Protracted Bacterial Bronchitis In Children

• Is an infective cause of chronic wet cough lasting longer than 4 weeks in children.
• Occurs in <5 years of age
• If the child has a dry cough, this excludes the diagnosis of protracted bacterial bronchitis.
• Evidence suggests that PBB may be a common enough condition to warrant its inclusion in national and international cough guidelines.
• The hallmarks of PBB are
  • prolonged moist or productive cough
  • lasts >4 weeks
  • response to antibiotics.
• the key distinguishing feature of PBB is usually an absence of waxing and waning coryzal symptoms with improvement to dry cough.
• If left untreated, children with PBB continue to have wet cough for months or years.
• Wheeze is documented in 50–75% of these children
• the diagnosis has a high degree of overlap with other wheezing conditions including asthma, tracheomalacia and bronchomalacia.
• rarely evolves into pneumonia, but concern exists that in the long term, if left untreated, bronchiectasis may develop
• Bronchoscopy is no longer considered necessary, because of its semi-invasive nature, and usually one or two courses (2–6 week) of antibiotics (usually amoxicillin/clavulanic acid), are curative
• Evidence of antibiotic efficacy with symptom dissipation usually occurs within 2 weeks but continuation of antibiotics for a further 4 weeks is thought to be required to allow for airways healing if symptoms have been prolonged.
• Despite initial resolution, later recurrence and need for repeat treatment is required in the majority of patients.

Symptoms: Cough

• • Present for longer than 4 weeks
  • Cough is an isolated symptom and the child is otherwise well
  • Wet or moist in nature,
  • ‘rattly’ sound often present on chest examination
  • The cough is present day and night
  • Worsens when changing posture
  • Coughing episodes can cause shortness of breath but shortness of breath is not present at other times.

Causes

• Haemophilus influenzae
• Streptococcus pneumoniae
• Moraxella catarrhalis.

Differentials

• Asthma—consider if wheeze, shortness of breath and night cough are present
• Environmental exposure to cigarette smoke—smoke is a significant trigger for cough.
• Postviral cough—following an acute viral respiratory tract infection, such as acute rhinosinusitis or acute bronchitis, cough may last up to 8 weeks
• Upper airway cough syndrome (previously called postnasal drip)—consider if the child has acute rhinitis
• Retained inhaled foreign body—if the cough was sudden in onset, particularly if cough started while the child was eating or playing with small objects
• Infections
  • Pertussis (whooping cough)
  • Lung abscess
  • Tuberculosis
• Congenital airway abnormalities
  • Tracheomalacia
  • Vascular ring
• Chronic lung disease (eg bronchiectasis)—consider if clubbing of the fingers, chest wall deformity or abnormal growth or development are observed.
• See cough in adults or cough in children for an overview of diagnosis and general

Treatment:

• Amoxicillin+ Clavulanate (child 2 months or older) 22.5+3.2 mg/kg up to 875+125 mg orally, 12-hourly for 2 weeks     Or

• Cefuroxime (child 3 months or older) 15 mg/kg up to 500 mg orally, 12-hourly for 2 weeks Or
• Trimethoprim+sulfamethoxazole (child 1 month or older) 5+25 mg/kg up to 160+800 mg orally, 12-hourly for 2 weeks

• Duration of therapy :
  • Continue antibiotic therapy for the full 2-week course because symptoms often return if the course is shortened.  If the cough does not resolve within 2 weeks, extend antibiotic therapy for a further 2 weeks (4 weeks total duration of therapy).
  • If the cough does not resolve after 4 weeks of antibiotic treatment, or if the child has frequent recurrences of cough, refer the child to a paediatrician or paediatric respiratory specialist to exclude other causes of chronic cough such as bronchiectasis