bronchitis%20-%20chronic%20in%20acute%20exacerbation
BRONCHITIS - CHRONIC IN ACUTE EXACERBATION

Chronic bronchitis is an infection of the trachea and bronchi for at least 3 consecutive months for more than 2 consecutive years.
The patient experiences symptoms of increase in dyspnea, sputum volume and sputum purulence over baseline on most days.

Diagnosis is basically based on clinical presentation.

Diagnosis

Diagnosis is typically based on clinical presentation.

History

  • History of chronic bronchitis with acute onset of symptoms which include the following:
    • Major criteria: Increase in sputum volume, increase in sputum purulence and increased dyspnea
    • Minor criteria: Wheezing, sore throat, cough and symptoms of a common cold (eg nasal congestion/discharge, fever, 20% increase in respiratory rate or heart rate above baseline)
  • Exacerbation is usually considered if at least 2 major criteria are present or depending on the definition used, the presence of at least 1 major and 1 minor symptom for at least 2 consecutive days

Physical Examination

  • There are no characteristic physical findings in acute exacerbation of chronic bronchitis (AECB) but the following physical findings may be found:
    • Increased respiratory rate
    • Increased wheezing
    • Diffuse crackles without localization, may be present
  • Consider the possibility of pneumonia if there is evidence of consolidation (eg localized crackles, bronchial breath sounds, dullness on percussion)
  • Elevated body temperature usually suggests viral infection or underlying pneumonia as a cause of an AECB

Laboratory Tests

Gram Stain/Culture

  • Sputum Gram stain and culture should be limited to patients with severe chronic obstructive pulmonary disease (COPD), frequent exacerbations or bronchiectasis in whom the presence of more virulent and/or resistant bacteria is more likely
    • Gram stain/culture has a limited role in the investigation of AECB since 30-50% of chronic bronchitis sufferers are colonized with non-encapsulated Haemophilus influenzae, Streptococcus pneumoniae & Moraxella catarrhalis

Pulmonary Function

  • Pre-morbid forced expiratory volume in 1 sec (FEV1) values are a predictor of adverse outcomes during an AECB but it is not necessary to perform FEV1 during the actual exacerbation
  • There is no clear correlation between transient falls in lung function and the severity of exacerbation
    • Objective measurements of pulmonary function should be done after the recovery of patients with AECB

Oxygen Saturation, Arterial Blood Gas

  • Measurement of O2 saturation (+/- blood gases) is recommended in moderate to severe cases to guide therapy

Imaging

Chest X-Ray

  • Chest x-ray is not helpful in making the diagnosis of AECB
    • May consider if needed to exclude other diseases that may complicate the condition eg pneumonia or congestive heart failure (CHF)

Evaluation

Severe Exacerbation

  • Severe exacerbation is considered when all 3 major criteria are present:
    • Increase in sputum volume, increase in sputum purulence and increased dyspnea
  • Patients with severe exacerbations are more likely to benefit from antibiotic treatment

Moderate Exacerbation

  • Moderate exacerbation is considered when 2 of the 3 major criteria are present
  • These patients may benefit from antibiotic treatment

Mild Exacerbation

  • Mild exacerbation is considered when 1 of the major criteria is present along with at least 1 minor criteria
  • Studies have shown that antibiotics are generally no more effective than placebo in these patients
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