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.

Principles of Therapy

  • Rapid resolution of symptoms
  • Prevent transient loss of pulmonary function
  • Reduce the bacterial burden in the lower respiratory tract
  • Prevent relapse or lengthen the time between exacerbations
  • Re-evaluation of the disease to reduce the risk of future exacerbations

Pharmacotherapy

Bronchodilators

  • Bronchodilators should be used for the treatment of dyspnea accompanying an exacerbation

Short-Acting Anticholinergics (Inhaled)

  • Eg Ipratropium bromide
  • Effects: An effective bronchodilator with a slower onset of action and a slightly longer duration of action compared to short-acting beta2-agonists, but no appreciable difference between the two in terms of effects on pulmonary function
    • Decreased cough frequency & sputum volume have been noted in patients using Ipratropium
    • Side effects may be fewer compared to Salbutamol
  • Available in metered-dose inhalers (MDIs) and nebulizer solution
    • There is no significant difference in pulmonary function outcomes between delivery system, but in most situations, MDIs with an appropriate spacer would be preferred

Short-Acting Beta2-Agonists (Inhaled)

  • Short-acting inhaled beta2-agonists are usually the preferred bronchodilators
    • Addition of anticholinergics is recommended should there be no prompt response with inhaled beta2-agonists
  • Produce effective bronchodilatation with a faster onset of action than anticholinergics, but no appreciable difference between the two in terms of effects on pulmonary function
  • Available in MDI and nebulizer solution
  • The role of long-acting beta2-agonists has not been studied in AECB therefore are not recommended for treatment of the condition at the present time

Methylxanthines

  • The use of methylxanthines in AECB does not appear to be indicated
    • The addition of Aminophylline to inhaled bronchodilators does not appear to improve FEV1
  • Patients already on methylxanthines should continue the medications but monitor for drug interactions with antibiotics

Corticosteroid Hormones

  • The use of oral or parenteral steroids is supported for most patients with moderate to severe AECB
  • Action: Reduce airway edema & mucus hypersecretion
  • Effects: Rapid improvement in pre- & post-bronchodilator FEV1, rapid recovery of partial pressure of O2, decreased treatment failures, shorter hospitalization rates, speed up recovery in AECB & may reduce the frequency of exacerbations & likelihood of relapse

Inhaled Corticosteroid Hormones

  • Recommended when airflow obstruction is severe or very severe (eg FEV1 <50%) & when there is a history of frequent exacerbations
  • May be given in stable patients w/ chronic bronchitis together w/ a long-acting beta2-agonist to control chronic cough

Systemic Corticosteroid Hormones

  • Beneficial in cases of significant pulmonary compromise, particularly if the patient requires hospitalization
  • Treatment is recommended for 5-14 days
  • The exact dose & duration of therapy should be individualized
    • Eg the use of high-dose & prolonged steroids must be carefully weighed in the elderly patients
    • Prednisone PO is usually used initially at a dosage of 0.5-1.0 mg/kg/day & then tapered at a rate & duration based on response
  • Methylprednisolone 40-125 mg IV 8-12 hourly or Hydrocortisone 100 mg IV 6-8 hourly may be used initially in severely ill patients or in patients who are unable to take oral medications
  • In studies, the major side effect in the steroid-treated group was hyperglycemia

Empiric Antibiotic Therapy

Based on the current available evidence, antibiotic therapy should be given in patients with exacerbations of COPD if:

  • With presence of the 3 cardinal symptoms (increased dyspnea, increased sputum purulence & increased sputum volume)
  • Two of the cardinal symptoms are present with increased sputum purulence as one of the 2 symptoms
  • The exacerbation is severe requiring mechanical ventilation (invasive or non-invasive)

Therapy should be based on local resistance patterns along with patient risk stratification to prevent therapeutic failure

  • Some studies have shown that severity of bronchitis is an important determinant of the type of pathogen
    • S pneumoniae predominates in patients with mild exacerbation
    • H influenzae & M catarrhalis are the frequent pathogens as FEV1 declines & patients have more frequent exacerbations &/or comorbid diseases
    • P aeruginosa may be present in those with severe airway restriction
  • Antibiotics used should have significant in vitro & in vivo activity against the pathogens most commonly associated with AECB, including H influenzae, S pneumoniae & M catarrhalis
  • In patients with more severe airway obstruction, coverage may need to be extended to include other potential pathogens eg Gram-negative bacilli
  • Aminopenicillins, Co-trimoxazole & Doxycycline are considered 1st-line antibiotics for AECB
  • Amoxicillin/clavulanic acid, macrolides, 2nd- or 3rd-generation cephalosporins & quinolones are good alternatives in areas with increasing antibiotic resistance to older agents

Aminopenicillins

  • Recommendation for treatment of simple AECB with aminopenicillins is justified since there are no clinical or pharmacoeconomic studies showing the advantage of more potent agents
    • Studies showing the effectiveness of these agents are >10 years old & were performed prior to the current concerns regarding antibiotic resistance
  • No activity against atypical & beta-lactamase-producing pathogens, limited activity against Enterobacteriaceae
  • High dose is effective against Penicillin-resistant S pneumoniae

Aminopenicillin/Beta-lactamase Inhibitors

  • Covers major bacterial pathogens including beta-lactamase-producing pathogens, moderate activity against Enterobacteriaceae, but no activity against atypical pathogens
  • High dose of Aminopenicillin component is effective against Penicillin-resistant S pneumoniae
  • Short-term effectiveness of Amoxicillin/clavulanic acid is equivalent to that of macrolides & quinolones

Cephalosporins (2nd & 3rd Generation)

  • If resistant S pneumonia & H influenzae is a concern, selected 2nd & 3rd generation cephalosporins may be preferred over older agents
  • Offer enhanced stability against beta-lactamases of H influenzae, H parainfluenzae & M catarrhalis & improved efficacy against Penicillin-susceptible S pneumoniae & Methicillin-susceptible S aureus

Co-trimoxazole [Sulfamethoxazole (SMZ) & Trimethoprim (TM)]

  • Recommendation for treatment of simple AECB with Co-trimoxazole is justified since there are no clinical or pharmacoeconomic studies showing the advantage of more potent agents
    • Studies showing the effectiveness of this agent are >10 years old & were performed prior to the current concerns regarding antibiotic resistance
  • Covers major bacterial pathogens, no activity against atypical pathogens & resistance in S pneumoniae is common; resistance limits its usefulness
  • May be an acceptable alternative for patients who are allergic to Penicillin
 Doxycycline
  • Recommendation for treatment of simple AECB with Doxycycline is justified since there are no clinical or pharmacoeconomic studies showing the advantage of more potent agents
    • Studies showing the effectiveness of this agent are >10 years old & were performed prior to the current concerns regarding antibiotic resistance
  • Covers major bacterial & atypical pathogens, but S pneumoniae resistance is common
  • Alternative to quinolones and macrolides when atypical coverage is required
  • Acceptable as an alternative for patients who are allergic to Penicillin, cephalosporins and newer macrolides

Advanced Macrolides & Ketolide

  • If resistant S pneumoniae & H influenzae are a concern, advanced macrolides may be preferred over older agents
  • Active against atypical pathogens, not active against Enterobacteriaceae, & macrolide-resistant S pneumoniae is common but this does not appear to reduce clinical effectiveness
    • Ketolide is effective against macrolide-resistant strains of S pneumoniae
  • Reasonable option in beta-lactam allergic patients

Quinolones

  • Has good tracheobronchial penetration
  • Cover all major bacterial and atypical pathogens as well as Enterobacteriaceae & some agents cover P aeruginosa
  • Quinolones with enhanced activity to drug-resistant S pneumoniae are preferred
    • Eg Levofloxacin, Moxifloxacin
  • Ciprofloxacin
    • Considered 1st-line agents in ambulatory AECB patients only if P aeruginosa coverage is required
    • Least active against S pneumoniae & should not be used routinely in the management of AECB; most active against P aeruginosa

Other Pharmacotherapy Agents

  • Expectorants/cough suppressants have not been shown to improve lung function or hasten the clinical recovery but may produce a subjective improvement
  • Chronic use of mucolytics helps reduce the frequency of exacerbations & days of illness but does not improve ventilatory function
  • Chest physiotherapy has not been shown to improve lung function or hasten clinical recovery in AECB
  • There is still no evidence supporting the use of leukotriene receptor antagonists in AECB
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