at least half of affected infants will have subsequent episodes of respiratory illness. Despite this, there are wide variations in management. Initial assessment of respiratory status should include a measure of oxygenation and oxygen should be given when there is clinical evidence of respiratory distress even before full assessment is completed. Fluid and nutritional status should also be assessed early and decisions made about use of intravenous fluids, nasogastric feeding, or maintenance of frequent feeds orally. Given the lack of evidence on all drug therapies for bronchiolitis, clinicians should carefully evaluate treatments for their ability to reduce symptoms, decrease length of hospital stay and reduce sequelae. Furthermore, clinicians should monitor antibiotic use carefully and develop a strategy to change current physician practice.
Article
To provide an overview of pediatric cough, with specific emphasis on various causes, to aid in diagnosis and treatment. Relevant articles and references published between January 1, 1961, and May 1, 2009, were found through a PubMed search using the following keywords: pediatric cough and cough in children. All key relevant articles and textbook sections were reviewed, and the most relevant were selected for inclusion in this review. Although asthma, gastroesophageal reflux disease, and postnasal drip can be causes of cough in children, it is important to think of other potential causes, such as bronchitis, postviral cough, and foreign-body inhalation. Testing and treatment for cough will vary, depending on the presentation and diagnosis. Just as in adults, in children, the cause of cough can be multifactorial. Pediatric cough is commonly encountered by primary care physicians and allergists. Physicians should be aware of the various potential causes of cough in children to properly determine the cause so that testing and treatment can proceed appropriately.
Article
Acute viral bronchiolitis remains a cause of substantial morbidity and health care costs in young infants. It is the most common lower respiratory tract condition and most common reason for admission to hospital in infants. Many respiratory viruses have been associated with acute viral bronchiolitis although respiratory syncytial virus (RSV) remains the most frequently identified virus. Most infants have a mild self limiting illness while others have more severe illness and require hospital admission and some will need ventilatory support. Differences in innate immune function in response to the respiratory viral insult as well as differences in the geometry of the airways may explain some of the variability in clinical pattern. Young age and history of prematurity remain the most important risk factors although male gender, indigenous status, exposure to tobacco smoke, poor socioeconomic factors and associated co-morbidities such as chronic lung disease and congenital heart disease increase the risks of more severe illness. Supportive therapy remains the major treatment option as no specific treatments to date have been shown to provide clinically important benefits except for inhaled hypertonic saline. Prophylaxis of high risk infants with palivizumab should be considered although the cost effectiveness is still unclear. Many questions remain regarding optimal management approaches for infants requiring hospitalisation with bronchiolitis including use of nasogastric feeding, the optimal role of supplemental oxygen, optimal use of hypertonic saline and the role of combinations of therapies, the use of heliox or modern physiotherapy approaches.
Article
Procalcitonin, the prohormone of calcitonin, is a relatively new and innovative marker of bacterial infection that has multiple potential applications in the pediatric emergency department. In healthy individuals, circulating levels of procalcitonin are generally very low (<0.05 ng/mL), but in the setting of severe bacterial infection and sepsis, levels can increase by hundreds to thousands of fold within 4 to 6 hours. Although the exact physiologic function of procalcitonin has not been determined, the consistent response and rapid rise of this protein in the setting of severe bacterial infection make procalcitonin a very useful biomarker for invasive bacterial disease. In Europe, serum procalcitonin measurements are frequently used in the diagnosis and the management of patients in a variety of clinical settings. To date, the use of procalcitonin has been limited in the United States, but this valuable biomarker has many potential applications in both the pediatric emergency department and the intensive care unit. The intent of this article is to review the history of procalcitonin, describe the kinetics of the molecule in response to bacterial infection, describe the laboratory methods available for measuring procalcitonin, examine the main causes of procalcitonin elevation, and evaluate the potential applications of procalcitonin measurements in pediatric patients.
Article
Respiratory tract viral infection continues to be among the most common reasons for emergency department visits and hospitalization of children, particularly infants younger than 1 year, in the United States. Throughout the years, clinicians have considered respiratory syncytial virus followed by influenza as the most common pathogens responsible. Over the past decade, new viruses have been discovered through both more specific testing and the finding of new agents causing infection. This includes human metapneumovirus, which leads to similar but often epidemiologically more severe clinical symptoms than respiratory syncytial virus. Other agents responsible for lower respiratory tract infection include Coronavirus (severe acute respiratory syndrome), Bocavirus, and others. This review serves to focus on some of the recent literature on these agents and the clinical impact they have on pediatric lung infection.
Pädiatrische Pneumologie
  • C Rieger
  • Von Der Hardt
  • H Sennhauser
  • Fh Wahn
Rieger C, von der Hardt H, Sennhauser FH, Wahn U, Zach M (Eds.). (2004). Pädiatrische Pneumologie, Springer-Verlag, ISBN 3-540-43627-8, Berlin
DGPI Handbuch, Infektionen bei Kindern und Jugendlichen, Thieme-Verlag, ISBN 978-3-13-144715-9 Procalcitonin as a marker of severe bacterial infection in children in the emergency department
Deutsche Gesellschaft für Pädiatrische Infektiologie (DGPI) e. V. (2009). DGPI Handbuch, Infektionen bei Kindern und Jugendlichen, Thieme-Verlag, ISBN 978-3-13-144715-9, Stuttgart Deis JN, Creech CB, Estrada CM, Abramo TJ. (2010). Procalcitonin as a marker of severe bacterial infection in children in the emergency department. Pediatr Emerg Care, 26 (1), 51-63, ISSN 0749-5161
Global Strategy for Asthma Management and Prevention
Global Initiative for Asthma (GINA). (2010). Global Strategy for Asthma Management and Prevention, available from: http://www.ginasthma.org