Diagnosis of bronchitis in children

The diagnosis of bronchitis is established based on its clinical picture (for example, the presence of obstructive syndrome) and in the absence of signs of damage to the lung tissue (no infiltrative or focal shadows on the radiograph). Bronchitis is often combined with pneumonia, in which case it is included in the diagnosis with a significant addition to the clinical picture of the disease. Unlike pneumonia, bronchitis in ARVI is always diffuse in nature and usually affects the bronchi of both lungs evenly. If local bronchitis changes predominate in any part of the lung, the following definitions are used: basal bronchitis, unilateral bronchitis, bronchitis of the afferent bronchus, etc.

Clinical examination

Acute bronchitis (simple). The main symptom is cough. At the beginning of the disease, the cough is dry, after 1-2 days it becomes wet, and persists for 2 weeks. A longer cough is observed after previous tracheitis. If coughing fits (especially in schoolchildren) continue for 4-6 weeks in the absence of other symptoms, one should think about another possible cause, such as whooping cough, a foreign body in the bronchus, etc.

At the beginning of the disease, sputum has a mucous character. In the 2nd week of the disease, sputum may acquire a greenish color, caused by an admixture of fibrin dehydration products, and not by the addition of a secondary bacterial infection, and does not require the prescription of antibiotics.

In children of the first year of life, moderate dyspnea may be observed (respiratory rate (RR) up to 50 per minute). Percussion sometimes reveals a box-like shade of the pulmonary sound, or there are no changes. Auscultation reveals diffuse dry and moist large and medium bubbling rales in the lungs, which may change in quantity and character, but do not disappear when coughing. Some children develop wheezing during exhalation during sleep. Asymmetry of auscultatory changes should be alarming in terms of pneumonia.

Acute obstructive bronchitis. Bronchial obstruction syndrome is characterized by dyspnea (respiratory rate up to 60-70 per minute), increased obsessive dry cough, dry wheezing rales against the background of prolonged exhalation not only during auscultation, but also audible at a distance. Half of the patients also have moist, scanty, fine-bubble rales. The chest is distended. The temperature is moderate or absent. The child is restless.

Acute bronchiolitis usually develops as the first obstructive episode on the 3rd-4th day of ARVI, most often of RS-virus etiology. Bronchial obstruction is associated more with mucosal edema, rather than with bronchoconstriction. Body temperature is usually normal or subfebrile. Bronchiolitis is characterized by dyspnea with retraction of compliant areas of the chest (jugular fossa and intercostal spaces), flaring of the wings of the nose in small children, with a respiratory rate of up to 70-90 per minute, prolongation of exhalation (may be absent with tachypnea). The cough is dry, sometimes with a "high" spasmodic sound. Perioral cyanosis is noted.

Acute obliterating bronchiolitis (postinfectious obliterating bronchiolitis). The disease is characterized by an extremely severe course and a vivid clinical picture. In the acute period, severe respiratory disorders are observed against the background of persistent febrile temperature and cyanosis. Noisy "wheezing" breathing is noted. During auscultation, against the background of an extended exhalation, an abundance of crepitating and fine-bubble moist rales are heard. Usually asymmetrical.

Mycoplasma bronchitis most often develops in school-age children. A distinctive feature of mycoplasma bronchitis is a high temperature reaction from the first days of the disease, conjunctivitis, usually without effusion, obsessive cough, pronounced obstructive syndrome (prolonged exhalation, wheezing) in the absence of toxicosis and deterioration of general well-being. Catarrhal phenomena are expressed insignificantly.

With mycoplasma infection, small bronchi are affected, therefore, during auscultation, crepitant wheezing and a lot of small-bubble moist sounds are heard, which are localized asymmetrically, indicating uneven damage to the bronchi.

Mycoplasma bronchitis may proceed atypically: without obstructive syndrome and dyspnea. The presence of asymmetric wheezing and conjunctivitis allows one to suspect this etiology of bronchitis.

Chlamydial bronchitis in children of the first months of life is caused by Chlamydia trachomatis. Infection occurs during childbirth from a mother with a chlamydial infection of the genitals. Against the background of good health and normal temperature at the age of 2-4 months, a picture of bronchitis occurs. Cough appears, which intensifies in the 2-4th week. In some cases, it becomes paroxysmal, as with whooping cough, but unlike the latter, it occurs without reprises. Obstruction and toxicosis are weakly expressed, dyspnea is moderate. Against the background of harsh breathing, small and medium-sized moist rales are heard.

A characteristic anamnesis and the presence of conjunctivitis in the first month of life help in the diagnosis of chlamydial bronchitis.

In school-age children and adolescents, bronchitis is caused by Chlamydia pheumonia and is characterized by a general deterioration, high temperature, hoarseness due to concomitant pharyngitis, and a sore throat may be observed. Obstructive syndrome often develops, which can contribute to the development of "late-onset bronchial asthma."

In these cases, it is necessary to exclude pneumonia, which is confirmed by the absence of focal or infiltrative changes in the lungs on the radiograph.

Recurrent bronchitis. The main symptoms of recurrent bronchitis are a moderate increase in temperature for 2-3 days followed by the appearance of a cough, often wet, but unproductive. Then the cough becomes productive with the release of mucopurulent sputum. During auscultation, wet wheezing of various sizes of a widespread nature is heard. The disease can last from 1 to 4 weeks.

Recurrent obstructive bronchitis. In the first days of ARVI (2-4 days), the bronchial obstruction syndrome occurs as acute obstructive bronchitis, but the obstruction syndrome can persist for a long time with dyspnea, initially dry and then wet cough with mucopurulent sputum. Auscultation reveals dry whistling and various wet rales against the background of prolonged exhalation, wheezing can be heard at a distance.

Laboratory diagnostics

Acute bronchitis (simple). Changes in the clinical blood test are most often caused by a viral infection, moderate leukocytosis may be observed.

Acute obstructive bronchitis. The hemogram shows characteristic signs of a viral infection.

_{Acute bronchiolitis. The} hemogram shows hypoxemia (pA _O2 decreases to 55-60 mm Hg) and hyperventilation (pA _O2decreases ).

Acute obliterating bronchiolitis (postinfectious obliterating bronchiolitis). The clinical blood test shows moderate leukocytosis, neutrophilic shift, increased ESR. Hypoxemia and hypercapnia are also characteristic.

Mycoplasma bronchitis. There are usually no changes in the clinical blood test, sometimes the ESR increases with a normal leukocyte count. There are no reliable express methods for diagnostics. Specific IgM appears much later. The increase in antibody titer allows only a retrospective diagnosis.

Chlamydial bronchitis. The hemogram shows leukocytosis, eosinophilia, and increased ESR. Chlamydial antibodies of the IgM class are detected in a titer of 1:8 or more, and of the IgG class in a titer of 1:64 or more, provided that the mother has lower levels than the child.

Instrumental methods

Acute bronchitis (simple). Radiographic changes in the lungs are usually presented as an increase in the pulmonary pattern, more often in the root and lower medial zones, sometimes an increase in the airiness of the lung tissue is noted. Focal and infiltrative changes in the lungs are absent.

Acute obstructive bronchitis. X-ray shows swelling of lung tissue.

Acute bronchiolitis. Radiographs reveal signs of lung tissue swelling, increased bronchovascular pattern, and less commonly, small atelectases, linear and focal shadows.

Acute obliterating bronchiolitis (postinfectious obliterating bronchiolitis). Radiographs reveal soft-shadowed merging foci, often unilateral, without clear contours - "cotton wool lung" with an air bronchogram picture. Respiratory failure increases during the first two weeks.

Mycoplasma bronchitis. The radiograph shows an increase in the pulmonary pattern, localized in the same way as the localization of the maximum amount of wheezing. Sometimes the shadow is so pronounced that it must be differentiated from the area of non-homogeneous infiltration typical of mycoplasma pneumonia.

Chlamydial bronchitis. In the case of chlamydial pneumonia, the radiograph shows small focal changes, and the clinical picture is dominated by severe dyspnea.

Recurrent bronchitis. Radiologically, an increase in the bronchovascular pattern is noted; in 10% of children, there is increased transparency of the lung tissue.

Recurrent obstructive bronchitis. Radiographs reveal some swelling of the lung tissue, increased bronchovascular pattern, absence of foci of lung tissue infiltration (unlike pneumonia). Chronic lung diseases that also occur with obstruction should be excluded: cystic fibrosis, obliterating bronchioblitis, congenital malformations of the lungs, chronic aspiration of food, etc.

Differential diagnostics

Acute bronchitis (simple). In case of repeated episodes of obstructive bronchitis, bronchial asthma should be excluded.

Acute obstructive bronchitis. In case of persistent obstructive bronchitis resistant to therapy, it is necessary to think about other possible causes, such as bronchial malformations, foreign bodies in the bronchi, habitual aspiration of food, persistent inflammatory focus, etc.

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