Bronchitis Pathophysiology

7/22/2019 Bronchitis Pathophysiology

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Bronchitis is one of the top conditions for which patients seek medical care. It is characterized by inflammationof the bronchial tubes (or bronchi), the air passages that extend from the trachea into the small airways andalveoli. (ee !linical "resentation.)

!hronic bronchitis is defined clinically as cough with sputum expectoration for at least # months a year during aperiod of $ consecutive years. !hronic bronchitis is associated with hypertrophy of the mucus%producing glandsfound in the mucosa of large cartilaginous airways. &s the disease advances, progressive airflow limitationoccurs, usually in association with pathologic changes of emphysema. 'his condition is called chronicobstructive pulmonary disease. (ee !linical "resentation.)

hen a stable patient experiences sudden clinical deterioration with increased sputum volume, sputumpurulence, andor worsening of shortness of breath, this is referred to as an acute exacerbation of chronicbronchitis, as long as conditions other than acute tracheobronchitis are ruled out. (ee *iagnosis.)

'riggers of bronchitis may be infectious agents, such as viruses or bacteria, or noninfectious agents, such assmoking or inhalation of chemical pollutants or dust. Bronchitis typically occurs in the setting of an upperrespiratory illness+ thus, it is observed more freuently in the winter months. (ee -tiology.)

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&llergens and irritants can produce a similar clinical picture. &sthma can be mistakenly diagnosed as acutebronchitis if the patient has no prior history of asthma. In one study, one third of patients who had beendetermined to have recurrent bouts of acute bronchitis were eventually identified as having asthma. enerally,bronchitis is a diagnosis made by exclusion of other conditions such as sinusitis, pharyngitis, tonsillitis, andpneumonia. (ee *iagnosis.)

&cute bronchitis is manifested by cough and, occasionally, sputum production that last for no more than #weeks. &lthough bronchitis should not be treated with antimicrobials, it is freuently difficult to refrain fromprescribing them. &ccurate testing and decision%making protocols regarding who might benefit fromantimicrobial therapy would be useful but are not currently available. (ee 'reatment and /anagement, as wellas /edication.)

'o see complete information on "ediatric Bronchitis, please go to the main article by clicking here.

Pathophysiology

*uring an episode of acute bronchitis, the cells of the bronchial%lining tissue are irritated and the mucousmembrane becomes hyperemic and edematous, diminishing bronchial mucociliary function. !onseuently, theair passages become clogged by debris and irritation increases. In response, copious secretion of mucusdevelops, which causes the characteristic cough of bronchitis.

In the case of mycoplasmal pneumonia, bronchial irritation results from the attachment of the organism(Mycoplasma pneumoniae) to the respiratory mucosa, with eventual sloughing of affected cells. &cutebronchitis usually lasts approximately 01 days. If the inflammation extends downward to the ends of thebronchial tree, into the small bronchi (bronchioles), and then into the air sacs, bronchopneumonia results.

!hronic bronchitis is associated with excessive tracheobronchial mucus production sufficient to cause cough

with expectoration for # or more months a year for at least $ consecutive years. 'he alveolar epithelium is boththe target and the initiator of inflammation in chronic bronchitis.

& predominance of neutrophils and the peribronchial distribution of fibrotic changes result from the action ofinterleukin 2, colony%stimulating factors, and other chemotactic and proinflammatory cytokines. &irwayepithelial cells release these inflammatory mediators in response to toxic, infectious, and inflammatory stimuli,in addition to decreased release of regulatory products such as angiotensin%converting enzyme or neutralendopeptidase.

!hronic bronchitis can be categorized as simple chronic bronchitis, chronic mucopurulent bronchitis, or chronicbronchitis with obstruction. /ucoid sputum production characterizes simple chronic bronchitis. "ersistent or

recurrent purulent sputum production in the absence of localized suppurative disease, such asbronchiectasis,characterizes chronic mucopurulent bronchitis.

!hronic bronchitis with obstruction must be distinguished from chronic infective asthma. 'he differentiation isbased mainly on the history of the clinical illness3 patients who have chronic bronchitis with obstruction presentwith a long history of productive cough and a late onset of wheezing, whereas patients who have asthma withchronic obstruction have a long history of wheezing with a late onset of productive cough.

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!hronic bronchitis may result from a series of attacks of acute bronchitis, or it may evolve gradually because ofheavy smoking or inhalation of air contaminated with other pollutants in the environment. hen so%calledsmoker4s cough is continual rather than occasional, the mucus%producing layer of the bronchial lining hasprobably thickened, narrowing the airways to the point where breathing becomes increasingly difficult. ithimmobilization of the cilia that sweep the air clean of foreign irritants, the bronchial passages become more

vulnerable to further infection and the spread of tissue damage.

Etiology

5espiratory viruses are the most common causes of acute bronchitis, and cigarette smoking is indisputably thepredominant cause of chronic bronchitis.

Viral and becterial infections in acute bronchitis

'he most common viruses include influenza & and B, parainfluenza, respiratory syncytial virus, andcoronavirus, although an etiologic agent is identified only in a minority of cases.607

&cute bronchitis is usually caused by infections, such as those caused by Mycoplasmaspecies, Chlamydiapneumoniae, Streptococcus pneumoniae, Moraxella catarrhalis,andHaemophilus influenzae,and by viruses,such as influenza, parainfluenza, adenovirus, rhinovirus, and respiratory syncytial virus. -xposure to irritants,such as pollution, chemicals, and tobacco smoke, may also cause acute bronchial irritation.

Bordetella pertussisshould be considered in children who are incompletely vaccinated, though studiesincreasingly report this bacterium as the causative agent in adults as well.6$7

Smoking and other causes of chronic bronchitis

!igarette smoking is indisputably the predominant cause of chronic bronchitis. !ommon risk factors for acuteexacerbations of chronic bronchitis are advanced age and low forced expiratory volume in one second (8-90).

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/ost (:1%21;) acute exacerbations of chronic bronchitis are estimated to be due to respiratory infections.61; of chronic bronchitis and chronic obstructivepulmonary disease. tudies indicate that smoking pipes, cigars, and mari?uana causes similar damage. mokingimpairs ciliary movement, inhibits the function of alveolar macrophages, and leads to hypertrophy andhyperplasia of mucus%secreting glands.

moking can also increase airway resistance via vagally mediated smooth muscle constriction. @nless someother factor can be isolated as the irritant that produces the symptoms, the first step in dealing with chronicbronchitis is for the patient to stop smoking.

&ir pollution levels have been associated with increased respiratory health problems among people living inaffected areas. 'he &ir "ollution and 5espiratory Aealth Branch of the ational !enter for -nvironmentalAealth directs the fight of the @ !enters for *isease !ontrol and "revention against respiratory illnessassociated with air pollution.

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&ccording to theHealthy People 2000report, each year in the @nited tates, health costs of human exposure tooutdoor air pollutants range from C


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Bacterial superinfection

"neumonia develops in about =; of patients with bronchitis (incidence of subseuent pneumonia,

unaffected by antibiotic treatment)

!hronic bronchitis may develop with repeated episodes of acute bronchitis

5eactive airway disease can occur as a result of acute bronchitis

Aemoptysis

Patient Education

"atient education is essential in the prevention and treatment of acute bronchitis. @nfortunately, health careproviders usually underemphasize education. "atients should be counseled to take the following measures3

&void smoking and secondhand smoke

Eive in a clean environment 5eceive the influenza vaccine yearly between Fctober and *ecember

5eceive the pneumonia vaccine every =%01 years if aged D= years or older or with chronic disease

Fbtain a complete history, including information on exposure to toxic substances and smoking. "atients withchronic bronchitis are often overweight and cyanotic. Initially, cough is present in the winter months. Fver theyears, the cough progresses from hibernal to perennial, and mucopurulent relapses increase in freuency, theduration and severity of which increase to the point of exertional dyspnea.

!ough is the most commonly observed symptom. It begins early in the course of many acute respiratory tractinfections and becomes more prominent as the disease progresses. &cute bronchitis may be indistinguishablefrom an upper respiratory tract infection during the first few days, though cough lasting greater than = days maysuggest acute bronchitis.6D7

In patients with acute bronchitis, cough generally lasts from 01%$1 days. putum production is reported inapproximately half the patients in whom cough occurred. putum may be clear, yellow, green, or even blood%tinged. "urulent sputum is reported in =1; of persons with acute bronchitis. !hanges in sputum color are due toperoxidase released by leukocytes in sputum+ therefore, color alone cannot be considered indicative of bacterialinfection.

8ever is a relatively unusual sign and, when accompanied by cough, suggests either influenza or pneumonia.ausea, vomiting, and diarrhea are rare. evere cases may cause general malaise and chest pain. ith severetracheal involvement, symptoms include burning, substernal chest pain associated with respiration, andcoughing.

*yspnea and cyanosis are not observed in adults unless the patient has underlying chronic obstructivepulmonary disease or another condition that impairs lung function.



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Fther symptoms of acute bronchitis include the following3

ore throat

5unny or stuffy nose

Aeadache /uscle aches

-xtreme fatigue

Physical Examination

'he physical examination findings in acute bronchitis can vary from normal%to%pharyngeal erythema, localizedlymphadenopathy, and rhinorrhea to coarse rhonchi and wheezes that change in location and intensity after adeep and productive cough.

*iffuse wheezes, high%pitched continuous sounds, and the use of accessory muscles can be observed in severecases. Fccasionally, diffuse diminution of air intake or inspiratory stridor occurs+ these findings indicateobstruction of a ma?or bronchi or the trachea, which reuires seuentially vigorous coughing, suctioning, and,possibly, intubation or even tracheostomy.

ustained heave along the left sternal border indicates right ventricular hypertrophy secondary to chronicbronchitis. !lubbing on the digitsandperipheral cyanosisindicate cystic fibrosis. Bullous myringitis maysuggest mycoplasmal pneumonia. !on?unctivitis, adenopathy, and rhinorrhea suggest adenovirus infection.

treptococcal pharyngitis is most commonly caused by group & streptococci (


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Fccupational exposures

Differential Diagnoses

&lpha0%&ntitrypsin *eficiency

&sthma

Bronchiectasis

Bronchiolitis

!hronic Bronchitis

!hronic Fbstructive "ulmonary *isease

astroesophageal 5eflux *isease

Influenza

"haryngitis, Bacterial

"haryngitis, 9iral

inusitis, &cute

inusitis, !hronic

treptococcus roup & Infections

Approach ConsiderationsBronchitis may be suspected in patients with an acute respiratory infection with cough+ yet, because many moreserious diseases of the lower respiratory tract cause cough, bronchitis must be considered a diagnosis ofexclusion. & complete blood count with differential may be obtained.

Cultures and Staining

Fbtain cultures of respiratory secretions for influenza virus,Mycoplasmapneumoniae,andBordetella pertussiswhen these organisms are suspected. !ulture methods and immunofluorescence tests have been developed forlaboratory diagnosis of C pneumoniaeinfection.

Fbtain a throat swab. !ulture and gram stain of sputum is often performed, though these tests usually show nogrowth or only normal respiratory florae.607

Blood culture may be helpful if bacterial superinfection is suspected.

Procalcitonin Levels

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"rocalcitonin levels may be useful to distinguish bacterial infections from nonbacterial infections. 'rials from$112 and $11> have shown that they may help guide therapy and reduce antibiotic use. 6:, 27

Sputum Cytology

putum cytology may be helpful if the cough is persistent.

Chest adiography

!hest radiography should be performed in those patients whose physical examination findings suggestpneumonia. -lderly patients may have no signs of pneumonia+ therefore, chest radiography may be warranted inthese patients, even without other clinical signs of infection.

!ronchoscopy

Bronchoscopy may be needed to exclude foreign body aspiration, tuberculosis, tumors, and other chronicdiseases of the tracheobronchial tree and lungs.

"nfluen#a $esting

Influenza tests may be useful. &dditional serologic tests, such as that for atypical pneumonia, are not indicated.

Spirometry

pirometry may be useful because patients with acute bronchitis often have significant bronchospasm, with a

large reduction in forced expiratory volume in one second (8-90). 'his generally resolves over


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'he most effective means for controlling cough and sputum production in patients with chronic bronchitis is theavoidance of environmental irritants, especially cigarette smoke.

'o see complete information on "ediatric Bronchitis, please go to the main article by clicking here.

Symptomatic $reatment

Based on $11D &merican !ollege of !hest "hysicians (&!!") guidelines, 6>, 017 central cough suppressants suchas codeine and dextromethorphan are recommended for short%term symptomatic relief of coughing in patientswith acute and chronic bronchitis.6007

&lso based on $11D &!!" guidelines, therapy with short%acting beta%agonists ipratropium bromide andtheophylline can be used to control symptoms such as bronchospasm, dyspnea, and chronic cough in stablepatients with chronic bronchitis. 8or this group, treatment with a long%acting beta%agonist, when coupled withan inhaled corticosteroid, can be offered to control chronic cough.

8or details on these guidelines, see !hronic cough due to chronic bronchitis3 &!!" evidence%based clinicalpractice guidelinesand !hronic cough due to acute bronchitis3 &!!" evidence%based clinical practiceguidelines.

8or patients with an acute exacerbation of chronic bronchitis, therapy with short%acting agonists oranticholinergic bronchodilators should be administered during the acute exacerbation. In addition, a shortcourse of systemic corticosteroid therapy may be given and has been proven to be effective.

In acute bronchitis, treatment with beta$%agonist bronchodilators may be useful in patients who have associatedwheezing with cough and underlying lung disease. Eittle evidence indicates that the routine use of beta$%agonists is otherwise helpful in adults with acute cough.60$7

onsteroidal anti%inflammatory drugs are helpful in treating constitutional symptoms of acute bronchitis,including mild%to%moderate pain. &lbuterol and guaifenesin products treat cough, dyspnea, and wheezing.

In patients with chronic bronchitis or chronic obstructive pulmonary disease (!F"*), treatment with mucolyticshas been associated with a small reduction in acute exacerbations and a reduction in the total number of days ofdisability. 'his benefit may be greater in individuals who have freuent or prolonged exacerbations.60#7

/ucolytics should be considered in patients with moderate%to%severe !F"*, especially in the winter months.6#7

Antibiotic $herapy

&mong otherwise healthy individuals, antibiotics have not demonstrated any consistent benefit in thesymptomatology or natural history of acute bronchitis.60


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&ntibiotics, however, are recommended in patients older than D= years with acute cough if they have had ahospitalization in the past year, have diabetes mellitus or congestive heart failure, or are on steroids.60D7

In patients with acute exacerbations of chronic bronchitis, the use of antibiotics is recommended. 'rials haveshown that antibiotics improve clinical outcomes in such cases, including a reduction in mortality.60:, 027

& meta%analysis found no difference in treatment success for acute exacerbations of chronic bronchitis withmacrolides, uinolones, or amoxicillinclavulanate.60>7 &nother meta%analysis comparing the effectiveness ofsemisynthetic penicillins to trimethoprim%based regimens found no difference in treatment success or toxicity.6$17 'hese findings support earlier studies that have shown antibiotics to be useful in exacerbations of chronicbronchitis, regardless of the agent used.

In addition, a short course of antibiotics (= d) is as effective as the traditional longer treatments (H= d) in thesepatients.6$07 "atients with severe exacerbations and those with more severe airflow obstruction at baseline are themost likely to benefit. In stable patients with chronic bronchitis, long%term prophylactic therapy with antibioticsis not indicated.

"nfluen#a Vaccinations

'he influenza vaccine may reduce the incidence of upper respiratory tract infections and, subseuently, reducethe incidence of acute bacterial bronchitis. 'he influenza vaccine may be less effective in preventing illnessthan it is in preventing serious complications and death.6$$7

In the @nited tates, the flu season usually occurs from approximately Fctober to &pril. 'he !enters for*isease !ontrol and "revention (!*!) provisional recommendations for the $101%$100 influenza seasonrecommend vaccination for all people aged D months and older. 'he $101$100 vaccine will be a trivalentvaccine, which will cover A00. In certain situations, such as in nursing homes, consider administration of

oseltamivir or zanamivir when an index case is found until the vaccine has had a chance to take effect."neumococcal vaccination is recommended in patients with chronic bronchitis.

'inc

everal studies have shown conflicting results on the use of zinc as an ad?unct treatment against influenza &./ost studies demonstrated favorable results, but participants complained of a bad taste and significant nausea.

Fn June 0D, $11>, the @ 8ood and *rug &dministration (8*&) issued a public health advisory and notifiedconsumers and health care providers to discontinue use of intranasal zinc products. 'he intranasal zinc products

(Kicam asal elasal wab products by /atrixx Initiatives) are herbal cold remedies that claim to reduce theduration and severity of cold symptoms and are sold without a prescription. 'he 8*& received more than 0#1reports of anosmia (inability to detect odors) associated with intranasal zinc. /any of the reports described theloss of the sense of smell with the first dose.6$#7

Consultations



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"rimary care providers can usually treat acute bronchitis unless severe complications occur or the patient hasunderlying pulmonary disease or immunodeficiency. "ulmonary medicine specialists and infectious diseasespecialists also may need to be consulted.

Long($erm )onitoring

5outine follow%up care is usually not necessary. If symptoms worsen (eg, shortness of breath, high fever,vomiting, persistent cough), consider an alternative diagnosis. If symptoms recur (H # episodesy), furtherinvestigation is recommended. If symptoms persist beyond 0 month, reassess patient for other causes of cough.

)edication Summary

'herapy for patients with acute bronchitis is generally aimed toward alleviation of symptoms and includes theuse of analgesics, antipyretics, antitussives, and expectorants.

&mong otherwise healthy individuals, antibiotics have not demonstrated consistent benefit in thesymptomatology or natural history of acute bronchitis.6>, $


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'his agent inhibits bacterial cell wall synthesis by binding to penicillin%binding proteins. 'he addition ofclavulanate inhibits beta%lactamaseproducing bacteria.

It is a good alternative antibiotic for patients allergic to or intolerant of the macrolide class. It is usually welltolerated and provides good coverage of most infectious agents, but it is not effective against /ycoplasma andEegionella species. 'he half%life of the oral dosage is 0%0.# hours. It has good tissue penetration but does notenter the cerebrospinal fluid.

8or children older than # months, base the dosing protocol on amoxicillin content. Because of differentamoxicillinclavulanic acid ratios in the $=1%mg tab ($=10$=) vs the $=1%mg chewable tab ($=1D$.=), do notuse the $=1%mg tab until the child weighs more than


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9iew full drug information

Cefditoren *Spectracef+

!efditoren is a semisynthetic cephalosporin administered as a prodrug. It is hydrolyzed by esterases duringabsorption and is distributed in circulating blood as active cefditoren.

Bactericidal activity results from inhibition of cell wall synthesis via an affinity for penicillin%binding proteins.o dose ad?ustment is necessary for mild renal impairment (!r!l =1%21 mEmin0.:# m$) or mild%to%moderatehepatic impairment. It is indicated for acute exacerbation of chronic bronchitis caused by susceptible strains of pyogenes.

'he


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Clarithromycin *!iaxin+

!larithromycin is a semisynthetic macrolide antibiotic that reversibly binds to the " site of the =1 ribosomal

subunit of susceptible organisms and may inhibit 5&%dependent protein synthesis by stimulating dissociationof peptidyl t%5& from ribosomes, causing bacterial growth inhibition.


Doxycycline *!io($ab- Doryx- Vibramycin+

*oxycycline is a broad%spectrum, synthetically derived bacteriostatic antibiotic in the tetracycline class. It isalmost completely absorbed, concentrates in bile, and is excreted in urine and feces as a biologically active

metabolite in high concentrations.

It inhibits protein synthesis and, thus, bacterial growth by binding to #1 and possibly =1 ribosomal subunitsof susceptible bacteria. It may block dissociation of peptidyl t%5& from ribosomes, causing 5&%dependentprotein synthesis to arrest.

Antitussives/expectorants

Class Summary

parse data attest to the efficacy of expectorants outside the test tube.

0uaifenesin 1ith dextromethorphan *%umibid D)- obitussin D)+

'his agent treats minor cough resulting from bronchial and throat irritation.


Codeine/guaifenesin *obitussin AC+

'he prototype antitussive, codeine, has been used successfully in some chronic cough and induced%coughmodels, but scant clinical data exist for upper respiratory tract infections.

!ronchodilators

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Class Summary

tudies (although limited) have shown an advantage to using bronchodilators and possible superiority toantibiotics for relieving bronchitis symptoms.


Albuterol *Proventil- Ventolin+

&lbuterol relaxes bronchial smooth muscle by action on beta$%receptors with little effect on cardiac musclecontractility.

)etaproterenol sulfate

/etaproterenol is a beta agonist for bronchospasms that relaxes bronchial smooth muscle by action on beta$receptors with little effect on cardiac muscle contractility.


$heophylline *$heo(23- 4niphyl+

'heophylline is used to control symptoms such as bronchospasm, dyspnea, and chronic cough in stable patientswith chronic bronchitis. It potentiates exogenous catecholamines and stimulates endogenous catecholaminerelease and diaphragmatic muscular relaxation, which, in turn, stimulates bronchodilation.


"pratropium

Ipratropium is an anticholinergic bronchodilator that is often used to control symptoms such as bronchospasm,dyspnea, and chronic cough in stable patients with chronic bronchitis.

Corticosteroids- Systemic

Class Summary

8or patients with an acute exacerbation of chronic bronchitis, a short course of systemic corticosteroid therapymay be given and has been proven to be effective.

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Prednisolone *Pediapred- 5rapred+

"rednisolone works by decreasing inflammation by suppressing migration of polymorphonuclear leukocytesand reducing capillary permeability.


Prednisone *Sterapred+

"rednisone may decrease inflammation by reversing increased capillary permeability and suppressing

polymorphonuclear leukocyte activity. "rednisone stabilizes lysosomal membranes and suppresses lymphocytesand antibody production.

Corticosteroids- "nhaled

Class Summary

!orticosteroids are the most potent anti%inflammatory agents. Inhaled forms are topically active, poorlyabsorbed, and least likely to cause adverse effects. In patients who are stable with chronic bronchitis, treatmentwith a long%acting beta%agonist coupled with an inhaled corticosteroid may offer relief of chronic cough.


!eclomethasone *6var+

Beclomethasone inhibits bronchoconstriction mechanisms, causes direct smooth muscle relaxation, and maydecrease the number and activity of inflammatory cells, which, in turn, decrease airway hyperresponsiveness. Itis available in a metered%dose inhaler (/*I) that delivers


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!udesonide *Pulmicort &lexhaler- Pulmicort espules+

Budesonide reduces inflammation in airways by inhibiting multiple types of inflammatory cells and decreasingproduction of cytokines and other mediators involved in the asthmatic response. It is available as 8lexhalerpowder for inhalation (>1 mcgactuation 6delivers approximately 21 mcgactuation7) and 5espules suspensionfor inhalation.

Antiviral Agents

Class Summary

Influenza vaccinations offer greater protection for the appropriate populations because they offer coverage forinfluenza & and B. 'he !enters for *isease !ontrol and "revention (!*!) provisional recommendations for the$101%$100 influenza season recommend expanded vaccination+ all people aged D months and older shouldreceive annual influenza vaccine.6$D7 'he $101%$100 vaccine will be a trivalent vaccine.

Influenza & viruses, including the $ subtypes A00 and A#$, and influenza B viruses currently circulateworldwide, but the prevalence of each can vary among communities and within a single community over thecourse of an influenza season.

In the $11>%$101 flu season, approximately >>; of typed influenza viruses were A00. In the @nited tates,

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Bronchitis Pathophysiology

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