Chronic Bronchitis: Difference between revisions

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== Normal Lung Function &amp; Anatomy  ==


The two lungs are organs responsible for respiration, air enters and leaves the lungs via main the bronchi, which are branches of the trachea. The lungs supply the body with oxygenated blood, which allows us to live. The pulmonary arteries deliver deoxygenated blood to the lungs from the right ventricle of the heart. Oxygenated blood returns to the left atrium via the pulmonary veins and is then pumped through the rest of the body to deliver oxygen where needed.<ref name="Drake et al.">Drake RL, Vogl AW, Mitchell AW. Gray's Anatomy for Students. 2nd ed. Edinburgh: Churchill Livingstone, 2010.</ref>[[File:Lung_anatomy_nci_407.jpg|261x261px|thumb]]roper lung function is essential for quality of life, yet there are many ways this can be disrupted including disease and infection. If not monitored and treated these can cause spasms, sputum retention, inflammation and irritation which all leading to poor lung function, increased work of breathing and reduced quality of life.
== Definition/Description ==
[[File:What-is-Chronic-Bronchitis-2-300x215.jpg|alt=|right|frameless]]Chronic [[Bronchitis]] (CB) is defined as a chronic cough and [[sputum]] production for at least 3 months a year for 2 consecutive years. <ref name="Kim and Criner">Kim V, Criner GJ. Chronic Bronchitis and Chronic Obstructive Pulmonary Disease. Am J Respir Crit Care Med 2013;187:228-237</ref>&nbsp;


<ref>About Cancer. www.aboutcancer.com/ling_anatomy_nci_407.jpg (accessed May 7 2015)</ref><br>
It is covered under the umbrella term of [[Chronic Obstructive Pulmonary Disease Rehabilitation Class|Chronic Obstructive Pulmonary Disease (COPD)]]. The COPD spectrum ranges from [[Emphysema]] to Chronic Bronchitis. Many patients have characteristics of both, putting them somewhere along the spectrum.<ref name="Kim and Criner" />


== Definition/Description  ==
* CB is the [[Inflammation Acute and Chronic|inflammation]] and excessive mucus build-up in the bronchi.<ref name="British Lung Foundation">British Lung Foundation. COPD: Chronic obstructive pulmonary disease. Available from: http://www.blf.org.uk/Page/chronic-obstructive-pulmonary-disease-COPD (accessed 4 May 2015).</ref>
* Emphysema occurs when the [[Alveoli|alveolar]] membrane breaks down .
The overall prognosis for most patients is poor, with many patients being disabled from the progressive [[Dyspnoea|shortness of breath]]<ref name=":0" />. The prevalence of the disease has a great impact on society and on health care systems [[Global Health|around the world]].


Chronic Bronchitis (CB) is defined as a chronic cough and sputum production for at least 3 months a year for 2 consecutive years. <ref name="Kim and Criner">Kim V, Criner G.J. Chronic Bronchitis and Chronic Obstructive Pulmonary Disease. Am J Respir Crit Care Med 2013;187:228-237</ref>&nbsp;It is covered under the umbrella term of Chronic Obstructive Pulmonary Disease (COPD). The COPD spectrum ranges from Emphysema to Chronic Bronchitis and it occurs when the airways become inflamed and the air sacs in your lungs are damaged. Emphysema occurs when your alveolar membrane breaks down whereas CB is the inflammation and excessive mucus build-up in your bronchi.<ref name="British Lung Foundation">British Lung Foundation. COPD: Chronic obstructive pulmonary disease. http://www.blf.org.uk/Page/chronic-obstructive-pulmonary-disease-COPD (accessed May 4 2015).</ref> Many patients have characteristics of both, putting them somewhere along the spectrum.<ref name="Kim and Criner" />
[[File:What-is-Chronic-Bronchitis-2-300x215.jpg|thumb]]
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4418311/<br>
== Epidemiology  ==
== Epidemiology  ==
[[File:Maxresdefault1.jpg|thumb|300x300px]]
The occurrence of Chronic bronchitis
*COPD kills around 30,000 people per year in the UK alone and it is estimated that around 3 million people in the UK have COPD, 2 million of which are undiagnosed.<ref name="British Lung Foundation" /><br>
*CB occurs in 3.4 to 22% of the US adult population and rates are even higher in patients with COPD.<ref name="Kim and Criner" />
*The prevalence of the disease has a great impact on society and on the health care system around the world.
*The primary risk factor for CB is smoking, and up to 25% of long-term smokers will go on to develop COPD. Other factors are long-term exposure to air pollution, fumes, and dust from the environment or workplace.<ref name="British Lung Foundation" /><br>


== Aetiology ==
* In the general population has been documented to vary between 3% to 7% of healthy adults.
* It is estimated to be as high as 74% among those diagnosed to have COPD.  


CB is caused by overproduction and hypersecretion of mucus by goblet cells, increasing airflow obstruction. This can be due to smoke inhalation, a viral or bacterial infection, or inflammatory cell activation of mucin gene transcription.<ref name="Kim and Criner" />
Subjects under the age of 50 years who are otherwise healthy and have chronic bronchitis are at a higher risk of morbidity and mortality when compared to healthy subjects.


As mentioned, smoking is the primary risk factor, this can be from those who inhale second-hand smoke as well as smokers. This is caused by the inflammation and permanent damage to the airways due to toxins in cigarette smoke. Other factors include fumes and dust and air pollution which can all affect your lung tissue when inhaled.<ref name="NHS">National Health Services. Chronic Obstructive pulmonary disease. http://www.nhs.uk/Conditions/Chronic-obstructive-pulmonary-disease/Pages/Introduction.aspx (accessed May 4 2015)</ref>  
The increasing prevalence of chronic bronchitis is thought to be associated with increasing age, [[Smoking and Exercise|tobacco smoking]], occupational exposure, and socioeconomic status.<ref name=":0">Widysanto A, Mathew G. [https://www.ncbi.nlm.nih.gov/books/NBK482437/?report=reader Chronic Bronchitis]. StatPearls [Internet]. 2020 Aug 23.Available from: https://www.ncbi.nlm.nih.gov/books/NBK482437/?report=reader<nowiki/>(accessed 24.5.2021)</ref>


There is also a genetic factor associated with COPD, it is a deficiency in alpha-1-antitrypsin. This genetic marker is indicative of Emphysema, but many patients on the COPD spectrum have characteristics of both Emphysema and CB and should be taken into account.<ref name="British Lung Foundation" /> <br>
== Etiology ==
There are many known causes of chronic bronchitis.


== Pathophysiology  ==
The most important causative factor is exposure to cigarette smoke either due to active smoking or passive inhalation. Other causes include:


The pathological foundation for CB is due to the over-production of mucus in response to the inflammatory signals, this is known as mucous metaplasia. In COPD patients this overproduction and hypersecretion is due to the goblet cells and decreased the elimination of mucus.<ref name="Kim and Criner" /> The mechanisms responsible for mucous metaplasia in COPD patients is associated with the function of the T cells, although it is still poorly understood. It is believed to be linked to end production of the Th2 inflammation cells while the cellular response is thought to be attributed to the Th1 inflammation cells, both produce cytokines that have an influence on mucus production associated with COPD patients.<ref name="Kim and Criner" />  
* Inhaled irritants to the respiratory tract eg smog, industrial pollutants, airborne chemicals (eg ammonia and sulfur) can cause chronic bronchitis.
* Repeated exposure to [[Viral Infections|viral infections]] can cause chronic bronchitis.
* People with an associated background in [[Respiratory Disorders|respiratory diseases]] eg [[asthma]], [[Cystic Fibrosis|cystic fibrosis]], or [[bronchiectasis]] have a higher predisposition to develop chronic bronchitis.
* Chronic [[Gastroesophageal Reflux Disease|gastroesophageal reflux]] is a well documented but less frequent cause of chronic bronchitis<ref name=":0" />.
* There is also a [[Genetic Conditions and Inheritance|genetic factor]] associated with COPD, it is a deficiency in alpha-1-antitrypsin. This genetic marker is indicative of Emphysema, but many patients on the COPD spectrum have characteristics of both Emphysema and CB.<ref name="British Lung Foundation" />


Mucus metaplasia causes airflow obstruction by several mechanisms: it causes luminal occlusion; the thickening of the epithelial layer intrudes on the airway lumen, and the mucus alters the airway surface tension. These all leave the airway at a greater risk for collapsing and decreases the capacity for airflow and gas exchange.<ref name="Kim and Criner" />  
== Pathophysiology ==
[[File:Maxresdefault1.jpg|300x300px|alt=|right|frameless]]Chronic bronchitis is thought to be caused by overproduction and hypersecretion of mucus by goblet cells. Epithelial cells lining the airway response to toxic, infectious stimuli by releasing inflammatory mediators  and eg pro-inflammatory [[cytokines]].
During an acute exacerbation of chronic bronchitis, the bronchial mucous membrane becomes hyperemic and edematous with diminished bronchial mucociliary function. This, in turn, leads to airflow impediment because of luminal obstruction to small airways. The airways become clogged by debris and this further increases the irritation. The characteristic cough of bronchitis is caused by the copious secretion of mucus in chronic bronchitis.<ref name=":0" />[[File:Goblet cells.gif|right|frameless|370x370px]]Image 2: Pseudostratified epithelium, highlighting the pseudostratified epithelial cells, goblets cells (shown in blue), then underlying [[Connective Tissue Disorders|connective tissue]]


It was also found that smokers with moderate COPD and CB had a greater number of goblet cells in their peripheral airways<ref name="Kim and Criner" />, which increases the potential of mucus in the lungs. It was found that as a greater number of small airways were blocked with mucus the greater the severity of the disease.<ref name="Kim and Criner" />
* Smokers with moderate COPD and CB had a greater number of goblet cells in their peripheral airways<ref name="Kim and Criner" />, which increases the potential of mucus in the lungs (a greater number of small airways were blocked with mucus increases the severity of the disease).<ref name="Kim and Criner" />
 
* Mucus hypersecretion is one of the risks associated with cigarette smoke exposure, viral infections, bacterial infections, or inflammatory cell activation. When combined with poor ciliary function, distal airway occlusion, ineffective cough, [[Muscles of Respiration|respiratory muscle]] weakness, and reduced [[Spirometry|peak expiratory flow]] clearing secretions is extremely difficult and requires high energy consumption.&nbsp;<ref name="Kim and Criner" />
Mucus hypersecretion is one of the risks associated with cigarette smoke exposure, viral infections, bacterial infections, or inflammatory cell activation. When combined with poor ciliary function, distal airway occlusion, ineffective cough, respiratory muscle weakness and reduced peak expiratory flow clearing secretions is extremely difficult and requires high energy consumption.&nbsp;<ref name="Kim and Criner" /> <br>


== Clinical Manifestations  ==
== Clinical Manifestations  ==
 
[[File:Bronchitis.jpg|right|frameless]]
The clinical presentation can be increased exacerbation rate, accelerated decline in lung function, worse health-related quality of life and increase in mortality. <ref name="Kim and Criner" />  
The clinical presentation can be an increased exacerbation rate, accelerated decline in lung function, worse health-related quality of life and an increase in mortality.<ref name="Kim and Criner" /> Common symptoms outlined by the British Lung Foundation include<ref name="British Lung Foundation" />:
 
'''Common symptoms outlined by the British Lung Foundation include:'''
*Wheezing, particularly breathing out  
*Wheezing, particularly breathing out  
*Breathlessness when resting or active  
*Breathlessness when resting or active  
*Tight chest  
*Tight chest  
*Cough  
*Cough  
*Producing more mucus or phlegm than usual<ref name="British Lung Foundation" /><br>
*Producing more mucus or phlegm than usual<br>
 
These symptoms would be persistent for at least 3 months a year for 2 consecutive years to be considered Chronic Bronchitis.<ref name="Kim and Criner" /><br>
 
== Investigations  ==
 
If a patient presents with some or all of the symptoms your doctor will follow up with more investigations such as:
 
'''Spirometry Test:''' This is a breathing test to assess how well your lungs work. You breathe into a machine and two measurements are taken; forced expiratory volume (FEV1) and forced vital capacity (FVC). The readings are then compared to normal ranges for your age, to determine if your airways are compromised.<ref name="NHS" />
 
{{#ev:youtube|6kbgZWS5wH0}}<ref>The European Lung Foundation. Spirometry: how to take a lung function test. https://www.youtube.com/watch?v=6kbgZWS5wH0 [last accessed 5/6/15]</ref>
 
<br>'''Chest X-ray: '''This will show whether there are other lung conditions that may be causing the symptoms, or in what area the obstruction is in.&nbsp;<ref name="NHS" /> This can give an indication of what areas to focus on during treatment, and the severity and progression of the obstruction.
 
'''Blood test:''' This is to see if your symptoms could be due to anemia, or to see if the symptoms are due to the genetic marker alpha-1-antitrypsin deficiency.<ref name="NHS" />
 
'''Phlegm sample:''' This is to check to see if there is an infection that is causing the symptoms, this is to primarily rule out other possibilities to ensure proper treatment.<ref name="NHS" /> <br>
 
== Physiotherapy and Other Management  ==
 
The treatment of CB may include a variety of interventions including management through medications, education, physical exercise and respiratory exercises. The goal of the physiotherapist should involve education, improve exercise tolerance, reduce exacerbations and hospitalization, assist in sputum clearance, and increase thoracic mobility and lung volume. <br>
 
'''Medication'''
 
There are various kinds of short term and long term medications individuals with CB might take to reduce flare-ups, decrease obstruction, improve activity and decrease shortness of breath. These medications may include bronchodilators, corticosteroids, and antibiotics.<ref name="Hough" /><br>


'''Exercise'''
These symptoms would be persistent for at least 3 months a year for 2 consecutive years to be considered Chronic Bronchitis.<ref name="Kim and Criner" />


Regular exercise can have positive effects on the management, treatment, and prevention of CB and COPD. Aerobic exercise and upper &amp; lower limb resistance training have shown positive changes in the reduction of airflow obstruction, clearing of airways, improved functional capabilities increased energy levels and sputum expectoration. Exercise programs should be under the supervision of the treating clinical team and a discussion with the general practitioner should be had before taking part in any exercise program.<ref name="ACSM" /><br>
== Evaluation ==
The most critical factor in the diagnosis of chronic bronchitis is a typical history to exclude other possible diseases of the lower respiratory tract.


'''Postural Drainage'''
The investigations which assist in confirming the diagnosis of chronic bronchitis are: 


The use of various positions to assist in the expectoration of sputum by using gravity to move sputum towards the throat and mouth. Is can be used with other treatment techniques. These positions can be modified for each clients condition and their preferences. Ideally, the client is placed in a position where the affected area is higher up than the unaffected area.<ref name="Hough" /> <br>
*'''[[Blood Tests|Blood test]]:''' This is to see if your symptoms could be due to anemia, or to see if the symptoms are due to the genetic marker alpha-1-antitrypsin deficiency.<ref name="NHS">National Health Services. Chronic Obstructive pulmonary disease. Available from: http://www.nhs.uk/Conditions/Chronic-obstructive-pulmonary-disease/Pages/Introduction.aspx (accessed 4 May 2015)</ref>
* A [[Chest X-Rays|chest x-ray]] in the [[Older People - Patterns of Illness, Physiological Changes and Multiple Pathology|elderly]] and when physical findings suggest pneumonia is important.
* A culture of the sputum when a [[Bacterial Infections|bacterial]] infection is suspected is indicated.
* The additional investigations which are a helpful measurement of oxygen saturation, and [[Pulmonary Function Test|pulmonary function tests]] eg [[spirometry]]<ref name=":0" />


{{#ev:youtube|TPZsP1ujg0U|300}}<ref>faisal alg. Postural Drainage. https://www.youtube.com/watch?v=TPZsP1ujg0U. Accessed May 6, 2015</ref><br>
{{#ev:youtube|6kbgZWS5wH0}}<ref>The European Lung Foundation. Spirometry: how to take a lung function test. https://www.youtube.com/watch?v=6kbgZWS5wH0 [last accessed 5/6/15]</ref>


'''Active Cycle of Breathing'''
=== Treatment / Management ===
[[File:Bronchodilators.png|right|frameless|399x399px]]
The primary aim of treatment for chronic bronchitis is to relieve symptoms, prevent complication and slow the progression of the disease. The primary goals of therapy are aimed at reducing the overproduction of mucus, controlling inflammation and lowering cough. These are achieved by pharmacological as well as nonpharmacological interventions.


Consists of the combination of Controlled Breathing, Thoracic Expansion Exercises and “The Huff” or Force Expiration Exercises at different lung volumes. Can be used to reduce bronchospasms, coughing, airway obstruction and promote collateral airway ventilation and sputum expectoration. This technique can be modified to the needs of the client and their preferences.<ref name="Hough" />
The mainstay of pharmacological interventions are the following:


{{#ev:youtube|l0eKW-A7Pwo|300}}<ref>Jamie Williams. Active Cycle of Breathing. https://www.youtube.com/watch?v=l0eKW-A7Pwo. Accessed May 6, 2015</ref> <br>
# Bronchodilators: Short and long-acting β-Adrenergic receptor Agonists as well as Anticholinergic help by increasing the airway lumen, increasing ciliary function and by increasing mucous hydration.
# Glucocorticoids: Reduce inflammation and mucus production.Inhaled corticosteroids reduce exacerbation and improve quality of life.However, it is administered under medical supervision and for short periods of time as long-term usage can induce osteoporosis, diabetes, and hypertension.
# Antibiotic therapy: is not indicated in the treatment of chronic bronchitis however macrolide therapy has been shown to have anti-inflammatory property and hence may have a role in the treatment of chronic bronchitis.
# Phosphodiesterase-4 inhibitors: decrease inflammation and promote airway smooth muscle relaxation by preventing the hydrolysis of cyclic adenosine monophosphate a substance when degraded leads to the release of inflammatory mediators.


'''Autogenic Drainage'''
== Nonpharmacological interventions. ==


This technique allows for larger airflow in the bronchi without causing a collapse of the airway with proper breathing. This has been shown to promote sputum expectoration, collateral airway airflow and a reduction in carbon dioxide retention. Similar to Active Cycle of Breathing this technique can be modified to the needs of the client and their preferences<ref name="Hough" /><br>
== Physiotherapy ==
[[File:Cardio Boxing Group Fitness Class.jpg|right|frameless]]
The goal of the physiotherapist should involve education, improve exercise tolerance, reduce exacerbations and hospitalization, assist in sputum clearance, and increase thoracic mobility and lung volume.


'''Percussion and Vibrations'''
[[Pulmonary Rehabilitation|Pulmonary rehabilitation]] and [[Respiratory Physiotherapy]]<nowiki/>are important parts of treatment for chronic bronchitis. See links for fantastic detail..


Usually used in conjunction with postural drainage. The theory behind the use of percussions and vibrations is that it will assist with clearing of sputum stuck on the airways. There is little evidence of this effect however, some clients do believe it helps with sputum expectoration. Percussion is the rhythmic clapping on the chest or back of the client with a loose wrist and cupped hands. The clapping should be soothing and relaxing to the client, each client may have their own personal preference. Vibrations consists of while the therapists hands are against the clients chest or back performing fine movements of the hands down and inwards while the client is exhaling after a large breath.&nbsp;<ref name="Hough" /> <br>
== Education ==
Chronic bronchitis has a significant impact on morbidity and [[Quality of Life|quality of life]]. Education of the individual with CB by the treating clinical staff in terms of the presenting condition, medication use, treatment options, and self-management may help the psychological effects associated with having a chronic condition and promote a proactive approach to management.  


{{#ev:youtube|ErMTXJLE5es|300}}<ref>enmurrcp. RT Chest Physiotherapy Demonstration. https://www.youtube.com/watch?v=ErMTXJLE5es. Accessed May 6, 2015</ref> <br>
The most critical nonpharmacological intervention is [[Smoking Cessation and Brief Intervention|smoking cessation]]. Smoking cessation improves mucociliary function and decreases goblet cell hyperplasia. Smoking cessation has also been shown to reduce airway injury resulting in lower levels of exfoliated mucus in tracheobronchial cells.


'''Education'''
== Exercise ==
Regular [[Therapeutic Exercise|exercise]] can have positive effects on the management, treatment, and prevention of CB and COPD. [[Aerobic Exercise|Aerobic exercise]] and upper &amp; lower limb resistance training have shown positive changes in the reduction of airflow obstruction, clearing of airways, improved functional capabilities increased energy levels, and sputum expectoration. Exercise programs should be under the supervision of the treating clinical team (eg physiotherpist) and a discussion with the general practitioner should be had before taking part in any exercise program.<ref name="ACSM">Dressendorfer R, Haykowsky M, Eves N. Exercise for Persons with Chronic Obstructive Pulmonary Disease. Available from: http://www.acsm.org/docs/current-comments/exerciseforpersonswithcopd.pdf. (Accessed 6 May 2015).</ref>


Education of the individual with CB by the treating clinical staff in terms of the presenting condition, medication use, treatment options and self-management may help the psychological effects associated with having a chronic condition and promote a proactive approach to management.&nbsp;<ref name="Hough" /> <br>
=== Physical Fitness ===
Aerobic exercise and upper & lower limb resistance training have the ability to increase physical fitness, functional tolerance, energy levels, and decrease concern over the shortness of breath, exacerbations, and hospital visits. Specific guidelines are put in place in concern to exercise for individuals with chronic bronchitis and COPD. The Discussion should be held with the treating clinical team before participation in any exercise program begins.  


== Prevention  ==
== Prevention  ==


There is presently no cure for CB. However, with lifestyle changes, education and proper management it is possible to prevent exacerbations of the condition. <br>
There is presently no cure for CB. However, with lifestyle changes, education, and proper management it is possible to prevent exacerbations of the condition.  
 
=== Avoiding Irritants ===
'''Stopping Smoking'''
Being aware of possible irritants within the household, workplace, and places of recreation can help reduce risk factors associated with chronic bronchitis and reduce exacerbations. Irritants to be aware of can include dust, chemicals, vapors, air pollution, and smoke. Proper respiratory protective equipment should be made readily available if contact with irritants in the workplace commonly occurs.&nbsp;<ref name="Mayo">Mayo Clinic Staff. Diseases and Conditions. COPD Prevention. 2014. Available from: http://www.mayoclinic.org/diseases-conditions/copd/basics/prevention/CON-20032017. Accessed 6 May 2015).</ref>  
 
Smoking can irritate the lungs leading to irritation, inflammation, and scar. The longer an individual smokes the more damage occurs to the lungs which can lead to increased amounts of exacerbations of the condition. By quitting smoking this can decrease the amount of exacerbations, hospital visits and lead to a better quality of life.<ref name="Health">National Health Services. Bronchitis. 14/07/2014; Available at: http://www.nhs.uk/conditions/Bronchitis/Pages/Introduction.aspx. Accessed May, 06, 2015.</ref> <br>
 
'''Physical Fitness'''
 
Aerobic exercise and upper &amp; lower limb resistance training have the ability to increase physical fitness, functional tolerance, energy levels and decrease concern over the shortness of breath, exacerbations, and hospital visits. Specific guidelines are put in place in concern to exercise for individuals with chronic bronchitis and COPD.The Discussion should be held with the treating clinical team before participation in any exercise program begins.&nbsp;<ref name="ACSM">Dressendorfer R, Haykowsky M, Eves N. Exercise for Persons with Chronic Obstructive Pulmonary Disease. Available at: http://www.acsm.org/docs/current-comments/exerciseforpersonswithcopd.pdf. Accessed May, 6, 2015.</ref> <br>
 
'''Avoiding Irritants'''
 
Being aware of possible irritants within the household, work place and places of recreation can help reduce risk factors associated with chronic bronchitis and reduce exacerbations. Irritants to be aware of can include dust, chemicals, vapors, air pollution and smoke. Proper respiratory protective equipment should be made readily available if contact with irritants in the work place commonly occurs.&nbsp;<ref name="Mayo">Mayo Clinic Staff. Diseases and Conditions COPD Prevention. 2014; Available at: http://www.mayoclinic.org/diseases-conditions/copd/basics/prevention/CON-20032017. Accessed May, 6, 2015.</ref> <br>
 
'''Practice Proper Hygiene'''
 
Practicing good hygiene can reduce the spread of germs, bacteria, and infections. This can help reduce the risk factors associated with bronchitis and help reduce exacerbations of chronic bronchitis.<ref name="Health" /> <br>
 
'''Education'''


Education can play a vital aspect in the prevention and management of CB. Education about the presenting condition, risk factors associated with it and treatment can help reduce anxiety associated with the development of any chronic condition and a proper understanding of the condition and how to manage it can encourage the individual to take a proactive approach to their management program.<ref name="Hough">Hough A. Respiratory Disorders. Physiotherapy In Respiratory And Cardiac Care: An Evidence-Based Approach. Fourth ed.: Cenegage Learning; 2014. p. 77-84.</ref> <br>
=== Practice Proper Hygiene ===
Practicing good hygiene can reduce the spread of germs, bacteria, and infections. This can help reduce the risk factors associated with bronchitis and help reduce exacerbations of chronic bronchitis.<ref name="Health">National Health Services. Bronchitis. 14/07/2014; Available from: http://www.nhs.uk/conditions/Bronchitis/Pages/Introduction.aspx. (Accessed 6 May 2015).</ref>  


== References  ==
== References  ==
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[[Category:Cardiopulmonary]] [[Category:Chronic_Respiratory_Disease]] [[Category:COPD]] [[Category:Glasgow_Caledonian_University_Project]]
[[Category:Conditions]]
[[Category:Cardiopulmonary]]
[[Category:Cardiopulmonary - Conditions]]  
[[Category:Respiratory_Disease]]  
[[Category:Respiratory Disease - Conditions]]
[[Category:Glasgow_Caledonian_University_Project]]

Latest revision as of 01:41, 9 July 2021

Original Editors - Students from Glasgow Caledonian University's Cardiorespiratory Therapeutics Project.

Top Contributors - Lindsey Chisholm, Kelly D'Autremont, Lucinda hampton, Kim Jackson, Esraa Mohamed Abdullzaher, Admin, Evan Thomas, Uchechukwu Chukwuemeka, Michelle Lee, WikiSysop and Fasuba Ayobami

Definition/Description[edit | edit source]

Chronic Bronchitis (CB) is defined as a chronic cough and sputum production for at least 3 months a year for 2 consecutive years. [1] 

It is covered under the umbrella term of Chronic Obstructive Pulmonary Disease (COPD). The COPD spectrum ranges from Emphysema to Chronic Bronchitis. Many patients have characteristics of both, putting them somewhere along the spectrum.[1]

  • CB is the inflammation and excessive mucus build-up in the bronchi.[2]
  • Emphysema occurs when the alveolar membrane breaks down .

The overall prognosis for most patients is poor, with many patients being disabled from the progressive shortness of breath[3]. The prevalence of the disease has a great impact on society and on health care systems around the world.

Epidemiology[edit | edit source]

The occurrence of Chronic bronchitis

  • In the general population has been documented to vary between 3% to 7% of healthy adults.
  • It is estimated to be as high as 74% among those diagnosed to have COPD.

Subjects under the age of 50 years who are otherwise healthy and have chronic bronchitis are at a higher risk of morbidity and mortality when compared to healthy subjects.

The increasing prevalence of chronic bronchitis is thought to be associated with increasing age, tobacco smoking, occupational exposure, and socioeconomic status.[3]

Etiology[edit | edit source]

There are many known causes of chronic bronchitis.

The most important causative factor is exposure to cigarette smoke either due to active smoking or passive inhalation. Other causes include:

  • Inhaled irritants to the respiratory tract eg smog, industrial pollutants, airborne chemicals (eg ammonia and sulfur) can cause chronic bronchitis.
  • Repeated exposure to viral infections can cause chronic bronchitis.
  • People with an associated background in respiratory diseases eg asthma, cystic fibrosis, or bronchiectasis have a higher predisposition to develop chronic bronchitis.
  • Chronic gastroesophageal reflux is a well documented but less frequent cause of chronic bronchitis[3].
  • There is also a genetic factor associated with COPD, it is a deficiency in alpha-1-antitrypsin. This genetic marker is indicative of Emphysema, but many patients on the COPD spectrum have characteristics of both Emphysema and CB.[2]

Pathophysiology[edit | edit source]

Chronic bronchitis is thought to be caused by overproduction and hypersecretion of mucus by goblet cells. Epithelial cells lining the airway response to toxic, infectious stimuli by releasing inflammatory mediators and eg pro-inflammatory cytokines. During an acute exacerbation of chronic bronchitis, the bronchial mucous membrane becomes hyperemic and edematous with diminished bronchial mucociliary function. This, in turn, leads to airflow impediment because of luminal obstruction to small airways. The airways become clogged by debris and this further increases the irritation. The characteristic cough of bronchitis is caused by the copious secretion of mucus in chronic bronchitis.[3]

Goblet cells.gif

Image 2: Pseudostratified epithelium, highlighting the pseudostratified epithelial cells, goblets cells (shown in blue), then underlying connective tissue

  • Smokers with moderate COPD and CB had a greater number of goblet cells in their peripheral airways[1], which increases the potential of mucus in the lungs (a greater number of small airways were blocked with mucus increases the severity of the disease).[1]
  • Mucus hypersecretion is one of the risks associated with cigarette smoke exposure, viral infections, bacterial infections, or inflammatory cell activation. When combined with poor ciliary function, distal airway occlusion, ineffective cough, respiratory muscle weakness, and reduced peak expiratory flow clearing secretions is extremely difficult and requires high energy consumption. [1]

Clinical Manifestations[edit | edit source]

Bronchitis.jpg

The clinical presentation can be an increased exacerbation rate, accelerated decline in lung function, worse health-related quality of life and an increase in mortality.[1] Common symptoms outlined by the British Lung Foundation include[2]:

  • Wheezing, particularly breathing out
  • Breathlessness when resting or active
  • Tight chest
  • Cough
  • Producing more mucus or phlegm than usual

These symptoms would be persistent for at least 3 months a year for 2 consecutive years to be considered Chronic Bronchitis.[1]

Evaluation[edit | edit source]

The most critical factor in the diagnosis of chronic bronchitis is a typical history to exclude other possible diseases of the lower respiratory tract.

The investigations which assist in confirming the diagnosis of chronic bronchitis are:

  • Blood test: This is to see if your symptoms could be due to anemia, or to see if the symptoms are due to the genetic marker alpha-1-antitrypsin deficiency.[4]
  • A chest x-ray in the elderly and when physical findings suggest pneumonia is important.
  • A culture of the sputum when a bacterial infection is suspected is indicated.
  • The additional investigations which are a helpful measurement of oxygen saturation, and pulmonary function tests eg spirometry[3]

[5]

Treatment / Management[edit | edit source]

Bronchodilators.png

The primary aim of treatment for chronic bronchitis is to relieve symptoms, prevent complication and slow the progression of the disease. The primary goals of therapy are aimed at reducing the overproduction of mucus, controlling inflammation and lowering cough. These are achieved by pharmacological as well as nonpharmacological interventions.

The mainstay of pharmacological interventions are the following:

  1. Bronchodilators: Short and long-acting β-Adrenergic receptor Agonists as well as Anticholinergic help by increasing the airway lumen, increasing ciliary function and by increasing mucous hydration.
  2. Glucocorticoids: Reduce inflammation and mucus production.Inhaled corticosteroids reduce exacerbation and improve quality of life.However, it is administered under medical supervision and for short periods of time as long-term usage can induce osteoporosis, diabetes, and hypertension.
  3. Antibiotic therapy: is not indicated in the treatment of chronic bronchitis however macrolide therapy has been shown to have anti-inflammatory property and hence may have a role in the treatment of chronic bronchitis.
  4. Phosphodiesterase-4 inhibitors: decrease inflammation and promote airway smooth muscle relaxation by preventing the hydrolysis of cyclic adenosine monophosphate a substance when degraded leads to the release of inflammatory mediators.

Nonpharmacological interventions.[edit | edit source]

Physiotherapy[edit | edit source]

Cardio Boxing Group Fitness Class.jpg

The goal of the physiotherapist should involve education, improve exercise tolerance, reduce exacerbations and hospitalization, assist in sputum clearance, and increase thoracic mobility and lung volume.

Pulmonary rehabilitation and Respiratory Physiotherapyare important parts of treatment for chronic bronchitis. See links for fantastic detail..

Education[edit | edit source]

Chronic bronchitis has a significant impact on morbidity and quality of life. Education of the individual with CB by the treating clinical staff in terms of the presenting condition, medication use, treatment options, and self-management may help the psychological effects associated with having a chronic condition and promote a proactive approach to management.

The most critical nonpharmacological intervention is smoking cessation. Smoking cessation improves mucociliary function and decreases goblet cell hyperplasia. Smoking cessation has also been shown to reduce airway injury resulting in lower levels of exfoliated mucus in tracheobronchial cells.

Exercise[edit | edit source]

Regular exercise can have positive effects on the management, treatment, and prevention of CB and COPD. Aerobic exercise and upper & lower limb resistance training have shown positive changes in the reduction of airflow obstruction, clearing of airways, improved functional capabilities increased energy levels, and sputum expectoration. Exercise programs should be under the supervision of the treating clinical team (eg physiotherpist) and a discussion with the general practitioner should be had before taking part in any exercise program.[6]

Physical Fitness[edit | edit source]

Aerobic exercise and upper & lower limb resistance training have the ability to increase physical fitness, functional tolerance, energy levels, and decrease concern over the shortness of breath, exacerbations, and hospital visits. Specific guidelines are put in place in concern to exercise for individuals with chronic bronchitis and COPD. The Discussion should be held with the treating clinical team before participation in any exercise program begins.

Prevention[edit | edit source]

There is presently no cure for CB. However, with lifestyle changes, education, and proper management it is possible to prevent exacerbations of the condition.

Avoiding Irritants[edit | edit source]

Being aware of possible irritants within the household, workplace, and places of recreation can help reduce risk factors associated with chronic bronchitis and reduce exacerbations. Irritants to be aware of can include dust, chemicals, vapors, air pollution, and smoke. Proper respiratory protective equipment should be made readily available if contact with irritants in the workplace commonly occurs. [7]

Practice Proper Hygiene[edit | edit source]

Practicing good hygiene can reduce the spread of germs, bacteria, and infections. This can help reduce the risk factors associated with bronchitis and help reduce exacerbations of chronic bronchitis.[8]

References[edit | edit source]

  1. ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 Kim V, Criner GJ. Chronic Bronchitis and Chronic Obstructive Pulmonary Disease. Am J Respir Crit Care Med 2013;187:228-237
  2. ↑ 2.0 2.1 2.2 British Lung Foundation. COPD: Chronic obstructive pulmonary disease. Available from: http://www.blf.org.uk/Page/chronic-obstructive-pulmonary-disease-COPD (accessed 4 May 2015).
  3. ↑ 3.0 3.1 3.2 3.3 3.4 Widysanto A, Mathew G. Chronic Bronchitis. StatPearls [Internet]. 2020 Aug 23.Available from: https://www.ncbi.nlm.nih.gov/books/NBK482437/?report=reader(accessed 24.5.2021)
  4. ↑ National Health Services. Chronic Obstructive pulmonary disease. Available from: http://www.nhs.uk/Conditions/Chronic-obstructive-pulmonary-disease/Pages/Introduction.aspx (accessed 4 May 2015)
  5. ↑ The European Lung Foundation. Spirometry: how to take a lung function test. https://www.youtube.com/watch?v=6kbgZWS5wH0 [last accessed 5/6/15]
  6. ↑ Dressendorfer R, Haykowsky M, Eves N. Exercise for Persons with Chronic Obstructive Pulmonary Disease. Available from: http://www.acsm.org/docs/current-comments/exerciseforpersonswithcopd.pdf. (Accessed 6 May 2015).
  7. ↑ Mayo Clinic Staff. Diseases and Conditions. COPD Prevention. 2014. Available from: http://www.mayoclinic.org/diseases-conditions/copd/basics/prevention/CON-20032017. Accessed 6 May 2015).
  8. ↑ National Health Services. Bronchitis. 14/07/2014; Available from: http://www.nhs.uk/conditions/Bronchitis/Pages/Introduction.aspx. (Accessed 6 May 2015).
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