Updated: 5/7/2019

Chronic Bronchitis

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Introduction
  • chronbronDefined as expectoration for > 3 months for > 2 consecutive years
  • Pathophysiology
    • overproduction of mucus due to inflammation
    • central and peripheral airways involved
    • results in hyperplasia of bronchiolar mucus glands and fibrosis of terminal bronchioles
    • ciliary dysfunction
  • Causes
    • smoking
      • chronic irritation promotes hyperplasia of mucus glands and increases mucus production
      • toxicity of smoke destroys ciliated epithelium and reduces mucus clearance
    • cystic fibrosis
      • loss of CFTR function results in increased viscosity of mucus and decreased mucus clearance
Presentation
  • Symptoms
    • dyspnea
    • productive cough
  • Physical exam 
    • wheezing and crackles on auscultation
    • prolonged expiration
    • classic pursed lip breathing
    • "blue bloater" (end-stage)
      • chronic alveolar hypoxia leads to pulmonary hypertension
        • edematous due to right heart failure (end-stage)
      • cyanosis of skin
Evaluation
  • Labs
    • ABG during exacerbation shows hypoxemia and may show acute respiratory acidosis
      • hypoxemia can stimulate increased erythropoetin production by the kidneys 
        • can see polycythemia with prolonged hypoxemia
    • chronic respiratory acidosis 
  • Chest radiograph 
    • cardiomegaly (horizontally oriented)
    • increased bronchial markings (due to mucus)
  • Clinical diagnosis confirmed by lung biopsy (rarely indicated)
    • ↑ Reid index 
      • gland layer > 50% of total diameter of bronchial wall
        • bronchial wall measured from the surface epithelium to the beginning (but not including) the cartilaginous rings
    • patch squamous metaplasia
    • neutrophil infiltration
  • Pulmonary function tests
    • hallmark is obstruction 
    • ↓ FEV / FVC  
      • similar to emphysema
    • ↑ TLC (less than emphysema)
Treatment
  • Conservative
    • smoking cessation
    • home oxygen
  • Pharmacological
    • bronchodilators and inhaled steroids
      • for long-term maintenance
    • systemic steroids and antibiotics
      • for acute exacerbations
    • roflumilast
      • for severe disease
Complications
  • Pulmonary hypertension 
    • chronic alveolar hypoxia results in pulmonary vasoconstriction
      • right side ventricular hypertrophy and failure (cor pulmonale)
      • distended neck veins
      • hepatomegaly
 

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Questions (7)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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(M1.PL.138) A 70-year-old male with a 10-year history of COPD visits his pulmonologist for a checkup. Physical examination reveals cyanosis, digital clubbing, and bilateral lung wheezes are heard upon auscultation. The patient has a cough productive of thick yellow sputum. Which of the following findings is most likely present in this patient? Review Topic

QID: 100941
1

Decreased arterial carbon dioxide content

0%

(0/9)

2

Increased pulmonary arterial resistance

78%

(7/9)

3

Increased pH of the arterial blood

22%

(2/9)

4

Increased cerebral vascular resistance

0%

(0/9)

5

Increased right ventricle compliance

0%

(0/9)

M1

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PREFERRED RESPONSE 2

(M1.PL.133) A 65-year-old male presents to the emergency department from his home complaining of dyspnea. He is alert and oriented. The following arterial blood gas readings are drawn: pH: 7.33 (Normal: 7.35-7.45), pCO2: 70 mmHg (Normal: 35-45 mmHg), HCO3 33 (Normal: 21-26 mEq/L) Which of the following is most likely to have produced this patient’s condition? Review Topic

QID: 100936
1

Panic attack

0%

(0/13)

2

Mechanical ventilation

8%

(1/13)

3

Diabetic ketoacidosis

8%

(1/13)

4

Pulmonary embolus

8%

(1/13)

5

Chronic obstructive bronchitis

69%

(9/13)

M1

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PREFERRED RESPONSE 5

(M1.PL.84) A 45-year-old man presents with a chronic productive cough that he has had for the past few years. He admits to having smoked 1 pack of cigarettes a day for the past 25 years. A chest radiograph reveals an enlarged heart. The patient's pulmonary function tests would be similar to that seen in a patient with: Review Topic

QID: 100887
1

Asymptomatic asthma

0%

(0/16)

2

Silicosis

6%

(1/16)

3

Emphysema

88%

(14/16)

4

Coal worker's pneumonitis

6%

(1/16)

5

Prior lung radiation

0%

(0/16)

M1

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PREFERRED RESPONSE 3

(M1.PL.76) A post-mortem lung examination of a 68-year-old male overweight male with evidence of chronic lower extremity edema, a 60 pack-year smoking history and daily productive cough would be most likely to reveal: Review Topic

QID: 100879
1

Hypereosinophilia

0%

(0/12)

2

Reid Index > 50%

83%

(10/12)

3

Non-caseating granulomas

0%

(0/12)

4

Evidence of a necrotizing infection

0%

(0/12)

5

Keratin pearls

8%

(1/12)

M1

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PREFERRED RESPONSE 2

(M1.PL.65) A 68-year-old male smoker dies suddenly in a car accident. He had smoked 2 packs per day for 40 years. His past medical history is notable for a frequent, very productive cough, recurrent respiratory infections and occasional wheezing. He had no other medical problems. At autopsy, which of the following is most likely to be found in this patient? Review Topic

QID: 100868
1

Interstitial fibrosis of the lung

9%

(1/11)

2

Pleural plaques

0%

(0/11)

3

Increased number and activity of goblet cells

82%

(9/11)

4

Ferruginous bodies

0%

(0/11)

5

Mucous gland atrophy

9%

(1/11)

M1

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PREFERRED RESPONSE 3

(M1.PL.46) A 65-year-old male presents to your office complaining of worsening shortness of breath. He has experienced shortness of breath on and off for several years, but is noticing that it is increasingly more difficult. Upon examination, you note wheezing and cyanosis. You conduct pulmonary function tests, and find that the patient's FEV1/FVC ratio is markedly decreased. What is the most likely additional finding in this patient? Review Topic

QID: 100849
1

Decreased bicarbonate

5%

(5/101)

2

Increased erythropoietin

62%

(63/101)

3

Nasal polyps

5%

(5/101)

4

Increased IgE

17%

(17/101)

5

Pleural effusion

9%

(9/101)

M1

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PREFERRED RESPONSE 2
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