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Bronchitis means inflammation/irritation of the upper airways (tracheobronchial tree). The cause is usually infectious, but other causes include allergens, irritants (smog) and smoke. Bronchitis typically occurs following an upper respiratory tract infection. These infections are more common during the winter months and are often mistaken for asthma. Bronchitis affects all age groups, ethnic groups and affects women slightly more than men. Bronchitis may be acute or chronic.
In the US, close to 15-18 million individuals are diagnosed with acute bronchitis each year. This condition is one of the most common reasons for younger and older individuals going to the emergency room. In most cases of acute bronchitis, the disorder lasts for a few days and is self limited. It does account for a common reason for school absenteeism. Acute bronchitis is a common disorder in young children and is caused by numerous viruses (Influenza, parainfluenza, adenovirus, rhinovirus) and sometimes bacteria.
Chronic bronchitis is a common manifestation in individuals with chronic obstructive pulmonary disease (COPD), and is a leading cause of death in North America. About 10 million Americans are affected by some degree of chrnoic bronchitis and each year more than 40,000 individuals die from complications related to COPD. Chronic bronchitis is a clinical diagnosis characterized by a productive cough for over three months' duration during two consecutive years. Additionally, these individuals have poor lung function and exercise endurance. Chronic bronchitis is a much more serious disorder than the acute variety. The excess mucus and sputum production causes difficulty with breathing and also leads to destruction of the airways over time. Unlike the acute disorder, chronic bronchitis is associated with cigarette smoking. The majority of individuals with chronic bronchitis have a smoking history. In chronic bronchitis, there is definitive worsening of the lung function which can easily be documented. These lung changes remain even 10 years after individuals have stopped smoking. Chronic bronchitis is a common cause of death in North America and once the lungs fail, it carries a very high death rate. Respiratory failure is a common reason for admission of the individuals to the ICU. When the condition worsens, the majority of the individuals need to be seen by their physicians. Chronic bronchitis is usually worsened by upper respiratory tract infections, allergies, smoke and changes in weather.
People who smoke or who live with a smoker are at greatest risk of both acute and chronic bronchitis. Children are susceptible to bronchitis from second hand smoke. Other factors that increase your risk of bronchitis include:
Immunocompromised: There are some individuals who may have another illness and may not be able to fight off the infection. This is common in cancers, children and the elderly.
Environmental Exposure: There are many pollutants in the environments which can initiate or worsen bronchitis. Some occupations may also cause exposure to chemicals, gases, grains and dust. The cough associated with occupational bronchitis may be dry (nonproductive). Occupational bronchitis usually clears up when you're no longer exposed to these substances.
In most cases of bronchitis, there is copious sputum production. The sputum is always yellowish to green and is quite thick and viscous. This is a typical presentation of bronchitis. These secretions are usually persistent all day but worse in the mornings. The majority of these secretions are swallowed or coughed up. When these secretions persist for more than 3 months, the diagnosis of chronic bronchitis is made. When the mucus is colored and foul smelling, it generally indicates the presence of an infection. However, this is not a golden rule and in many cases, the mucus may be white and yet be infected. In children the diagnosis of bronchitis can be deceptive as they do not cough up the mucus and instead swallows there's a secondary infection.
One of the biggest questions that people have is about how to detect bronchitis symptoms. In all cases, the individual will present with a purulent cough which may be associated with - Fever - Fatigue - Runny nose - Congested nose - Sore throat - Difficulty breathing wheezing - Shortness of breath - Muscle and joint aches The classic findings on physical exam include the presence of wheezing or coarse sounds in the lungs. The physical examination findings may include a bluish tinge on the skin and lips and a fast breathing rate. In children, an ear or eye infection may be evident, but in most cases the examination is unremarkable.
When to seek medical advice
Most cases of bronchitis clear on their own in a few days, especially if you rest, drink plenty of fluids, avoid exposure to tobacco smoke and maintain adequate humidity in the home. However, if the bronchitis is prolonged and fails to resolve after a few days, one should seek medical therapy. Warning signs of worsening include: - difficult sleeping - nocturnal coughing - ongoing fever - chills
The diagnosis of bronchitis is based on the history, physical exam and a chest x ray. In most cases, sputum is analyzed and cultured.
Sputum: In most individuals with chronic bronchitis, analysis of sputum is a waste of time and money. The organism present in the sputum may not reflect the organism present in the lower parts of the lung. To prevent this error in starting antibiotics, special guidelines have been made when evaluating sputum which has been obtained after inducing a deep cough.
Blood: In the individual with chronic bronchitis, shortness of breath is a common feature. This can be better assessed by measuring the amount of oxygen in the blood. This can be used to follow response to treatment.
Chest X ray: chest x-rays in a patient with chronic bronchitis are not useful. There is nothing specific seen on the x ray that may indicate bronchitis.
Electrocardiogram: The ECG is not diagnostic of bronchitis but in individuals with long standing bronchitis, it may reveal abnormal heart rhythms.
Lung Function: Even though chronic bronchitis may be diagnosed on clinical grounds, the only way to objectively quantify the disease is using special equipment to measure the airflow patterns in the lung. This not only provides the physician with the status of the patient but also allows the physician to assess the responsiveness of the patient to treatment. The test simply requires one to take a deep breath and blow out air in one second in a special machine. Other methods may involve assessing the respiratory functions and volumes in the lung. These studies provide a baseline for determining improvement following treatment. Most adults develop a decline in the elasticity of their lungs and lose about 30 cc of volume each year after the age of 35-40. This volume loss then continues until old age.
Biopsy: In the rare case of long standing bronchitis, a biopsy of the airways may be done with the use of a bronchoscope (camera with forceps). The visualization may reveal thickening of the airways and may also help clear up the secretions.
Therapy is generally based on the presentation of the individual and may include the use of: Pain killers Cough suppressant Antibiotics Bronchodilators Steroids In general, there is little evidence that antibiotics are of any help to individual with acute bronchitis. In fact over use of antibiotics has led to the development of resistant organisms. However, the primary care physicians still appear to be ignorant about these facts and continue to prescribe antibiotics for all individuals. Numerous studies have shown that the use of antibiotics in acute bronchitis does not reduce the duration or intensity of infection. For viral bronchitis, antibiotics are not indicated. The best treatment for bronchitis is: - Get plenty of rest. - Drink extra liquids. - Take a nonprescription cough medicine.
Cough suppressants: Despite many doctors prescribing cough suppressants it is not a good idea to keep all that junk in your lungs. The remedy for excess secretions is to cough them up. Coughing helps remove the irritant mucus and clears the airways. One should just take adequate cough medication that will not completely suppress the cough. Cough medications are best taken at night so that one can sleep comfortably. There are countless cough medications obtained over the counter and there is no real difference between them. If a stronger cough prescription is required, one needs to see a physician.
Bronchodilators: One feature about bronchitis is that individuals may develop wheezing. These individuals are typically smokers or may have a history of asthma. In most cases bronchitis can worsen asthma and a number of individuals will require drugs to treat the asthma. The major drugs for the treatment of chronic bronchitis are bronchodilators. These drugs decrease the wheezing and open up the airways. There are numerous drugs which act as bronchodilators. These drugs rapidly open up the airways and provide relief in a few minutes. There are numerous types of bronchodilators and there are various formulations available. Some can be inhaled, others can be taken orally. Today, we also have newer anti asthmatic agents such as zafirlukast (Accolate), or leukotriene inhibitors (5-lipoxygenase blockers), such as zileuton (Zyflo), which offer new strategies for the management of chronic bronchitis. All individuals who use inhalers must be taught how to use the medication. If the drug is not inhaled properly, most of it ends up in the mouth and then the stomach. Various adaptive devices are available through occupational therapists, may permit easier administration by patients with impaired hand function.Those suffering any symptoms that are necessary for this medication can benefit by switching to online ordering. There is no predicting when a wheezing, coughing, or asthmatic attack might occur, which is why it is important to always be prepared by carrying the proper medication.
Theophylline: Another class of drug which is frequently used in patients with wheezing is Theophylline. It is known to open up the airways and improve the strength of the respiratory muscles. It also helps in coughing up the secretions. The drug is available in various formulations and is quite effective. However, it does have the potential to interact with other drugs and one should discuss with the physician all drugs before one starts Theophylline.
Steroid Therapy: In severe cases of bronchitis associated with wheezing and lack of response to antibiotics, one may require a short term course of steroids. The steroids may be administered via inhalation, orally or by IV. This short burst of steroids is excellent for acute worsening of bronchitis. Long-term oral steroid therapy in chronic bronchitis is usually reserved for individuals who have had a diagnosis of COPD or emphysema and continue to go downhill. However long term steroids also have numerous complications which include: Muscle wasting Cataracts Ulcers Osteoporosis Ulcers etc fractures Therefore, the benefits of prolonged systemic steroid therapy should be carefully documented.
Antibiotic Therapy: Even though some cases of bronchitis are viral, there are others which may be bacterial and antibiotics may help. However, the routine administration of antibiotics in bronchitis is questionable. There are some guidelines as to who should get antibiotics. Individuals who have a fever, greenish sputum, and chills should be administered antibiotics. There are several groups of antibiotics and the choice is dependent on the physicians. Commonly used antibiotics include: - sulphonomides - tetracyclines - fluoroquinolones - macrolides Those individuals who are in hospital with a diagnosis of bronchitis will need IV antibiotics. Some may even need bronchoscopy to help clear the secretions. Some physicians recommend that in an individual who gets 4 or more episodes of bronchitis per year, should receive continuous antibiotics. However, this regimen has not been shown to improve either patient morbidity or hospital admissions. In addition, continuous antibiotics are associated with development of bacterial resistance. All individuals with chronic bronchitis should be vaccinated against the polyvalent pneumococcal vaccine at least once. Re-vaccination with the pneumococcal vaccine should be considered after seven years in patients with renal impairment. Unfortunately, the currently available Haemophilus b conjugate vaccine (Acthib, Comvax, Hibtiter) is not expected to be helpful in patients with chronic bronchitis.
When the bronchitis is chronic and associated with persistent shortness of breath, both the survival and quality of life are seriously undermined. Oxygen is an important part of therapy for chronic bronchitis. Some individuals require oxygen at night and some require it for most of the day. Oxygen can improve the quality of sleep and can prevent the development of abnormal heart rhythms. Oxygen is available in various forms for home use. However the therapy is not cheap and thus low flow rates are recommended with oxygen conserving devices. These newer devices only open when triggered by inspiration to deliver a fixed dose of oxygen. Those individual who have thick and viscous sputum may benefit from expectorant mucolytic therapy. The medications can thin up the secretions enabling one to cough it up. Cough suppressants and sedatives should be avoided as routine measures. One should continue to remain active and participate in some from of exercise. This will help loosen up the secretion through adequate hydration and constant coughing. Morphine type drugs are effective to decrease cough but only when the regular cough medications fail. Surgery is not a treatment for bronchitis. Only after all medical therapy has failed, is surgery considered. In some individuals with COPD or emphysema, the lung is destroyed and in these cases, surgery may be an option. However, the surgery is extremely high risk and the results are poor. Lung transplant is an option but donor lungs are scarcely available and one has to take life long chemotherapeutic drugs.
Optimizing Functional Capacity
Even after treatment of bronchitis, individuals with chronic bronchitis should undergo rehabilitation to help improve their airway function and improve endurance. The aim of the pulmonary rehab is to condition the chest muscles and improve the strength of the diaphragm. Besides the pulmonary rehabilitation, one needs to stop smoking, increase fluid intake and maintain a decent lifestyle. Improved hydration through greater fluid intake and provision of airway humidity can also facilitate sputum mobilization, more so than pharmacologic expectorants or mucolytic agents.
Nutrition and Dietary Supplements
Nutrient is important in individual with chronic bronchitis. The acute stage only last a few days but for chronic bronchitis it is essential to increase fresh fruits, vegetables and eliminating milk, eggs and other foods with preservatives. There are some who claim that increasing onions and garlic in the diet decrease the episodes of bronchitis –but this is just hearsay and not scientifically proven.
N-Acetyl-Cysteine (NAC): Even though N acetyl Cysteine can reduce the viscosity of the sputum, it is not available as a pill. Rather one can take methionine which is a precursor of N acetyl Cysteine. Zinc: Zinc is purported to enhance immune system activity and protect against a range of infections including colds and upper respiratory infections (such as bronchitis). Other supplements to consider may help prevent you from catching an infection or may help relieve symptoms from bronchitis:
Bromelain: Bromelain is used in a vast array of medical conditions. It was first introduced in this area in 1957, and works by blocking some proinflammatory metabolites that accelerate and worsen the inflammatory process. It has been used to treat everything in medicine and thus its effective is similar to drinking water from a stream. Other nutrients that have been postulated to decrease the infections and improve the symptoms of bronchitis are lactobacillus, Quercetin and Vitamin C.
Almost every herb in the forests of Europe and North America is postulated to cure bronchitis. Every single day new herbs are added in food stores with preposterous claims of curing cancers, infections and preventing illness. Despite all these claims, there is not one iota of scientific evidence that these products do anything except clean your pockets. There are tons of anecdotal data which claim that these products are helpful. Today, many of these herbs are manufactured outside of north America and the purity of the herbs or the ingredients in the herb remain unknown. Numerous cases of contamination have been found and recent analysis of some herbs from China has revealed that in fact a number of herbs are actually contaminated with real pharmaceutical medications. The herbs which have been postulated to fight the lung infections include: - Barberry (Berberis vulgaris) - Eucalyptus (Eucalyptus globules) - Peppermint (Mentha x piperita) - Slippery elm (Ulmus fulva) - Stinging nettle (Urtica dioica) - Echinacea (Echinacea angustifolia/Echinacea pallida/Echinacea purpurea) - garlic (Allium sativum) - Ginger (Zingiber officinale) - Aconitum - Antimonium tartaricum - Hepar sulphuricum - Ipecacuanha - Phosphorus Some of the herbs are extremely toxic and are not safe. So in the end-buyer beware.
The most important treatment for chronic bronchitis is to stop smoking. Once smoking is stopped, the excess sputum will start to decrease, the cough will disappear and the wheezing will improve. The majority of individuals who stop smoking indicate that their physical endurance and overall health are much improved. In addition, lung tests reveal that a significant number of individuals recover their lung function over time. There have been many tools to help one stop smoking but their effectiveness is minimal. The best treatment is cold turkey. The physicians can help educate the family and friends on the importance of smoking cessations.
It appears that most of alternative medicine is a field which is still trying to look for a disease to cure. Other recommended cures for bronchitis include: - Massage and Physical Therapy - Aromatherapy (inhaling cedarwood, eucalyptus moisture) - Acupuncture: Acupuncture can help relieve symptoms of acute bronchitis and, possibly, help improve quality of life for those with chronic bronchitis. - breathing exercises - lifestyle counseling
Prognosis and Complications
For acute bronchitis, symptoms usually resolve within 5 to 10 days if one is healthy and does not have any other medical problems. In some, a dry, hacking cough can linger for a number of months. The chance for recovery is poor for advanced chronic bronchitis. Early recognition and treatment, combined with smoking cessation, significantly improve the chance of a good outcome.
It is essential that one have good nutrition, hydration and maintain some physical activity during episodes of bronchitis flare up. Other things one can do at home include: Humidification: Warm, moist air helps relieve coughs and loosens mucus in your airways. One has to buy a decent quality of a humidifier which will not grow bacteria and fungi in the water tank.
Pain relief: To relieve pain and lower a high fever, acetaminophen (Tylenol, others) and other over the counter pain medications may help. Adults may also use aspirin but it is not recommended for children. Aspirin is known to cause a fatal liver disorder in children, known as Reye's syndrome.
Avoid exposure to irritants: Smog, smoke and other chemicals in the air can trigger bronchitis. For those who are sensitive to environmental pollutants, one should wear a mask or avoid the area.
lu vaccine: Many causes of bronchitis are related to a viral infection and this it is highly recommended that these individuals get an annual flu vaccine. Educating the patient and family caregivers is an important aspect of care. The disorder can impact the entire family. The family and the individual should learn more about the disorder and its home management. All appointments with the physician should be kept and compliance with medical therapy is a must. Stopping smoking will go a long ways to reducing the impact of bronchitis.