Bronchiectasis in children — structured oral (viva)

Branch 1 — The wet cough and first move

Examiner: "This girl has coughed for five months. What is the single feature that concerns you most, and what is your first thought?" Candidate: The feature that concerns me most is that this is a daily wet, productive cough lasting far beyond four weeks that only ever partly settles with antibiotics. That pattern is chronic suppurative lung disease until proven otherwise — the reversible front end of bronchiectasis — rather than a run of viral infections. My first thought is that this needs proper assessment, a chest high-resolution CT, and a systematic search for a cause, not another short antibiotic course. [1]

Branch 2 — Pattern and differential

Examiner: "The clinical cluster here is striking. What does it point to?" Candidate: The combination of unexplained neonatal respiratory distress in a term infant, chronic glue ear and nasal discharge from infancy, and a chronic wet cough points strongly to primary ciliary dyskinesia. In ciliary dyskinesia the cilia are immotile, so mucus is never swept upward, and the same clearance failure that causes the sinopulmonary disease drives bronchiectasis. I would also keep cystic fibrosis and an immunodeficiency firmly on the list, because bronchiectasis is a symptom that always demands a cause. [1] [2]

Examiner: "Why does the neonatal history matter?" Candidate: Unexplained respiratory distress in a term neonate is a recognised early feature of primary ciliary dyskinesia, and combined with chronic rhinosinusitis and recurrent otitis media it forms a classic cluster. I would specifically ask about situs inversus, which occurs in about half of these children. [2]

Branch 3 — Investigation

Examiner: "How will you investigate her?" Candidate: I would confirm the airway change with a chest high-resolution CT, since a plain film is insensitive and here shows only non-specific change. In parallel I would do the aetiological work-up: nasal nitric oxide screening followed by specialist ciliary function and structural studies for primary ciliary dyskinesia, a sweat test and CF genetics, an immune screen with immunoglobulins and vaccine-response titres, and a lower-airway culture to define the organisms and flag Pseudomonas aeruginosa. [2] [1]

Branch 4 — Management and why timing matters

Examiner: "Assume the CT confirms bronchiectasis and she has primary ciliary dyskinesia. How do you manage her, and why act now?" Candidate: Management rests on daily airway clearance physiotherapy and prompt, prolonged, culture-guided antibiotics for exacerbations, alongside optimised nutrition, full immunisation, smoke avoidance, and specialist multidisciplinary care for the ciliary dyskinesia. I would eradicate Pseudomonas if isolated and consider long-term macrolide prophylaxis only for a high exacerbation burden. Acting now matters because in young children early bronchiectasis can regress with intensive treatment, whereas late diagnosis and chronic Pseudomonas infection commit her to fixed, progressive airway damage. [3] [1]