PULMONOLOGY1

ACUTE BRONCHITIS
Inflammatory dz of lower respiratory tract 2/2 acute infection. Viral agents responsible for overwhelming majority of cases. Mycoplasma pneumoniae and Chlamydia pneumoniae found in up to 10%

infection. Hypothesized that asthma symptoms in these patients actually represent a chronic Chlamydia bronchitis infection.

Pts experience SOB along with in the severity of cough or character of the sputum. These types of episodes are categorized as an acute exacerbation of chronic bronchitis, which should not Not all pts w/viral respiratory infections have acute be confused with acute bronchitis in an otherwise bronchitis. Interaction between an infectious agent and healthy person. a susceptible host. Pathophysiology Pts w/pre-existing bronchial irritation from sources such as cigarettes or occupational exposures and those with Patients with chronic bronchitis have: Daily productive cough for more than 3 months/yr a predisposition to reactive airways are more likely to for 2 consecutive years. exhibit symptoms consistent with acute bronchitis during a viral respiratory infection. Experience irreversible bronchial wall thickening and hypertrophy of underlying mucous glands Pathophysiology secondary to prolonged exposure to bronchial Excessive mucus production and airway narrowing irritants such as cigarette smoke. Excessive mucus associated with acute inflammation Symptoms. secretion results in the daily sputum production that Spirometry reversible airway obstruction ~ typifies chronic bronchitis. asthmatics. As acute bronchitis episode resolves, Because of the excessive mucus production and poor spirometry revert to normal. mucociliary clearance, patients with chronic bronchitis often experience superinfection with Clinical presentation bacteria and are more susceptible to respiratory often accompany those of URI viruses. Because the mucus present in the bronchial 1) Low-grade fever tree is an ideal culture medium for bacteria, the 2) Productive cough that worsens with exercise or bacteria found in sputum often do not represent an reclining. Generally lasts 1-2 weeks, although up to acute infection; rather, they are colonizers. There is no 25% of patients may cough for > 1 month simple way to differentiate colonization from 3) Night cough superinfection, however. 4) Occ. audible wheezing. 5) Variable colored sputum: usually clear or white but Diagnosis may be yellow, green, or blood-tinged. Color is not Acute exacerbation of chronic bronchitis is defined as accurate predictor of whether bacteria are involved changes in respiratory status and sputum appearance in the infection. without evidence of underlying pneumonia. 6) Minor blood-streaking of sputum. Caused by inflammatory changes in the bronchial tree. Large Symptoms: amounts of bleeding or a cough producing blood respiratory distress or clots should prompt evaluation for other sources of worsened dyspnea in the presence of bleeding. change in the color or consistency of sputum, or severity CXR: Should be limited to pts in whom PNA is strongly of cough usually are sufficient to make the diagnosis. suspected. Not indicated if pt does not have a high fever or signs of PNA on PE. Because of the compromised respiratory status of May be useful if pt has hemoptysis and is at high patients with chronic bronchitis, a chest radiograph risk for bronchogenic malignancies; however, in may be useful to exclude pneumonia as the cause of high-risk patients, cancer is not excluded by a these symptoms. normal chest film. Causative Agents: CBC and Gram's stain of the sputum: not useful in Gram's stain of sputum is not useful in directing therapy making the diagnosis or guiding treatment. because many organisms may colonize the respiratory tract in pts with chronic bronchitis, Treatment: 1) M. pneumonia Because > % of cases of acute bronchitis caused by a 2) Haemophilus influenzae virus, Abx not effective 3) Streptococcus pneumoniae Symptomatic treatment: 4) Branhamella catarrhalis 1) bronchodilators: pts treated with active drug were Many acute exacerbations actually may be viral in origin almost twice as likely to have stopped coughing in 1 . week as those treated with antibiotics or placebo. 2) cough suppressants: useful in patients w/cough that Treatment interferes with their ability to work or rest. Codeine- Due to underlying bacteria in respiratory tract of pts containing cough medications are effective agents. w/chronic bronchitis & difficulty in deciding when a bacterial infection is present, most acute exacerbations Complications of chronic bronchitis are treated with Abx. Nearly all pts w/acute bronchitis have resolution of their Antibiotic selection: symptoms within 2 weeks. Difficult offending organism is not usually small proportion continue to cough for 1 month or identified. Although multiple suggestions have been longer. Chronic use of a bronchodilator may offered to guide Abx selection, the original studies alleviate their symptoms. that demonstrated improvement all used either Possible Mycoplasma, Bortadella pertussis or tetracycline analogues, amoxicillin, or Chlamydia infection: Little evidence to substantiate sulfamethoxazole-trimethoprim (SMZ-TMP). that bacterial infections are more likely in patients Because there is no evidence that cephalosporins, with chronic cough. Nevertheless, empirical use of quinolones, or macrolides are superior to these drugs a macrolide when coughing for a month may be and all are more expensive, treatment with more cost effective than pursuing other laboratory tetracycline/doxycycline or amoxicillin, or SMZ-TMP or radiologic tests. Short courses of corticosteroids: Adult-onset asthma: large proportion have Prednisone: may shorten the course and severity of serologic evidence of previous C. pneumoniae acute exacerbations of chronic bronchitis.

CHRONIC BRONCHITIS

2PULMONOLOGY
Acute exacerbations may also afford another opportunity to counsel tobacco-using patients about the need to discontinue smoking.

Complications
Respiratory failure & need for mechanical ventilation are rare but can occur in pts w/very limited respiratory reserve.

Prevention
Smoking cessation is the first key to reducing progression of chronic bronchitis and risk of an exacerbation. Annual influenza vaccination