Chronic Bronchitis

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This is chronic inflammation of the bronchial mucosa due to irritants such as tobacco smoke. It occurs after the age of 40 years and is part of the syndrome of chronic obstructive pulmonary disease (COPD). There is progressive worsening with age, eventually resulting in chronic respiratory  failure. It is aggravated by recurrent viral and bacterial infections.

Oxygen therapy in these patients must be given with caution to prevent carbon dioxide retention due to depression of respiration. High flow rates remove the central  hypoxic drive that maintains respiratory effort and can be harmful.

Cause

  • Cigarette smoking
  • Industrial dust
  • Chemical irritants
  • Inhaled smoke from use of biomass fuels (eg. charcoal, wood)

Symptoms

  • Shortness of breath, particularly on exertion
  • Wheeze 
  • Fever 
  • Cough with production of sputum for most of the year
  • Infective exacerbation associated with increased quantity of thick purulent sputum

Signs

  • May be none 
  • Barrel chest
  • Pursed lip breathing
  • Clubbing 
  • Cyanosis
  • Increased respiratory rate
  • Use of assessory muscles i.e.neck and/or abdominal muscles, for breathing 
  • Hyperresonance on percussion and loss of cardiac dullness
  • Wheeze or rhonchi
  • Reduced Peak Expiratory Flow Rate (PEFR) 

Investigations

  • FBC
  • Spirometry, shows reduced lung volumes, particularly FEV1 which is not reversed post-bronchodilator administration
  • Chest X-ray
  • Sputum culture and gram stain

TreatmentTreatment Objectives

  • To minimise or stop cough
  • To prevent or minimise wheeze and shortness of breath
  • To reduce quantity of sputum produced 
  • To prevent infective exacerbations

Non-pharmacological treatment

  • Smoking cessation
  • Physical exercise
  • Good nutrition
  • Use of face mask in high risk occupations

Pharmacological treatment 

See sections below

Referral Criteria

  • Refer all patients not improving on initial management, with acute exacerbation, recurrent infective exacerbations or rapidly deteriorating to a specialist

Stable chronic bronchitis

Evidence Rating: [B]

  • Salbutamol, inhaled, (via pMDI)

Adults

100 microgram (2 puffs) 4-6 hourly as required

Children (by nebulisation)

2.5-5 mg 4-6 hourly as required

And

  • Tiotropium, inhaled (dry powder inhaler),

Adults

18 microgram (2 puffs) daily

Children 

> 12 years; 18 microgram (2 puffs) daily

< 12 years; not recommended 

And

  • Fluticasone/salmeterol, inhaled (via accuhaler or pMDI),

Adults

100/50 microgram or 250/50 microgram or 500/50 microgram, 1 puff 12 hourly

Children 

4-12 years; 100/50 microgram, 1 puff 12 hourly

< 4 years; safety not established 

Or

  • Budesonide/formoterol, inhaled (via accuhaler or pMDI),

Adults

160/4.5 microgram 1-2 puffs 12 hourly

Children 

>12 years; 160/4.5 microgram 1-2 puffs 12 hourly

<12 years; efficacy not established

Chronic bronchitis with infective exacerbation

Evidence Rating: [C]

  • Oxygen 

By nasal prongs, 2-6 L/min

Or 

Face mask, 4-8 L/min

Or 

Non-rebreather mask, 10-15 L/min

And

  • Salbutamol, nebulised,

Adults

2.5-5 mg repeated initially after 15-30 minutes, then every 2-4 hours until improved

Children

2.5-5 mg 4-6 hourly

And

  • Ipratropium bromide, nebulised,

Adults

500 microgram 4-6 hourly, until improved

Children

6-12 years; 250 microgram 4-6 hourly

1-5 years;  125 microgram 4-6 hourly
(max. dose for children 1 mg/24 hours) 

And 

  • Amoxicillin (Amoxycillin), oral,

Adults

500 mg 8 hourly for 7-14 days

Children

6-12 years; 250 mg 8 hourly for 7-14 days

1-5 years; 125 mg 8 hourly for 7-14 days

<1 year; 62.5 mg 8 hourly for 7-14 days

Or

  • Erythromycin, oral,

Adults

500 mg 6 hourly for 7-14 days

Children

8-18 years; 250-500 mg 6 hourly 7-14 days

2-8 years; 250 mg 6 hourly 7-14 days

6 months-2 years; 125 mg 6 hourly 7-14 days

Or

  • Azithromycin, oral,

Adult

500 mg daily for 6 days

Children

10 mg/kg daily for 6 days

Or

  • Amoxicillin + Clavulanic Acid, oral,

Adults

1 g 12 hourly for 7-10 days

Children

> 12 years; One 500/125 tablet 12 hourly for 7-10 days

4-12 years; 5 ml of 400/57 suspension 12 hourly for 7-10 days

1-4 years; 5 ml of 200/28 suspension 12 hourly for 7-10 days

3 months-1 year; 20 mg/kg (of amoxicillin) 12 hourly for 7-10 days 

< 3 months; 15 mg/kg (of amoxicillin) 12 hourly for 7-10 days

And 

  • Prednisolone, oral, 

Adults

30-40 mg for 7 days 

Then 

20 mg daily for 5 days, 10 mg daily for 5 days, 5 mg daily for 5 days.  Tail down over 2-3 weeks and stop.

Children

1-2 mg/kg for 3-5 days. Tail down over 2-3 weeks and stop.

And 

  • Acetylcysteine, oral, 

Adults

10 ml 8 hourly for 5-7 days

Children (paediatric formulation)

5-10 ml 8 hourly for 5-7 days

Or

  • Carbocysteine, oral, 

Adult

500-750 mg 6-8 hourly

Children

2-5 years; 62.5-125 mg 6 hourly 

< 2 years; not recommended