Bronchitis

• Bronchitis is one of the top conditions for which patients seek medical care.

Bronchitis is characterized by inflammation of the bronchial tubes (or bronchi), which are the air passages that extend from the trachea into the small airways and alveoli.

• Triggers may be infectious agents, such as viruses or bacteria, or non-infectious agents,

such as smoking or inhalation of chemical pollutants or dust.

• There two types of bronchitis, namely acute and chronic bronchitis.

• Acute bronchitis is manifested by cough and, occasionally, sputum production that last

for not more than 3 weeks.

• Chronic bronchitis is defined clinically as the presence of a cough productive of sputum

not attributable to other causes on most days for at least 3 months over 2 consecutive

years.

Etiology of Acute Bronchitis

• Respiratory viruses are the most common causes of acute bronchitis

The most common viruses include

Influenza A and B

Parainfluenza

Respiratory syncytial virus

Coronavirus

Other infections

Mycoplasma species

Chlamydia pneumoniae

Streptococcus pneumoniae

Moraxella catarrhalis

Haemophilus influenzae

Exposure to irritants, such as pollution, chemicals, and tobacco smoke may also

cause acute bronchial irritation

 

Etiology of Chronic Bronchitis

• Cigarette smoking is indisputably the predominant cause of chronic bronchitis.

Estimates suggest that cigarette smoking accounts for 85-90% of chronic bronchitis

and chronic obstructive pulmonary diseases (COPD).

o Studies indicate that smoking pipes, cigars, and marijuana cause similar damage.

Smoking impairs ciliary movement, inhibits the function of alveolar macrophages,

and leads to hypertrophy and hyperplasia of mucus-secreting glands.

Smoking can also increase airway resistance via vagally mediated smooth muscle

constriction.

Unless some other factor can be isolated as the irritant that produces the symptoms,

the first step in dealing with chronic bronchitis is for the patient to stop smoking.

• Bacterial or viral infections

• Environmental pollution

 

Epidemiology of Bronchitis

• Although found in all age groups, acute bronchitis is most frequently diagnosed in

children younger than 5 years.

• Whereas chronic bronchitis is more prevalent in people older than 50 years.

• Bronchitis affects males more than females

• Bronchitis occurs more frequently in

Populations with a low socioeconomic status

People who live in urban and highly industrialized areas

• No difference in the racial distribution has been reported

 

Clinical Features of Bronchitis

Symptom of Acute Bronchitis

• Cough is the most commonly observed symptom; generally lasts from 10-20 days

• Purulent sputum is reported in 50% of persons with acute bronchitis

• Sore throat

• Runny or stuffy nose

• Headache

• Muscle aches

• Extreme fatigue

• Fever is a relatively unusual sign and, when accompanied by cough, suggests either

influenza or pneumonia.

• Nausea, vomiting and diarrhea are rare.

• Severe cases may cause general malaise and chest pain.

• With severe tracheal involvement, burning, substernal chest pain associated with

respiration and coughing may occur.

• Dyspnea and cyanosis is not observed in adults unless the patient has underlying COPD

or another condition that impairs lung function

 

Signs of Acute Bronchitis

• Conjunctivitis, adenopathy and rhinorrhea suggest adenovirus infection

• Inspiratory stridor may occur

• Localized lymphadenopathy

• Rhinorrhea to coarse rhonchi

• Use of accessory, muscles can be observed in severe cases

• Pharyngeal erythema may or may not be present

 

Symptoms of Chronic Bronchitis

• Onset is typically in the fifth decade

• Productive cough

• A morning ‘smoker's cough’ is frequent, usually mucoid in character but becoming

purulent during exacerbations, which in early disease are intermittent and infrequent.

• Volume is generally small. Production of more than 60 mL/d should prompt investigation

for bronchiectasis

• Wheezing maybe present but does not indicate the severity of illness

• As chronic bronchitis progresses, exacerbations become more severe and more frequent.

• Gas exchange disturbances, worsen and dyspnea becomes progressive

• Exercise tolerance becomes progressively limited

• With worsening hypoxemia, erythrocytosis, and cyanosis may occur

• The development of morning headache may indicate the onset of significant CO2 retention

• In advanced disease, weight loss is frequent and correlates with an adverse prognosis

• When blood gas derangements are severe, cor pulmonale may manifest itself by

peripheral edema and water retention

 

Signs of Chronic Bronchitis

• The physical examination has poor sensitivity and variable reproducibility in chronic

bronchitis.

• Findings may be minimal or even normal in mild disease, requiring objective laboratory

data for confirmation.

• In early disease, the only abnormal findings may be wheezes on forced expiration and a

forced expiratory time prolonged beyond 6 s.

• With progressive disease, findings of hyperinflation become more apparent.

• These include an increased anteroposterior diameter of the chest, decreased cardiac

dullness, and distant heart and breath sounds.

• Coarse inspiratory crackles and rhonchi may be heard, especially at the bases

• Breathing through pursed lips prolongs expiratory time and may help reduce dynamic

hyperinflation.

• Cor pulmonale and right heart failure may be evidenced by dependent edema and an

enlarged, tender liver.

• Cyanosis is a somewhat unreliable manifestation of severe hypoxemia and is seen when

severe hypoxemia and erythrocytosis is present.

 

Differential Diagnosis of Acute Bronchitis

• Asthma

• Pneumonia

• Bronchiectasis

• Chronic bronchitis

• Pharyngitis

• Sinusitis, acute

 

Differential Diagnosis of Chronic Bronchitis

• Bronchiectasis

• Tuberculosis

• Congestive heart failure

 

Investigations

• Obtain a complete blood count with differential

• A sputum sample showing neutrophil granulocytes (inflammatory white blood cells)

• Gram stain and Ziel Neilsen stain

• A chest X-ray that reveals hyperinflation

Some conditions that predispose to bronchitis may be indicated by chest radiography.

• A sputum sample showing neutrophil granulocytes (inflammatory white blood cells)

Gram stain and Ziel Neilsen stain, culture showing that has pathogenic microorganisms

such as Streptococcus spp.

 

Treatment of Acute Bronchitis

• Therapy is generally aimed toward the alleviation of symptoms.

• Care for acute bronchitis is primarily supportive and should ensure that the patient is

oxygenated adequately.

• In acute bronchitis, treatment with beta2-agonist bronchodilators may be useful in

patients who have associated wheezing with cough and underlying lung disease.

 

Treatment of Chronic Bronchitis

• Treatment of chronic bronchitis is based on

The principles of prevention of further evolution of disease

Preservation of airflow

Preservation and enhancement of functional capacity

Management of physiologic complications

Avoidance of Acute exacerbations

• Smoking cessation

Elimination of tobacco smoking confers significant survival benefit to patients with

chronic bronchitis

 

Bronchodilators

• These drugs improve dyspnea and exercise tolerance by improving airflow and by

reducing end-expiratory lung volume and air-trapping.

• Bronchodilator medication is available in a metered-dose inhaler (and some dry-powder

inhalers) and in nebulize and oral forms.

• Inhalers deliver medications directly to the airways and have limited systemic absorption

and side effects.

• Salbutamol (short-acting beta 2 agonists).

Acute symptoms: 2 inhalations repeated 6 hourly

• Other bronchodilators include Theophylline

 

Glucocorticoids

• Chronic bronchitis is a disease associated with airway inflammation; therefore,

glucocorticoids are an intuitively attractive therapeutic modality.

• Long-term systemic glucocorticoid use is associated with multiple side effects.

In particular, they have been associated with worsened osteoporosis and increased risk of

vertebral fracture.

• If systemic steroids are used, the lowest effective dose should be employed, and alternate day

dosing used whenever possible, e.g. prednisolone.

• The use of inhaled glucocorticoids ameliorates systemic side effects. Examples include

Beclomethasone dipropionate (4puffs) twice daily or 100mcg (2 puffs) 3 – 4 times daily by

aerosol inhalation/d (42 mcg per actuation, 12-20 puffs qid) inhaled PO divided

tid/qid

Oxygen Therapy

• Severe and progressive hypoxemia is often seen in advanced chronic bronchitis and may

result in cellular hypoxia with deleterious physiologic consequences.

• Long-term O2 therapy has been shown to reverse secondary polycythemia; improve body

weight; ameliorate cor pulmonale; and enhance neuropsychiatric function, exercise

tolerance, and activities of daily living.

• Oxygen is most frequently delivered through a nasal cannula at rates of 2 to 5 L/min.

Note: Most of the treatment options might not be present at the primary health care levels

(dispensary and health center) and therefore referring the patient to hospitals for proper

management will be unavoidable.

Home Therapy

• For patients with mild exacerbations for whom outpatient therapy is appropriate, a

combination of anticholinergic and short-acting b2-adrenergic agonist bronchodilators

should be prescribed.

• The presence of increased sputum volume or purulence suggests an infectious cause of an

exacerbation. With either of these features are present in conjunction with increased

breathlessness or when both are present, antibiotics should be prescribed.

• The organisms most frequently associated with mild chronic bronchitis exacerbations

include Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis.

• Common drugs used are

o Trimethoprim/sulfamethoxazole (cotrimoxazole) 960 mg PO 12 hourly for 10-14

days

o Doxycycline 100 mg PO bid for 10 days.

o Amoxicillin and clavulanate 500 mg PO 8 hourly for 7-10 d; not to exceed 2 g/d

Hospital Management

• Hospitalized patients should receive bronchodilators, antibiotics, oral glucocorticoids, and

sufficient O2 to keep the SaO2 > 90%. β2-agonists and anticholinergic agents should be

given together every 4 to 6 hours.

Note: In absence of an oximeter indication for oxygen therapy will depend on clinical

grounds based on signs like: dyspnoea, tachypnoea, and cyanosis Note that all patients

who need admission/hospitalization need to be referred

REFERENCES;

•      Braunwald & Fauci (2001). Harrison’s principles of internal medicine 15th Ed.  Oxford: McGraw Hill

•      Davidson, S (2006). Principles and practice of medicine 20th Ed.  Churchill: Livingstone.

Kumar & Clark (2003) Textbook of clinical medicine. Churchill: Livingstone.

•      Douglas Model (2006): Making sense of Clinical Examination of the Adult patient. 1^st Ed. Hodder Arnold

•      Longmore, M., Wilkinson, I., Baldwin, A., & Wallin, E. (2014). Oxford handbook of clinical medicine. Oxford

•      Macleod, J. (2009). Macleod's clinical examination. G. Douglas, E. F. Nicol, & C. E. Robertson (Eds.). Elsevier Health Sciences.

•      Nicholson N., (1999), Medicine of Non-communicable diseases in adults. AMREF

•      Stuart and Saunders (2004): Mental health Nursing principles and practice. 1^st Ed. Mosby

•      Swash, M., & Glynn, M. (2011). Hutchison's clinical methods: An integrated approach to clinical practice.