Management of children with chronic wet cough: the experience of the Pediatric Pulmonary Unit of the Giannina Gaslini University Hospital

Background. Cough is a physiological defense mechanism, but it may also be the first, initial symptom of a variety of respiratory tract disorders and, more rarely, of extrapulmonary diseases. Independently from its nature, when persistent or recurrent, cough can severely impact the quality of life of children and their families and be one of the most common medical complaints for which parents seek medical assistance. Prompt recognition and early management is necessary to prevent inappropriate treatment and, possibly, the onset of persistent damage to the airways. Materials and methods. We retrospectively studied 110 children, referred to our Unit, diagnosed for chronic/recurrent wet cough in according to international guidance. Fiberoptic bronchoscopy with bronchoalveolar lavage (BAL) and chest CT scan were included in the evaluation, when clinically indicated. Results. Out of the 71 children in which endoscopy was performed, 38 (53.5%) had evidence of bronchial inflammation with mucopurulent secretions and 23 (32.4%) of airway malacia due to extrinsic pulsatile airway compression in 19 (26.8%). Evaluation BAL fluid showed a neutrophilic alveolitis in 51 of the samples and significant bacterial growth in 48 patients: H. influenzae in 37 samples, Str. pneumoniae and, M. catharralis in 7. Chest CT scan performed in 79 children showed the presence of bronchiectasis in 30 and mediastinal vascular anomalies in 19 of them: aberrant innominate artery (AIA) in 15, right aortic arch (RAA) in 2 and AIA + RAA association in 2. Comparing children with or without bronchiectasis, we found that the median age at admission was significantly higher in the formers, who also tended to have a higher age at symptoms onset and a longer period between symptom onset and diagnosis. Moreover, the “bronchiectasis group” had a higher percentage of children with airway malacia (p<0.001), and cultures positive for Haemophilus influenzae (p<0.02). Patients were treated with respiratory physiotherapy and high-dose amoxicillin/clavulanic acid (40 mg/kg/ day) up to 6 weeks Evaluation of the long-term outcome showed that 40.6% could be classified as “completely asymptomatic”, 28.1% as “intermittent symptomatic, 18.7% as “recurrent symptoms, with substantial interference upon life-style” and 12.5%, of which 3 with bronchiectasis, as “unsatisfactory result”. Conclusions. These data may be useful to describe the possible evolutionary conditions in children with chronic wet cough and the best therapeutic approach in these patients even employing prolonged antibiotic therapies plus respiratory physiotherapy. Protection of the airway against respiratory bacteria for a longer period may reduce the risk of recurrence and may be protective against bronchial wall degeneration leading to the development of bronchiectasis. Delayed diagnosis or inappropriate treatments may give enough time for the "vicious cycle": infection, inflammation, and impaired mucociliary clearance to destroy the integrity of the bronchi and proceed toward the development of bronchiectasis.