Updated: 8/20/2020

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 replaces with squamous cells which ultimately 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 (8)
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(M1.PL.15.138) 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? Tested Concept

QID: 100941
1

Decreased arterial carbon dioxide content

3%

(2/58)

2

Increased pulmonary arterial resistance

62%

(36/58)

3

Increased pH of the arterial blood

21%

(12/58)

4

Increased cerebral vascular resistance

5%

(3/58)

5

Increased right ventricle compliance

9%

(5/58)

M 2 D

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(M1.PL.13.133) 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? Tested Concept

QID: 100936
1

Panic attack

0%

(0/39)

2

Mechanical ventilation

5%

(2/39)

3

Diabetic ketoacidosis

18%

(7/39)

4

Pulmonary embolus

18%

(7/39)

5

Chronic obstructive bronchitis

56%

(22/39)

M 2 D

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(M1.PL.13.84) 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: Tested Concept

QID: 100887
1

Asymptomatic asthma

0%

(0/46)

2

Silicosis

4%

(2/46)

3

Emphysema

85%

(39/46)

4

Coal worker's pneumonitis

9%

(4/46)

5

Prior lung radiation

0%

(0/46)

M 2 E

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(M1.PL.13.65) 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? Tested Concept

QID: 100868
1

Interstitial fibrosis of the lung

3%

(1/38)

2

Pleural plaques

0%

(0/38)

3

Increased number and activity of goblet cells

92%

(35/38)

4

Ferruginous bodies

0%

(0/38)

5

Mucous gland atrophy

5%

(2/38)

M 2 E

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(M1.PL.13.46) 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? Tested Concept

QID: 100849
1

Decreased serum bicarbonate

4%

(6/139)

2

Increased erythropoietin

68%

(94/139)

3

Nasal polyps

4%

(5/139)

4

Increased IgE

16%

(22/139)

5

Pleural effusion

7%

(10/139)

M 1 E

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