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Updated: Aug 20 2020

Chronic Bronchitis

  • Introduction
    • Defined 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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