Bronchiectasis results from conditions associated with repeated damage to bronchial walls and with abnormal mucociliary clearance, which causes a breakdown of supporting tissue adjacent to the airways. Such conditions include:

In bronchiectasis, hyperplastic squamous epithelia denuded of cilia replace ulcerated columnar epithelia. Abscess formation occurs, involving all layers of the bronchial walls. This produces inflammatory cells and fibrous tissues. The result is both dilation and narrowing of the airways. Sputum stagnates in the dilated bronchi and leads to secondary infection, characterized by inflammation and leukocytic accumulations. Additional debris collects in and occludes the bronchi. Building pressure from the retained secretions induces mucosal injury. Extensive vascular proliferation of bronchial circulation occurs and produces frequent hemoptysis.

Antibiotic therapy (oral or I.V.) for 7 to 10 days—or until sputum production decreases—is the principal treatment. Bronchodilators and postural drainage and chest percussion help remove secretions if the patient has bronchospasm and thick, tenacious sputum. Occasionally, bronchoscopy may be used to remove secretions. Oxygen therapy may be used for hypoxia. Segmental resection, bronchial artery embolization, or lobectomy may be necessary if pulmonary function is poor.

The only cure for bronchiectasis is surgical removal of the affected lung portion. However, the patient with bronchiectasis affecting both lungs probably won’t benefit from surgery.

Croup usually results from a viral infection. Parainfluenza viruses cause about two-thirds of such infections; adenoviruses, respiratory syncytial virus (RSV), influenza viruses, measles viruses, and bacteria (pertussis and diphtheria) account for the rest.

For most children with croup, home care with rest, cool humidification during sleep, and antipyretic drugs such as acetaminophen (Tylenol) relieve signs and symptoms. However, respiratory distress that interferes with oral hydration usually requires hospitalization and parenteral fluid replacement to prevent dehydration. If the patient has croup from a bacterial infection, he needs antibiotic therapy. Oxygen therapy may also be required.

For moderately severe croup, aerosolized racemic epinephrine may temporarily reduce airway swelling. Intubation is performed only if other means of preventing respiratory failure are unsuccessful.

Corticosteroids reduce subglottic edema and inflammation. Dexamethasone (Decadron) given in a single dose early in the course of croup allows a shorter hospital stay and reduces cough, dyspnea and, commonly, the need for intubation.

Epiglottiditis usually results from infection with Haemophilus influenzae type B and, occasionally, pneumococci or group A streptococci. Epiglottiditis is becoming more rare.

A patient with acute epiglottiditis and airway obstruction requires emergency hospitalization. Place the patient in a cool-mist tent with added oxygen. If complete or near-complete airway obstruction occurs, he may also need emergency endotracheal intubation or a tracheotomy. Arterial blood gas (ABG) analysis or pulse oximetry may be used to assess his progress.

Treatment may also include parenteral fluids to prevent dehydration when the disease interferes with swallowing and a 10-day course of parenteral antibiotics—usually ampicillin (Principen). If the patient is allergic to penicillin or could have ampicillin-resistant endemic H. influenzae, chloramphenicol (Chloromycetin) or another antibiotic may be prescribed.

Corticosteroids may be prescribed to reduce edema during early treatment. Oxygen therapy also may be used.

Keep in mind that preventive measures should be taken. In the late 1980s, the American Academy of Pediatrics recommended that all children receive the Haemophilus b conjugate (Hib) vaccine, and it remains on the recommended schedule of immunizations today. Begin Hib vaccine immunization at age 2 months and continue for three or four doses, depending on the manufacturer. Since the introduction of the Hib vaccine, the incidence of epiglottiditis has declined dramatically.

Pharyngitis may occur as a result of a virus, such as rhinovirus, coronavirus, adenovirus, influenza, and parainfluenza. Mononucleosis can also cause pharyngitis. In children, streptococcal bacteria commonly cause pharyngitis. Fungal pharyngitis can develop with prolonged use of an antibiotic in an immunosuppressed patient, such as one with human immunodeficiency virus. Gonococcal pharyngitis is caused by release of a toxin produced by Corynebacterium diphtheriae.

Based on the patient’s symptoms, treatment for acute viral pharyngitis consists mainly of rest, warm saline gargles, throat lozenges containing a mild anesthetic, plenty of fluids, and an analgesic, as needed. If the patient can’t swallow fluids, he may need hospitalization for I.V. hydration.

Bacterial pharyngitis requires rigorous treatment with penicillin (or another broad-spectrum antibiotic if the patient is allergic to penicillin) because streptococcus is the chief infecting organism. Continue antibiotic therapy for 48 hours after visible signs of infection have disappeared or for at least 7 to 10 days.
An antifungal is used to treat fungal pharyngitis. An equine antitoxin is given for diphtheria pharyngitis.

Chronic pharyngitis requires the same supportive measures as acute pharyngitis, but with greater emphasis on eliminating the underlying cause such as an allergen.

Preventive measures include humidifying the air and avoiding excessive exposure to air conditioning. In addition, urge patients who smoke to stop.

A transudative pleural effusion—an ultrafiltrate of plasma containing a low concentration of protein—may result from heart failure, hepatic disease with ascites, peritoneal dialysis, hypoalbuminemia, and disorders that increase intravascular volume.

The effusion stems from an imbalance of osmotic and hydrostatic pressures. Normally, the balance of these pressures in parietal pleural capillaries causes fluid to move into the pleural space; balanced pressure in visceral pleural capillaries promotes reabsorption of this fluid. However, when excessive hydrostatic pressure or decreased osmotic pressure causes excessive fluid to pass across intact capillaries, a transudative pleural effusion results.

Exudative pleural effusions can result from tuberculosis (TB), subphrenic abscess, pancreatitis, bacterial or fungal pneumonitis or empyema, cancer, parapneumonia, pulmonary embolism (with or without infarction), collagen disease (lupus erythematosus and rheumatoid arthritis), myxedema, intra-abdominal abscess, esophageal perforation, and chest trauma.

Such an effusion occurs when capillary permeability increases, with or without changes in hydrostatic and colloid osmotic pressures, allowing protein-rich fluid to leak into the pleural space.

Empyema usually stems from an infection in the pleural space. The infection may be idiopathic or may be related to pneumonitis, carcinoma, perforation, penetrating chest trauma, or esophageal rupture.