Chronic Bronchitis: Diagnosis and Treatment

Bronchitis

• Bronchitis Etiology may be Viral or due to Smoking
• Bronchitis pathophysiology is inflammation of the epithelium of large airways from infection or irritation
• Clinical presentation includes a cough and fever less than 102.2°F, with a normal chest radiography

Bronchitis Treatment

• Antipyretics and analgesics are the usual treatment
• Aerosolized beta 2-receptor agonists and corticosteroids do not provide benefit
• Antitussives should be used with caution when cough is productive, examples include dextromethorphan, codeine and guiafenesin; Medicare does not cover cough suppressants
• Guaifenesin and H₂O are expectorants; clinical effectiveness for expectorants is not well established
• Antibiotics are for healthy patients with persistent fever or respiratory symptoms for more than 5 to 7 days or for predisposed patients, where specific agents such as Azithromycin, Levofloxacin or Moxifloxacin
• Note: There are differences between IDSA and GOLD guidelines for chronic bronchitis; GOLD guidelines are covered during COPD lecture

Chronic Bronchitis Etiology

• Smoking is a primary cause
• Exposure to occupational dusts, fumes, and environmental pollutants is also a factor
• There is a thickening of the bronchial wall
• Increase in number of mucus-secreting goblet cells on the surface epithelium of both larger and smaller bronchi

Chronic Bronchitis Diagnosis

• Chronic cough productive of sputum should last for more than 3 consecutive months of the year for 2 consecutive years
• This must occur without an underlying etiology of bronchiectasis or tuberculosis

Clinical Presentation of Chronic Bronchitis

• The clinical presentation includes excessive sputum expectoration, cough, cyanosis in advanced disease
• Chest auscultation may reveal inspiratory and expiratory rales, rhonchi, and mild wheezing
• Hyperresonance on percussion can occur with obliteration of the area of cardiac dullness; Normal vesicular breathing sounds are diminished
• Patients may exhibit clubbing of digits in advanced disease or obesity
• Chest radiograph may show increase in anteroposterior diameter of the thoracic cage (barrel chest) and a depressed diaphragm
• Erythrocytosis is observed as an increased hematocrit in laboratory tests for advanced disease
• Pulmonary function tests show decreased vital capacity and prolonged expiratory flow

Common Bacterial Pathogens in Chronic Bronchitis

• H. influenzae is observed in 45%; often Beta-lactamase positive; vast majority are non-typable stains
• M. catarrhalis accounts for 30%
• S. pneumoniae accounts for 20%; more than 25% strains may have intermediate or high resistance to penicillin
• E. coli, Enterobacter species, Klebsiella species, P. aeruginosa accounts for 5%

Chronic Bronchitis Treatment

• Smoking cessation via nicotine replacement therapy, or bupropion or varenicline Pulmonary rehabilitation includes resistance and aerobic exercises; chest physiotherapy
• Aerosolized mucolytic aerosols such as N-acetylcysteine may be beneficial (NAC cleaves the disulfide bonds of mucus, decreasing its viscosity)

Chronic Bronchitis with Antibiotics

• Use antibiotics based on Anthonisen criteria; two of the following three criteria: increase in shortness of breath, increase in sputum volume, production of purulent sputum
• Duration of therapy is 5-7 days

Oral Antibiotics - Chronic Bronchitis

• Ampicillin dosed at 250-500mg 4x daily
• Amoxicillin dosed at 500-815mg 2-3x daily
• Amoxicillin-clavulanate dosed at 500-875mg 2-3x daily
• Ciprofloxacin dosed at 500-750mg 2x daily
• Levofloxacin dosed at 500-750mg 1x daily
• Moxifloxacin dosed at 400mg 1x daily
• Doxycycline dosed at 100mg 2x daily
• Minocycline dosed at 100mg 2x daily
• Tetracycline HCl dosed at 500mg 4x daily
• Trimethoprim sulfamethoxazole dosed at 1 DS 2x daily
• Azithromycin dosed at 250-500mg 1x daily
• Erythromycin dosed at 500mg 4x daily
• Clarithromycin dosed at 250-500mg 2x daily
• Cephalexin dosed at 500mg 4x daily

Pharmacological Treatment Options

• Short acting beta 2-agonist bronchodilator, Albuterol
• Combination long-acting beta-receptor agonist (LABA) and a corticosteroid (Salmeterol-fluticasone; Formoterol-mometasone)
• Anticholinergics, including Ipratropium and Tiotropium
• Phosphodiesterase 4 inhibitors (PDE-4) such as Roflumilast

Treatment of Simple Chronic Bronchitis (CB) - no risk factors

• Consider Azithromycin 500mg PO Qday or Amox/clav. 875mg BID or Doxycycline 100mg BID or Levofloxacin 500mg Qday; note Azithromycin has (PAE) so five days of therapy is acceptable

Treatment of Complicated CB

• Considered with: age > 65, chronic COPD, > 4 exacerbations / year, heart disease, home oxygen use, abx use in past 3 months, corticosteroid use in past month
• Consider Amox/clav. 875mg BID or Doxycycline 100mg BID or Levofloxacin 500mg Qday
• Use Levofloxacin 750mg IV daily (empirically covering P. aeruginosa) for inpatient complicated CB

Bronchiolitis

• Affects approximately 50% of children during the first year of life and 100% by age 2 years; in 75% of cases is due to respiratory syncytial virus (RSV)

Clinical Presentation - Bronchiolitis

• Signs and symptoms: Prodrome with irritability, restlessness, and mild fever, Cough and coryza, Vomiting, diarrhea, and increased respiratory rate as symptoms progress, laboured breathing, retractions of the chest wall, nasal flaring, and grunting
• Examination: Tachycardia and respiratory rate of 40-80 per minute in hospitalized infants with wheezing and inspiratory rales, conjunctivitis of patients 1/3, other media patients present 5%-10%
• Laboratory tests show peripheral white blood cell count normal or slightly elevated, along with abnormal arterial blood gases (hypoxemia and, rarely, hypercarbia

Bronchiolitis Treatment

• The American Academy of Pediatrics (AAP) recommend nebulized hypertonic saline
• They also advise against aerosolized beta 2-agonists and corticosteroids
• Ribavirin, a synthetic nucleoside, is not routinely recommended
• Vaccines: Abrysvo and Arexvy are used in adults >/=60-75 years of age, with dosing that is IM and ~0.5 mL as a single dose
• Palivizumab is a monoclonal antibody
• Nirsevimab is a preferred monoclonal antibody

Influenza Etiology

• Influenza A is seasonal flu, influenza B is sporadic outbreaks
• Antigenic DRIFT is point mutations in antigens
• Antigenic SHIFT is genetic reassortment culminating in novel surface antigens

Influenza Pathophysiology

• Influenza A antigens include hemagglutinin and neuraminidase
• Hemagglutinin allows virus to enter host cells by attaching to sialic acid receptors; N1-N9 allows the release of new viral particles from host cells by catalyzing the cleavage of linkages to sialic acid
• Transmission is via person-to-person inhalation of respiratory droplets; infectious period is 1 day before symptom onset and up to 7 days after symptom onset
• Children may be infectious for up to 10 days after onset

Influenza Symptoms

• Fever, myalgia, headache, malaise, nonproductive cough, sore throat, and rhinitis occur.
• Primary viral pneumonia is usually in pregnant women of those with underlying cardiovascular disease

Influenza Diagnosis

• Primary viral pneumonia is the usual case in pregnant women w/ underlying CV disease
• Use reverse-transcription polymerase chain reaction (RT-PCR) with 1-6 hours for results
• Rapid influenza molecular assays RIMAs; tests are 90-95% sensitive and has 55-99% specific
• Rapid influenza diagnostic tests Enzyme for immunoassay; differentiates between flu A and B but NOT subtyping; 10-15 minutes for results Immunofluorescence 15 min – 4 hours
• Flu and pneumonia were #8 cause of death in the US in 2020, and 2021-2023 Flu & pneumo deadliest infectious disease due to mortality

Influenza Prevention

• Influenza vaccine with a booster four weeks after the initial dose in children 6 months to 9 years if no previous vaccination
• High-dose vaccine is given to individuals of 65 years or older or with a solid organ transplant; safe to use at any trimester during pregnancy but immunocompromised patients benefit from high dose vaccine

Influenza Post-exposure Prophylaxis

• Post-exposure prophylaxis is given within 48 hours of exposure for Oseltamivir and Zanamivir
• Oseltamivir is FDA approved for treatment in patients 14+ days and older, chemoprophylaxis 1+ year, but CDC has expanded recommendation to include for those less than 14 days, chemoprophylaxis in those 3 months and over

Influenza Prophylaxis Therapy

• Administer to high risk individuals, or people who have had vaccine but not gotten results from it, or severely immunodeficient, or have an inadequate response to vaccines
• Give ASAP after exposure, ideally no later than 48 hours

Recommended Dosing of Influenza Antiviral Meds

• Oseltamivir is a neurominidase inhibitor
• Baloxavirb an endonuclease inhibitor

Influenza Treatment

• Antihistamines and antipyretics, throat lozenges, cap-dependent endonuclease inhibitors, baloxavir, NA inhibitors (Oseltamivir, Zanamivir, Peramivir) are options recommended
• Adamantanes (Amantadine and rimantadine) are no longer recommended due to resistance
• Baloxavir can be used in 12 years and older with chronic illnesses such as asthma, heart disease and diabetes - avoid chelation
• Neuraminidase inhibitors with reduced viral replication include delirium, potential seizures
• Use a rapid diagnostic test; begin treatment within 48 hours of symptom onset for Oseltamivir 75mg BID x 5.
• Consider Weight-based dose for pediatrics depending on CrCl renal clearance

Antitussives

• Benzonatate suppresses cough via topical anesthetic action on respiratory stretch receptors (100 - 200mg tid those 10 yr & over; no renal or hepatic impairment)
• Opioids suppress cough at the medullary center
• Hydrocodeine and chlorpheniramine is Schedule CII (Hydrocodone 10mg / Chlorpheniramine 8mg / 5mL ER); dosing: 5mL every 12 hours (max 10mL per day)
• Hydrocodeine and homatropine is Schedule CII (Hydrocodone 5mg / Homatropine 1.5mg / 5mL); dosing: 5mL every 4-6 hours or 30mL/24 hours
• Codeine and guiafenesin is Schedule CV (Codeine 10mg / Guaifenesin 100mg / 5mL); dosing: 15mL every 4-6 hours or 90mL/24 hours (these all can include Nausea, itching, constipation and respiratory depression)
• Consider the FDA in January 2018 recommending against routine use of codeine/hydrocodone

Bromfed DM

• Should be used with caution; AAP warns of the risk of severe effects including death. Recommended in those at least 2 years
• Children 2 to 6 years: 2.5 mL every 4 hours as needed (max 15/24 hrs.).
• Children over 12 & adults: 10 mL every 4 hours (max 60/24 hrs.).
• Consists in Brompheniramine (antihistamine), pseudoephedrine (decongestant), and dextromethorphan.

Pneumonia Epidemiology and Etiology

• Mortality rate as high as 50% depends on the severity
• CAP causes include: S. pneumoniae, H. influenzae, M. pneumoniae, & C. pneumoniae, S. aureus w/ cystic fibrosis or antecedent viral respiratory infection
• E. coli, K. pneumoniae is commonly seen with alcoholism and diabetes mellitus
• VAP causes inlcude: P. aeruginosa, Acinetobacter spp., K. pneumoniae, and E. coli, and S. aureus with ventilator-associated pneumonia (VAP)

Pneumonia Pathophysiology

• Main factors are impaired alveolar macrophage function, direct inhalation of infectious droplets, and aspiration of oropharyngeal contents
• In special populations, note that Mycobacterium tuberculosis concern for people w crowded living conditions and poor access to healthcare such as those homeless or incarcerated

Outpatient CAP

• For CURB-65 <2; no more is given, options include Amoxicillin (Strongest recommendation), doxycycline, azithromycin or clarithromycin
• If there are chronic infections or patients have comorbidities- Use Oral beta-lactam beta-lactamase inhibitor/cephalosporin/macrolide including amox clav at 875mg azithromycin or a Respiratory fluoroquinolone like levofloxacin moxifloxacin

Nonsevere CAP

• Combination therapy for (CURB-65 = 2 and no more than 2 minor criteria) with IV beta-lactam beta-lactamase inhibitor/cephalosporin/macrolide including ampicillin sulbactam with Azythro or just Respiratory fluoroquinolone

CAP Treatment Overview

• There is a need to consider using empirical for MRSA or P.aeruginosa
• Legionella and Pneumococcal urinary antigen testing
• Procalcitonin levels for bacterial versus viral: Low levels usually mean: viral etiology and High levels mean: bacterial etiology
• There is typically use of corticosteriods if not routinely and not used unless refractory and a septic shock CAP
• Oseltamivir should be routinely used and is useful independent of time before/after start of symptoms, but given together with a concominant antibiotic therapy
• Last between 5-7 days depending on use

Pneumonia Empirical Therapy (HAP/VAP)

• Includes directed treatment based on samples and lab studies with culture
• Risk factors include IV antibiotics in past 90 days, >20% of MRSA in S Aureus for MRSA 2 Agents include: Vanc or linezolid, piperacillin tazobactam or levo for other resistance issues

Pneumonia Directed Therapy HAP/VAP

• To treat AERO- don’t often you aminoglycosides as mono. Instead, do multiple culturing for more tests Culture and testing is critical Use Carbapenem or sulbactam for acinetobacter spp, can be used when there are no other issues with more testing

Therapeutic Drug Monitoring

• Aminoglycosides use standard
• Use loading doses for vanc at 25:30 then for target 15:20
• High peak concentrations are necessary to obtain microbiologically active concentrations in the alveoli and is concentration-dependent

COVID-19

• Is still a concern but has several guielines and changing a lots
• Endemic as of right now.
• Paxlovid is Peptidomimetic and protease inhibitor 300mg for both nirma + Ritonavir twice for 5 days Review for potential drug to drug issue and can be contraindicated if you are taking hepato or drugs th Note adverse reaction is Dysgeusia and diarrhea with possible HIV

Explore chronic bronchitis diagnosis and treatments incorporating Anthonisen criteria and appropriate antibiotic use. Learn about medications like PDE-4 inhibitors and combination therapies. Understand diagnostic criteria and treatment approaches.