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Bronchiectasis a Long-Term Follow-Up of Medical and Surgical Cases from Childhood

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Bronchiectasis a Long-Term Follow-Up of Medical and Surgical Cases from Childhood Arch Dis Child: first published as 10.1136/adc.36.190.587 on 1 December 1961. Downloaded from BRONCHIECTASIS A LONG-TERM FOLLOW-UP OF MEDICAL AND SURGICAL CASES FROM CHILDHOOD BY C. ELAINE FIELD* 8 Sunnydale Gardens, London, N. W. 7 (RECEIVED FOR PUBLICATION APRIL 12, 1961) Over the past 30 years the natural history of into the twenties. It remains to be seen what bronchiectasis must have been considerably modified happens in later life. by the varying treatments which have been intro- Earlier studies on these patients were reported in duced. Laennec's original description in 1829 1949 (Field) and the present study is a continuation was made from post-mortem material, the diag- of this work. nosis in those early years only being made in The Present Study severe clinical cases or at autopsy. With the intro- duction by Sicard and Forestier in 1922 of an This report consists of 104 patients treated medi- opaque substance to outline the bronchial tree, cally and 121 treated surgically. Although the more accurate diagnosis was possible, but whilst author has been in Singapore for the past 11 years, this new diagnostic technique was being improved, contact with the patients was made on each home measures to combat the disease were introduced. leave, and in 1956 137 patients were asked to attend copyright. Physiotherapy with postural drainage and breathing for a clinical examination; 84 attended and 25, who exercises was soon assisted by the introduction of were unable to attend, replied to a special question- chemotherapy and antibiotics. At about the same naire. There was no reply in 28 cases, usually tiesurgicalprocedures, i.e. lobectomyandpneumon- because they had moved and the address was un- ectomy, were adopted and later multiple segmental known. Out of these 109 patients, four were resections were practised in an attempt to remove, surgically treated and have been included in the if possible, all the diseased parts. But it was soon surgical series and one who had died eight years that bronchiectasis was not just an anatomi- previously was excluded, thus leaving 104 patients realized treated of cal dilatation ofcertain bronchi, but usually a general who constitute the medically patients http://adc.bmj.com/ disease complex, and removal of all diseased parts this study. All of these had at one time shown some did not necessarily relieve all the symptoms. As a dilatation of the bronchi by bronchogram, but in result surgery was recommended less and less, 38 instances this was mild and of doubtful per- particularly as chemotherapy was able to control manency. All had symptoms of chronic chest the respiratory exacerbations. disease. The present survey of 225 patients observed over Most of the surgical patients had been operated a perio of eight to 21 years covers this period of on by Professor R. S. Pilcher and his staff, and were changing conditions. In most cases the diagnosis being followed up regularly in his clinic. With his on October 1, 2021 by guest. Protected was made before the introduction of antibiotics kind co-operation a special questionnaire was and in some cases before the use of sulphonamides. filled in by the patients when they attended the clinic In spite of the varying treatments a definite pattern and the examining doctor filled in the clinical record. of disease seems to emerge in which the onset of A full record was obtained of 117 cases out of 150, damage to the lung is maximal in the first five years and with four patients who had had operations from of life. Thereafter the symptoms may be trouble- the medical clinic there were 121 surgically treated some until puberty, when a surprising improvement patients. In no way can this surgical series be in health occurs, lasting usually through the 'teens compared with the medical series as selection for operation is essential, but the two records are given side by side. No attempt has been made to grade * Address from May 1962: The Paediatric Unit, Queen Mary Hospital, Hong-Kong. the severity of the bronchiectasis as this study is 587 Arch Dis Child: first published as 10.1136/adc.36.190.587 on 1 December 1961. Downloaded from 588 ARCHIVES OF DISEASE IN CHILDHOOD DURATION OF FOLLOW-UP AGE OF PATIENTS AT 1956 SURVEY 26 Go 0 B4 10 15 20 25 29 Age in Years Number of Years FIG. 1 FIG. 2 more one of progress of the disease itself. There SITE OF DISEASED BRONCHI was no selection of cases at the onset; all cases who showed dilatation of the bronchi and who attended the children's Chest Clinics at two London hospitals over a period of several years were in- cluded. There were, however, different observers for the medical and surgical follow-ups. Duration of Follow-up. It will be seen from Fig. 1 copyright. that the minimum number of years for which the ax d patients have been followed is eight years and the v maximum 21 years; the majority have been followed $4 for 11 to 15 years. .0 Age. The majority of patients during the 1956 z survey were between the ages of 14 and 24 years, the youngest being 10 years and the oldest 29 years (Fig. 2). http://adc.bmj.com/ Sex. There are 102 males and 123 females; this supports the common finding of a slight prepon- derance of females. Diseased Lobes Site of Disease (Fig. 3). As previously recorded FIG. 3 (Field, 1949) the left lower lobe and lingula of the left upper lobe are most frequently affected, followed on October 1, 2021 by guest. Protected by the right middle lobe. In this series the right lower lobe is not quite so frequently affected. TABLE 1 PERCENTAGE INCIDENCE OF TYPE OF Type of Bronchiectasis. Four types of bronchi- BRONCHIECTASIS ectasis are described, but there are many variations of these and more than one type can be seen in Type Per cent. one patient (Table 1). is often the early stage of the Tubular 35 Tubular dilatation Saccular 30 disease in children, and this explains the high Varicose 27 FusifOrm .1. 1I incidence. As the terminal part distends and becomes more bulbous, the bronchiectasis becomes Arch Dis Child: first published as 10.1136/adc.36.190.587 on 1 December 1961. Downloaded from BRONCHIECTASIS 589 TABLE 2 by their own doctors for exacerbation of chest AGE OF ONSET AND NUMBER OF CASES symptoms, but as far as I know none of them received continuous chemotherapy. Age of Onset Number of Cases Pulmonary Resection. As might be expected, First 12 months . 50 I year-S years . 119 the lingula of the left upper lobe, the right middle S years-10 years 51 10 years- 15 years . 3 lobe and the left lower lobe were the most frequently No record . 2 removed lobes of the lung; partial resection of a lobe was also performed not infrequently (Table 3). saccular in type. Varicose has been used here to describe the irregular dilatations along the length Duration since Last Operation (Fig. 4). The of the bronchus, and fusiform, the dilatation which majority of patients had their operation between is most marked in the middle of the bronchus three and 12 years ago, although three cases had a (Field, 1949). The varicose and fusiform types further operation only one year before clinical usually have a good prognosis. assessment. Children were only seen up to the age of 12 years in the chest clinics, but the figures in Table 2 show NUMBER OF YEARS SINCE LAST OPERATION that the dangerous period is in the first five years of 15 life, when 75% of the.cases occurred. 7 Clinical Features. Although careful records were kept from the beginning of this study, it was only after several years that the importance of certain e 10 clinical features was recognized and recorded; Ca0 the clinical records for these features, therefore, are inadequate for when the patients were first seen. However, where it is helpful, the records copyright. available will be shown. For the more important ~ 5 symptoms such as cough, sputum, nasal discharge, clubbing and moist sounds in the lungs, the early records are reasonably adequate, but where no record was available this is recorded. I I I I I I I I I I I I I I I 5 10 15 18 Treatment. The medically treated patients Years since last Operation received no special treatment; the majority had FIG. 4 given up postural drainage and they were on no http://adc.bmj.com/ regular treatment. Antibiotics were usually given Results of the Follow-up Clinical Impressions. -In the past, before statis- TABLE 3 tical evidence was considered so necessary, great SITE OF PULMONARY RESECTION* importance was attached to a good clinical descrip- tion of a disease or disease process. At present Number of Patients clinicians find it necessary to prove their point Site of Resection Right Lobe Left Lobe statistically before it is accepted. Studying the on October 1, 2021 by guest. Protected Upper lobes present figures after the follow-up clinics in 1956 Complete .. 4 12 I realized how inadequate such figures were to Segmental-antero-lateral 16 9 Segmental-apical . 2 0 express the clinical change that takes place in these Segmental-postero-lateral 0 0 bronchiectatic children. Therefore, before attempt- Middle and lingula lobes .. .. 67 72 ing to give the results of this investigation, I shall Lower lobes briefly describe my own clinical impressions of the Complete . .. 20 56 Partial-anterior basic 16 7 disease process. Partial-middle basic 4 1 The bronchiectatic process most commonly Partial-posterior basic 1 4 Partial-dorsal .
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