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The Respiratory SystemBronchitis Clinical features, Diagnosis, Management, Prognosis, Strict
criteria have been developed for diagnosis of chronic bronchitis to be made:
productive cough on most days on at least three consecutive months for more
than two successive years, providing other causes of productive cough such as
bronchiectasis and untreated chronic asthma have been excluded. Chronic
bronchitis appears develops in response to the long-continued action of
various types of irritants on the
bronchial mucosa in susceptible individuals. These are:
cigarette
tobacco smoke (the most important one)
dust
smokes
and fumes occurring at workplace in certain industries (apparently cadmium is
especially toxic)
general
atmospheric pollution in industrial cities and towns particularly with sulphur
dioxide and particulates (increasingly important problem) Infection usually with Streptococcus pneumoniae (pneumococcus) and/or Haemophilus
influenzae is very important in aggravating the established condition, but it
is not essential for development/progression of the condition. In other words
chronic bronchitis is not a chronic bacterial infection. It is now known that
many exacerbations of chronic bronchitis are due to upper respiratory viral
infections (e.g., rhinoviruses) and to environmental factors such as exposure
to dampness, sudden changes in temperature and to fog. Pathologically, there is
mucosal oedema with infiltration with macrophages and neutrophils,
hypertrophy of bronchial glands and permanent structural damage (scaring) of
the airway walls that reduce the calibre of the air passages. A
major proportion of airflow obstruction in chronic bronchitis is irreversible unlike the airflow obstruction in chronic asthma. Air
becomes “trapped?in the alveoli because the degree of obstruction is
greater during expiration. Overdistension of the alveoli results and
disruption of their walls may occur (emphysema). Chronic
bronchitis can occur in several forms that to some extent reflect the natural
progression of the disease:
Initially
patients tend to have simple chronic
bronchitis; the productive cough raises mucoid
sputum, but airflow is not obstructed; this type can not be regarded as COPD
If the
sputum also contains pus, presumably because of secondary infections, the
patient is said to have chronic
mucopurulent bronchitis; also not included in COPD
Some
patients with chronic bronchitis may demonstrate hyper-responsive airways and
intermittent episodes of asthma. This condition, termed chronic asthmatic bronchitis, is often difficult to distinguish from
real asthma. Actually it appears that in cases like this there is concomitant
asthma. Eventually bronchitic patients develop persistent airway obstruction, and they are said to have chronic obstructive bronchitis; this form is associated with substantial morbidity and mortality Clinical features: < BACK TO TOP >
The
main feature is repeated attacks of productive cough, usually after colds
during the winter months, but eventually cough is present all the year round.
Morning
cough with large amounts of sputum is characteristic, especially in heavy
smokers (smoking reduces ciliary clearance of mucus).
Sputum
may be mucoid and tenacious and occasionally streaked with blood
(haemoptysis); purulent sputum was thought to be an indication of bacterial
infection, but this may not be the case in all patients.
Wheeze,
breathlessness and tightness in the chest are almost always found, central
cyanosis due to impaired gas exchange and hypoxaemia may follow when the
mucous membranes of the lips and tongue appear bluish.
For
reasons not entirely clear, the patients tend to be obese.
Clinical
pattern often referred to as the “blue
and bloated?/i> type may be seen in late stage of chronic bronchitis;
these patients are cyanosed and bloated from obesity and right-sided heart
failure (see below) with consequent peripheral oedema. Important complications:
Pulmonary hypertension due to reflex constriction of pulmonary arterioles
in hypoventilated areas of the lungs as well as due to destruction of the
pulmonary vascular bed by associated emphysema. Right ventricular failure (cor pulmonale) is a final consequence of the pulmonary hypertension and the major cause of death in these patients. Diagnosis: < BACK TO TOP >
It is
largely clinical when above mentioned criteria are met.
X-ray
of the lungs usually produces no characteristic abnormalities.
Pulmonary
function tests are abnormal ?TLC, RV are reduced, forced expiratory volume
in one second (FEV1), peak expiratory flow (PEF) and VC are reduced
which is consistent with airflow obstruction. These findings are not
substantially improved by inhaled bronchodilators although most patients
report subjective improvement.
In more
advanced stages hypoxaemia (reduction of PO2)
can be found, later on followed by hypercapnia (a rise in PCO2). Exercise test (e.g., distance walked in 10 minutes, number of stairs the patient can climb in a continuous attempt) is a valuable estimate of everyday disability. Management < BACK TO TOP >
Reduction
of bronchial irritation is achieved through stopping smoking (the only measure
that can slow down progression of the disease), avoidance of dusty and
smoke-laden atmospheres and even a change of occupation if necessary.
Treatment
of respiratory infection (if identified) is very important; the vast majority
of bacterial infections are caused by Streptococcus pneumoniae and Haemophilus
influenzae which respond to many broad-spectrum antibiotics; however this type
of treatment does not significantly alter the course of the disease.
It is
useful to try to stimulate expectoration by giving the patient plenty of
fluid, hot drinks or inhalations of steam (drugs which claim to reduce sputum
viscosity such as guaiphenesin [Robitussin], bromhexine [Bisolvon] and
acetylcysteine [Mucomyst] are of little or no value).
Bronchodilator
drugs can be tried, and their value in each particular case should be
assessed. In general they are much less effective than in bronchial asthma,
but they still improve symptoms and exercise tolerance.
The
type of chronic inflammation found in chronic bronchitis does not respond well
to corticosteroids in contrast to bronchial asthma. In case of severe exacerbations hospital treatment is necessary with bronchodilator therapy, intravenous rehydration, oxygen therapy and physiotherapy (tapping massage) to assist expectoration. Prognosis < BACK TO TOP >
Nutrition < BACK TO TOP > Nutrition that alleviate or prevent bronchitis :- Herbs < BACK TO TOP > Herbs that alleviate or prevent bronchitis :- (source :
Dr Zoran Pletikosa) |
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