Bronchitis - Chronic in Acute Exacerbation (1 of 11) 1 Patient w/ chronic bronchitis presents w/ increasing symptoms 2 DIAGNOSIS Is acute exacerbation of No ALTERNATIVE chronic bronchitis DIAGNOSIS (AECB) con rmed? Yes 3 EVALUATION Mild Does patient have mild, Severe moderate or severe exacerbation? Moderate A Non-pharmacological A Non-pharmacological A Non-pharmacological therapy therapy therapy • Lifestyle modi cation • Lifestyle modi cation • Lifestyle modi cation • Patient education MIMS• Patient education • Patient education B Pharmacological therapy • Supportive therapy • Supportive therapy • Bronchodilators (Inhaled) - O, if required - O, if required - Noninvasive - Noninvasive positive-pressure positive-pressure ventilation, if required ventilation, if required B Pharmacological therapy B Pharmacological therapy • Bronchodilators (Inhaled) • Bronchodilators (Inhaled) • Corticosteroids (Systemic) • Corticosteroids (Systemic) © • Empiric antibiotics • Empiric antibiotics Not all products are available or approved for above use in all countries. Specifi c prescribing information may be found in the latest MIMS. B1 © MIMS 2019 Bronchitis - Chronic in Acute Exacerbation (2 of 11) 1 ACUTE EXACERBATION OF CHRONIC BRONCHITIS (AECB) • Chronic bronchitis: Clinical diagnosis of sputum expectoration on most days during at least 3 consecutive months for ≥2 consecutive years • Symptoms of exacerbation are increase in dyspnea, sputum volume & sputum purulence over baseline 2 DIAGNOSIS BRONCHITIS - CHRONIC • Diagnosis is typically based on clinical presentation Clinical Presentation History • History of chronic bronchitis w/ acute onset of symptoms which include the following: - Major criteria: Increase in sputum volume, increase in sputum purulence & increased dyspnea - Minor criteria: Wheezing, sore throat, cough & 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 de nition used, the presence of at least 1 major & 1 minor symptom for at least 2 consecutive days Physical Exam • ere are no characteristic physical ndings in acute exacerbation of chronic bronchitis (AECB) but the following physical ndings may be found: - Increased respiratory rate - Increased wheezing - Di use 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 Risk Factors for Exacerbations • Tracheobronchial infections (eg in uenza, streptococcal infection) • Environmental exposures (eg air pollution) • Noncompliance w/ inhaled bronchodilator therapy or pulmonary rehabilitation program Further Investigations 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) Gram Stain/Culture • Sputum Gram stain & culture should be limited to patients w/ severe chronic obstructive pulmonary disease (COPD), frequent exacerbations or bronchiectasis in whom the presence of more virulent &/or resistant bacteria is more likely - Gram stain/culture has a limited role in the investigation of AECB since 30-50% of chronic bronchitis su erers are colonized w/ non-encapsulated Haemophilus infl uenzae, Streptococcus pneumoniae & Moraxella catarrhalis Pulmonary Function • Pre-morbid forced expiratory volume in 1 second (FEV) values are a predictor of adverse outcomes during an AECB but it is not necessary to performMIMS FEV during the actual exacerbation • ere is no clear correlation between transient falls in lung function & the severity of exacerbation - Objective measurements of pulmonary function should be done after the recovery of patients w/ AECB O2 Saturation, Arterial Blood Gas • Measurement© of O saturation (+/- blood gases) is recommended in moderate to severe cases to guide therapy B2 © MIMS 2019 Bronchitis - Chronic in Acute Exacerbation (3 of 11) 3 EVALUATION Severe Exacerbation • Severe exacerbation is considered when all 3 major criteria are present: - Increase in sputum volume, increase in sputum purulence & increased dyspnea • Patients w/ severe exacerbations are more likely to bene t from antibiotic treatment Moderate Exacerbation • Moderate exacerbation is considered when 2 of the 3 major criteria are present BRONCHITIS - CHRONIC • ese patients may bene t from antibiotic treatment Mild Exacerbation • Mild exacerbation is considered when 1 of the major criteria is present along w/ at least 1 minor criteria • Studies have shown that antibiotics are generally no more e ective than placebo in these patients GOALS 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 A NON-PHARMACOLOGICAL THERAPY Lifestyle Modi cation Smoking Cessation • A discussion of smoking behavior & the setting of a speci c cessation date should be part of every physician-pa- tient encounter • Patients presenting w/ AECB should be encouraged to stop smoking since it is the most e ective way to reduce the risk of future morbidity from chronic bronchitis • It can lead to dramatic symptomatic bene ts for patients w/ chronic bronchitis eg stopping cough in 94-100%; when coughing stops, it can occur in as quickly as 4 weeks in 54% of patients Reduction/Elimination of Irritants • Reduction or elimination of any source of irritants that may worsen lower airway in ammation - Includes environmental pollutants (eg dust, pollutants & second-hand smoke) & occupational irritants Patient Education • Educate patient about the nature of the chronic bronchitis (the progressive nature & its potential impact on future lifestyle & function) • Review w/ the patient the signs of onset of infection (eg increased purulence, viscosity or volume of secretions) that should be treated early • Discuss measures that may limit the spread of viral infections (eg hand washing) • Encourage patients to exercise regularly - Although not accompanied by measurable improvement in lung function, it will increase exercise tolerance & improve the patient’s sense of well-being Supportive erapy MIMS Hydration • Maintain adequate hydration to prevent excessive mucus viscosity Nutritional Programs • ere are no direct or measurable e ects on lung function in treating malnutrition but subjective relief & objective improvement in strength & exercise performance do occur - Dietary supplementation should be considered if patient is malnourished (body weight <85% of ideal) or experiencing early satiety • Advise patient© to obtain nutritional counseling to reduce weight if obese B3 © MIMS 2019 Bronchitis - Chronic in Acute Exacerbation (4 of 11) A NON-PHARMACOLOGICAL THERAPY (CONT'D) Supportive erapy (Cont'd) Oxygen erapy • Cornerstone of COPD exacerbation treatment • Low- ow O should be administered if hypoxemia is present • Excess use of O should be avoided as this may lead to progressive hypercapnia, either by decreasing hypoxic ventilatory drive or by worsening ventilation-perfusion mismatching within the lungs BRONCHITIS - CHRONIC • Once O therapy is initiated, arterial blood gas should be monitored 30-60 minutes later to ensure satisfactory oxygenation without acidosis or CO retention • Goal of supplemental O therapy should be arterial oxygen partial pressure at or just above 60 mmHg Noninvasive Positive Pressure Ventilation • Frequently used for inpatient management of AECB patients who are signi cantly hypoxemic or w/ a serum pH <7.3 • Improves ventilation & lower pCO levels & may be a means of avoiding intubation • Decreases hospital or intensive care unit length of stay & morbidity B PHARMACOLOGICAL THERAPY Bronchodilators • Bronchodilators should be used for the treatment of dyspnea accompanying an exacerbation Short-Acting Anticholinergics (Inhaled) • Eg Ipratropium bromide • E ects: An e ective bronchodilator w/ a slower onset of action & a slightly longer duration of action compared to short-acting beta-agonists, but no appreciable di erence between the two in terms of e ects on pulmonary function - Decreased cough frequency & sputum volume have been noted in patients using Ipratropium - Side e ects may be fewer compared to Salbutamol • Available in metered-dose inhalers (MDIs) & nebulizer solution - ere is no signi cant di erence in pulmonary function outcomes between delivery system, but in most situations, MDIs w/ an appropriate spacer would be preferred Short-Acting Beta-Agonists (Inhaled) • Short-acting inhaled beta-agonists are usually the preferred bronchodilators - Addition of anticholinergics is recommended should there be no prompt response w/ inhaled beta2-agonists • Produce e ective bronchodilatation w/ a faster onset of action than anticholinergics, but no appreciable di erence between the two in terms of e ects on pulmonary function • Available in MDI & nebulizer solution • e role of long-acting beta-agonists has not been studied in AECB therefore are not recommended for treatment of the condition at the present time Methylxanthines • e use of methylxanthines in AECB is not indicated - e addition of Aminophylline to