Chronic Bronchitis – Causes, Symptoms, Treatment

Chronic Bronchitis can be defined as a chronic productive cough lasting more than 3 months occurring within a span of 2 years. There is a strong causal association with smoking and is very often secondary to chronic obstructive pulmonary disease (COPD). [rx]

Chronic bronchitis is a serious, ongoing illness characterized by a persistent, mucus-producing cough that lasts longer than 3 months out of the year for more than 2 years. People with chronic bronchitis have varying degrees of breathing difficulties, and symptoms may get better and worse during different parts of the year.If chronic bronchitis occurs with emphysema, it may become chronic obstructive pulmonary disease (COPD).

Pathophysiology of Chronic Bronchitis

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 such as interleukin 8, colony-stimulating factor, and other pro-inflammatory cytokines. There is also an associated decrease in the release of regulatory substances such as angiotensin-converting enzyme and neutral endopeptidase. The alveolar epithelium is both the target as well as the initiator of the inflammatory process in chronic bronchitis. 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.[rx]

Causes of Chronic Bronchitis

There are many known causes of chronic bronchitis, but the most important causative factor is exposure to cigarette smoke either due to active smoking or passive inhalation. Many inhaled irritants to the respiratory tract such as smog, industrial pollutants, and toxic chemicals can cause chronic bronchitis. Although bacterial and viral infections usually cause acute bronchitis repeated exposure to infections can cause chronic bronchitis. The predominant viruses that are causative are Influenza type A and B, and the dominant bacterial agents are Staphylococcus, Streptococcus, and Mycoplasma pneumonia. People who have an associated background in respiratory diseases such as asthma, cystic fibrosis, or bronchiectasis have a higher predisposition to develop chronic bronchitis. People who have repeated exposure to environmental pollutants such as dust or airborne chemicals such as ammonia and sulfur dioxide have a higher risk of developing chronic bronchitis. Chronic gastroesophageal reflux is a well documented but less frequent cause of chronic bronchitis. [rx]

Diagnosis of Chronic Bronchitis

History and Physical

The most common symptom of patients with chronic bronchitis is a cough. The history of a cough typical of chronic bronchitis is characterized to be present for most days in a month lasting for 3 months with at least 2 such episodes occurring for 2 years in a row. A productive cough with sputum is present in about 50% of patients. The sputum color may vary from clear, yellow, green or at times blood-tinged. The color of sputum may be dependent on the presence of secondary bacterial infection. Very often changes in sputum color can be due to peroxidase released by leucocytes in the sputum. Therefore, color alone is not a definite indication of bacterial infection.

It is of prime importance to elicit a complete history from the patient including information regarding possible exposure to inhaled irritants or chemicals as well as full details regarding smoking habits. Fever is uncommon in chronic bronchitis and when present can be suggestive of associated influenza or pneumonia. Generalized malaise is a commonly associated symptom. Rarely patients may complain of chest pain or abdominal muscle pain caused by continuous forceful coughing. When there is inflammation of the airway, there can be an associated wheeze.

Uncomplicated chronic bronchitis presents with a cough, and there is no evidence of airway obstruction physiologically. When patients have chronic asthmatic bronchitis, there is usually a wheeze present due to a hyperactive airway leading to intermittent bronchospasm. When there is obstructive bronchitis which is the more severe end of the spectrum of the disease, there is small airway disease which at times results in emphysema.[rx]

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.

The investigations which assist in confirming the diagnosis of chronic bronchitis are a complete blood count with differential. A serum procalcitonin level can help in distinguishing associated bacterial from non-bacterial infection. 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 test.[rx]

Treatment of Chronic Bronchitis

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. [rx][rx][rx]

The mainstay of pharmacological interventions are the following:

• 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 properties 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.

Non Pharmacological Measures

• 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.
• Pulmonary rehabilitation is an important part of treatment for chronic bronchitis is pulmonary rehabilitation which consists of education, lifestyle modification, regular physical activity and avoidance of exposure to known pollutants either at work or living environment.[rx]

References