Chronic Bronchitis - Case Study

Case Scenario: 

Mr. XYZ 52 years old, truck driver, normotensive, nondiabetic, smoker, hailing from …, presented
with frequent attack of cough with profuse expectoration of mucoid sputum for … years. Initially,
cough was present during winter only and persisted for 2 to 3 months. For the last … month, it is
present throughout day and night, more marked in the morning and also on exposure to cold and
dust. The patient also complains of occasional tightness all over the chest, which is worse on coughing.
He also complains of difficulty in breathing, more marked during moderate to severe exertion, relieved by taking rest. There is no history of chest pain, hemoptysis, paroxysmal nocturnal dyspnea. He does not give any history of fever, swelling of the ankle or weight loss. His bowel and bladder habits are normal.
 2 years back he was admitted in the hospital due to severe attack of cough and breathlessness.
He smokes 30 sticks a day for last 35 years. All the family members are in good health. No such
illness in family. He used to take tablet aminophylline, cough syrup, salbutamol inhaler,
beclomethasone inhaler and sometimes local doctor prescribed antibiotics, the name of which he
cannot mention.

On examination –
General examination

•  The patient is emaciated
•  Central cyanosis present
•  No anamia, jaundice, edema, clubbing, koilonychia or leukonychia
•  No lymphadenopathy or thyromegaly
•  Pulse: 120/min, high volume
• B.P: 120/70 mm Hg
• Respiratory rate: 20/min
• JVP: not raised

Systemic examination .
Respiratory system

• Inspection:
• Shape of the chest: Normal
• Movement of the chest: Bilaterally restricted
• Intercostal space: Appears full.

Palpation: 

• Trachea: Central
• Apex beat: in the left 5th intercostal space in the midclavicular line, normal in character
• Chest expansion: Reduced
• Vocal fremitus: Normal.

Percussion:

• Percussion note: Normal resonance
• Area of liver dullness: In the right 5th ICS in midclavicular line
• Area of cardiac dullness: Impaired

Auscultation:

• Breath sounds: Vesicular with prolonged expiration
• Added sounds: Plenty of rhonchi, in both lung fields, present in both inspiration and expiration
• Vocal resonance: Normal

FET (forced expiratory time): 8 seconds (normally <6 seconds).

Examination of other systems reveals no abnormalities.

Diagnosis: Chronic Bronchitis.

Q1. What are your differential diagnoses?. As follows:

• COPD
• Chronic persistent bronchial asthma
• Emphysema
• Bilateral extensive bronchiectasis.

Q2. Why not this is COPD?
Because in the history, there is frequent attack of cough with profuse expectoration 2 to 3 months
in a year during winter. But in COPD, usually there should be breathlessness which is progressive
and not fully reversible.

Q3. What investigations should be done in chronic bronchitis?
. As follows:
1. Full blood count
2. Chest X-ray PA views (no significant abnormality)
3. ECG (usually normal. In cor pulmonale, there may be features of RVH)
4. Lung function tests:

•  FEV1 (reduced)
•  FVC (reduced)
•  Ratio of FEV1: FVC is also reduced (indicates obstructive airway disease).
•  Other tests – residual volume (RV is increased), total lung capacity (TLC is increased), gas transfer (either normal or mildly reduced).

5. PEFR (reduced).
6. Blood gas analysis:

• PO2 (reduced)
• PCO2 (normal or increased)
• PH (acidosis).

7. CT scan in some cases.

Q4. What is chronic bronchitis?
 It is defined as “presence of cough with sputum, not attributable to other causes, on most of the
days of at least 3 consecutive months for 2 successive years”.

Q5. What are the causes of chronic bronchitis?
 Multiple factors are responsible:

•  Smoking.
• Exposure to dust, fume, foggy environment (may be occupational). Dampness, sudden change in temperature—all exaggerate chronic bronchitis.
• Infection (H. influenzae, Streptococcus pneumoniae, Moraxella catarrhalis – all of these exaggerate chronic bronchitis).

Q6. What are the presentations of chronic bronchitis?
 Usual presentations are:

• Cough with sputum expectoration, more marked in the morning, on exposure to cold and during winter. The sputum is mucoid or mucopurulent, usually not associated with hemoptysis.
• Tightness of the chest, and breathlessness on exertion.
• In advanced stage, features of pulmonary hypertension and cor pulmonale are present. The patient looks cyanosed and edematous (blue bloater).

Q7. What are the complications of chronic bronchitis?
As follows:

• Respiratory failure, both type I and type II
• Emphysema
• Secondary polycythemia
• Secondary infection
• Pulmonary hypertension
• Cor pulmonale.

Q8. How to treat chronic bronchitis? 

 As follows:

1. Smoking must be stopped

2. Avoid air pollution (dust, fume)

3. Control of infection with appropriate antibiotic

4. Bronchodilator:

•  Inhaled b agonist—salbutamol (200 μg 4 to 6 hourly), terbutaline
•  Inhaled antimuscarinic—ipratropium (40 μg 4 hourly), tiotropium (18 μg daily), oxitropium (200 μg BD)
•  Long acting b agonist - salmeterol, formeterol
•  Oral theophylline (in some cases).

5. Inhaled corticosteroid beclomethasone (400 μg BD) or budensonide or fluticasone. In severe case,

oral prednisolone 30 mg for 2 weeks, followed by maintenance dose.

6. Mucolytic agents like bromhexine or N-acetylcysteine (200 mg 8 hourly orally for 8 weeks) may

be given.

7. Other measures:

• Chest physiotherapy
•  Exercise and weight reduction, if obese
•  Long-term domiciliary oxygen
•  Pulmonary rehabilitation
•  Annual influenza vaccine, 5 yearly pneumococcal vaccine and Haemophilus influenzae vaccine
• may be given.

Q9. What are the indications of long-term domiciliary oxygen therapy in COPD?

 As follows:

1. PaO2 < 7.3 kPa (55 mm Hg) irrespective of PaCO2 and FEV1 < 1.5 L.

2. PaO2 7.3 to 8 kPa (55 to 60 mm Hg) associated with:

•  Pulmonary hypertension
•  Peripheral edema
•  Nocturnal hypoxemia
•  Secondary polycythemia.

3. Carboxyhemoglobin < 3% (in patient who have stopped smoking).

4. Terminally ill patient of whatever cause with PaO2 < 7.3 kPa.

Q10. How to treat acute exacerbations?

As follows:

• Nebulized bronchodilators like terbutaline, ipratropium bromide.
• IV antibiotic to control infection.
• Oxygen inhalation (24%, 1 to 3 L/min).
• IV hydrocortisone and oral steroid (steroid is only used in acute exacerbations and unlike in asthma, it does not influence the course of chronic bronchitis).