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Updated: Dec 23 2021

Chronic Bronchitis

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  • Snapshot
    • A 46-year-old female presents to her primary care physician for follow up for a severe, unrelenting, productive cough that she has had on and off for more than 2 years. She also complains of worsening dyspnea on exertion. She has smoked 1 pack per day since she was 18. A chest radiograph is obtained.
  • Introduction
    • Clinical definition
      • chronic obstructive pulmonary disease (COPD) is defined as persistent airflow limitation due to mixture of small airway disease and parenchymal destruction
        • early classifications distinguished chronic bronchitis and emphysema
          • no longer distinguished but helpful to separate for pathophysiologic understanding and clinical management
      • chronic bronchitis is defined as a productive cough for > 3 months of the year for 2 consecutive years
  • Epidemiology
    • Demographics
      • males > females
      • 4th most common cause of death globally
    • Risk factors
      • tobacco use (most common)
      • air pollution
      • occupational exposure
      • cystic fibrosis
  • ETIOLOGY
    • Pathogenesis
      • chronic irritation promotes hyperplasia of mucus gland cells, mucus hypersecretion, cilia damage, and infiltration of neutrophils and CD8+ T cells
  • Presentation
    • Symptoms
      • dyspnea, especially on exertion
      • productive cough
        • worse in the morning
    • Physical exam
      • "blue bloaters"
        • cyanosis
        • peripheral edema
      • hypoxia
      • coarse rhonchi
      • end-expiratory wheezing and/or prolonged expiration
      • pursed-lip breathing
      • decreased breath sounds, if advanced
      • signs of pulmonary hypertension
        • right ventricular hypertrophy with signs of right heart failure
        • jugular venous distension (JVD)
        • hepatomegaly
        • edema
  • imaging
    • Chest radiograph
      • not required for routine diagnosis
      • increased bronchial markings (due to mucus)
      • hyperinflation/flattened diaphragm
      • cardiomegaly
  • studies
    • Pulmonary function tests (PFTs)
      • best initial test
      • decreased FEV1 / FVC (< 0.7) that is incompletely reversible
        • obstructive pattern
        • diagnostic
        • FEV1 = forced expiratory volume
        • FVC = forced vital capacity
      • decreased % FEV1
        • used to categorize severity based on Global initiative for chronic Obstructive Lung Disease (GOLD)
          • mild: > 80%
          • moderate: 50-79%
          • severe: 30-49%
          • very severe: < 30%
      • normal or decreased FVC
      • normal or increased total lung capacity (TLC)
        • less than with emphysema
      • roughly normal DLCO (vs. decreased DLCO in emphysema)
        • DLCO = diffusing capacity of the lungs for carbon monoxide
    • Arterial blood gas (ABG)
      • indicated for O2 saturation < 92%, altered mental status, or acute exacerbation
      • hypoxemia
        • decreased PO2
        • may cause increased hemoglobin/polycythemia
      • acute or chronic respiratory acidosis
      • increased PCO2 (hypercapnia) due to retention
  • Differential
    • Asthma
      • distinguishing factor
        • obstructive pattern on PFTs are reversible after administration of inhaled bronchodilator
    • Bronchiectasis
      • distinguishing factor
        • computed tomography (CT) is gold standard for diagnosis
          • large internal bronchial diameter, thickened bronchial wall, and altered airway geometry
          • "tram-track" and "signet-ring" signs
  • Treatment
    • First-line
      • conservative
        • smoking cessation
          • greatest impact on mortality
        • home O2
          • indicated if resting PaO2 < 55 mmHg or SaO2 < 89%
        • flu and pneumococcal vaccines
      • pharmacological
        • step-wise depending on GOLD classification of disease severity
          • mild
            • short-acting inhaled bronchodilators
              • short-acting inhaled beta-agonist (e.g., albuterol) as needed
              • short-acting inhaled anticholinergic (e.g., ipratropium) as needed
            • most patients will present in more advanced stages
          • moderate
            • long-acting inhaled bronchodilator
              • long-acting beta-agonist (e.g., salmeterol or formoterol)
              • long-acting anticholinergic (e.g., tiotropium)
              • can be used in combination
          • severe
            • inhaled corticosteroid (e.g., budesonide or fluticasone) + long-acting bronchodilator
          • very severe
            • triple therapy
              • inhaled corticosteroid + long-acting anticholinergic + long-acting beta-agonist
            • may require roflumilast
              • phosphodiesterase (PDE)-4 inhibitor
            • theophylline
              • PDE inhibitor and adenosine receptor blocker
              • indicated for severe and refractory disease
              • low therapeutic index
    • Second-line
      • lung resection or transplantation
        • may be beneficial in severe cases refractory to medical management
    • Other treatments
      • mucolytics (e.g., N-acetylcysteine)
  • Complications
    • Acute exacerbation
    • Cor pulmonale
      • pathogenesis
        • alveolar hypoventilation and hypoxia cause pulmonary vasoconstriction
        • leads to pulmonary hypertension
        • if severe can cause eventual right heart failure
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