Introduction and Objectives Persistent bacterial bronchitis (PBB) is increasingly recognised as a cause of chronic cough in young children but there is lack of consensus about investigation and treatment. At UHNS, children with a wet cough for >6 weeks unresponsive to oral antibiotics prescribed by the GP are investigated with CXR, baseline immune function and flexible bronchoscopy with bronchoalveolar lavage (FB-BAL). Patients with confirmed PBB are then treated with a prolonged course of an appropriate antibiotic. Some centres reserve FB-BAL for those who do not respond to blind treatment with co-amoxiclav or clinically relapse. The objective was to review bronchoscopic findings and immune function in children with chronic cough to determine which investigations are necessary.
Methods A retrospective case note review of all children investigated for chronic cough between May 2011 and June 2013.
Results The notes of 44 children with chronic cough were reviewed. BAL samples were taken from 6 lobes in every patient. Median (IQR) age at bronchoscopy was 3.3 (1.8–4.4) years. Positive BAL cultures were obtained from 35 patients (80%). Ten patients (23%) isolated ≥2 organisms. Haemophilus influenza was identified in 20 (46%), Moraxella catarrhalis in 11 (25%), Staphylococcusl aureus in 10 (23%) and Streptococcus pneumoniae in 6 (14%). Candida albicans, Group A Streptococcus, Haemophilus parainfluenzae and a gram negative bacillus were each identified in 1 patient (2%). In 13 (30%) at least 1 organism was isolated that was unlikely to respond to co-amoxiclav. If the right middle lobe (RML) had been the only lobe sampled (as per ERS guidance) organisms would have been missed in 14 patients (32%). Suboptimal functional antibodies to Haemophilus influenza or Pneumococcus were identified in 7 patients (16%). Appropriate antibiotics were prescribed for all patients with a positive culture. Co-amoxiclav was the most commonly prescribed antibiotic and was used in 20 patients (57%). Treatment duration varied between 4 and 8 weeks.
Conclusions FB-BAL is a useful investigation to aid the diagnosis and guide treatment in PBB. The best time to perform FB-BAL is not known. In PBB a number of organisms will be missed if BAL is only taken from the RML.