Chronic suppurative lung disease (CSLD) and bronchiectasis in children

• Respiratory disease with frequent infections and chronic moist or productive cough
• Bronchiectasis in children can be reversed — try to achieve cough-free status

Consider CSLD in child who has any of 

• 2 or more chest infections in past year
• 3 admissions to hospital for chest problems (ever)
• Episode of severe pneumonia (in ICU) or treated for pneumonia in last 4 weeks
• Moist or wet cough that doesn't respond to 4 weeks of antibiotics 
• Chest deformity (puffed up)
• Past history of risk factors — extreme prematurity, history of inhaled foreign body, immunodeficiency, cardiac illness
• Signs of abnormality when listening with stethoscope — crackles, unequal air entry, bronchial breathing

Ask

• If exposure to smoke — tobacco, campfires, e-cigarettes
• About nutritional intake

Check

• Head-to-toe exam
• Immunisation status

Do

• If productive cough — sputum for MC&S
• Plot growth on growth chart
• Medical consult
• Chest x-ray
• Note review, hospital discharge summaries
• Check with family — number and severity of chest infections, treatment in hospital, frequency of cough, productive cough, getting tired when playing, other respiratory symptoms
• Refer to paediatrician for
• Confirmation of diagnosis, hospital treatment if needed
• Further investigations — HRCT scan, immune function tests, bronchoscopy
• Support family members to quit smoking, keep child away from smoke
• Make management plan including physiotherapy, treatment of exacerbations 
• Encourage exercise
• Educate carers about CSLD — see supporting resources

Follow-up

• If unwell, trouble breathing, weight loss, growth faltering — Medical consult may need to send to hospital
• Clinic review every month — Table 3.20
• Medical follow-up every 3 months
• Paediatrician review every 6 months
• Revise management plan together — consider telehealth case conferences
• Some children may have regular hospital admissions for IV antibiotics and intensive chest physiotherapy, some will be on weekly antibiotics

Exacerbation (acute episode) of CSLD

Diagnose exacerbation if 

• Increased cough (for 3 days or more)
• Change in colour or amount of sputum
• Increasing shortness of breath
• Can’t exercise as usual without shortness of breath
• Usually no fever

Check

• Head-to-toe exam — with attention to respiratory distress
• Immunisation status

Do

• Sputum for MC&S
• Increase chest physiotherapy to twice a day
• Encourage child to regularly cough up and spit sputum into tissue or suitable container. Dispose of safely
• Encourage small, frequent meals including snacks
• Work out which antibiotic to use
• Look at past sputum culture results, sensitivity patterns
• Look at management plan, specialist letter
• Consider child's and family’s ability to manage regular medicine
• If unsure — medical/paediatrician consult. May suggest
  
• Amoxicillin-clavulanic acid oral — child 22.5+3.2mg/kg/dose up to 875+125mg — doses — twice a day (bd) for 14 days
• If allergy to penicillin — medical consult for cefuroxime oral — child (3 months and over) 15mg/kg/dose up to 500mg — doses — twice a day (bd) for 14 days
  Note: Doses are higher than usual

Follow-up

• Review in 3 days, at 1 week, and then in 2 weeks
• If not getting better or getting worse — medical consult
• May need to send to hospital for IV antibiotics
• Check sputum result
• Long-term
• Make sure management plan being followed, reviews happen when they should
• Bronchiectasis in children can be reversed — try to achieve cough-free status

Supporting resources

• Lung health for kids app
• Bronchiolitis (lower respiratory tract infection) flipchart
• Bronchiectasis physiotherapy toolbox