18  Bronchiectasis

Published

September 20, 2025

18.1 Introduction

Bronchiectasis is a chronic pulmonary disorder characterised by irreversible dilatation and distortion of the bronchi, associated with chronic inflammation, impaired mucociliary clearance, and recurrent respiratory infections. Although once thought to be rare, bronchiectasis remains a significant cause of childhood morbidity in many low- and middle-income countries, including Ghana.

In West Africa, persistent respiratory infections, tuberculosis, post-measles complications, and poorly treated severe pneumonias contribute substantially to the burden of disease. For clinicians, early recognition is crucial because timely treatment improves quality of life and reduces long-term lung damage.

This chapter provides a comprehensive overview of bronchiectasis in children, tailored to the realities of clinical practice in Ghana and neighbouring countries.

18.2 Epidemiology

  • Bronchiectasis prevalence is under-reported in Africa due to limited diagnostic capacity, especially the low availability of CT scans.
  • Higher prevalence occurs in areas with:
    • High rates of severe pneumonia, tuberculosis, and HIV.
    • Delayed access to quality healthcare.
    • Malnutrition and environmental exposures such as indoor air pollution.
  • In Ghana, common antecedents include:
    • Recurrent pneumonia
    • Post-TB lung disease
    • Severe measles
    • Foreign body aspiration
    • Chronic aspiration from neurological impairment

Worldwide, non–cystic fibrosis (non-CF) bronchiectasis is more common in LMICs than CF-related bronchiectasis.

18.3 Pathophysiology

Bronchiectasis develops through a “vicious cycle” (or “vicious vortex”) of:

18.3.1 Infection

Recurrent or severe infections initiate inflammation and disrupt mucociliary clearance.

18.3.2 Inflammation

Neutrophil-dominated inflammation leads to the release of proteases and oxidative stress, damaging bronchial walls.

18.3.3 Impaired Mucociliary Clearance

Damaged cilia and thick mucus impair clearance, predisposing to persistent infection.

18.3.4 Structural Damage

Bronchial dilatation becomes irreversible, leading to airflow obstruction, mucus plugging, and parenchymal destruction.

Factors contributing in Ghana include:

  • Delayed treatment of pneumonia and TB
  • Inadequate immunisation (especially measles)
  • Chronic aspiration from gastro-oesophageal reflux

18.4 Aetiology

Common causes in children:

18.4.1 Post-Infectious (Most Common in Ghana)

  • Severe bacterial pneumonia
  • Tuberculosis
  • Post-viral infections: measles, pertussis, adenovirus

18.4.2 Congenital and Genetic

  • Cystic fibrosis (rare in West Africa)
  • Primary ciliary dyskinesia
  • Primary immunodeficiency

18.4.3 Obstruction

  • Retained foreign body
  • Tumours (rare)

18.4.5 Immunodeficiency

  • HIV
  • Antibody deficiency (e.g., IgG subclass deficiency)

18.5 Clinical Features

Symptoms often begin after a severe pneumonia or gradually over months to years.

18.5.1 Respiratory Symptoms

  • Chronic wet or productive cough (hallmark)
  • Sputum that is:
    • Mucoid or purulent
    • Persistent despite antibiotic use
  • Recurrent or persistent pneumonia
  • Wheezing or breathlessness
  • Exercise intolerance

18.5.2 Systemic Features

  • Failure to thrive
  • Fatigue
  • Digital clubbing in advanced disease

18.5.3 Physical Examination

  • Crackles (coarse, persistent)
  • Wheezing
  • Signs of hyperinflation
  • Chest deformities (in chronic severe disease)

18.6 Investigations

18.6.1 Imaging

Chest X-ray (CXR)

  • May show:
    • Tram-track lines
    • Peribronchial thickening
    • Atelectasis
    • Hyperinflation
  • Limited sensitivity; a normal CXR does not exclude disease.

High-Resolution CT Scan (Gold Standard)

  • Confirms diagnosis
  • Shows bronchial dilatation (broncho-arterial ratio >1), lack of tapering, signet-ring sign
  • Not always accessible in rural Ghana.

18.6.2 Laboratory Tests

  • Full blood count (leucocytosis in infections)
  • Sputum culture (including TB workup)
  • HIV testing where indicated
  • Immunoglobulin levels if immunodeficiency is suspected

18.6.3 Other Tests

  • Spirometry (for children ≥5 years): obstructive pattern
  • Bronchoscopy:
    • Suspected foreign body
    • Localised bronchiectasis

18.7 Differential Diagnosis

  • Uncontrolled asthma
  • Recurrent pneumonia due to underlying immunodeficiency
  • Cystic fibrosis (rare locally, but consider in persistent cases)
  • Post-TB lung disease
  • Chronic aspiration syndromes

18.8 Management

Management goals:

  1. Reduce symptoms
  2. Prevent exacerbations
  3. Improve lung function
  4. Prevent further lung damage.

18.8.1 Airway Clearance Techniques (Core Treatment)

  • Chest physiotherapy
  • Postural drainage
  • Percussion and vibration
  • Oscillatory PEP devices (e.g., Flutter valve) if available

Parents should be trained to perform airway clearance at home.

18.8.2 Antibiotics

18.8.2.1 Acute Exacerbations

  • Amoxicillin–clavulanate (first-line)
  • Alternatives: cefuroxime, macrolides (if atypical pathogens suspected)
  • Duration: 10–14 days

18.8.2.2 Chronic Colonisation

  • Long-term macrolide therapy can reduce exacerbations, but requires specialist oversight.

18.8.3 Bronchodilators

  • Useful in children with coexisting wheeze
  • Consider a salbutamol trial.

18.8.4 Anti-inflammatory Therapy

  • Inhaled corticosteroids are not routinely indicated unless asthma overlaps.

18.8.5 Management of Underlying Causes

  • Remove foreign body
  • Treat TB
  • Manage GERD and aspiration.
  • Treat immunodeficiency

18.8.6 Vaccinations

  • Ensure full immunisation
  • Annual influenza vaccination, where available
  • Pneumococcal vaccine

18.8.7 Nutritional Support

  • High-calorie diet for children with chronic disease
  • Treat malnutrition aggressively

18.8.8 Surgical Intervention

  • Consider lobectomy in children with:
    • Localised bronchiectasis
    • Recurrent severe infections
    • Failure to respond to medical therapy
  • Only after thorough evaluation

18.9 Complications

  • Recurrent pneumonia
  • Haemoptysis
  • Lung abscess
  • Respiratory failure
  • Pulmonary hypertension (rare but serious)
  • Reduced quality of life and growth failure

18.10 Prognosis

  • Good if diagnosed early and managed appropriately
  • Poorer outcomes in:
    • Delayed diagnosis
    • Severe post-infectious disease
    • Associated immunodeficiency
  • Lifelong follow-up may be needed.

18.11 Prevention

  • Early and adequate treatment of pneumonia
  • Prevention and early treatment of TB
  • Prompt immunisation (especially measles, pertussis)
  • Reduce indoor air pollution (charcoal and biomass exposure)
  • Train caregivers in early recognition of respiratory symptoms
  • Improve access to child health services

18.12 Key Points

  • Bronchiectasis is underdiagnosed in Ghana due to limited access to imaging.
  • A chronic productive cough should prompt evaluation for bronchiectasis.
  • Airway clearance is the cornerstone of therapy.
  • Antibiotics are essential for the treatment of exacerbations and for controlling chronic infections.
  • Preventive strategies—especially vaccination and pneumonia control are critical.

18.13 Further Reading

  1. Chang AB, Bush A. Paediatric bronchiectasis: modern management.
  2. Ghana Health Service. Standard Treatment Guidelines.
  3. WHO. Pocket Book of Hospital Care for Children.
  4. Singleton RJ et al. Bronchiectasis in childhood. Lancet.
  5. Al-Saleh S, et al. Non-CF bronchiectasis in Africa and LMICs.