Chronic Bronchitis

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

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Normal Lung Function & Anatomy

The two lungs are organs responsible for respiration, air enters and leaves the lungs via main 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 pump through the rest of the body to deliver oxygen where needed.

Proper lung function is essential for quality of life, 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, work of breathing and reduced quality of life.

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Definition/Description

Chronic Bronchitis (CB) is defined as a chronic cough and sputum production for at least 3 months a year for two consecutive years.  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 where as CB is the inflammation and excessive mucus build-up in your bronchi. Many patients have characteristics of both, putting them somewhere along the spectrum.

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Epidemiology

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. CB occurs in 3.4 to 22% of the US adults population and rates are even higher in patients with COPD.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 work place.

Aetiology

CB is caused by overproduction and hyper secretion of mucus by goblet cells, increasing airflow obstruction. This can be due to an infection caused by a virus or bacteria.

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.

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.

Pathophysiology

The pathological foundation for CB is due to the over-production of mucus is in response to the inflammatory signals. In COPD patients this overproduction and hypersecretion is due to the goblet cells, and decreased elimination of mucus.

Mucus hypersecretion is one of the risk 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. 

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 lung work. You breath 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.

- 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. 

- Blood test: This is to see if your symptoms could be due to anaemia, or to see if the symptoms are due to the genetic marker alpha-1-antitrypsin deficiency.

- Phlegm sample: This is to check to see if there is an infection that is causing the symptoms.

Clinical Manifestations

The clinical presentation can be increased exacerbation rate, accelerated decline in lung function, worse health-related quality of life and increase in mortality. 

Common symptoms outline by the British Lung Foundation include:

-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.

Physiotherapy and Other Management

The treatment of chronic bronchitis may include a variety of treatments including management through medications, education, physical exercise and respiratory exercises. The goal of the physiotherapist should involve education, improving exercise tolerances, reducing exacerbations and hospitalization, assist in sputum clearance and increase thoracic mobility and lung volume.

Medication

There are various kinds of short term and long term medications individuals with chronic bronchitis might take to reduce flare ups, decrease obstruction, improve activity and decrease shortness of breath. These medications may include bronchodilators, corticosteroids and antibiotics.

Exercise

Regular exercise can have positive effects on the management, treatment and prevention of chronic bronchitis 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 and a discussion with the general practitioner should be had before taking part in any exercise program.

Postural Drainage

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 non – affected area.

Active Cycle of Breathing

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.

Autogenic Drainage

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 air flow 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

Percussion and Vibrations

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 behind 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

Education

Education of the individual with chronic bronchitis 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,

Prevention

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

Stopping Smoking

Smoking can irritate the lungs leading to irritation, inflammation and scaring. 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.

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 shortness of breath, exacerbations and hospital visits. Specific guidelines are put in place in concern to exercise for individuals with chronic bronchitis and COPD. Discussion should be held with the treating clinical team before participation in any exercise program begins.

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.

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.

Education

Education can play a vital aspect in the prevention and management of chronic bronchitis. 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.

Resources

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Recent Related Research (from Pubmed)

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References

6. 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.

7. National Health Services. Bronchitis. 14/07/2014; Available at: http://www.nhs.uk/conditions/Bronchitis/Pages/Introduction.aspx. Accessed May, 06, 2015.

8. Chartered Society of Physiotherapy. Physiotherapy works: Chronic obstructive pulmonary disease. Available at: http://www.csp.org.uk/professional-union/practice/evidence-base/physiotherapy-works/COPD. Accessed May, 6, 2015.

9. 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.

10. Hough A. Respiratory Disorders. Physiotherapy In Respiratory And Cardiac Care: An Evidence-Based Approach. Fourth ed.: Cenegage Learning; 2014. p. 77-84.