Bronchiectasis. Third report on a follow-up study of medical and surgical cases from childhood

The In-between: Time to Talk About Bronchiectasis in Adolescents and Their Transition to Adult Care

Paediatric and adult bronchiectasis patients have been addressed in the literature as two different populations due to several differences, but there is insufficient evidence to understand how and when disease characteristics really change along patients' lifespan. This lack of knowledge is evident in all aspects of the transition: insufficient data is available about radiology, lung function, microbiology and treatment, and only limited information is currently available about changes in clinical presentation and psychosocial aspects. For instance, symptoms seem to improve during the third and fourth decades of life, a period sometimes referred to as the "honeymoon phase". However, adolescents with bronchiectasis have poorer quality of life than healthy peers, suggesting, therefore, potential disease underestimation at this age. This scarcity of data most likely hinders the design of appropriate evidence-based transition protocols, ultimately limiting our ability to understand the factors driving disease progression and how to prevent it. Nowadays it is crucial to raise awareness about this neglected aspect of bronchiectasis care, and fill this cultural and scientific gap by joining forces between pediatricians and adult physicians, to understand and stop disease progression and, lastly, to provide the best possible care to our patients in all phases of their lives.

Utilization of Inhaled Antibiotics in Pediatric Non-Cystic Fibrosis Bronchiectasis: A Comprehensive Review

The lack of available treatments in pediatric non-cystic fibrosis (non-CF) bronchiectasis is a major concern, especially in the context of the increasing disease burden due to better detection rates with advanced imaging techniques. Recurrent infections in these patients are the main cause of deterioration, leading to impaired lung function and increasing the risk of morbidity and mortality. Since pediatric non-CF bronchiectasis with early recognition and appropriate treatment can be reversible, optimal management is an issue of growing significance. The use of inhaled antibiotics as a treatment option, although a standard of care for CF patients, has been poorly studied in patients with non-CF bronchiectasis, especially in children. In this review, we present the current data on the potential use of inhaled antibiotics in the treatment of non-CF bronchiectasis and assess their safety and efficacy profile, focusing mainly on children. We conclude that inhaled antibiotics as an adjuvant maintenance treatment option could be tried in a subgroup of patients with frequent exacerbations and recent or chronic Pseudomonas aeruginosa infection as they appear to have beneficial effects on exacerbation rate and bacterial load with minimal safety concerns. However, the level of evidence in children is extremely low; therefore, further research is needed on the validity of this recommendation.

Time to re-set our thinking about airways disease: lessons from history, the resurgence of chronic bronchitis / PBB and modern concepts in microbiology

In contrast to significant declines in deaths due to lung cancer and cardiac disease in Westernised countries, the mortality due to 'chronic obstructive pulmonary disease' (COPD) has minimally changed in recent decades while 'the incidence of bronchiectasis' is on the rise. The current focus on producing guidelines for these two airway 'diseases' has hindered progress in both treatment and prevention. The elephant in the room is that neither COPD nor bronchiectasis is a disease but rather a consequence of progressive untreated airway inflammation. To make this case, it is important to review the evolution of our understanding of airway disease and how a pathological appearance (bronchiectasis) and an arbitrary physiological marker of impaired airways (COPD) came to be labelled as 'diseases'. Valuable insights into the natural history of airway disease can be obtained from the pre-antibiotic era. The dramatic impacts of antibiotics on the prevalence of significant airway disease, especially in childhood and early adult life, have largely been forgotten and will be revisited as will the misinterpretation of trials undertaken in those with chronic (bacterial) bronchitis. In the past decades, paediatricians have observed a progressive increase in what is termed 'persistent bacterial bronchitis' (PBB). This condition shares all the same characteristics as 'chronic bronchitis', which is prevalent in young children during the pre-antibiotic era. Additionally, the radiological appearance of bronchiectasis is once again becoming more common in children and, more recently, in adults. Adult physicians remain sceptical about the existence of PBB; however, in one study aimed at assessing the efficacy of antibiotics in adults with persistent symptoms, researchers discovered that the majority of patients exhibiting symptoms of PBB were already on long-term macrolides. In recent decades, there has been a growing recognition of the importance of the respiratory microbiome and an understanding of the ability of bacteria to persist in potentially hostile environments through strategies such as biofilms, intracellular communities, and persister bacteria. This is a challenging field that will likely require new approaches to diagnosis and treatment; however, it needs to be embraced if real progress is to be made.

Transition of pediatric patients with bronchiectasis to adult medical care in the Northern Territory: A retrospective chart audit

Background

Bronchiectasis is increasingly being recognized to exist in all settings with a high burden of disease seen in First Nations populations. With increasing numbers of pediatric patients with chronic illnesses surviving into adulthood, there is more awareness on examining the transition from pediatric to adult medical care services. We undertook a retrospective medical chart audit to describe what processes, timeframes, and supports were in place for the transition of young people (≥14 years) with bronchiectasis from pediatric to adult services in the Northern Territory (NT), Australia.

Methods

Participants were identified from a larger prospective study of children investigated for bronchiectasis at the Royal Darwin Hospital, NT, from 2007 to 2022. Young people were included if they were aged ≥14 years on October 1, 2022, with a radiological diagnosis of bronchiectasis on high-resolution computed tomography scan. Electronic and paper-based hospital medical records and electronic records from NT government health clinics and, where possible, general practitioner and other medical service attendance were reviewed. We recorded any written evidence of transition planning and hospital engagement from age ≥14 to 20 years.

Results

One hundred and two participants were included, 53% were males, and most were First Nations people (95%) and lived in a remote location (90.2%). Nine (8.8%) participants had some form of documented evidence of transition planning or discharge from pediatric services. Twenty-six participants had turned 18 years, yet there was no evidence in the medical records of any young person attending an adult respiratory clinic at the Royal Darwin Hospital or being seen by the adult outreach respiratory clinic.

Conclusion

This study demonstrates an important gap in the documentation of delivery of care, and the need to develop an evidence-based transition framework for the transition of young people with bronchiectasis from pediatric to adult medical care services in the NT.

A decade on: Follow-up findings of indigenous children with bronchiectasis

OBJECTIVE

The sole prospective longitudinal study of children with either chronic suppurative lung disease (CSLD) or bronchiectasis published in the current era was limited to a single center. We sought to extend this study by evaluating the longer-term clinical and lung function outcomes and their associated risk factors in Indigenous children of adolescents from Australia, Alaska, and New Zealand who participated in our previous CSLD or bronchiectasis studies during 2004-2010.

METHODS

Between 2015 and 2018, we evaluated 131 out of 180 (72.8%) children of adolescents from the original studies at a single follow-up visit. We administered standardized questionnaires, reviewed medical records, undertook clinical examinations, performed spirometry, and scored available chest computed tomography scans.

RESULTS

Participants were seen at a mean age of 12.3 years (standard deviation: 2.6) and a median of 9.0 years (range: 5.0-13.0) after their original recruitment. With increasing age, rates of acute lower respiratory infections (ALRI) declined, while lung function was mostly within population norms (median forced expiry volume in one-second = 90% predicted, interquartile range [IQR]: 81-105; forced vital capacity [FVC] = 98% predicted, IQR: 85-114). However, 43 out of 111 (38.7%) reported chronic cough episodes. Their overall global rating judged by symptoms, including ALRI frequency, examination findings, and spirometry was well (20.3%), stable (43.9%), or improved (35.8%). Multivariable regression identified household tobacco exposure and age at first ALRI-episode as independent risk factors associated with lower FVC% predicted values.

CONCLUSION

Under our clinical care, the respiratory outcomes in late childhood or early adolescence are encouraging for these patient populations at high-risk of premature mortality. Prospective studies to further inform management throughout the life course into adulthood are now needed.

Clinical course of chronic suppurative lung disease and bronchiectasis in Alaska Native children

INTRODUCTION

Alaska Native (AN) children from the Yukon Kuskokwim (YK) Delta region have high rates of chronic suppurative lung disease (CSLD), including bronchiectasis. We characterized the clinical progress of an AN adolescent cohort with CSLD/bronchiectasis, and estimated bronchiectasis prevalence trends in this region.

METHODS

The original cohort comprised 41 AN children (originally aged 0.5-8 years) with CSLD/bronchiectasis, recruited between 2005 and 2008, with follow-up in 2015-2016. Clinical assessments, lung function, radiography, medical chart review, and spirometry were obtained. We also conducted data queries of bronchiectasis diagnoses in YK individuals born between 1990 and 2010 to estimate prevalence.

RESULTS

Thirty-four (83%) of the original cohort aged 7.3-17.6 years were reviewed, of whom 14 (41%) had high-resolution computed tomography (HRCT)-confirmed bronchiectasis, eight (24%) had no evidence of bronchiectasis on HRCT scans, while 12 (35%) had not undergone HRCT scans. Annual lower respiratory tract infection (LRTI) frequency decreased with age, although 27 (79%) still had respiratory symptoms, including all with HRCT-confirmed bronchiectasis, who were also more likely than those without confirmed bronchiectasis to have recent wheeze (80 vs 25%, P = 0.005), auscultatory crackles (60 vs 0%, P < 0.001), and lower mean forced expiratory volume in 1-second/forced vital capacity ratio (73 vs 79%, P = 0.03). The bronchiectasis prevalence for YK AN people born during 2000-2009 was 7 per 1000 births, which was lower than previously reported.

CONCLUSION

Despite reduced LRTI frequency, most AN children with CSLD/bronchiectasis had symptoms/signs of underlying lung disease as they entered adolescence. Close clinical follow-up remains essential for managing these patients as they transition to adulthood.

Inhaled corticosteroids for bronchiectasis

BACKGROUND

Bronchiectasis is being increasingly diagnosed and recognised as an important contributor to chronic lung disease in both adults and children in high- and low-income countries. It is characterised by irreversible dilatation of airways and is generally associated with airway inflammation and chronic bacterial infection. Medical management largely aims to reduce morbidity by controlling the symptoms, reduce exacerbation frequency, improve quality of life and prevent the progression of bronchiectasis. This is an update of a review first published in 2000.

OBJECTIVES

To evaluate the efficacy and safety of inhaled corticosteroids (ICS) in children and adults with stable state bronchiectasis, specifically to assess whether the use of ICS: (1) reduces the severity and frequency of acute respiratory exacerbations; or (2) affects long-term pulmonary function decline.

SEARCH METHODS

We searched the Cochrane Register of Controlled Trials (CENTRAL), the Cochrane Airways Group Register of trials, MEDLINE and Embase databases. We ran the latest literature search in June 2017.

SELECTION CRITERIA

All randomised controlled trials (RCTs) comparing ICS with a placebo or no medication. We included children and adults with clinical or radiographic evidence of bronchiectasis, but excluded people with cystic fibrosis.

DATA COLLECTION AND ANALYSIS

We reviewed search results against predetermined criteria for inclusion. In this update, two independent review authors assessed methodological quality and risk of bias in trials using established criteria and extracted data using standard pro forma. We analysed treatment as 'treatment received' and performed sensitivity analyses.

MAIN RESULTS

The review included seven studies, involving 380 adults. Of the 380 randomised participants, 348 completed the studies.Due to differences in outcomes reported among the seven studies, we could only perform limited meta-analysis for both the short-term ICS use (6 months or less) and the longer-term ICS use (> 6 months).During stable state in the short-term group (ICS for 6 months or less), based on the two studies from which data could be included, there were no significant differences from baseline values in the forced expiratory volume in the first second (FEV1) at the end of the study (mean difference (MD) -0.09, 95% confidence interval (CI) -0.26 to 0.09) and forced vital capacity (FVC) (MD 0.01 L, 95% CI -0.16 to 0.17) in adults on ICS (compared to no ICS). Similarly, we did not find any significant difference in the average exacerbation frequency (MD 0.09, 95% CI -0.61 to 0.79) or health-related quality of life (HRQoL) total scores in adults on ICS when compared with no ICS, though data available were limited. Based on a single non-placebo controlled study from which we could not extract clinical data, there was marginal, though statistically significant improvement in sputum volume and dyspnoea scores on ICS.The single study on long-term outcomes (over 6 months) that examined lung function and other clinical outcomes, showed no significant effect of ICS on any of the outcomes. We could not draw any conclusion on adverse effects due to limited available data.Despite the authors of all seven studies stating they were double-blind, we judged one study (in the short duration ICS) as having a high risk of bias based on blinding, attrition and reporting of outcomes. The GRADE quality of evidence was low for all outcomes (due to non-placebo controlled trial, indirectness and imprecision with small numbers of participants and studies).

AUTHORS' CONCLUSIONS

This updated review indicates that there is insufficient evidence to support the routine use of ICS in adults with stable state bronchiectasis. Further, we cannot draw any conclusion for the use of ICS in adults during an acute exacerbation or in children (for any state), as there were no studies.

The Role of the Immune Response in the Pathogenesis of Bronchiectasis

Bronchiectasis is a prevalent respiratory condition characterised by permanent and abnormal dilation of the lung airways (bronchi). There are a large variety of causative factors that have been identified for bronchiectasis; all of these compromise the function of the immune response to fight infection. A triggering factor may lead to the establishment of chronic infection in the lower respiratory tract. The bacteria responsible for the lower respiratory tract infection are usually found as commensals in the upper respiratory tract microbiome. The consequent inflammatory response to infection is largely responsible for the pathology of this condition. Both innate and adaptive immune responses are activated. The literature has highlighted the central role of neutrophils in the pathogenesis of bronchiectasis. Proteases produced in the lung by the inflammatory response damage the airways and lead to the pathological dilation that is the pathognomonic feature of bronchiectasis. The small airways demonstrate infiltration with lymphoid follicles that may contribute to localised small airway obstruction. Despite aggressive treatment, most patients will have persistent disease. Manipulating the immune response in bronchiectasis may potentially have therapeutic potential.

A review of the etiology and clinical presentation of non-cystic fibrosis bronchiectasis: A tertiary care experience

INTRODUCTION

Non-cystic fibrosis(CF) bronchiectasis has been recognized in children for the past 200 years. Early childhood pneumonia and underlying conditions such as immunodeficiency, primary ciliary dyskinesia(PCD), and congenital lung pathology should be considered in the etiology. The aim of our study was to describe the clinical characteristics, laboratory, and radiological findings of a large population of patients with non-CF bronchiectasis at a tertiary center.

METHODS

We analyzed the clinical findings of 187 patients diagnosed with non-CF bronchiectasis over a period of 10 years (January 2005-December 2015) at the Hacettepe University Faculty of Medicine Department of Pediatric Pulmonology.

RESULTS

The median age at the time of diagnosis of non-CF bronchiectasis was 8 years (1-18 years). Consanguinity was positive in 59.4% (n = 111) of patients and 19.8% (n = 37) of patients had a positive family history for non-CF bronchiectasis. Common causes were PCD in 51.3% (n = 96), immunodeficiency in 15% (n = 28), history of tuberculosis in 5.9% (n = 11), post-infectious complication in 3.2% (n = 6) and other anomalies in 2.1% (n = 4) of patients. The frequency of pulmonary lobe involvement was as follows: 71.1% left-lower lobe, 59.4% right lower lobe, 54% right-middle lobe, 26.8% left lingula, 13.9% right upper lobe, and 9.6% left upper lobe.

CONCLUSIONS

Diagnosis of non-CF bronchiectasis is often delayed because of a failure to recognize the significance of symptoms. Through clinical investigation, including a HRCT scan of the chest, sweat test, studies of immune function, and ciliary function in a child with a prolonged suppurative cough, remains important. In Turkey, the most common causes of non-CF bronchiectasis are PCD and immunodeficiency, related to a high frequency of consanguinity.

The Likelihood of Preventing Respiratory Exacerbations in Children and Adolescents with either Chronic Suppurative Lung Disease or Bronchiectasis

Chronic suppurative lung disease (CSLD) and bronchiectasis in children and adolescents are important causes of respiratory morbidity and reduced quality of life (QoL), also leading to subsequent premature death during adulthood. Acute respiratory exacerbations in pediatric CSLD and bronchiectasis are important markers of disease control clinically, given that they impact upon QoL and increase health-care-associated costs and can adversely affect future lung functioning. Preventing exacerbations in this population is, therefore, likely to have significant individual, familial, societal, and health-sector benefits. In this review, we focus on therapeutic interventions, such as drugs (antibiotics, mucolytics, hyperosmolar agents, bronchodilators, corticosteroids, non-steroidal anti-inflammatory agents), vaccines and physiotherapy, and care-planning, such as post-hospitalization management and health promotion strategies, including exercise, diet, and reducing exposure to environmental toxicants. The review identified a conspicuous lack of moderate or high-quality evidence for preventing respiratory exacerbations in children and adolescents with CSLD or bronchiectasis. Given the short- and long-term impact of exacerbations upon individuals, their families, and society as a whole, large studies addressing interventions at the primary and tertiary prevention phases are required. This research must include children and adolescents in both developing and developed countries and address long-term health outcomes.

Persistent and Recurrent Bacterial Bronchitis-A Paradigm Shift in Our Understanding of Chronic Respiratory Disease

The recent recognition that the conducting airways are not "sterile" and that they have their own dynamic microbiome, together with the rapid advances in our understanding of microbial biofilms and their roles in the causation of respiratory diseases (such as chronic bronchitis, sinusitis, and chronic otitis media), permit us to update the "vicious circle" hypothesis of the causation of bronchiectasis. This proposes that chronic inflammation driven by persistent bacterial bronchitis (PBB) causes damage to both the epithelium, resulting in impaired mucociliary clearance, and to the airway wall, which eventually manifests as bronchiectasis. The link between a "chronic bronchitis" and a persistence of bacterial pathogens, such as non-typable Haemophilus influenzae, was first made more than 100 years ago, and its probable role in the causation of bronchiectasis was proposed soon afterward. The recognition that the "usual suspects" are adept at forming biofilms and hence are able to persist and dominate the normal dynamically changing "healthy microbiome" of the conducting airways provides an explanation for the chronic colonization of the bronchi and for the associated chronic neutrophil-dominated inflammation characteristic of a PBB. Understanding the complex interaction between the host and the microbial communities of the conducting airways in health and disease will be a key component in optimizing pulmonary health in the future.

The Epidemiology of Chronic Suppurative Lung Disease and Bronchiectasis in Children and Adolescents

In the modern era, the global burden of childhood chronic suppurative lung disease (CSLD) remains poorly captured by the literature. What is clear, however, is that CSLD is essentially a disease of poverty. Disadvantaged children from indigenous and low- and middle-income populations had a substantially higher burden of CSLD, generally infectious in etiology and of a more severe nature, than children in high-income countries. A universal issue was the delay in diagnosis and the inconsistent reporting of clinical features. Importantly, infection-related CSLD is largely preventable. A considerable research and clinical effort is needed to identify modifiable risk factors and socioeconomic determinants of CSLD and provide robust evidence to guide optimal prevention and management strategies. The purpose of this review was to update the international literature on the epidemiology, etiology, and clinical features of pediatric CSLD.

Pediatric bronchiectasis: No longer an orphan disease

Bronchiectasis is described classically as a chronic pulmonary disorder characterized by a persistent productive cough and irreversible dilatation of one or more bronchi. However, in children unable to expectorate, cough may instead be wet and intermittent and bronchial dilatation reversible in the early stages. Although still considered an orphan disease, it is being recognized increasingly as causing significant morbidity and mortality in children and adults in both affluent and developing countries. While bronchiectasis has multiple etiologies, the final common pathway involves a complex interplay between the host, respiratory pathogens and environmental factors. These interactions lead to a vicious cycle of repeated infections, airway inflammation and tissue remodelling resulting in impaired airway clearance, destruction of structural elements within the bronchial wall causing them to become dilated and small airway obstruction. In this review, the current knowledge of the epidemiology, pathobiology, clinical features, and management of bronchiectasis in children are summarized. Recent evidence has emerged to improve our understanding of this heterogeneous disease including the role of viruses, and how antibiotics, novel drugs, antiviral agents, and vaccines might be used. Importantly, the management is no longer dependent upon extrapolating from the cystic fibrosis experience. Nevertheless, substantial information gaps remain in determining the underlying disease mechanisms that initiate and sustain the pathophysiological pathways leading to bronchiectasis. National and international collaborations, standardizing definitions of clinical and research end points, and exploring novel primary prevention strategies are needed if further progress is to be made in understanding, treating and even preventing this often life-limiting disease.

Respiratory exacerbations in indigenous children from two countries with non-cystic fibrosis chronic suppurative lung disease/bronchiectasis

BACKGROUND

Acute respiratory exacerbations (AREs) cause morbidity and lung function decline in children with chronic suppurative lung disease (CSLD) and bronchiectasis. In a prospective longitudinal cohort study, we determined the patterns of AREs and factors related to increased risks for AREs in children with CSLD/bronchiectasis.

METHODS

Ninety-three indigenous children aged 0.5 to 8 years with CSLD/bronchiectasis in Australia (n = 57) and Alaska (n = 36) during 2004 to 2009 were followed for > 3 years. Standardized parent interviews, physical examinations, and medical record reviews were undertaken at enrollment and every 3 to 6 months thereafter.

RESULTS

Ninety-three children experienced 280 AREs (median = 2, range = 0-11 per child) during the 3-year period; 91 (32%) were associated with pneumonia, and 43 (15%) resulted in hospitalization. Of the 93 children, 69 (74%) experienced more than two AREs over the 3-year period, and 28 (30%) had more than one ARE in each study year. The frequency of AREs declined significantly over each year of follow-up. Factors associated with recurrent (two or more) AREs included age < 3 years, ARE-related hospitalization in the first year of life, and pneumonia or hospitalization for ARE in the year preceding enrollment. Factors associated with hospitalizations for AREs in the first year of study included age < 3 years, female caregiver education, and regular use of bronchodilators.

CONCLUSIONS

AREs are common in children with CSLD/bronchiectasis, but with clinical care and time AREs occur less frequently. All children with CSLD/bronchiectasis require comprehensive care; however, treatment strategies may differ for these patients based on their changing risks for AREs during each year of care.

Antimicrobial treatment of non-cystic fibrosis bronchiectasis

Bronchiectasis unrelated to cystic fibrosis is characterized by chronic wet or productive cough, recurrent exacerbations and irreversible bronchial dilatation. After antibiotics and vaccines became available and living standards in affluent countries improved, its resulting reduced prevalence meant bronchiectasis was considered an 'orphan disease'. This perception has changed recently with increasing use of CT scans to diagnose bronchiectasis, including in those with severe chronic obstructive pulmonary disease or 'difficult to control' asthma, and adds to its already known importance in non-affluent countries and disadvantaged Indigenous communities. Following years of neglect, there is renewed interest in identifying the pathogenetic mechanisms of bronchiectasis, including the role of infection, and conducting clinical trials. This is providing much needed evidence to guide antimicrobial therapy, which has relied previously upon extrapolating treatments used in cystic fibrosis and chronic obstructive pulmonary disease. While many knowledge gaps and management challenges remain, the future is improving for patients with bronchiectasis.

Bronchiectasis-associated hospitalizations in Germany, 2005-2011: a population-based study of disease burden and trends

Background

Representative population-based data on the epidemiology of bronchiectasis in Europe are limited. The aim of the present study was to investigate the current burden and the trends of bronchiectasis-associated hospitalizations and associated conditions in Germany in order to inform focused patient care and to facilitate the allocation of healthcare resources.

Methods

The nationwide diagnosis-related groups hospital statistics for the years 2005–2011 were used in order to identify hospitalizations with bronchiectasis as any hospital discharge diagnosis according to the International Classification of Diseases, 10th revision, code J47, (acquired) bronchiectasis. Poisson log-linear regression analysis was used to assess the significance of trends. In addition, the overall length of hospital stay (LOS) and the in-hospital mortality in comparison to the nationwide overall mortality due to bronchiectasis as the primary diagnosis was assessed.

Results

Overall, 61,838 records with bronchiectasis were extracted from more than 125 million hospitalizations. The average annual age-adjusted rate for bronchiectasis as any diagnosis was 9.4 hospitalizations per 100,000 population. Hospitalization rates increased significantly during the study period, with the highest rate of 39.4 hospitalizations per 100,000 population among men aged 75–84 years and the most pronounced average annual increases among females. Besides numerous bronchiectasis-associated conditions, chronic obstructive pulmonary disease (COPD) was most frequently found in up to 39.2% of hospitalizations with bronchiectasis as the primary diagnosis. The mean LOS was comparable to that for COPD. Overall, only 40% of bronchiectasis-associated deaths occurred inside the hospital.

Conclusions

The present study provides evidence of a changing epidemiology and a steadily increasing prevalence of bronchiectasis-associated hospitalizations. Moreover, it confirms the diversity of bronchiectasis-associated conditions and the possible association between bronchiectasis and COPD. As the major burden of disease may be managed out-of-hospital, prospective patient registries are needed to establish the exact prevalence of bronchiectasis according to the specific underlying condition.

The role of macrolides in childhood non-cystic fibrosis-related bronchiectasis

Non-cystic fibrosis-related bronchiectasis is a chronic inflammatory lung disease, which is regarded as an “orphan” lung disease, with little research devoted to the study of this condition. Bronchiectasis results in impaired quality of life and mortality if left untreated. The tools available in the armamentarium for the management of bronchiectasis entail antibiotic therapy traditionally used to treat exacerbations, stratagems to improve mucociliary clearance, and avoidance of toxins. Macrolides have been known for the last two decades to have not only anti-bacterial effects but immunomodulatory properties as well. In cystic fibrosis, the use of macrolides is well documented in subjects colonized with Pseudomonas aeruginosa, to improve quality of life and lung function. There is currently emerging evidence to suggest the benefit of macrolides in subjects not colonized with Pseudomonas aeruginosa. This beneficial effect has been less explored in the context of bronchiectasis from other causes. The purpose of this paper is to review the current literature on the use of macrolides in non-cystic fibrosis related bronchiectasis in paediatrics.

Differences and similarities in non-cystic fibrosis bronchiectasis between developing and affluent countries

Non-CF bronchiectasis remains a major cause of morbidity not only in developing countries but in some indigenous groups of affluent countries. Although there is a decline in the prevalence and incidence in developed countries, recent studies in indigenous populations report higher prevalence. Due to the lack of such data, epidemiological studies are required to find the incidence and prevalence in developing countries. Although the main characteristics of bronchiectasis are similar in developing and affluent countries, underlying aetiology, nutritional status, frequency of exacerbations and severity of the disease are different. Delay of diagnosis is surprisingly similar in the affluent and developing countries possibly due to different reasons. Long-term studies are needed for evidence based management of the disease. Successful management and prevention of bronchiectasis require a multidisciplinary approach, while the lack of resources is still a major problem in the developing countries.

Do New Zealand children with non-cystic fibrosis bronchiectasis show disease progression?

BACKGROUND

There is minimal literature available on the long-term outcome of pediatric non-cystic fibrosis (CF) bronchiectasis.

AIM

To document 5-year outcomes of children with chest computerized tomography (CT) scan diagnosed bronchiectasis from a tertiary New Zealand (NZ) respiratory clinic.

METHODS

Review of a clinical database identified 91 children. Demographics, clinical data, lung function, chest X-ray (CXR), sputum, presumed etiology, admission data, and the NZ deprivation index (NZDep) were collected. Univariate and multivariate regression were used to correlate clinical findings with lung function data and CXR scores using the Brasfield Scoring System.

RESULTS

Of the 91 children, 53 (59%) were Pacific Island, 22 (24%) Maori, 14 (15%) European, and 2 (2%) Other. The median follow-up period was 6.7 years (range 5.0-15.3 years) and median age at diagnosis was 7.3 years (range 11 months-16 years). Lung function data (n = 64) showed a mean decline of -1.6% predicted/year. In 30 children lung function declined (mean FEV(1) -4.4% predicted/year, range 1-17%), remained stable in 13 and improved in 21 children (mean FEV(1) of +3% predicted/year, range 1-15%). Reduced lung function was associated with male gender, chronic Haemophilus influenzae infection, longevity of disease, and Maori and Pacific Island ethnicity. There was a significant correlation with FEV(1) and CXR score at beginning (n = 47, r = 0.45, P = 0.001) and end (n = 26, r = 0.59, P = 0.002) of the follow-up period. The only variable consistently related to CXR score was chronic Haemophilus influenzae infection occurring in 27 (30%) (r(2)  = 0.52, P = <0.0001). Only four children were chronically infected with Pseudomonas species. Six children died.

CONCLUSION

In our experience despite management in a tertiary multidisciplinary bronchiectasis clinic, progression of lung disease continues in a group of children and young adults.

A review of 151 cases of pediatric noncystic fibrosis bronchiectasis in a tertiary care center

OBJECTIVE:

This study was conducted to review the etiological factors and diseases associated with pediatric noncystic fibrosis bronchiectasis in a tertiary care center in Saudi Arabia.

MATERIALS AND METHODS:

A retrospective review of all patients with confirmed noncystic fibrosis (Non-CF) bronchiectasis by chest X-ray and/or CT chest in a pulmonary clinic during the period 1993–2005 at a tertiary care center in Riyadh.

RESULTS:

A total of 151 cases were diagnosed as Non-CF bronchiectasis. Seventy-five (49.7%) were male, 76 (50.3%) were female; 148 (98%) are alive and 3 (2%) died. The southwestern regions constituted 72 (50%) of the cases. There was a period of (5 ± 3.2) years between the start of symptoms and diagnosis of bronchiectasis. More than two-thirds of the patients had cough, tachypnea, wheezing, sputum production and failure to thrive. Ninety-one (60%) had associated diseases: Pulmonary diseases in 48 (32%), immunodeficiency in 27 (18%), central nervous system anomalies in 10 (7%), cardiac in 10 (7%) and asthma in 103 (68%) of the patients. Left lower lobe was commonly involved in 114 (76%) patients. Sixty-eight (67%) were found to have sinusitis. More than two-thirds of patients had two or more associated diseases. Forty-nine (32%) developed gastroesophageal reflux. Hemophilus influenza was cultured in 56 (37%), strept pneumoniae in 25 (17%) and pseudomonas aeruginosa in 24 (16%) of the patients. Eighty percent of the patients who had pulmonary function test had abnormal changes. Disease progression was related to development of symptoms before 5 years of age, persistent atelectasis and right lower lobe involvement (P< 0.05).

CONCLUSION:

Non-CF bronchiectasis should be included in the differential diagnosis of recurrent chest infection in Saudi Arabia. Early diagnosis and identification of associated diseases is needed to prevent progression of the disease.

Inhaled steroids for bronchiectasis

BACKGROUND

Bronchiectasis is increasingly recognized as a major cause of respiratory morbidity especially in developing countries and in some ethnic populations of affluent countries. It is characterized by irreversible dilatation of airways, generally associated with chronic bacterial infection. Medical management largely aims to reduce morbidity by controlling the symptoms and by preventing the progression of bronchiectasis.

OBJECTIVES

To evaluate the efficacy of inhaled corticosteroids (ICS) in children and adults with bronchiectasis (a) during stable bronchiectasis; and for reducing; (b) the severity and frequency of acute respiratory exacerbations and (c) long term pulmonary decline.

SEARCH STRATEGY

The Cochrane Register of Controlled Trials (CENTRAL), the Cochrane Airways Group Specialized Register Collaboration and Cochrane Airways Group, MEDLINE and EMBASE databases were searched by the Cochrane Airways Group. The latest searches were performed in September 2007.

SELECTION CRITERIA

All randomised controlled trials comparing ICS with a placebo or no medication. Children and adults with clinical or radiographic evidence of bronchiectasis were included, but patients with cystic fibrosis (CF) were excluded.

DATA COLLECTION AND ANALYSIS

Results of searches were reviewed against pre-determined criteria for inclusion.

MAIN RESULTS

There were no paediatric studies. Six adult studies fulfilled the inclusion criteria. Of the 303 randomised, 278 subjects completed the trials. In the short term group (ICS for less then 6 months duration), adults on huge doses of ICS (2g per day of budesonide equivalent) had significantly improved forced expiratory volume in the first second (FEV(1)), forced vital capacity (FVC), Quality of life (QOL) score and sputum volume but no significant difference in peak flow, exacerbations, cough or wheeze, when compared to adults in the control arm (no ICS). When only placebo-controlled studies were included, there were no significant difference between groups in all outcomes examined (spirometry, clinical outcomes of exacerbation or sputum volume etc). The single study on long term outcomes showed no significant effect of inhaled steroids in any of the outcomes.

AUTHORS' CONCLUSIONS

The present review indicates that there is insufficient evidence to recommend the routine use of inhaled steroids in adults with stable state bronchiectasis. While a therapeutic trial may be justified in adults with difficult to control symptoms and in certain subgroups, this has to be balanced with adverse events especially if high doses are used. No recommendation can be made for the use of ICS in adults during an acute exacerbation or in children (for any state) as there were no studies.

Oral non steroid anti-inflammatories for children and adults with bronchiectasis

BACKGROUND

Bronchiectasis is increasing recognised as a co-morbidity in many respiratory illness. Anti inflammatory drugs may reduce the inflammatory cascade and thus reduce symptoms and slow long term pulmonary decline.

OBJECTIVES

To assess the role of non steroid anti inflammatory drugs (NSAIDs) on symptom control and natural history of the disease in children and adults with bronchiectasis.

SEARCH STRATEGY

The Cochrane Central Register of Controlled Trials (CENTRAL), the Cochrane Airways Group Specialised Register, MEDLINE and EMBASE databases were searched by the Cochrane Airways Group up to December 2006.

SELECTION CRITERIA

Only randomised controlled trials were considered. Patients with radiological or clinical evidence of bronchiectasis were included. Patients with Cystic Fibrosis were excluded.

DATA COLLECTION AND ANALYSIS

The titles, abstracts and citations were independently reviewed by two reviewers to assess potential relevance for full review. No eligible trials were identified and thus no data were available for analysis.

MAIN RESULTS

No randomised or controlled trials were found.

AUTHORS' CONCLUSIONS

There are no randomised controlled that examined the effect of oral NSAIDs in patients with bronchiectasis. In view of some benefit shown by inhaled NSAIDs in bronchiectasis, RCTs are clearly needed to study the beneficial effect of oral NSAIDs in patients with bronchiectasis.

Clinical profile of Saudi children with bronchiectasis

OBJECTIVE

This study represents the experience of a tertiary care center in Saudi Arabia on non-cystic fibrosis bronchiectasis.

METHODS

A retrospective review of all patients with confirmed Non-Cystic Fibrosis (Non-CF) bronchiectasis by chest X-ray and or CT chest in a pulmonary clinic for the period 1993-2005 at a tertiary care center in Riyadh.

RESULTS

A0 total of 151 cases were diagnosed as Non-CF bronchiectasis. Siventy-five (49.7%) were males, 76(50.3%) were females. One hundred forty-eight (98%) are alive and 3(2%) died. The southwestern regions constituted 72(50%) of the cases. There is a period (5+/- 3.2) years between the start of symptoms and the diagnosis of bronchiectasis. More than 2/3 of the patients had cough, tachypnea, wheezing, sputum production and failure to thrive. Ninety one (60%) had associated disease: Pulmonary diseases in 48(32%), immunodefficiency in 27(18%), CNS in 18(12%), cardiac in 12(8%) and asthma in 103(68%) of the patients. Left lower lobes were commonly involved in 114(76%) cases. Sixty-eight (67%) were found to have sinusitis. Forty-nine (32%) developed gastroesophgeal reflux (GER). Hemophilus influenza was cultured in 56(37%), Strept pneumoniae in 25(17%) and Pseudomonas aeruginosa in 24(16%) of the patients. 80% of the patients who had pulmonary function test had abnormal changes. Disease progression was related to development of symptoms before 5 years of age, persistent atelectasis and right lower lobe involvement (p<0.05).

CONCLUSION

Non-CF bronchiectasis is a common problem in Saudi Arabia. Early recognition and institution of treatment with proper vaccination of available anti-bacterial and anti-viral vaccines are encouraged to prevent progression of the disease.

Lung structure abnormalities, but normal lung function in pediatric bronchiectasis

BACKGROUND

Bronchiectasis is not considered to be uncommon in children anymore. The relationship between pulmonary function and severity of bronchiectasis is still controversial.

STUDY OBJECTIVES

To assess the extent and severity of bronchiectasis through high-resolution CT (HRCT) scan score, and to correlate it with clinical, microbiological, and functional data.

PATIENTS AND METHODS

Forty-three white children with HRCT-diagnosed bronchiectasis were studied. Bronchiectasis extent, bronchial wall thickening severity, and bronchial wall dilatation severity were evaluated using the Reiff score. Clinical, microbiological, and spirometry results were related to total HRCT scan score and to subscores as well.

RESULTS

The percentages of affected lobes were as follows: right lower lobe, 65%; middle lobe, 56%; left lower lobe, 51%; right upper lobe, 37%; lingula, 30%; and left upper lobe, 30% (chi(2) = 18.4; p = 0.002). The mean (+/- SEM) HRCT score was 20 +/- 2.6. Total score or subscores of bronchiectasis extent, bronchial wall thickening severity, and bronchial wall dilatation severity were not significantly related to FEV(1) and FVC. Seventy-four percent of patients had asthma. The age at the onset of cough correlated with age at the time of the HRCT scan (p = 0.004) and with the presence of asthma (p = 0.01). Positive findings of deep throat or sputum cultures were found more frequently in atopic patients (p = 0.02) and asthmatic (p < 0.01) patients, and in children who were < 2 years of age at the onset of cough (p < 0.01).

CONCLUSIONS

Normal lung function may coexist with HRCT scan abnormalities and does not exclude damage to the bronchial structure. Pulmonary function is not an accurate method for assessing the severity of lung disease in children with bronchiectasis.

Bronchiectasis: the consequence of late diagnosis in chronic respiratory symptoms

Bronchiectasis is still common among some developing countries like Turkey. The aim of this study was to document the number of children with non-cystic fibrosis (CF) bronchiectasis, to evaluate the risk factors and to emphasize early diagnosis and treatment. All children, except those diagnosed with CF, with bronchiectasis established by chest radiogram, bronchography and/or computed tomography or biopsy material, were retrospectively reviewed. They were tested for serum total eosinophil count, nasal smear, serum levels of immunoglobulins A, G, M, E, and serum alpha-1 antitrypsin level. Pulmonary function tests, rigid bronchoscopy, nasal biopsy, lung scintigraphy, and echocardiogram were also performed. There were 204 patients whose most common presenting symptoms were cough, sputum expectoration, and dyspnea. Bronchiectasis was present mostly in the left lower lobe. The cause could not be determined in 49 per cent of patients. Among the identified causes, infection was present in most patients, followed by asthma, primary ciliary dyskinesia, congenital immune deficiency, and foreign body aspiration. It is possible to prevent bronchiectasis in children with vaccinations and improved nutrition in developing countries. Early diagnosis and treatment will increase the quality of life and survival of patients with bronchiectasis, which has irreversible and progressive complications if untreated.

Non-Cystic-Fibrosis Bronchiectasis in Children: A Persisting Problem in Developing Countries

BACKGROUND

Non-cystic-fibrosis (non-CF) bronchiectasis in childhood is still one of the most common causes of childhood morbidity in developing countries. The management of these patients remains problematic, and there are few studies of long-term outcome.

OBJECTIVE

The aim of this retrospective study was to define the general characteristics, underlying causative factors and long-term follow-up results of non-CF bronchiectasis patients.

METHODS

One hundred and eleven consecutive children, diagnosed with non-CF bronchiectasis were included in the study. General characteristics and underlying causes were recorded from the medical records. Clinical outcomes were evaluated in terms of lung function tests, annual exacerbation rates and patient/parent perception of health status.

RESULTS

Mean age of the patients was 7.4 +/- 3.7 years at presentation, and patients had been followed 4.7 +/- 2.7 years on average. In 62.2% of the patients, an underlying etiology was identified, whereas postinfectious bronchiectasis was the most common (29.7%). In spite of intensive medical treatment, 23.4% of the patients required surgery. The annual lower respiratory infection rate has decreased from a mean of 6.6 +/- 4.0 to 2.9 +/- 2.9 during follow-up (p < 0.0001). Lung function tests were also found to be improved (mean FEV1% 63.3 +/- 21.0 vs. 73.9 +/- 27.9; p = 0.01; mean FVC% 68.1 +/- 22.2 vs. 74.0 +/- 24.8; p = 0.04). There was clinical improvement in both the surgical (73%) and medical (70.1%) groups (p > 0.05).

CONCLUSION

In conclusion, bronchiectasis remains a disease of concern to pediatricians, particularly in developing countries. Infections are still important causes of bronchiectasis, and clinical improvement can be achieved by appropriate treatment. Although medical treatment is the mainstay of management, surgery should be considered in selected patients.

Hospital-based case-control study of bronchiectasis in indigenous children in Central Australia

BACKGROUND

Childhood pneumonia has been reported to be associated with the development of bronchiectasis but there are no case-control studies that have examined this. This study examined the relationship between hospital admission for episode(s) of pneumonia and the risk of radiologically proven bronchiectasis.

METHODS

A medical record-based case-control study of bronchiectasis in Indigenous children was conducted in Central Australia. Controls (183), matched to cases (61) by gender, age and year of diagnosis, were Indigenous children hospitalized with other conditions.

RESULTS

There was a strong association between a history of hospitalized pneumonia and bronchiectasis [odds ratio (OR), 15.2; 95% confidence interval (95% CI) 4.4-52.7]. This was particularly evident in recurrent hospitalized pneumonia (P for trend < 0.01), severe pneumonia episodes with longer hospital stay (P for trend < 0.01), presence of atelectasis (OR 11.9; 95% CI 3.1-45.9) and requirement for oxygen (P for trend < 0.01). The overall number of pneumonia episodes, rather than its site, was associated with bronchiectasis. Although the total number of pneumonia episodes in the first year of life did not increase the risk of bronchiectasis, more severe episodes early in life did. Malnutrition, premature birth and being small for gestational age were more common findings among cases. Breast-feeding appeared to be a protective factor (OR 0.2; 95% CI 0.1-0.7).

CONCLUSIONS

Although we cannot fully answer the question of why bronchiectasis is much more common in Indigenous children, we have provided strong evidence of an association between bronchiectasis and severe and recurrent pneumonia episodes in infancy and childhood.

Paediatric bronchiectasis in the twenty-first century: experience of a tertiary children's hospital in New Zealand

OBJECTIVE

Despite its decline in developed countries, bronchiectasis appeared to be a common diagnosis in Auckland, New Zealand children. The aims of this study were: to document the number of children in Auckland with bronchiectasis, their severity, clinical characteristics and possible aetiologies; to assess whether there was a relationship between ethnicity and poverty; and to estimate a crude bronchiectasis prevalence rate for New Zealand.

METHODS

A retrospective review of the case histories of all children attending a tertiary children's hospital in Auckland with bronchiectasis diagnosed by high-resolution chest computed tomography (CT) scan, during the period 1998-2000 was undertaken. Data collected included patient demographics, number of hospitalizations pre- and post-diagnosis, lung function tests, radiology and investigations. The New Zealand deprivation 1996 index was applied to the data to obtain a measure of socio-economic status.

RESULTS

Bronchiectasis was found to be common, with an estimated prevalence of approximately one in 6000 in the Auckland paediatric population. It was disproportionately more common in the Pacific Island and Maori children. In Pacific Island children, bronchiectasis not caused by cystic fibrosis was nearly twice as common in the general population than cystic fibrosis. Socio-economic deprivation and low immunization rates may be significant contributing factors. The bronchiectasis seen was extensive. Ninety-three percent had bilateral disease and 64% had involvement of four or more lobes on chest CT scan. A wide range of comorbidities and underlying aetiologies were evident.

CONCLUSIONS

Paediatric bronchiectasis in Auckland, New Zealand, is common but underresourced. Only the most severe cases are being recognized, providing a significant challenge for paediatric health professionals.

Bronchiectasis in Alaska Native children: causes and clinical courses

Although bronchiectasis has become a rare condition in U.S. children, it is still commonly diagnosed in Alaska Native children in the Yukon Kuskokwim Delta. The prevalence of bronchiectasis has not decreased in persons born during the 1980s as compared with those born in the 1940s. We reviewed case histories of 46 children with bronchiectasis. We observed that recurrent pneumonia was the major preceding medical condition in 85% of patients. There was an association between the lobes affected by pneumonia and the lobes affected by bronchiectasis. Eight (17%) patients had surgical resection of involved lobes. We conclude that the continued high prevalence of bronchiectasis appears to be related to extremely high rates of infant and childhood pneumonia. Pediatr Pulmonol. 2000;29:182-187. Published 2000 Wiley-Liss, Inc.

Bronchiectasis in Finland: trends in hospital treatment

The incidence of bronchiectasis has probably declined in developed countries in recent years, but no reliable statistical data on this are available. The present paper describes the use made of hospital services by bronchiectatic patients in Finland. Data on a total of 12,539 treatment periods for bronchiectasis that had occurred between 1972 and 1992 were collected from the discharge register maintained by the National Research and Development Centre for Welfare and Health (diagnosis 518 in the International Classification of Diseases up to 1986, and 494 from 1987 onwards). The number of admissions, new occurrences of bronchiectasis and days in hospital were calculated by sex and age in relation to the total population at the end of each year. There were 143 and 87 admissions per million inhabitants in 1972 and 1992, respectively. The admissions, new occurrences and the days in hospital all decreased, at annual rates of 1.3, 4.2 and 5.7%, respectively. Thus, where the number of new occurrences was 50 per million persons in 1977, it was 27 per million in 1992. In summary, bronchiectasis-related hospital treatment declined markedly between 1972 and 1992. Trend is attributed to effective treatment of pulmonary infections and the reduction in tuberculosis.

Bronchiectasis and related disorders

Bronchiectasis is defined in current medical parlance as the abnormal and permanent dilatation of one or more bronchi, and in clinical practice, the condition is often characterized by features of chronic bronchial infection. Apart from occurring as a primary lung disease, bronchiectasis is a major component of two other disease entities, cystic fibrosis and diffuse panbronchiolitis. Although the three conditions have distinctly different underlying causes, they share the similarity of a predominantly neutrophilic airways inflammation, and the persistent bronchial infection by bacteria, in particular Pseudomonas aeruginosa. Hence, new knowledge in one disease may be explored and applied in the others.

Bronchiectasis due to lipid aspiration in childhood: clinical and pathological correlates

We report the clinical and pathological features in six Arab children with bronchiectasis caused by ghee lipid aspiration. They all had a history of ghee administration followed by a history of chronic cough dating from early childhood. Chest radiographs showed consolidation/collapse of the right middle and left lower lobes in the majority, and bronchography and chest CT scan confirmed bronchiectasis. The children were treated medically, without any improvement, and five required surgery. The histology of the lung revealed dilated bronchi filled with vacuolated granular eosinophilic material and the peripheral lung tissue was mostly atelectatic with patchy lymphocytic bronchiolitis. Frozen sections of the lung tissue showed scattered lipogranulomas with fat-laden macrophages and fat droplets within peripheral and perivascular lymphatics. In communities where the traditional practice of force-feeding infants and children with ghee exists, it may be an important predisposing cause of bronchiectasis.

Thoracic surgical problems in infancy and childhood

Thoracic surgical problems in infants and children range from congenital anomalies to acquired inflammatory problems. This article reviews the most common parenchymal, pleural, and mediastinal problems encountered in infants and children and presents recommendations for prompt and accurate diagnosis and therapy.

Rheumatoid arthritis and chronic bronchial suppuration

Twenty-two patients with rheumatoid arthritis and severe chronic bronchial suppuration are described. In 11 patients the respiratory symptoms appeared after the onset of arthritis at an unusually late age. We discuss causes for the disease association, in particular the possibility that disease modifying drugs in rheumatoid arthritis may predispose to the development of chronic bronchial suppuration; such a possibility requires prospective investigation.

Bronchiectasis in childhood

Although bronchiectasis is relatively uncommon, it should be considered in a child with any of the following findings that persist: infiltrate on x-ray cough, purulent sputum, crackles or harsh breath sounds on auscultation of the chest, or hemoptysis. It is very likely that a pediatrician will encounter one or more children with this condition. This article deals with the pathogenesis, diagnosis, and treatment of bronchiectasis in childhood.

The surgical management of childhood bronchiectasis. A review of 96 consecutive pulmonary resections in children with nontuberculous bronchiectasis

In 195 children with nontuberculous bronchiectasis, periodic bronchography and clinical examinations were conducted over a period of 16 years (average 9.4 years). This was provided a critical assessment of surgical accomplishments in 96 consecutive resections and a parallel observation of 111 cases not submitted to resection. The final clinical assessment of the surgical cases shows 75% to be well or much improved, 22% to be improved, and 4% unchanged, while patients not submitted to resection have remained largely unchanged (69%) or have become worse (23%). The isolated superior segment can be preserved in children with good results, provided there is clear bronchographic evidence that the segment is entirely free of disease. When partially diseased segments are retained and required to fill a large volume, there is a tendency for even slightly altered bronchi to deteriorate postoperatively. Serial bronchography has proved helpful in determining when the disease has reached a mature, stable state and in planning the extent of resection.

Present outlook in bronchiectasis: clinical and social study and review of factors influencing prognosis

One hundred and sixteen patients with proven bronchiectasis diagnosed at least five years previously were studied to determine the clinical outcome, change in pulmonary function, and degree of social disability. Twenty-two patients had died and the mean duration of follow-up in the survivors was 14 years. The patients who died were characterised by a poorer initial ventilatory capacity than the survivors and cor pulmonale was present in 37% at the time of death. The survivors showed a tendency for improvement in symptoms whether treated surgically or medically. Thirty per cent were better than at diagnosis while only 11% were worse. Measurements of FEV1 and FVC were made at diagnosis and at review, mild airways obstruction being the predominant abnormality. The change in pulmonary function was expressed as the decline in FEV1 in ml/yr. The decline in FEV1 was no greater than expected in 80% of patients and in a further 15% was of the order seen in cigarette smokers with mild airways obstruction. Poor ventilatory capacity was therefore not an important limitation in these patients. Of the survivors 77% had a good work record with less than two weeks loss of work annually from chest illness. The spouses of all married patients were interviewed at home by a trained social worker. Fifty per cent reported no social problem but 46% of spouses found the patient's cough distasteful and 29% of couples had experienced difficulties with normal sexual life. Seven per cent of the patients were severely disabled. While the overall prognosis of our patients was good a minority still have severe physical and social problems as a result of bronchiectasis.