Commentary
Recurrent pneumonia . . . Not!
Daniel Hughes MD FRCPC
C ough is a common presenting symptom of children encoun-
tered in primary care. It usually arises from intercurrent viral
infections and is of short duration. When cough is associated with
other respiratory symptoms or signs, such as fever and tachypnea,
in a generally unwell child, pneumonia is suspected.
Paediatricians, paediatric respiratory physicians and infec-
tious disease specialists are frequently asked to assess patients
believed to have a diagnosis of recurrent pneumonia. Recurrent
pneumonia is defined as ≥2 episodes in one year or ≥3 episodes
ever, with radiographic clearing of densities between episodes (1).
The initial difficulty for the consultant is often determining the
basis on which a diagnosis of pneumonia was made. If there was
no evidence on auscultation of bronchial breath sounds or focal
crackles/crepitations, and especially when chest radiographs were
not always performed to assess for evidence of airspace disease/
consolidation, the term ‘acute or recurrent lower respiratory infec-
tion’ better describes the situation (2). In some cases, the referral
is triggered by the radiologists’ reports of ‘pneumonia’, while in
others, the parent requests a referral due to concern regarding the
repeated ‘diagnoses of pneumonia’ requiring multiple courses of
antibiotics. The latter situation may be accompanied by the parent
producing a computerized list of their child’s medications provided
by the pharmacist.
The typical referred patient is a preschool/early school-age
child (two to eight years of age) with a history of recurring (not
chronic) respiratory symptoms associated with fever, in which the
clinical and/or radiological findings have suggested repeated epi-
sodes of ‘pneumonia’. It is not uncommon for a diagnosis of ‘pneu-
monia’ to have been made on purely clinical grounds (a challenge
in a young child) without a chest radiograph being performed.
Multiple courses of antibiotics have usually been prescribed. A
more focused history may reveal that the episodes begin with
coryza followed by cough, the latter persisting for as long as two to
four weeks. Associated features include fever of up to 39°C to
40°C, lack of energy and loss of appetite. Chest radiographs, when
performed, often reveal ‘pneumonia’ and antibiotics are usually
prescribed. These episodes may recur frequently, particularly in the
winter, and, when close to one another, leave the parents with the
impression that their child is always sick. This pattern of illness is
particularly noted in children attending nursery schools, daycares
and other settings in which exposure to viral infections is com-
mon. School-age siblings may also transmit viruses. The child’s
cough, initially dry, becomes wet-sounding and parents, if
prompted, will report being able to feel congestion when they
place their hands on the child’s chest, consistent with the ruttle
reported by Elphick et al (3). Classical wheeze may or may not be
heard. Atopic features in the child and/or family are occasionally
noted. Between exacerbations, particularly in the summer, the
child is usually asymptomatic. The wet cough and chest conges-
tion may be apparent to the consultant when the child is exam-
ined during an exacerbation. At these times, chest radiographs
Correspondence and reprints: Dr Daniel Hughes, Pediatric Respiratory Medicine, IWK Health Centre, 5850 University Avenue,
PO Box 9700, Halifax, Nova Scotia B3K 6R8. Telephone 902-470-8218, e-mail dan.hughes@iwk.nshealth.ca
Accepted for publication May 9, 2013
Paediatr Child Health Vol 18 No 9 November 2013
usually demonstrate retained secretions, bronchial wall thickening
and, occasionally, atelectasis (often involving the right middle
lobe [RML]). Lobar consolidation reflecting airspace disease is
rarely observed when radiographs are reviewed by an experienced
paediatric radiologist. A diagnosis of asthma may have been con-
sidered in some cases but excluded when the child failed to
respond to inhaled bronchodilators and/or inhaled corticosteroids,
usually administered using metered-dose inhalers. In this situation,
these observations should not be interpreted as ruling out asthma.
In addition to antibiotics, the medication list provided by the
pharmacist often includes inhaled bronchodilators, corticosteroids
and other asthma medications. An important clue to the clinical
diagnosis may arise if the parent reports significant improvement
in the child’s symptoms when they are treated with bronchodila-
tors administered through wet nebulization and/or systemic ster-
oids, usually associated with an emergency department visit.
There is evidence that the most common cause of ‘recurrent
pneumonia’ and ‘recurrent bronchitis’ in children is underappreci-
ated asthma (4), and hypersecretory asthma, in which production
of excess bronchial secretions is particularly prominent, may play
an important role (5). This is supported by the author’s clinical
experience. The radiographic opacities, interpreted incorrectly as
‘pneumonia’, result from these secretions. The difficulty in diag-
nosing pneumonia radiographically and the overdiagnosis of pneu-
monia have been well described (6,7).
That true recurrent pneumonia can occur in patients with an
underlying disorder, such as pulmonary aspiration, congenital car-
diac defects, neuromuscular disorders, immunodeficiency, etc, is
not questioned. The issue is whether otherwise healthy children
are subject to recurrent pneumonia or even whether recurrent
pneumonia is a complication of asthma. In a 10-year retrospective
survey of almost 3000 children admitted to hospital with pneu-
monia, only 8% met the criteria for recurrent pneumonia (8). An
underlying illness to explain the recurrences was identified in
92%. Eighteen patients had no underlying etiological diagnosis but
detailed testing had not been performed. In cases in which the
underlying etiology was discovered after the diagnosis of pneu-
monia, asthma was the most common.
Similarly, in patients seen in an ambulatory setting over a five-
year period, 70 of 2264 children (3%) attending a paediatric chest
clinic in India met the criteria for recurrent pneumonia (9). An
underlying cause was noted in 59 and no cause in 11, yet all of
these children had bronchiectasis. Of note, asthma was identified
to be the underlying cause in 10 of 59 patients.
The notion that asthma in children can be complicated by
recurrent pneumonia has a long history and contributes to the
confusion when assessing these children. This is especially true
when the RML is involved. The RML is subject to atelectasis
because of the anatomy of the bronchus and the lack of collateral
ventilation with other lobes. Excess mucus production in hyperse-
cretory asthma can lead to RML atelectasis. It is well recognized
©2013 Pulsus Group Inc. All rights reserved 459
Commentary
that the most common cause of the so-called ‘right middle lobe
syndrome’ is asthma. The confusion surrounding this issue dates
back to the 1950s and 1960s (10,11). Kjellman (11), in his study
investigating the relationship between asthma and recurrent pneu-
monia, noted that 14 of 125 asthmatic children fulfilled the cri-
teria for recurrent pneumonia and, radiographically, the RML was
over-represented but, unfortunately, as the author stated, no dis-
tinction was made between atelectasis and pneumonia.
Probably the most illustrative study was that by Eigen et al (4),
who examined 81 patients referred to their clinic with a diagnosis of
persistent or recurrent pneumonia. The diagnosis was based on abnor-
mal chest radiographs demonstrating “segmental or subsegmental
densities or an increase in bronchovascular associated densities.”
Twenty of 81 patients had an apparent cause for their persistent or
recurrent pneumonia. Of the 61 with no obvious etiology, 30 had a
history of allergy or family history of asthma, 19 had a history of
wheezing and 11 had wheezing noted on physical examination.
Nineteen patients with no underlying etiology underwent pulmonary
function testing, and nine had airflow obstruction, with four of five
demonstrating a bronchodilator response. Twelve patients were
recalled for pulmonary function testing and three had airways obstruc-
tion and bronchodilator response. The nine with normal lung func-
tion underwent a methacholine challenge, and eight had positive
responses. In total, 92% of the no-etiology group had evidence of air-
ways hyperreactivity. The authors concluded that their study had
“identified a group of asthmatics in whom excessive mucus production
rather than bronchospasm caused the majority of symptoms and in
whom the recurrent chest infiltrates originated as atelectasis from
mucus plugging rather than as infectious processes”.
Hypersecretory asthma does not completely fit the description
of a newly discovered entity referred to as ‘persistent or protracted
bacterial bronchitis’ (PBB) because the latter is described as
chronic wet cough lasting longer than four weeks and resolution of
cough with antibiotic treatment (12). However, there is the pos-
sibility that some patients with PBB have hypersecretory asthma.
Of 81 patients with PBB, Donnelly et al (13) noted a diagnosis of
asthma in 31%. The author suggested that PBB is often misdiag-
nosed as asthma; however, an alternative explanation is that
asthma is misdiagnosed as PBB.
It must be emphasized that this author is referring to children
with recurring wet cough associated with viral respiratory tract
infections, not chronic wet cough with or without sputum produc-
tion. In the latter situation, bronchiectasis should be considered.
Evidence of bronchiectasis on the chest radiograph includes persis-
tent patchy infiltrates, dilated mucous-filled bronchi resembling
fingers in a glove or dilated air-filled bronchi resembling tram
tracks. Bronchiectasis may be confirmed using computed tomog-
raphy of the chest. Causes of bronchiectasis include cystic fibrosis,
primary ciliary dyskinesia, immunodeficiency, retained foreign
body and recurrent aspiration (5).
The diagnostic confusion between asthma and recurrent pneu-
monia has recently been discussed by Brand et al (14). The authors
state that asthma is not a common underlying cause of recurrent
pneumonia but the probability remains that the diagnosis of recur-
rent pneumonia itself is questionable. It is recommended that the
consultant limit investigations to a review of previous chest radio-
graphs, sweat testing, serum immunoglobulins and, for individuals
old enough, spirometry. Young children swallow rather than
expectorate and, consequently, sputum is rarely available for cul-
ture or examination (15).
For children with recurrent ‘pneumonia-like’ symptoms due to
underlying asthma and/or hypersecretory asthma, exacerbations
typically improve with intermittent administration of salbutamol.
460
It has been the author’s experience that salbutamol delivered by
wet nebulization alone is particularly beneficial. Rarely has the
author encountered a child with this asthma phenotype who could
be successfully managed using metered-dose inhalers, although
they may exist. Oral steroids, such as prednisolone, may be
required for more severe exacerbations. Following an explanation
and reassurance that their otherwise healthy child has no reason to
experience recurring episodes of pneumonia (including written
instructions), the parents are instructed to initiate therapy at
home at the onset of the child’s symptoms and continue, generally
for seven to 10 days. Antibiotics are not prescribed. Children with
recurrent, more severe episodes benefit from the use of daily
inhaled steroids, similar to other children with asthma (16).
Having had the opportunity to follow these patients for many
years, it has become apparent that the recurring wet cough eventu-
ally becomes a dry one and none have developed bronchiectasis.
In 30 years, the author has never observed recurrent bacterial
pneumonia in an otherwise normal child, yet hardly a week passes
without being referred such a child subjected to multiple chest
radiographs and an abundance of antibiotics. Physicians should
consider a diagnosis of hypersecretory asthma in these children
and provide more appropriate and effective therapy.
Educational REsouRcEs foR PaREnts: Hypersecretory
Asthma – Information for Parents. Chest Clinic, IWK Health Centre
(Halifax, Nova Scotia).
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Paediatr Child Health Vol 18 No 9 November 2013