Bronchitis

Acute  bronchitis was defined as an acute self-limited lower respiratory tract infection manifested  predominantly by cough with or without sputum production, lasting no more than 3 weeks with no  clinical or any recent radiographic evidence to suggest an alternative explanation. In acute bronchitis  some  isolated  virus  (influenza  A  and  B  viruses,  parainfluenza  virus,  respiratory  syncytial  virus,  coronavirus,  adenovirus,  and  rhinovirus)  and  bacteria  (Bordetella  pertussis,  Chlamydophila  (Chlamydia) pneumoniae, and Mycoplasma pneumonia) 

Clinical presentation 

• Patients with acute bronchitis present with a cough lasting more than five days (typically one to three weeks), which may be associated with sputum production 
• Cough in the absence of fever, tachycardia, and tachypnoea suggests bronchitis
• Acute  bronchitis  should  be  distinguished  from  chronic  bronchitis  (see  below); it  is  not  a form of COPD 

Note: When  the  acute  bronchitis  persists  or  worsens,  we  suggest  that  the  patient  is  advised  to  seek  reassessment and do below targeted investigation(s). 

Investigation in COPD (bronchitis and emphysema) 

• FBP 
• ESR /CRP OR Procalcitonin 
• Serum alpha-1 antitrypsin levels 
• Chest radiography (if the patient is elderly or physical findings suggest pneumonia) 
• Sputum cytology (if the cough is persistent) 
• Blood culture and microbial sensitivity (if bacterial super-infection is suspected) 
• Bronchoscopy  (to  exclude  foreign  body  aspiration,  tuberculosis,  tumours,  and  other chronic diseases and patient with worsening symptoms) 
• Lung Function Test (Spirometry and Peak Expiratory Flow Rate) 

Note: An  exception,  however,  is  cough  in  elderly  patients;  pneumonia  in  elderly  patients  is  often  characterized by an absence of distinctive signs and symptoms. 

Symptomatic Treatment 

• With non-steroidal anti-inflammatory drugs: paracetamol, acetyl salicylic acid
• Cough management refer section 9.1.1
• There is NO benefit from antibiotic use in acute bronchitis
• Discourage smoking and other irritating factors

It  defined  by  a  chronic  productive  cough  for  three  months  in  each  of  two  successive  years  in  a  patient in whom other causes of chronic cough have been excluded. Patients may get secondary  bacterial infection with development of fever and production of thick smelly sputum. 

Risk Factors for Chronic Bronchitis 

1. Cigarette Smoking
2. Indoor air pollution
   • Exposure from burning wood
   • Heating in poorly ventilated dwellings
   • Exposure to biofuel mass exposure
3. Occupational exposure
   • Coal miners
   • Tunnel Workers
   • Hard-rock miners
   • Concrete manufacture
   • Livestock farming (i.e. to pesticides)
4. Exposure to agricultural
5. Use of domestic solid fuel

Investigation 

As in acute bronchitis

Non-pharmacological Treatment

• Stop smoking (Reducing loss of lung function) and/or remove from hazardous environment Prompt treatment of infective exacerbations
• Controlled oxygen therapy
• Physiotherapy
• Pulmonary Rehabilitation (consist of education, lifestyle modification, regular physical activities, physiotherapy and avoid indoor and outdoor pollutants)
  Nutrition support
• BIPAP in specialized center
• Influenza vaccine in specialized center

Pharmacological Treatment

• Pharmacological therapy for Chronic Bronchitis is directed towards 3 major goals
• Relieving symptoms during stable disease

Mucoactive Agents - Reduced overproduction and hypersecretion, increases elimination 

For pharmaceutical management, refer to emergency and critical care chapter

Hypertonic saline - stimulate productive cough and decreases sputum viscoelasticity, increases mucociliary clearance. 7% hypertonic saline or 0.9% saline BD,  PRN 

Bronchodilators (Beta-agonists) - Promote mucus clearance by increasing airway luminal diameter and ciliary beat frequency, reduces hyperinflation, improve PEF 

A: SABA: Salbutamol (Inhalation) 100µg 2puff 6hourly 

OR

LABA: salmeterol+fluticasone or in combination with steroids (salmeterol+fluticasone or budenoside fluticasone) 

OR

Muscarinic antagonists - Decrease contractility of smooth muscle in the lung, inhibits bronchoconstriction and mucus secretion 

SAMA: S: ipratropium bromide (aerosol) 20–80mcg, 6–8 hourly

LAMA: S: tiotropium (mist inhaler) 6mcg 2puffs 24hourly Preventing exacerbations

Mucoactive Agents - Refer to cough section 

Macrolides - (as indicated) antibacterial effects; Immune-modulatory and anti-inflammatory effects (Azithromycin/clarithromycin) 

Note:

• In specialized center, they may use N-acetyl cysteine and carbocysteine as mucolytic agents
• Macrolide should be given in consultation with respiratory physician/pulmonologist to avoid antimicrobial resistance (azithromycin and clarithromycin may be used)

Avoid use of systemic glucocorticoids due to numerous adverse side effects.