Protracted bacterial bronchitis in children: natural history and risk factors for bronchiectasis

BACKGROUND: Protracted bacterial bronchitis (PBB) and bronchiectasis are distinct diagnostic entities that share common clinical and laboratory features. It is postulated, but remains unproved, that PBB precedes a diagnosis of bronchiectasis in a subgroup of children. In a cohort of children with PBB, our objectives were to (1) determine the medium-term risk of bronchiectasis and (2) identify risk factors for bronchiectasis and recurrent episodes of PBB. METHODS: One hundred sixty-one children with PBB and 25 control subjects were prospectively recruited to this cohort study. A subset of 106 children was followed for 2 years. Flexible bronchoscopy, BAL, and basic immune function tests were performed. Chest CT was undertaken if clinical features were suggestive of bronchiectasis. RESULTS: Of 161 children with PBB (66% boys), 13 were diagnosed with bronchiectasis over the study period (8.1%). Almost one-half with PBB (43.5%) had recurrent episodes (> 3/y). Major risk factors for bronchiectasis included lower airway infection with Haemophilus influenzae (recovered in BAL fluid) (P ¼ .013) and recurrent episodes of PBB (P ¼ .003). H influenzae infection conferred a more than seven times higher risk of bronchiectasis (hazard ratio, 7.55; 95% CI, 1.66-34.28; P ¼ .009) compared with no H influenzae infection. The majority of isolates (82%) were nontypeable H influenzae. No risk factors for recurrent PBB were identified. CONCLUSIONS: PBB is associated with a future diagnosis of bronchiectasis in a subgroup of children. Lower airway infection with H influenzae and recurrent PBB are significant predictors. Clinicians should be cognizant of the relationship between PBB and bronchiectasis, and appropriate follow-up measures should be taken in those with risk factors.No Full Tex

A Guide to Expanding the Use of Buprenorphine Beyond Standard Initiations for Opioid Use Disorder.

Buprenorphine has become an important medication in the context of the ongoing opioid epidemic. However, complex pharmacologic properties and varying government regulations create barriers to its use. This narrative review is intended to facilitate buprenorphine use-including non-traditional initiation methods-by providers ranging from primary care providers to addiction specialists. This article briefly discusses the opioid epidemic and the diagnosis and treatment of opioid use disorder (OUD). We then describe the basic and complex pharmacologic properties of buprenorphine, linking these properties to their clinical implications. We guide readers through the process of initiating buprenorphine in patients using full agonist opioids. As there is no single recommended approach for buprenorphine initiation, we discuss the details, advantages, and disadvantages of the standard, low-dose, bridging-strategy, and naloxone-facilitated initiation techniques. We consider the pharmacology of, and evidence base for, buprenorphine in the treatment of pain, in both OUD and non-OUD patients. Throughout, we address the use of buprenorphine in children and adolescent patients, and we finish with considerations related to the settings of pregnancy and breastfeeding

A Guide to Expanding the Use of Buprenorphine Beyond Standard Initiations for Opioid Use Disorder

Abstract Buprenorphine has become an important medication in the context of the ongoing opioid epidemic. However, complex pharmacologic properties and varying government regulations create barriers to its use. This narrative review is intended to facilitate buprenorphine use—including non-traditional initiation methods—by providers ranging from primary care providers to addiction specialists. This article briefly discusses the opioid epidemic and the diagnosis and treatment of opioid use disorder (OUD). We then describe the basic and complex pharmacologic properties of buprenorphine, linking these properties to their clinical implications. We guide readers through the process of initiating buprenorphine in patients using full agonist opioids. As there is no single recommended approach for buprenorphine initiation, we discuss the details, advantages, and disadvantages of the standard, low-dose, bridging-strategy, and naloxone-facilitated initiation techniques. We consider the pharmacology of, and evidence base for, buprenorphine in the treatment of pain, in both OUD and non-OUD patients. Throughout, we address the use of buprenorphine in children and adolescent patients, and we finish with considerations related to the settings of pregnancy and breastfeeding

Rapid Transition to Buprenorphine in a Patient With Methadone-Related QTc Interval Prolongation.

BACKGROUND: Patients with opioid use disorder (OUD) who are managed on methadone often require transition to buprenorphine therapy. Current recommendations require months to gradually taper off of methadone; however, in some cases, the need to transition is urgent. Only a few rapid methadone-to-buprenorphine transitions have been reported and there are no established protocols to guide clinicians in these cases. CASE PRESENTATION: A 43-year-old man on 95 mg methadone for opioid use disorder experienced cardiac arrest attributable to ventricular fibrillation caused by QTc interval prolongation from methadone. In the hospital, a gradual taper of methadone was initiated but proved intolerable; the patient requested to restart his home dose of methadone and leave against medical advice. A rapid transition was initiated instead. Naltrexone (25 mg) was used to precipitate acute withdrawal followed 1 hour later by a rescue with buprenorphine/naloxone (16 mg/4 mg). The Clinical Opiate Withdrawal Score (COWS) peaked at 21 post-naltrexone and fell quickly to 15 within a half-hour of buprenorphine/naloxone administration. The patient was maintained on a total daily dose of 16 mg/4 mg buprenorphine/naloxone through the time of discharge. CONCLUSIONS: A patient requiring an urgent taper off of methadone due to adverse cardiac effects successfully transitioned to buprenorphine/naloxone within 2 hours by using naltrexone to precipitate withdrawal followed by a rescue with buprenorphine/naloxone. A relatively high dose of 16 mg/4 mg buprenorphine/naloxone successfully arrested withdrawal symptoms. With further refinement, this protocol may be an important technique for urgent methadone-to-buprenorphine transitions in the inpatient setting

Response

We thank Sacco et al1 for their interest in our study on children with protracted bacterial bronchitis (PBB), which described high PBB recurrence rates.2 Further, at 2-year follow-up, those diagnosed with bronchiectasis were significantly more likely to have had recurrent episodes (> 3 per year) and Haemophilus influenzae in their BAL at initial diagnosis.2 We agree with Sacco et al's1 suggestion that antibiotic adherence should be closely monitored and that the presence of biofilm in the lower airways of these children is likely important..

Outcomes of protracted bacterial bronchitis in children: a 5-year prospective cohort study

Background and objective Long‐term data on children with PBB has been identified as a research priority. We describe the 5‐year outcomes for children with PBB to ascertain the presence of chronic respiratory disease (bronchiectasis, recurrent PBB and asthma) and identify the risk factors for these. Methods Prospective cohort study was undertaken at the Queensland Children's Hospital, Brisbane, Australia, of 166 children with PBB and 28 controls (undergoing bronchoscopy for symptoms other than chronic wet cough). Monitoring was by monthly contact via research staff. Clinical review, spirometry and CT chest were performed as clinically indicated. Results A total of 194 children were included in the analysis. Median duration of follow‐up was 59 months (IQR: 50–71 months) post‐index PBB episode, 67.5% had ongoing symptoms and 9.6% had bronchiectasis. Significant predictors of bronchiectasis were recurrent PBB in year 1 of follow‐up (ORadj = 9.6, 95% CI: 1.8–50.1) and the presence of Haemophilus influenzae in the BAL (ORadj = 5.1, 95% CI: 1.4–19.1). Clinician‐diagnosed asthma at final follow‐up was present in 27.1% of children with PBB. A significant BDR (FEV1 improvement >12%) was obtained in 63.5% of the children who underwent reversibility testing. Positive allergen‐specific IgE (ORadj = 14.8, 95% CI: 2.2–100.8) at baseline and bronchomalacia (ORadj = 5.9, 95% CI: 1.2–29.7) were significant predictors of asthma diagnosis. Spirometry parameters were in the normal range. Conclusion As a significant proportion of children with PBB have ongoing symptoms at 5 years, and outcomes include bronchiectasis and asthma, they should be carefully followed up clinically. Defining biomarkers, endotypes and mechanistic studies elucidating the different outcomes are now required