ABSTRACK

Bronchitis is one of the top conditions for which patients seek medical care. It is
characterized by inflammation of the bronchial tubes (or bronchi), the air passages that
extend from the trachea into the small airways and alveoli.

Chronic bronchitis is defined clinically as cough with sputum expectoration for at

least 3 months a year during a period of 2 consecutive years. Chronic bronchitis is associated
with hypertrophy of the mucus-producing glands found in the mucosa of large cartilaginous
airways. As the disease advances, progressive airflow limitation occurs, usually in association
with pathologic changes of emphysema. This condition is called chronic obstructive
pulmonary disease.

When a stable patient experiences sudden clinical deterioration with increased sputum
volume, sputum purulence, and/or worsening of shortness of breath, this is referred to as an
acute exacerbation of chronic bronchitis, as long as conditions other than acute
tracheobronchitis are ruled out.

Triggers of bronchitis may be infectious agents, such as viruses or bacteria, or

noninfectious agents, such as smoking or inhalation of chemical pollutants or dust. Bronchitis
typically occurs in the setting of an upper respiratory illness; thus, it is observed more
frequently in the winter months.

Allergens and irritants can produce a similar clinical picture. Asthma can be
mistakenly diagnosed as acute bronchitis if the patient has no prior history of asthma. In one
study, one third of patients who had been determined to have recurrent bouts of acute
bronchitis were eventually identified as having asthma. Generally, bronchitis is a diagnosis
made by exclusion of other conditions such as sinusitis, pharyngitis, tonsillitis, and
pneumonia.1
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 Intoduction

1. Definition

Acute bronchitis is an inflamatory process of the large airways (trachea and

bronchi ) or what is commonly termed the lower respiratory track. Acute bronchitis is
track infection with cough as prominent feature.

Chronic bronchitis is defined as the presence of chronic productive cough on most

day for 3 months, in each of two consecutive years, in a patient in whom other causes of
chronic cough have been excluded.

2. Etiology

a) Viral and becterial infections in acute bronchitis

The most common viruses include influenza A and B, parainfluenza,

respiratory syncytial virus, and coronavirus, although an etiologic agent is identified
only in a minority of cases.2

Acute bronchitis is usually caused by infections, such as those caused by

Mycoplasma species, Chlamydia pneumoniae, Streptococcus pneumoniae, Moraxella
catarrhalis, and Haemophilus influenzae, and by viruses, such as influenza,
parainfluenza, adenovirus, rhinovirus, and respiratory syncytial virus. Exposure to
irritants, such as pollution, chemicals, and tobacco smoke, may also cause acute
bronchial irritation.

b) Smoking and other causes of chronic bronchitis

Cigarette smoking is indisputably the predominant cause of chronic bronchitis.

Common risk factors for acute exacerbations of chronic bronchitis are advanced age
and low forced expiratory volume in one second (FEV1).[3] Most (70-80%) acute
exacerbations of chronic bronchitis are estimated to be due to respiratory infections.[4]
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 Estimates suggest that cigarette smoking accounts for 85-90% of chronic
bronchitis and chronic obstructive pulmonary disease. Studies indicate that smoking
pipes, cigars, and marijuana causes similar damage. Smoking impairs ciliary
movement, inhibits the function of alveolar macrophages, and leads to hypertrophy
and hyperplasia of mucus-secreting glands.

Air pollution levels have been associated with increased respiratory health
problems among people living in affected areas. The Air Pollution and Respiratory
Health Branch of the National Center for Environmental Health directs the fight of the
US Centers for Disease Control and Prevention against respiratory illness associated
with air pollution.

3. Sign And Symptoms

Classifying an upper respiratory infection as bronchitis is imprecise.However,

studies of bronchitis and upper respiratory infections often use the same constellation
of symptoms as diagnostic criteria.
Cough is the most commonly observed symptom of acute bronchitis. The
cough begins within two days of infection in 85 percent of patients.15Most patients
have a cough for less than two weeks; however, 26 percent are still coughing after two
weeks, and a few cough for six to eight weeks.15 When a patients cough fits this
general pattern, acute bronchitis should be strongly suspected.
Although most physicians consider cough to be necessary to the diagnosis of
acute bronchitis, theyare very in additional requirements.Other signs and symptoms
may include sputum production, dyspnea, wheezing, chest pain, fever, hoarseness,
malaise, rhonchi, and rales.
Each of these may be present in varying degrees or may be absent altogether.
Sputum may be clear,white, yellow, green, or even tinged with blood. Peroxidase
released by the leukocytes in sputum causes the color changes; hence, color alone
should not be considered indicative of bacterial infection.3
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4. Pathophysiology

During an episode of acute bronchitis, the cells of the bronchial-lining tissue

are irritated and the mucous membrane becomes hyperemic and edematous,
diminishing bronchial mucociliary function. Consequently, the air passages become
clogged by debris and irritation increases. In response, copious secretion of mucus
develops, which causes the characteristic cough of bronchitis.

Chronic bronchitis is associated with excessive tracheobronchial mucus

production sufficient to cause cough with expectoration for 3 or more months a year
for at least 2 consecutive years.

Chronic bronchitis can be categorized as simple chronic bronchitis, chronic

mucopurulent bronchitis, or chronic bronchitis with obstruction. Mucoid sputum
production characterizes simple chronic bronchitis. Persistent or recurrent purulent
sputum production in the absence of localized suppurative disease, such as
bronchiectasis, characterizes chronic mucopurulent bronchitis.

Chronic bronchitis with obstruction must be distinguished from chronic

infective asthma. The differentiation is based mainly on the history of the clinical
illness: patients who have chronic bronchitis with obstruction present with a long
history of productive cough and a late onset of wheezing, whereas patients who have
asthma with chronic obstruction have a long history of wheezing with a late onset of
productive cough.

Chronic bronchitis may result from a series of attacks of acute bronchitis, or it

may evolve gradually because of heavy smoking or inhalation of air contaminated
with other pollutants in the environment. When so-called smoker's cough is continual
rather than occasional, the mucus-producing layer of the bronchial lining has probably
thickened, narrowing the airways to the point where breathing becomes increasingly
difficult. With immobilization of the cilia that sweep the air clean of foreign irritants,
the bronchial passages become more vulnerable to further infection and the spread of
tissue damage.3
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5. Physical Examination

The physical examination findings in acute bronchitis can vary from normal-
to-pharyngeal erythema, localized lymphadenopathy, and rhinorrhea to coarse rhonchi
and wheezes that change in location and intensity after a deep and productive cough.

Diffuse wheezes, high-pitched continuous sounds, and the use of accessory

muscles can be observed in severe cases. Occasionally, diffuse diminution of air
intake or inspiratory stridor occurs; these findings indicate obstruction of a major
bronchi or the trachea, which requires sequentially vigorous coughing, suctioning,
and, possibly, intubation or even tracheostomy.1,2

a) Cultures and Staining

Obtain cultures of respiratory secretions for influenza virus, Mycoplasma

pneumoniae, and Bordetella pertussis when these organisms are suspected. Culture
methods and immunofluorescence tests have been developed for laboratory diagnosis
of C pneumoniaeinfection.

Obtain a throat swab. Culture and gram stain of sputum is often performed,
though these tests usually show no growth or only normal respiratory florae.Blood
culture may be helpful if bacterial superinfection is suspected.

b) Chest Radiography

Chest radiography should be performed in patients whose physical

examination findings suggest pneumonia. Elderly patients may have no signs of
pneumonia; therefore, chest radiography may be warranted in these patients, even
without other clinical signs of infection.

c) Bronchoscopy

Bronchoscopy may be needed to exclude foreign body aspiration, tuberculosis,

tumors, and other chronic diseases of the tracheobronchial tree and lungs.
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 d) Histologic Findings

Goblet cell hyperplasia, mucosal and submucosal inflammatory cells,

edema, peribronchial fibrosis, intraluminal mucous plugs, and increased smooth
muscle are characteristic findings in small airways in chronic obstructive lung
disease.

6. Medication Summary

Antibiotic overuse contributes to the emergence of drug-resistant organisms.

Cognizant of this, the Centers for Disease Control and Prevention recently
collaborated with numerous medical societies to publish a series of articles on the
judicious use of antibiotics for several common conditions, including bronchitis, and
have recommended against routine antibiotic use in uncomplicated bronchitis.

Reviews have also noted that antibiotic use in smokers without chronic
obstructive pulmonary disease is no more effective than use in nonsmokers.

a) Antimicrobials

Amoxicillin and clavulanate

This agent inhibits bacterial cell wall synthesis by binding to penicillin-

binding proteins. The addition of clavulanate inhibits beta-lactamaseproducing
bacteria.

It is a good alternative antibiotic for patients allergic to or intolerant of the

macrolide class. It is usually well tolerated and provides good coverage of most
infectious agents, but it is not effective against Mycoplasma and Legionella species.
The half-life of the oral dosage is 1-1.3 hours. It has good tissue penetration but does
not enter the cerebrospinal fluid.

Erythromycin
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Erythromycin inhibits bacterial growth, possibly by blocking dissociation of

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peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest. It

 is indicated for staphylococcal, streptococcal, chlamydial, and mycoplasmal
infections.

Tetracycline

Tetracycline may be an option outside the United States. It treats gram-

positive and gram-negative organisms, as well as mycoplasmal, chlamydial, and
rickettsial infections. This agent inhibits bacterial protein synthesis by binding with
the 30S and, possibly, the 50S ribosomal subunit(s). It is less effective than
erythromycin.

Trimethoprim-sulfamethoxazole

Trimethoprim-sulfamethoxazole inhibits bacterial synthesis of dihydrofolic

acid by competing with para-aminobenzoic acid, resulting in inhibition of bacterial
growth. Antibacterial activity of trimethoprim-sulfamethoxazole includes common
urinary tract pathogens, except Pseudomonas aeruginosa. As with tetracycline, it has
in vitro activity against B pertussis. It is not useful in mycoplasmal infections.

Amoxicillin

Amoxicillin interferes with synthesis of cell wall mucopeptides during active

multiplication, resulting in bactericidal activity against susceptible bacteria.

Levofloxacin

Levofloxacin has a bacteriocidal property by inhibiting the DNA gyrase and,

consequently, cell growth.

Doxycycline

Doxycycline is a broad-spectrum, synthetically derived bacteriostatic

antibiotic in the tetracycline class. It is almost completely absorbed, concentrates in
bile, and is excreted in urine and feces as a biologically active metabolite in high
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concentrations.
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 b) Antitussives/expectorants

Guaifenesin with dextromethorphan

This agent treats minor cough resulting from bronchial and throat irritation.

Codeine/guaifenesin

The prototype antitussive, codeine, has been used successfully in some chronic
cough and induced-cough models, but scant clinical data exist for upper respiratory
tract infections.

c) Bronchodilators

Metaproterenol sulfate

Metaproterenol is a beta agonist for bronchospasms that relaxes bronchial

smooth muscle by action on beta2 receptors with little effect on cardiac muscle
contractility.

Theophylline

Theophylline is used to control symptoms such as bronchospasm, dyspnea,

and chronic cough in stable patients with chronic bronchitis. It potentiates exogenous
catecholamines and stimulates endogenous catecholamine release and diaphragmatic
muscular relaxation, which, in turn, stimulates bronchodilation.

Ipratropium

Ipratropium is an anticholinergic bronchodilator that is often used to control

symptoms such as bronchospasm, dyspnea, and chronic cough in stable patients with
chronic bronchitis.
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 d) Corticosteroids, Systemic

Prednisolone

Prednisolone works by decreasing inflammation by suppressing migration of

polymorphonuclear leukocytes and reducing capillary permeability.

Prednisone

Prednisone may decrease inflammation by reversing increased capillary

permeability and suppressing polymorphonuclear leukocyte activity. Prednisone
stabilizes lysosomal membranes and suppresses lymphocytes and antibody
production.

e) Corticosteroids, Inhaled

Fluticasone

Fluticasone has extremely potent vasoconstrictive and anti-inflammatory

activity.

Budesonide

Budesonide reduces inflammation in airways by inhibiting multiple types of

inflammatory cells and decreasing production of cytokines and other mediators
involved in the asthmatic. response.

f) Antiviral Agents

Zanamivir

Rimantadine

Oseltamivir

g) Analgesics/antipyretics
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 Ibuprofen

Ibuprofen is usually DOC for treatment of mild to moderate pain, if no

contraindications exist.

Acetaminophen

Acetaminophen is DOC for treatment of pain in patients who have

documented hypersensitivity to aspirin or NSAIDs, who have upper gastrointestinal
disease, or who are taking oral anticoagulants.

7. Complications

Complications occur in approximately 10% of patients with acute bronchitis

and include the following:

Bacterial superinfection
Pneumonia develops in about 5% of patients with bronchitis (incidence of subsequent
pneumonia, unaffected by antibiotic treatment)
Chronic bronchitis may develop with repeated episodes of acute bronchitis
Reactive airway disease can occur as a result of acute bronchitis
Hemoptysis

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 Conclution
Acute bronchitis is one of the top 10 conditions for which patients seek medical care.
Physicians show considerable variability in describing the signs and symptoms necessary
to its diagnosis. Because acute bronchitis most often has a viral cause,
symptomatic treatment with protussives, antitussives, or bronchodilators is appropriate.
However, studies indicate that many physicians treat bronchitis with antibiotics. These drugs
have generally been shown to be ineffective in patients with uncomplicated acute bronchitis.
Furthermore, antibiotics often have detrimental side effects, and their overuse
contributes to the increasing problem of antibiotic resistance. Patient satisfaction with the
treatment of acute bronchitis is related to the quality of the physician-patient interaction
rather than to prescription of an antibiotic. (Am Fam Physician 2002;65:2039-44, 2046.
Copyright 2002 American Academy of Family Physicians.)

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 REFERENSI

1. Glick, Greenberg. Burkets Oral Medicine Diagnosis anmd Treatment. Tenth Edition.
Bc Decker Inc. Spain : 2006
2. Macnee W. Chronic Bronchitis And Emphysema. Antony S, Douglas S, Leitch A G.
Crofton And Douglass Respiratory Disease. Fifth Edition. Volume I. 2000. Page :
616
3.

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