Updated: 4/9/2019

Chronic Bronchitis

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Snapshot
  • A 46-year-old female preseCXRnts 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
  • 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
    • hemoptysis
  • 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
Studies
  • Diagnostic testing
    • 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
          • 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, 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
    • pathogenesis
      • usually due to infection
    • symptoms
      • fever
      • worsening of symptoms not relieved by normal treatment
    • treatment
      • caution with supplemental O2 due to increased risk of hypercapnia
      • short-acting inhaled beta-agonists and anticholinergics
      • systemic glucocorticoids
      • antibiotics (e.g., azithromycin)
      • may require mechanical ventilation if severe
        • continuous positive airway pressure (CPAP)/bilevel positive airway pressure (BiPAP) if conscious and not altered
        • intubation if non-invasive measures fail, hemodynamically unstable, or altered mental status
  • 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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Questions (3)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
Calculator

(M2.PL.2) A 68-year-old, overweight gentleman with a 20-pack-year history of smoking presents to the primary care physician after noticing multiple blood-stained tissues after coughing attacks in the last month. His vital signs are within normal limits except for an O2 saturation of 93% on room air. He states that over the last 5 years his cough has continued to worsen and has never truly improved. He states that his shortness of breath has also worsened over this time period, as now he can barely make it up the flight of stairs in his home. In this patient, what is the most likely cause of his hemoptysis? Review Topic

QID: 105819
1

Acute pulmonary edema

5%

(1/20)

2

Lung abscess

0%

(0/20)

3

Chronic bronchitis

90%

(18/20)

4

Coagulopathy

0%

(0/20)

5

Goodpasture's disease

0%

(0/20)

M2

Select Answer to see Preferred Response

PREFERRED RESPONSE 3

(M2.PL.6) A 62-year-old female presents with complaint of chronic productive cough for the last 4 months. She states that she has had 4-5 month periods of similar symptoms over the past several years. She has never smoked, but she reports significant exposure to second-hand smoke in her home. She denies any fevers, reporting only occasional shortness of breath and a persistent cough where she frequently expectorates thick, white sputum. Vital signs are as follows: T 37.1 C, HR 88, BP 136/88, RR 18, O2 sat 94% on room air. Physical exam is significant for bilateral end-expiratory wheezes, a blue tint to the patient's lips and mucous membranes of the mouth, and a barrel chest. Which of the following sets of results would be expected on pulmonary function testing in this patient? Review Topic

QID: 105823
1

Decreased FEV1, Decreased FEV1/FVC ratio, Increased TLC, Decreased DLCO

52%

(11/21)

2

Decreased FEV1, Decreased FEV1/FVC ratio, Increased TLC, Normal DLCO

33%

(7/21)

3

Decreased FEV1, Normal FEV1/FVC, Decreased TLC, Decreased DLCO

10%

(2/21)

4

Decreased FEV1, Increased FEV1/FVC ratio, Decreased TLC, Normal DLCO

0%

(0/21)

5

Normal FEV1, Normal FEV1/FVC, Normal TLC, Normal DLCO

0%

(0/21)

M2

Select Answer to see Preferred Response

PREFERRED RESPONSE 2
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