Chronic Bronchitis

Overview

Chronic simple bronchitis characterized by mucoid sputum production, chronic mucopurulent bronchitis by persistent or recurrent purulent sputum production in absence of bronchiectasis and chronic asthmatic bronchitis in patients who experience severe dyspnea and wheezing during acute respiratory infections or following inhaled irritants

Epidemiology

Causes

1. Infection – (a) Result of acute bronchitis. (b) Infective focus in upper respiratory tract, the nasal sinuses or tonsils. (c) Infective focus in lungs, e.g. bronchiectasis, fibrosis, or tuberculosis.
2. Smoking – particularly of cigarettes.
3. Air pollution – due to industrial fumes and dust.
4. General illness – which favor infections, e.g. obesity, alcoholism, and chronic kidney disease.[1]

Types 

Risk factor of Chronic Bronchitis

Cigarette smoking

• Genetic factors can influence the severity of smoking effect on airways.

Occupational exposure

• Dusts, gases, fumes, or organic antigens can contribute to increased airways responsiveness.

Genetic factors

• Alpha-1 antitrypsin (AAT) deficiency is the leading genetic risk factor for developing chronic bronchitis. Some novel risk factors such as, small nucleotide polymorphisms and gene clusters, are assumed to be involved in developing chronic airway diseases.

Developmentally abnormal lungs

• Frequent childhood infection may cause scarring of lungs, decrease elasticity, thereby increasing risk for COPD. (4)

Pathogenesis 

Pathophysiology of Chronic Bronchitis

Chronic bronchitis exposure to an irritant over many years causes inflammation in the lungs which leads to the following changes:

• Continual irritants (smoking, infection, pollution) to the lungs cause the airways to become swollen and inflamed.
  • Constant irritants lead to hypertrophy (enlargement) of the mucus-secreting glands of the bronchial tree, an increase in the number of goblet cells, which results in increased mucus secretion.
  • The smooth muscle in the airways becomes thicker and narrows the bronchioles.
• Extra mucus is produced to trap any irritants and prevent them entering the lungs.
  • The cilia become unable to cope with excessive secretions and therefore the mucus blocks the airways. This is known as Reversible Airways Obstruction.
  • The mucus goes deeper into the lungs and becomes harder to clear.
• Excessive secretions are liable to infection.
  • The walls of the bronchioles become inflamed, continual inflammation causes gradual destruction of the bronchioles, resulting in fibrosis – Irreversible Airways Obstruction.
• Disease progression can also affect the pulmonary blood vessels
  • If the inflammation spreads to the blood vessels this will lead to capillary bed wall atrophy (wasting).  This increases the pressure of the pulmonary circulation. Pulmonary arteries may become distended (stretched) and blood may back track into the right side of the heart resulting in right sided hypertrophy (enlargement) and heart failure. This is known as Cor Pulmonale. (5)

Clinical Features

The Sign & Symptoms

Symptoms

1. Cough –

• Constant paroxysmal,
• worse in winter or on exposure to cold winds or sudden change of temperature.

2. Expectoration –Variable, may be little, thin and mucoid or thick or frothy, mucoid and sticky. May become mucopurulent during attacks of acute bronchitis in winter.
3. Dyspnea -In advanced cases, breathing becomes quick and wheezing present even at rest.
4. Fever – Absent except in acute exacerbation
5. Hemoptysis – Usually in the form of streaks of blood.

Signs

(a) Build – usually short and stocky.

(b) Cyanosis – rarely with clubbing.

(c) Signs of airway obstruction – Prolonged expiration, pursing of lips during expiration, contraction of expiratory muscles of respiration, fixation of scapulae by clamping the arms at the bedside, indrawing of supraclavicular fossae and intercostal spaces during inspiration, and jugular venous distension during expiration due to excessive swings of intrathoracic pressure. Widespread wheezes of variable pitch usually most marked in expiration. Crackles at lung bases in patients with excessive bronchial secretions. Both wheezing and crackles may be altered in character by coughing.

Physical examination of Chronic Bronchitis

Appearance of the Patient

• Typically a person higher in weight
• Cyanosis, typically in lips and fingers

Vital Signs

Respiratory Rate

• Tachypnea

Head

• Elevated jugular venous pulse (JVP)

Inspection

• Respiratory distress indicated by use of accessory respiratory muscles
• Hoover’s sign, presenting as paradoxical indrawing of lower intercostal spaces, is evident

Auscultation

• Prolonged expiration; wheezing
• Diffusely decreased breath sound
• Coarse crackles with inspiration
• Coarse rhonchi

Extremities

• Peripheral edema (6)

Diagnosis of Chronic Bronchitis

• Pulmonary function tests: This is a series of measurements of how much air your lungs can hold while breathing in and out.
• Chest X-ray: Uses radiation to make a picture of your lungs to rule out heart failure or other illnesses that make it hard to breathe.
• Computed tomography: This CT scan give a much more detailed look at your airways than a chest X-ray. (7)

Differential diagnosis of Chronic Bronchitis

• Congestive heart failure
• Chronic asthma
• Bronchiectasis
• Bronchiolitis obliterans (7)

Complications

Investigations

1. Ventilatory indices – Reduced PEF and VC.
2. Chest radiography may be normal. Infected episodes may produce patchy shadows of irregular distribution due to pneumonic consolidation and small linear fibrotic scarring may result. [1]

Treatment

TO REMOVE THE CAUSE IF POSSIBLE –

Air pollution, smoking. Elimination of aerosol sprays such as deodorants, insecticides and hair sprays. Other preventive measures include early vaccination against common influenza virus strains. Pneumococcal polysaccharide vaccine should be given only once because of danger of immunologic reactions following repeated vaccination.

TO PREVENT ACUTE EXACERBATIONS –

By avoiding overheated rooms, damp and foggy places, stuffy clothing, overfeeding, smoking and too much alcohol. Long term treatment with tetracycline group of drugs often produces striking improvement in patients who have a purulent sputum.

TO TRY AND ARREST THE PROGRESS OF THE CHRONIC DISEASE BY:

Increasing patient’s power of resistance – By giving to debilitated persons abundant butter, milk or cream, cheese and other fatty articles of diet. Weight reducing measures if obesity.

Physical methods – Regular exercises in fresh air and within limits of tolerance. Encouraging deep breathing and efficient clearance, coughing should follow a full inspiration. If economic condition permits, winter should be spent at warm resorts.

TO GIVE THE PATIENT AS MUCH COMFORT AS POSSIBLE –

(a) Antitussives – such as linctus codeine if dry cough.

(b) Mucolytics and inhalation of medicated steam.

(c) Expectorants –

(i) Ammonium salts, bromhexine or ambroxol in mixture form.

(ii) Hot alkaline drink – compound sodium chloride mixture 15 ml sipped in a cup of hot water first thing in the morning. This should be followed after 15 minutes by a systematic attempt to cough the bronchi clear of accumulated secretions.

(d) Bronchodilators –

Orciprenaline sulphate or ipratropium bromide as aerosol, or Salbutamol 2–4 mg or Terbutaline 2.5–5 mg t.d.s. by mouth or 0.5% by inhaler, or theophylline orally.

(e)Antibiotics –

Clarithromycin or Co-amoxiclav for 7–14 days, a good index of response being clearing of infected sputum. Long-term chemotherapy is not indicated and antibiotics should be started by the patient as soon as acute exacerbation occurs.

(f) Corticosteroids – may be given during bad spells with an antibiotic control of co-existing infection, or if patient is severely disabled.

(g) Postural drainage – In the patient who has a copious purulent sputum.[1]

Prevention of Chronic Bronchitis

• Practice good hand hygiene
• Make sure you and your child are to up-to-date with all recommended vaccines
• Don’t smoke and avoid secondhand smoke, chemicals, dust, or air pollution
• Always cover your mouth and nose when coughing or sneezing
• Keep your distance from others when you are sick, if possible (8)

Homeopathic Treatment of Chronic Bronchitis

Homeopathy treats the person as a whole. It means that homeopathic treatment focuses on the patient as a person, as well as his pathological condition. The homeopathic medicines selected after a full individualizing examination and case-analysis.

Which includes

• The medical history of the patient,
• Physical and mental constitution,
• Family history,
• Presenting symptoms,
• Underlying pathology,
• Possible causative factors etc.

A miasmatic tendency (predisposition/susceptibility) also often taken into account for the treatment of chronic conditions.

What Homoeopathic doctors do?

A homeopathy doctor tries to treat more than just the presenting symptoms. The focus is usually on what caused the disease condition? Why ‘this patient’ is sick ‘this way’?

The disease diagnosis is important but in homeopathy, the cause of disease not just probed to the level of bacteria and viruses. Other factors like mental, emotional and physical stress that could predispose a person to illness also looked for. Now a days, even modern medicine also considers a large number of diseases as psychosomatic. The correct homeopathy remedy tries to correct this disease predisposition.

The focus is not on curing the disease but to cure the person who is sick, to restore the health. If a disease pathology not very advanced, homeopathy remedies do give a hope for cure but even in incurable cases, the quality of life can greatly improve with homeopathic medicines.

Homeopathic Medicines for Chronic Bronchitis:

The homeopathic remedies (medicines) given below indicate the therapeutic affinity but this is not a complete and definite guide to the homeopathy treatment of this condition. The symptoms listed against each homeopathic remedy may not be directly related to this disease because in homeopathy general symptoms and constitutional indications also taken into account for selecting a remedy, potency and repetition of dose by Homeopathic doctor.

So, here we describe homeopathic medicine only for reference and education purpose. Do not take medicines without consulting registered homeopathic doctor (BHMS or M.D. Homeopath).

Medicines:

Allium Sativa

Herpetic constitution; the poison attacks the respiratory and digestive mucous membranes; chronic, pulmonary catarrh; dry cough, from scraping in the larynx; afterwards glutinous, bloody or purulent sputa of foul odor. Dyspnea, as if the anterior chest were compressed; pains in chest, so that he cannot expand it; stitches in shoulder-blades and pectoral muscles, increased by cough and deep inspiration; (<) by fresh, cold air,

Alumina

Dry, hacking cough soon after waking in the morning, ending in difficult raising of a little white mucus; cough with tearing pains and involuntary urination in old or withered looking people; (<) in the cold season and lasting till the warm season sets in again, cough (>) by lying flat on the face; sputum difficult and of a putrid taste.[2]

Ammonium Carb

BRONCHITIS OF THE OLDER PEOPLE. Copious bronchial secretion, with great difficulty of expectoration and bronchial dilatation. Numerous coarse rattles land yet he experiences no necessity to clear his chest. Cough in the morning or at night, disturbing sleep, with spasmodic oppression, incessant cough, excited by a sensation as if down in the larynx; (<) after eating, talking, in the open air, and on lying down, followed by exhaustion. VITALITY; AND ATONY OF THE BRONCHIAL TUBES, favoring emphysema. Catarrh of old people, beginning with the setting in of winter and continuing till summer heat prevails, (<) 3 to 4 A.M.

 Ammonium Mur

Pulmonary catarrh, with constant hacking and scraping as if a foreign body were in the throat, but he only brings up small pieces of white mucus. Dry cough; (<) evenings and at night, when lying on his back or on right side; (<) after rest, after a cold drink, or when taking a deep inspiration; stitches in the chest and hypochondria; oppression when moving the upper extremities; burning in the chest, and coarse, rattling murmurs; heat at night; followed by sweat; icy coldness between shoulders, which nothing warms; bronchiectasis, emphysema.

Antimonium Tartaricum

(Tartarus emet.)- Bronchitis of infants and old people; profuse mucus with feeble expulsive power; rattling of phlegm in chest, with increased irritability to cough; sudden and alarming symptoms of suffocation, with oppression and orthopnoea, so that he has to sit up; fits of suffocation mornings and evenings in bed; cough after midnight so that he throws up his supper;l adynamia of old people; stupor from blood poisoning; tendency to diarrhoea; hopeless and desponding.

 Arsenicum Album

CHRONIC BRONCHITIS OF THE OLDER PEOPLE. Dry catarrh, not of recent origin; dyspnoea, from more or less extensive emphysema and consecutive pulmonary congestions. Difficulty of breathing continues during the intervals upon coughing, and returns periodically, especially at night; bronchial secretion scanty with a sensation of dryness in the respiratory lining; titillation in the trachea and under the sternum, chiefly at night, provoking a dry, wheezing, often very violent cough, followed after a while by expectoration of a white, frothy, sometimes after eating and in the afternoon; emaciation; (<) about and after midnight, from lying down, from drinking cold water, from mental excitement.

Baryta Carb

Useful in infancy and in old age; to the former with indurated tonsils and engorged cervical glands; to the latter when enfeebled by antecedent diseases. Cough all the night, with sensation of excoriation in the chest; mucous expectoration; oppression as from a weight in the chest, with short and sometimes difficult respiration; stitches in the left chest; relieved by hot applications; hoarseness or aphonia; general chilliness in daytime; heat at night preventing sleep; followed by weakening night-sweats.

Carbo Veg

Chronic bronchitis of poor, exhausted constitutions and of aged people, with profuse foetid expectoration or with profuse mucous accumulation, with imperfect power of expectoration; blue nails and cold extremities, up to the knees; collapse; burning excoriating pressure in chest, shoulders and back; great tendency of the chest to perspire; (<) in fresh air or by going from a warm room into a cold one; evening hoarseness; pyrosis in daytime.

Causticum

Violent, racking cough, especially at night, pain in the throat and head, but he obliged to swallow the sputum; it comes up apparently with cough, but it cannot be spat out; greasy taste of the sputa; cough after getting warm in bed, or after recovering the natural heart from a colder state; cough, with pain in hip; COUGH IMMEDIATELY RELIEVED BY A COLD DRINK; spurting of urine with the cough; he cannot cough deep enough to get relief; weakness of lower extremities; morning hoarseness.[2]

Hydrastis

Bronchitis of old people, with great debility, loss of appetite, cachectic state, weakness; chronic cough, accompanied by febrile paroxysms evenings and night, and excessive prostration; sputa thick, yellowish, very tenacious, stringy and profuse; dry, hard cough with much laryngeal irritation, or loose but hard cough with much nasopharyngeal catarrh, and marked prostration.

Kali Bichromicum

Generally, Bronchitis oscillating between acute and torpid inveterate bronchitis, with a certain degree of irritation, vascular congestion also moderate muco-purulent secretion, frequently accompanied by periosteal or rheumatic pains. In detail, Cough resonant, whistling; loud rattling in chest; difficult expectoration of yellow, bluish or slate-colored, tough mucus, adherent, filamentous, sometimes foetid; burning sensation especially; in trachea and bronchi; tickling in the throat, which causes cough, hoarseness and aphony; (<) either in winter or during chilly summers, he must sit up in bed to breathe, (>) by bending forward and bringing up the stringy mucus.

Kali Carb

Dry cough, as if excited by a dry membrane in the trachea, which cannot be detached; slimy, salty, tenacious expectoration; cough evening also (<) after 3 A.M., from eating and drinking, with pain in lower part of chest; violent cough, but the dislodged mucus MUST BE SWALLOWED OR FLIES UNEXPECTEDLY FROM THE MOUTH AFTER LONG COUGHING; dry skin and dry stool; eyelids red also swollen, especially between brows also upper lids.[2]

Natrum Mur

Dry cough from tickling in the throat or pit of stomach, day and night; lungs feel raw and sore from continued coughing; headache especially, from coughing, as if the head would burst; stitches in the chest when taking a long breath or coughing, with involuntary flow of urine, with tickling in throat when talking, with involuntary flow of urine, with tickling in throat when talking. Besides this, cough excited by every empty deglutition; cough, with vomiting of food; physical also moral depression, weak voice, fluttering of heart, cutting pain in after urinating; sputa transparent, viscid. Lastly, (<) at the seashore.

Nux Vomica

Chronic bronchitis of old people; rough, dry and deep cough from dryness of larynx, with tension also pain in the larynx and bronchi; accumulation of tenacious mucus in the throat, which the patient is unable to detach; convulsive racking cough, caused by titillation in the throat, especially morning or at night in bed, after a meal, from exercise, either thinking or reading; cough, with vomiting or with bleeding from the nose or mouth.

Phosphorous

Subacute attacks of bronchitis in emaciated, cachectic, or young overgrown invalids; broncho-pulmonary catarrhs from dilatation or fatty degeneration of the heart. Cough abrupt, rough, sharp, dry; between each coughing spell a short interval; dry, tickling cough in the evening, with tightness across the chest and expectoration in the morning; pain in chest when coughing, relieved by external pressure; trembling of the whole body while coughing; cough gets worse when other people come into the room; tingling, soreness and rawness in the air-passages; dry cough, with expectoration of viscid or bloody mucus. Dilatation of the bronchi.

Sanguinaria

Dry cough, with considerable tickling in the pit of the throat, a crawling sensation extending downward beneath the sternum. Additionally, Severe cough, causing considerable pain beneath the upper part of the sternum, without expectoration. Besides this, teasing, dry, hacking cough, with dryness of the air-passages.

Sulphur

Inveterate bronchitis, with arterial and venous vascular irritability; great impressionability of the skin, which suffers from the slightest atmospheric variations, with exacerbation of all pectoral symptoms; chronic catarrhs of long standing, with secretion of large quantities of tenacious mucus (in other words, thickening of the lining membrane). Suffocation with palpitation; pain in chest during cough, aggravated by the horizontal position; cough, with nausea and vomiting. Besides this, heaviness of head and dim vision; sensation as of ice in chest, whenever chilled, or perspiration is checked.[2]

Diet & Regimen

A high-protein/high-calorie diet is necessary to correct malnutrition.

• A diet without tough or stringy foods and an anti-reflux regimen are useful. Gas-forming vegetables may cause discomfort for some patients.[3]
• Increased use of omega-3 fatty acids in foods such as salmon, haddock, mackerel, tuna, and other fish sources may be beneficial.
• Encourage a diet that meets Recommended Dietary Allowances for antioxidant vitamins A, C, also E. To enrich the diet with antioxidants, use more citrus fruits, whole grains, also nuts. There is a protective effect of fruit and possibly vitamin E.
• Fluid intake should be high, especially if the patient is febrile. Use 1 mL/kcal as a general rule. This may translate to eight or more cups of fluid daily. For discomfort, consume liquids between meals to increase ability to consume nutrient-dense foods at mealtimes.
• Limit salt intake. Too much sodium can cause fluid retention or peripheral edema, which may interfere with breathing.
• Fiber should be increased gradually, perhaps through use of psyllium, crushed bran, either prune juice, or extra fruits and vegetables.
• Use small, concentrated feedings at frequent intervals to lessen fatigue. For example, eggnogs and shakes may be helpful between meals.
• Morning may be the best meal of the day for many patients[3]

Do’s & Don’ts

Terminology 

Reference

1. Text Book of Medicine Golwala
2. Homoeopathic Therpeutics By Lilienthal
3. Nutrition and Diagnosis-Related Care (Nutrition and Diagnosis-Related Care ( Escott-Stump))
4. https://www.wikidoc.org/index.php/Chronic_bronchitis_risk_factors
5. https://www.respelearning.scot/topic-2-assessment-and-common-lung-diseases/common-lung-diseases/copd/chronic-bronchitis
6. https://www.wikidoc.org/index.php/Chronic_bronchitis_physical_examination#:~:text=Findings%20on%20general%20physical%20examination,venous%20pulse%2C%20and%20peripheral%20edema.
7. The Indian Study on Epidemiology of Asthma, Respiratory Symptoms and Chronic Bronchitis in adults (INSEARCH) published in 2010.
8. "Harrison’s Principles of Internal Medicine," 20th edition, published in 2018 by McGraw Hill, the authors (Kasper, Fauci, Hauser, Longo, Jameson, and Loscalzo).
9. "Robbins & Cotran Pathologic Basis of Disease," 10th Edition, published in 2021 by Elsevier, the authors (Kumar, Abbas, Aster).

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