Bronchiectasis in children — clinical case

Case summary

This girl presents with the defining picture of chronic suppurative lung disease: a daily wet cough lasting six months that briefly improves with antibiotics but never clears, in a child who is never really well. The essential clinical insight is that a wet cough recurring after antibiotics is not a run of viruses but an airway that cannot clear itself, and with early digital clubbing, faltering growth, and a fixed focal chest sign she has crossed from ordinary recurrent illness into established suppurative disease heading toward bronchiectasis. [1] [2]

Initial assessment and investigations

The history and examination are directed at characterising the cough, gauging severity, and hunting for a cause. The cough is confirmed as genuinely wet and daily, the clubbing and fixed left basal crackles mark established damage, and the faltering growth prompts a search for a systemic cause. Because a plain film is insensitive and shows only peribronchial thickening, a chest high-resolution CT is obtained and confirms cylindrical bronchiectasis of the left lower lobe. [1] [2]

Because bronchiectasis is a symptom rather than a diagnosis, a full aetiological work-up follows in parallel. Immune function is screened with immunoglobulins and vaccine-response titres, cystic fibrosis is excluded with a sweat test and genetics given the faltering growth, primary ciliary dyskinesia is assessed with nasal nitric oxide, and a lower-airway culture is obtained. Sputum grows non-typeable Haemophilus influenzae, the commonest organism in early paediatric bronchiectasis, and the immune screen reveals a treatable antibody deficiency. [2] [1]

Management

Management combines cause-specific treatment with the two pillars of airway clearance and adequate antibiotics. She starts daily airway clearance physiotherapy and receives a prolonged, culture-guided antibiotic course for her current exacerbation — about two weeks of amoxicillin-clavulanate directed at the Haemophilus grown, with azithromycin available as a proven non-inferior alternative from the BEST-2 trial. Immunoglobulin replacement is started for the antibody deficiency, her nutrition is optimised, immunisation is completed, and tobacco-smoke exposure is addressed. [3] [1]

Disposition and counselling

She is placed in structured multidisciplinary respiratory follow-up rather than serial primary-care antibiotic courses, with a written plan covering daily airway clearance, an exacerbation action plan, and regular monitoring of symptoms, growth, lung function, and airway microbiology. The family is counselled that her persistent wet cough was the sign of a treatable lung condition caught relatively early, that the treatable antibody deficiency explains the recurrent infection, and that consistent airway clearance and prompt treatment of exacerbations can stabilise and even improve her lungs while preventing further damage. [2] [1]