Acute bronchitis – acute diffuse inflammation of the mucous membrane (endobronchitis) or the entire wall of the bronchi (panbronchitis).
The etiology of acute bronchitis is a number of pathogenic factors affecting the bronchi:
1) physical: hypothermia, dust inhalation
2) chemical: inhalation of vapors of acids and alkalis
3) infectious: viruses - 90% of all acute bronchitis (rhinoviruses, adenoviruses, respiratory syncytial viruses, influenza), bacteria - 10% of all acute bronchitis (Mycoplasma pneumoniae, Chlamydia pneumoniae, Bordetella pertusis, Streptococcus pneumoniae) and their associations.
The main etiological factor is infectious, the others play the role of a trigger mechanism. There are also predisposing factors: smoking, alcohol abuse, heart disease with congestion in the pulmonary circulation, the presence of foci of chronic inflammation in the nasopharynx, oral cavity, tonsils, genetic inferiority of the bronchial mucociliary apparatus.
Pathogenesis of acute bronchitis:
Adhesion of pathogens to epithelial cells lining the trachea and bronchi + reduction in the effectiveness of local protective factors (the ability of the upper respiratory tract to filter inhaled air and free it from coarse mechanical particles, change the temperature and humidity of the air, cough and sneeze reflexes, mucociliary transport) Þ pathogen invasion Þ hyperemia and edema of the bronchial mucosa, desquamation of the cylindrical epithelium, the appearance of mucous or mucopurulent exudate Þ further disturbance of mucociliary clearance Þ edema of the bronchial mucosa, hypersecretion of the bronchial glands Þ development of an obstructive component.
Classification of acute bronchitis:
1) primary and secondary acute bronchitis
2) according to the level of damage:
a) tracheobronchitis (usually against the background of acute respiratory diseases)
b) bronchitis with predominant damage to the medium-caliber bronchi
c) bronchiolitis
3) according to clinical symptoms: mild, moderate and severe severity
4) according to the state of bronchial patency: obstructive and non-obstructive
Clinic and diagnosis of acute bronchitis.
If bronchitis develops against the background of an acute respiratory viral infection, hoarseness, sore throat when swallowing, a feeling of rawness in the chest, and an irritating dry cough (manifestations of tracheitis) first appear. The cough intensifies and may be accompanied by pain in the lower chest and behind the sternum. As inflammation in the bronchi subsides, the cough becomes less painful, and copious mucopurulent sputum begins to be released.
Symptoms of intoxication (fever, headaches, general weakness) vary greatly and are determined more often by the causative agent of the disease(with adenovirus infection - conjunctivitis, with parainfluenza virus - hoarseness, with influenza virus - high temperature, headache and scanty catarrhal symptoms, etc.).
Objectively-percussion: clear pulmonary sound, auscultation: hard breathing, dry rales of varying heights and timbres, and when a sufficient amount of liquid sputum is released - wet rales in large quantities; wheezing intensifies with forced breathing of the patient.
Laboratory findings are not specific. Inflammatory changes in the blood may be absent. During a cytological examination of sputum, all fields of view are covered with leukocytes and macrophages.
Treatment of acute bronchitis.
1. Stay at home, drink plenty of fluids
2. Mucolytic and expectorants: acetylcysteine (fluimucil) orally 400-600 mg/day in 1-2 doses or 10% solution in inhalation 3 ml 1-2 times/day for 7 days, bromhexine orally 8-16 mg 3 times/day for 7 days, ambroxol 30 mg, 1 tablet. 3 times/day 7 days.
3. In the presence of broncho-obstructive syndrome: short-acting beta-agonists (salbutamol in a dosage aerosol, 2 puffs).
4. For uncomplicated acute bronchitis, antimicrobial therapy is not indicated; The effectiveness of prescribing antibiotics to prevent bacterial infection has not yet been proven. In case of acute bronchitis against the background of influenza, the earliest possible use of rimantadine according to the regimen is indicated. ABs are used most often in elderly people with serious concomitant pathologies and in children in the first years of life. AB of choice – amoxicillin 500 mg 3 times/day for 5 days, alternative AB – cefaclor 500 mg 3 times/day for 5 days, cefuroxime axetil 500 mg 2 times/day for 5 days, if intracellular pathogens are suspected – clarithromycin 500 mg 2 times/day or josamycin 500 mg 3 times a day for 5 days.
5. Symptomatic treatment (NSAIDs, etc.).
Chronic bronchitis (CB) is a chronic inflammatory disease of the bronchi, accompanied by a constant cough with sputum production for at least 3 months a year for 2 or more years, while these symptoms are not associated with any other diseases of the bronchopulmonary system, upper respiratory tract or other organs and systems.
HB is distinguished:
A) primary– an independent disease not associated with damage to other organs and systems, most often of a diffuse nature
b) secondary– etiologically associated with chronic inflammatory diseases of the nose and paranasal sinuses, lung diseases, etc., most often it is local.
Etiology of chronic bronchitis:
1) smoking:
Nicotine, polycyclic aromatic hydrocarbons of tobacco (benzopyrene, cresol) are strong carcinogens
Dysfunction of the ciliated epithelium of the bronchi, mucociliary transport
Components of tobacco smoke reduce the phagocytic activity of macrophages and neutrophils of the respiratory tract
Tobacco smoke leads to metaplasia of the ciliated epithelium and Clara cells, forming the precursors of cancer cells
Stimulation of proteolytic activity of neutrophils, hyperproduction of elastase --> destruction of elastic fibers of the lungs and damage to the ciliated epithelium --> emphysema
- ACE activity of alveolar macrophages --> AT II synthesis --> pulmonary hypertension
Nicotine increases the synthesis of IgE and histamine, predisposing to allergic reactions
2) inhalation of polluted air– inhaled aggressive substances (nitrogen and sulfur dioxide, hydrocarbons, nitrogen oxides, aldehydes, nitrates) cause irritation and damage to the bronchopulmonary system.
3) influence of occupational hazards- various types dust (cotton, flour wood), toxic vapors and gases (ammonia, chlorine, acids, phosgene), high or low air temperature, drafts, etc. can lead to CB.
4) damp and cold climate– contributes to the development and exacerbation of chronic disease.
5) infection– more often it is secondary, joining when the conditions for infection of the bronchial tree have already been formed. The leading role in exacerbations of chronic disease is played by pneumococcus and Haemophilus influenzae, as well as viral infection.
6) previous acute bronchitis(most often untreated, protracted or recurrent)
7)genetic factors and hereditary predisposition
Pathogenesis of chronic bronchitis.
1. Dysfunction of the local bronchopulmonary defense system and immune systems:
A. dysfunction of mucociliary transport (ciliated epithelium)
b. dysfunction of the surfactant system of the lungs --> increased viscosity of sputum; violation of nonciliary transport; collapse of the alveoli, obstruction of small bronchi and bronchioles; colonization of microbes in the bronchial tree
V. violation of the content of humoral protective factors in the bronchial contents (deficiency of IgA, complement components, lysozyme, lactoferrin, fibronectin, interferons
d. violation of the ratio of proteases and their inhibitors (a 1 -antitrypsin and a 2 -macroglobulin)
d. decreased function of alveolar macrophages
e. dysfunction of local broncho-associated lymphoid tissue and the body’s immune system as a whole
2. Structural restructuring of the bronchial mucosa- a significant increase in the number and activity of goblet cells, hypertrophy of the bronchial glands --> excess mucus production, deterioration of the rheological properties of sputum --> mucostasis
3. Development of the classical pathogenetic triad(hypercrinia - increased mucus production, discrinia - mucus becomes viscous, thick, mucostasis - stagnation of mucus) and the release of inflammatory mediators and cytokines (histamine, arachidonic acid derivatives, TNF, etc.) --> a sharp violation of the drainage function of the bronchi, good conditions for microorganisms --> penetration of infection to deep layers and further damage to the bronchi.
Clinical picture of chronic bronchitis.
Subjectively:
1) cough– at the beginning of the disease it is periodic, bothers patients in the morning soon after waking up, the amount of sputum discharge is small; The cough increases in the cold and damp seasons, and in the summer it may stop completely. As CB progresses, the cough becomes constant, disturbing not only in the morning, but throughout the day and even at night. When the process worsens, the cough sharply intensifies, becomes annoying and painful. In the late stage of the disease, the cough reflex may fade, and the cough ceases to bother the patient, but bronchial drainage is sharply disrupted.
2) sputum separation– it can be mucous, purulent, mucopurulent, sometimes streaked with blood; V early stages disease, the sputum is light, mucous, easily separated, as the process progresses it acquires a mucopurulent or purulent character, is separated with great difficulty, and as the process worsens, its quantity increases sharply. Hemoptysis may be caused by damage to the blood vessels of the bronchial mucosa during a hacking cough (requires differential diagnosis with tuberculosis, lung cancer, bronchiectasis).
3) shortness of breath– begins to bother the patient with the development of bronchial obstruction and emphysema.
Objectively:
1) upon inspection, no significant changes are revealed; During an exacerbation of the disease, sweating and an increase in body temperature to subfebrile levels may be observed.
2) percussion clear pulmonary sound, with the development of emphysema - box sound.
3) auscultation: lengthening of exhalation, hard breathing (“roughness”, “unevenness” of vesicular breathing), dry wheezing (caused by the presence of viscous sputum in the lumen of the bronchi, in large bronchi - low-pitched bass, in the middle bronchi - buzzing, in small bronchi - whistling) . If there is liquid sputum in the bronchi - moist rales (in large bronchi - large-bubble, in the middle bronchi - medium-bubble, in small bronchi - fine-bubble). Dry and wet wheezing is unstable and may disappear after vigorous coughing and expectoration of sputum.
Variants of the clinical course of chronic disease: with and without symptoms of bronchial obstruction; latent course, with rare exacerbations, with frequent exacerbations and continuously relapsing course of the disease.
Clinical and diagnostic signs of exacerbation of chronic disease:
Increased general weakness, the appearance of malaise, decreased overall performance
The appearance of severe sweating, especially at night (a symptom of a damp pillow or sheet)
Low-grade body temperature
Tachycardia with normal temperature
Increased cough, increased amount and “purulence” of sputum
The appearance of biochemical signs of inflammation
A shift in the leukocyte formula to the left and an increase in ESR to moderate numbers
Diagnosis of chronic bronchitis.
1. Laboratory data:
A) UAC– little change, inflammatory changes are typical during exacerbation of the process
b) sputum analysis– macroscopic (white or transparent – mucous or yellow, yellow-green – purulent; streaks of blood, mucous and purulent plugs, bronchial casts can be detected) and microscopic (a large number of neutrophils, bronchial epithelial cells, macrophages, bacteria), bacteriological examination of sputum and determination of pathogen sensitivity to antibiotics.
V) TANK– biochemical indicators of inflammation activity allow us to judge its severity (decrease in albumin-globulin ratio, increase in haptoglobin, sialic acids and seromucoid).
2. Instrumental research:
A) bronchoscopy– bronchoscopically, diffuse (inflammation covers all endoscopically visible bronchi) and limited (inflammation covers the main and lobar bronchi, segmental bronchi are not changed) bronchitis is isolated, the intensity of bronchial inflammation is determined (degree I - the bronchial mucosa is pale pink, covered with mucus, does not bleed; II degree - the mucous membrane of the bronchi is bright red, thickened, often bleeds, covered with pus; grade III - the mucous membrane of the bronchi and trachea is thickened, purple-bluish in color, bleeds easily, covered with purulent secretion).
b) bronchography– carried out only after sanitation of the bronchial tree; Chronic bronchitis is characterized by:
The bronchi of orders IV-VII are cylindrically expanded, their diameter does not decrease towards the periphery, as is normal; the lateral branches are obliterated, the distal ends of the bronchi are blindly broken off (“amputated”);
In a number of patients, the dilated bronchi are narrowed in some areas, their contours are changed (the shape of a “rosary”), the internal contour of the bronchi is jagged, and the architectonics of the bronchial tree is disrupted.
V) chest x-ray– signs of chronic disease are detected only in long-term patients (intensification and deformation of the pulmonary pattern according to the loop-cellular type, increased transparency of the pulmonary fields, expansion of the shadows of the roots of the lungs, thickening of the bronchial walls due to peribronchial pneumosclerosis).
G) pulmonary function test(spirography, peak flowmetry) – to identify obstructive disorders
Complications of chronic disease.
1) directly caused by infection: a) pneumonia b) bronchiectasis c) broncho-obstructive syndrome d) bronchial asthma
2) due to the evolution of bronchitis: a) hemoptysis b) emphysema c) diffuse pneumosclerosis d) respiratory failure e) cor pulmonale.
Treatment of CB is different during the period of remission and during the period of exacerbation.
1. During remission: for chronic disease of mild severity - elimination of foci of infection (caries, tonsillitis, etc.), hardening of the body, therapeutic physical culture, breathing exercises; for moderate and severe CB – additional courses of pathogenetic treatment are carried out aimed at improving bronchial patency, reducing pulmonary hypertension and combating right ventricular heart failure.
2. During an exacerbation:
A) etiotropic treatment: oral AB taking into account the sensitivity of flora cultured from sputum (semi-synthetic penicillins: amoxicillin 1 g 3 times/day, protected penicillins: amoxiclav 0.625 g 3 times/day, macrolides: clarithromycin 0.5 g 2 times/day, respiratory fluoroquinolones: levofloxacin 0.5 g 1 time/day, moxifloxacin 0.4 g 1 time/day) for 7-10 days. If treatment is ineffective, parenteral administration of III-IV generation cephalosporins (cefepime IM or IV 2 g 2 times a day, cefotaxime IM or IV 2 g 3 times a day).
b) pathogenetic treatment, aimed at improving pulmonary ventilation, restoring bronchial patency:
Mucolytic and expectorant drugs: ambroxol 30 mg orally 3 times a day, acetylcysteine 200 mg orally 3-4 times a day for 2 weeks, herbal preparations (Thermopsis, ipecac, mucaltin)
Therapeutic bronchoscopy with bronchial rehabilitation
Bronchodilators (M-anticholinergics: ipratropium bromide 2 puffs 3-4 times a day, beta-agonists: fenoterol, their combination - Atrovent inhalation, long-acting aminophylline: theotard, teopek, theobilong orally 1 tablet 2 times a day)
Medicines, increasing the body's resistance: vitamins A, C, B, immunocorrectors (T-activin or thymalin 100 mg subcutaneously for 3 days, ribomunil, bronchomunal orally)
Physiotherapeutic treatment: diathermy, calcium chloride electrophoresis, quartz on the chest area, chest massage, breathing exercises
V) symptomatic treatment: drugs that suppress the cough reflex (for an unproductive cough - libexin, tusuprex, for a hacking cough - codeine, stoptussin)
Outcome of chronic bronchitis: in the obstructive form or CB with damage to the distal parts of the lungs, the disease quickly leads to the development of pulmonary failure and the formation of cor pulmonale.
Bronchitis refers to diseases of the respiratory system and is a diffuse inflammation of the mucous membrane of the trachea and bronchi. The clinical picture of bronchitis may differ depending on the form of the pathological process, as well as the severity of its course.
According to the international classification, bronchitis is divided into acute and chronic. The first is characterized by an acute course, increased sputum production, and a dry cough that gets worse at night. After a few days, the cough becomes wet and sputum begins to come out. Acute bronchitis usually lasts 2-4 weeks.
In accordance with the guidelines of the World Health Organization, signs of bronchitis, which allows it to be classified as chronic, is a cough with intense bronchial secretion, lasting more than 3 months for 2 years in a row.
In the chronic process, the damage spreads to the bronchial tree, the protective functions of the bronchi are disrupted, there is difficulty breathing, copious formation of viscous sputum in the lungs, and a prolonged cough. The urge to cough with expectoration is especially intense in the morning.
Reasons for the development of bronchitis
Various forms of bronchitis differ significantly from each other in their causes, pathogenesis and clinical manifestations.
The etiology of acute bronchitis is the basis for the classification, according to which diseases are divided into the following types:
- infectious (bacterial, viral, viral-bacterial, rarely fungal infection);
- staying in unfavorable harmful conditions;
- unspecified;
- mixed etiology.
More than half of all cases of the disease are caused by viral pathogens. The causative agents of the viral form of the disease in most cases are rhinoviruses, adenoviruses, influenza, parainfluenza, and respiratory interstitial.
Of the bacteria, the disease is most often caused by pneumococci, streptococci, Haemophilus influenzae and Pseudomonas aeruginosa, Moraxella catarrhalis, and Klebsiella. Pseudomonas aeruginosa and Klebsiella are more often detected in patients with immunodeficiencies who abuse alcohol. In smokers, the disease is more often caused by Moraxella or Haemophilus influenzae. Exacerbation of the chronic form of the disease is often provoked by Pseudomonas aeruginosa and staphylococci.
Mixed etiology of bronchitis is very common. The primary pathogen enters the body and reduces the protective functions of the immune system. This creates favorable conditions for the addition of a secondary infection.
The main causes of chronic bronchitis, in addition to bacteria and viruses, are exposure to harmful physical and chemical factors on the bronchi (irritation of the bronchial mucosa by coal, cement, quartz dust, vapors of sulfur, hydrogen sulfide, bromine, chlorine, ammonia), prolonged contact with allergens. In rare cases, the development of pathology is caused by genetic disorders. A connection has been established between the incidence rate and climatic factors; an increase is observed in the cold, damp period.
Atypical forms of bronchitis are caused by pathogens that occupy an intermediate niche between viruses and bacteria. These include:
- legionella;
- mycoplasma;
- chlamydia.
Atypical diseases are characterized by uncharacteristic symptoms with the development of polyserositis, damage to joints and internal organs.
Features of the pathogenesis of bronchial inflammation
The pathogenesis of bronchitis consists of the neuro-reflex and infectious stages of the development of the disease. Under the influence of provoking factors, trophic disorders are observed in the walls of the bronchi. An infectious disease begins with the adhesion of an infecting pathogen to the epithelial cells of the mucous membrane of the airways of the lungs. In this case, local protective mechanisms, such as air filtration, humidification, purification, are disrupted, and the activity of the phagocytic function of alveolar macrophages and neutrophils is reduced.
The penetration of pathogens into lung tissue is also facilitated by disruption of the immune system, increased sensitivity of the body to allergens or toxic substances formed during the life of pathogens of the inflammatory process. With constant smoking or contact with harmful conditions, the clearance of small irritants from the lungs slows down.
With further progression of the disease, obstruction of the tracheobronchial tree develops, redness and swelling of the mucous membrane are noted, and increased desquamation of the integumentary epithelium begins. As a result, an exudate of a mucous or mucopurulent nature is produced. Sometimes there may be complete blockage of the lumen of the bronchioles and bronchi.
In severe cases, purulent sputum of a yellowish or greenish color is formed. With hemorrhages from the blood vessels of the mucous membrane, the exudate takes on a hemorrhagic form with brown lumps (rusty sputum).
A mild degree of the disease is characterized by damage to only the upper layers of the mucous membrane; in severe cases, all layers of the bronchial wall undergo morphological changes. If the outcome is favorable, the consequences of the inflammatory process disappear within 2-3 weeks. In the case of panbronchitis, restoration of the deep layers of the mucosa lasts about 3-4 weeks. If pathological changes become irreversible, the acute phase of the disease becomes chronic.
The conditions for the pathology to become chronic are:
- a decrease in the body’s defenses to diseases, exposure to allergens, and hypothermia;
- viral respiratory diseases;
- foci of infectious processes in the organs of the respiratory system;
- allergic diseases;
- heart failure with congestion in the lungs;
- deterioration of drainage function due to disruptions in motility and disruption of the ciliated epithelium;
- presence of tracheostomy;
- socially unfavorable living conditions;
- dysfunction of the neurohumoral regulatory system;
- smoking, alcoholism.
The most significant thing in this type of pathology is the functioning of the nervous system.
The totality of manifestations of bronchitis
The symptoms of bronchitis, depending on the form of the disease, have significant differences, therefore, in order to correctly assess the patient’s condition, as well as prescribe appropriate treatment, it is necessary to identify the distinctive features of the pathology in time.
Clinical picture of acute bronchitis
Acute bronchitis clinic in initial stage manifested by signs of acute respiratory infections, runny nose, general weakness, headache, slight increase in body temperature, redness, sore throat). Along with these symptoms, a dry, painful cough occurs.
Patients complain of a sore feeling behind the sternum. After a few days, the cough acquires a wet character, becomes softer, and mucous exudate begins to disappear (catarrhal form of the disease). If infection with a bacterial agent is added to a viral pathology, the sputum becomes mucopurulent in nature. Purulent sputum in acute bronchitis is extremely rare. During severe coughing attacks, the exudate may be streaked with blood.
If inflammation of the bronchioles develops against the background of bronchitis, symptoms of respiratory failure may occur, such as shortness of breath and bluish skin. Rapid breathing may indicate the development of bronchial obstruction syndrome.
When tapping the chest, the percussion sound and trembling of the voice usually do not change. Hard breathing can be heard. In the initial stage of the disease, dry wheezing is observed, when sputum begins to leave, it becomes moist.
In the blood there is a moderate increase in the number of leukocytes with a predominance of neutrophils. The erythrocyte sedimentation rate may increase slightly. There is a high probability of the appearance of C-reactive protein, increased levels of sialic acids, alpha 2-globulins.
The type of pathogen is determined by bacterioscopy of lung exudate or sputum culture. For timely detection of blockage of the bronchi or bronchioles, peak flowmetry or spirometry is performed.
In acute bronchitis, pathology of the lung structure is usually not observed on an x-ray.
In acute bronchitis, recovery occurs in 10-14 days. In patients with weakened immune systems, the disease has a protracted course and can last more than a month. In children, more pronounced signs of bronchitis are observed, but the tolerance of the disease in pediatric patients is easier than in adults.
Symptoms of chronic bronchitis
Chronic non-obstructive or obstructive bronchitis manifests itself differently, based on the duration of the disease, the likelihood of heart failure or emphysema. The chronic form of the disease has the same varieties as the acute one.
In chronic bronchitis, the following clinical manifestations of the disease are noted:
- increased secretion and release of purulent sputum;
- whistling during inspiration;
- difficulty breathing, hard breathing when listening;
- severe painful cough;
- more often dry wheezing, moist with a large amount of viscous sputum;
- high temperature;
- sweating;
- muscle tremors;
- changes in the frequency and duration of sleep;
- severe headaches at night;
- attention disorders;
- rapid heartbeat, increased blood pressure;
- convulsions.
The main symptom of chronic bronchitis is a severe paroxysmal barking cough, especially in the morning, with copious discharge of thick sputum. After a few days of this cough, chest pain occurs.
The nature of the sputum secreted, its consistency, color, differ depending on the following types of chronic bronchitis:
- catarrhal;
- catarrhal-purulent;
- purulent;
- fibrinous;
- hemorrhagic (hemoptysis).
As bronchitis progresses, the patient begins to experience shortness of breath even without physical exertion.. Externally, this is manifested by cyanosis of the skin. The chest takes on the shape of a barrel, the ribs rise to a horizontal position, and the pits above the collarbones begin to protrude.
Hemorrhagic bronchitis is classified as a separate form. The disease is non-obstructive in nature, has a long-term course, and is characterized by hemoptysis caused by increased permeability of the vascular wall. The pathology is quite rare; in order to establish a diagnosis, it is necessary to exclude other factors in the formation of mucous secretion from the lungs mixed with blood. To do this, bronchoscopy determines the thickness of the walls of the mucosal blood vessels.
The fibrinous form of bronchitis is detected very rarely. A distinctive feature of this pathology is the presence of fibrin deposits, Kurshman spirals, and Charcot-Leyden crystals. The clinic is manifested by a cough, with expectoration of casts in the form of a bronchial tree.
Bronchitis is a common disease. With adequate therapy, it has a favorable prognosis. However, with self-medication, there is a high probability of developing serious complications or the disease becoming chronic. Therefore, at the first symptoms characteristic of bronchial inflammation, you need to consult a doctor.
Cough is the main symptom of any bronchitis. Complaints of a cough - dry or wet, paroxysmal or isolated coughs - always suggest bronchitis. But in order to figure out whether it is bronchitis and what type of bronchitis, you need to know the clinical features of this disease.
Clinic and symptoms of acute bronchitis
Most often, the onset of the disease is preceded by signs of ARVI: weakness and malaise, pain in muscles and joints, runny nose, sore throat, rise in body temperature.
Bronchitis itself begins with a rise in body temperature and the appearance of a cough. Clinical signs can suggest what causes acute bronchitis. Thus, bronchitis of influenza and parainfluenza etiology is characterized by abrupt start and persistence of fever for 2-3 days. If the temperature does not drop for about 7 days, this may indicate that the cause of bronchitis is adenoviruses or mycoplasmas.
A cough may appear before the development of bronchitis, as a manifestation of damage to the larynx and trachea. This is either a rough, barking cough (laryngitis) or a dry, painful cough, accompanied by painful sensations and a burning sensation in the chest (tracheitis). Quite often, the pathological process covers all the respiratory tract, laryngotracheobronchitis occurs, in which there is no point in isolating the symptoms of bronchitis. Complex treatment is required.
At the beginning of the disease, the cough is paroxysmal in nature. This is an unproductive, dry, persistent cough. Sometimes coughing attacks are so intense that they lead to headaches and chest pain. When auscultating the lungs during this period, hard breathing and scattered dry rales are heard.
Gradually, the cough becomes moist, mucopurulent sputum begins to leave, and moist fine bubbling rales are heard in the lungs. Laboratory tests may not reveal any abnormalities. But the x-ray will show an increase in the pulmonary pattern, expansion of the roots of the lungs.
In cases of severe disease, the cough is accompanied by shortness of breath, difficulty breathing, and abundant fine wheezing is heard in the lungs against the background of weakened breathing. With this clinical picture, laboratory tests show signs of an acute inflammatory reaction: leukocytosis, increased ESR.
Particular attention should be paid to acute obstructive bronchitis, which usually occurs in children and is fraught with serious complications. In such cases, the appearance of noisy wheezing with prolonged exhalation attracts attention. During the breathing process, auxiliary muscles are involved, retraction of the pliable areas of the chest is noted: supra- and subclavian fossae, intercostal spaces. On auscultation, abundant dry wheezing is heard, indicating bronchospasm.
Obstructive bronchitis is dangerous due to a possible attack of suffocation and the development of bronchial asthma.
Clinic and diagnosis of chronic bronchitis
Unlike acute bronchitis, chronic bronchitis begins unnoticed and can for a long time remain unnoticed, manifesting itself only as a slight cough in the morning, without in any way affecting well-being and performance. Gradually, the cough becomes more frequent and becomes a constant complaint of the patient, slightly “letting go” in the warm season. The amount of sputum increases and its properties change: from mucous, it gradually becomes mucopurulent or purulent. On auscultation, hard breathing is noted. Dry or moist fine bubbling rales are possible.
In the later stages of chronic bronchitis characteristic symptom shortness of breath becomes, occurring first during physical exertion and during exacerbation, gradually becoming more permanent. The appearance of shortness of breath indicates the spread of the process to the small bronchi and the development of ventilation (obstructive) disorders.
Chronic bronchitis is characterized by severe sweating, especially during physical activity and at night; warm acrocyanosis – the limbs are slightly bluish, but at the same time warm.
Diagnosis of chronic bronchitis at the initial stage is based primarily on clinical symptoms, since laboratory and x-ray examination methods do not reveal any abnormalities.
At later stages and in the phase of exacerbation of chronic bronchitis, a general blood test (leukocytosis, ESR) can be informative; biochemical blood test (appearance of CRP, changes in blood protein fractions (alpha-2-globulin), seromucoid, sialic acids); sputum examination (increased number of leukocytes, epithelial cells, macrophages).
Bronchoscopy helps to confirm the presence of a diffuse inflammatory process and clarify the nature of morphological changes in the bronchi, which allows not only to conduct a visual examination of the bronchi from the inside, but also to take a biopsy specimen for histological examination.
Functional diagnostic methods make it possible to assess the degree of respiratory impairment using pneumotachometry, spirography, peak flowmetry. In a patient with chronic bronchitis, the vital capacity of the lungs (VC), forced expiratory volume (FEV) and peak expiratory volume flow (PEF) decrease, and the residual lung volume (RLV) increases.
The progression of chronic bronchitis inevitably leads to the appearance of clinical signs of respiratory and heart failure.
is a diffuse inflammatory disease of the bronchi, affecting the mucous membrane or the entire thickness of the bronchial wall. Damage and inflammation of the bronchial tree can occur as an independent, isolated process (primary bronchitis) or develop as a complication against the background of existing chronic diseases and previous infections (secondary bronchitis). Damage to the mucous epithelium of the bronchi disrupts the production of secretions, the motor activity of the cilia and the process of cleansing the bronchi. There are acute and chronic bronchitis, which differ in etiology, pathogenesis and treatment.
ICD-10
J20 J40 J41 J42
General information
Bronchitis is a diffuse inflammatory disease of the bronchi, affecting the mucous membrane or the entire thickness of the bronchial wall. Damage and inflammation of the bronchial tree can occur as an independent, isolated process (primary bronchitis) or develop as a complication against the background of existing chronic diseases and previous infections (secondary bronchitis). Damage to the mucous epithelium of the bronchi disrupts the production of secretions, the motor activity of the cilia and the process of cleansing the bronchi. There are acute and chronic bronchitis, which differ in etiology, pathogenesis and treatment.
Acute bronchitis
The acute course of bronchitis is characteristic of many acute respiratory infections (ARVI, acute respiratory infections). The most common causes of acute bronchitis are parainfluenza viruses, respiratory syncytial virus, adenoviruses, less often - influenza virus, measles, enteroviruses, rhinoviruses, mycoplasma, chlamydia and mixed viral-bacterial infections. Acute bronchitis is rarely of a bacterial nature (pneumococci, staphylococci, streptococci, Haemophilus influenzae, whooping cough pathogen). The inflammatory process first affects the nasopharynx, tonsils, trachea, gradually spreading to the lower respiratory tract - the bronchi.
A viral infection can provoke the proliferation of opportunistic microflora, exacerbating catarrhal and infiltrative changes in the mucosa. The upper layers of the bronchial wall are affected: hyperemia and swelling of the mucous membrane, pronounced infiltration of the submucosal layer occurs, dystrophic changes and rejection of epithelial cells occur. With proper treatment, acute bronchitis has a favorable prognosis; the structure and function of the bronchi are completely restored within 3 to 4 weeks. Acute bronchitis is very often observed in childhood: This fact is explained by the high susceptibility of children to respiratory infections. Regularly recurring bronchitis contributes to the transition of the disease to a chronic form.
Chronic bronchitis
Chronic bronchitis is a long-term inflammatory disease of the bronchi, progressing over time and causing structural changes and dysfunction of the bronchial tree. Chronic bronchitis occurs with periods of exacerbations and remissions, and often has a hidden course. Recently, there has been an increase in the incidence of chronic bronchitis due to environmental deterioration (air pollution with harmful impurities), widespread bad habits(smoking), high level of allergization of the population. With prolonged exposure to unfavorable factors on the mucous membrane of the respiratory tract, gradual changes in the structure of the mucous membrane, increased sputum production, impaired drainage ability of the bronchi, and decreased local immunity develop. In chronic bronchitis, hypertrophy of the bronchial glands and thickening of the mucous membrane occur. The progression of sclerotic changes in the bronchial wall leads to the development of bronchiectasis and deforming bronchitis. A change in the air-conducting ability of the bronchi significantly impairs lung ventilation.
Classification of bronchitis
Bronchitis is classified according to a number of characteristics:
According to severity:
- mild degree
- medium degree
- severe
According to the clinical course:
Acute bronchitis
Acute bronchitis, depending on the etiological factor, is:
- infectious origin (viral, bacterial, viral-bacterial)
- non-infectious origin (chemical and physical harmful factors, allergens)
- mixed origin (combination of infection and the action of physical and chemical factors)
- unspecified etiology
According to the area of inflammatory damage, they are distinguished:
- bronchitis with predominant damage to the bronchi of medium and small caliber
- bronchiolitis
According to the mechanism of occurrence, primary and secondary acute bronchitis are distinguished. According to the nature of the inflammatory exudate, bronchitis is distinguished: catarrhal, purulent, catarrhal-purulent and atrophic.
Chronic bronchitis
Depending on the nature of the inflammation, catarrhal chronic bronchitis and purulent chronic bronchitis are distinguished. Based on changes in the function of external respiration, obstructive bronchitis and non-obstructive forms of the disease are distinguished. According to the phases of the process during chronic bronchitis, exacerbations and remissions alternate.
The main factors contributing to the development of acute bronchitis are:
- physical factors (damp, cold air, sudden temperature changes, exposure to radiation, dust, smoke);
- chemical factors (the presence of pollutants in the atmospheric air - carbon monoxide, hydrogen sulfide, ammonia, chlorine vapor, acids and alkalis, tobacco smoke, etc.);
- bad habits (smoking, alcohol abuse);
- stagnant processes in the pulmonary circulation ( cardiovascular pathologies, violation of the mucociliary clearance mechanism);
- the presence of foci of chronic infection in the oral and nasal cavity - sinusitis, tonsillitis, adenoiditis;
- hereditary factor (allergic predisposition, congenital disorders of the bronchopulmonary system).
It has been established that smoking is the main provoking factor in the development of various bronchopulmonary pathologies, including chronic bronchitis. Smokers suffer from chronic bronchitis 2-5 times more often than non-smokers. The harmful effects of tobacco smoke are observed in both active and passive smoking.
Long-term exposure to humans predisposes to the development of chronic bronchitis harmful conditions production: dust - cement, coal, flour, wood; vapors of acids, alkalis, gases; Uncomfortable temperature and humidity conditions. Air pollution by emissions industrial enterprises and transport, fuel combustion products have an aggressive effect primarily on the human respiratory system, causing damage and irritation of the bronchi. High concentration of harmful impurities in the air major cities, especially in calm weather, leads to severe exacerbations of chronic bronchitis.
Repeated acute respiratory viral infections, acute bronchitis and pneumonia, chronic diseases of the nasopharynx and kidneys can further cause the development of chronic bronchitis. As a rule, the infection is layered on top of the existing damage to the respiratory mucosa by other damaging factors. A damp and cold climate contributes to the development and exacerbation of chronic diseases, including bronchitis. Important role belongs to heredity, which under certain conditions increases the risk of chronic bronchitis.
Symptoms of bronchitis
Acute bronchitis
The main clinical symptom of acute bronchitis - low chest cough - usually appears against the background of existing manifestations of acute respiratory infection or simultaneously with them. The patient experiences fever (up to moderately high), weakness, malaise, nasal congestion, and runny nose. At the beginning of the disease, the cough is dry, with scanty, difficult to separate sputum, worsening at night. Frequent coughing attacks cause pain in the abdominal muscles and chest. After 2-3 days, sputum (mucous, mucopurulent) begins to come out abundantly, and the cough becomes moist and soft. Dry and moist rales are heard in the lungs. In uncomplicated cases of acute bronchitis, shortness of breath is not observed, and its appearance indicates damage to the small bronchi and the development of obstructive syndrome. The patient's condition returns to normal within a few days, but the cough may continue for several weeks. Prolonged high temperature indicates the addition of a bacterial infection and the development of complications.
Chronic bronchitis
Chronic bronchitis occurs, as a rule, in adults, after repeated acute bronchitis, or with prolonged irritation of the bronchi (cigarette smoke, dust, exhaust gases, vapors chemicals). Symptoms of chronic bronchitis are determined by the activity of the disease (exacerbation, remission), nature (obstructive, non-obstructive), and the presence of complications.
The main manifestation of chronic bronchitis is a prolonged cough for several months for more than 2 years in a row. The cough is usually wet, appears in the morning, and is accompanied by the release of a small amount of sputum. Increased cough is observed in cold, damp weather, and subsidence - in the dry, warm season. The general well-being of patients remains almost unchanged; coughing becomes a common occurrence for smokers. Chronic bronchitis progresses over time, the cough intensifies, takes on the character of attacks, and becomes annoying and unproductive. There are complaints of purulent sputum, malaise, weakness, fatigue, sweating at night. Shortness of breath occurs during exertion, even minor ones. In patients with a predisposition to allergies, bronchospasm occurs, indicating the development of obstructive syndrome and asthmatic manifestations.
Complications
Bronchopneumonia is a common complication of acute bronchitis and develops as a result of decreased local immunity and the accumulation of bacterial infection. Repeated acute bronchitis (3 or more times a year) leads to the transition of the inflammatory process to a chronic form. The disappearance of provoking factors (cessation of smoking, climate change, change of place of work) can completely relieve the patient from chronic bronchitis. As chronic bronchitis progresses, repeated acute pneumonia occurs, and with a long course, the disease can develop into chronic obstructive pulmonary disease. Obstructive changes in the bronchial tree are considered a pre-asthma condition (asthmatic bronchitis) and increase the risk of bronchial asthma. Complications appear in the form of pulmonary emphysema, pulmonary hypertension, bronchiectasis, and cardiopulmonary failure.
Diagnostics
Treatment of bronchitis
In the case of bronchitis with a severe concomitant form of ARVI, treatment is indicated in the pulmonology department; in case of uncomplicated bronchitis, treatment is outpatient. Therapy for bronchitis should be comprehensive: fighting infection, restoring bronchial patency, eliminating harmful provoking factors. It is important to complete the full course of treatment for acute bronchitis to prevent it from becoming chronic. In the first days of the illness, bed rest, drinking plenty of fluids (1.5 - 2 times more than normal), and a dairy-vegetable diet are indicated. During treatment, smoking cessation is required. It is necessary to increase the air humidity in the room where a patient with bronchitis is located, since the cough intensifies in dry air.
Therapy for acute bronchitis may include antiviral drugs: interferon (intranasal), for influenza - rimantadine, ribavirin, for adenovirus infection - RNase. In most cases, antibiotics are not used, except in cases of bacterial infection, in the case of prolonged acute bronchitis, or in cases of a pronounced inflammatory reaction according to the results of laboratory tests. To improve the removal of sputum, mucolytic and expectorant drugs are prescribed (bromhexine, ambroxol, expectorant herbal tea, inhalations with soda and saline solutions). In the treatment of bronchitis, vibration massage, therapeutic exercises, and physiotherapy are used. For a dry, unproductive, painful cough, the doctor may prescribe medications that suppress the cough reflex - oxeladine, prenoxdiazine, etc.
Chronic bronchitis requires long-term treatment, both during exacerbation and during remission. In case of exacerbation of bronchitis, with purulent sputum, antibiotics are prescribed (after determining the sensitivity of the isolated microflora to them), sputum thinners and expectorants. In the case of the allergic nature of chronic bronchitis, it is necessary to take antihistamines. Regimen – semi-bed, always warm, plenty of fluids (alkaline mineral water, tea with raspberries, honey). Sometimes therapeutic bronchoscopy is performed, with washing of the bronchi with various medicinal solutions (bronchial lavage). Breathing exercises and physiotherapy (inhalations, UHF, electrophoresis) are indicated. At home, you can use mustard plasters, medical cups, and warm compresses. To strengthen the body's resistance, vitamins and immunostimulants are taken. Outside of exacerbation of bronchitis, it is advisable spa treatment. Walking on the fresh air, normalizing respiratory function, sleep and general condition. If there are no exacerbations of chronic bronchitis within 2 years, the patient is removed from dispensary observation by a pulmonologist.
Forecast
Acute bronchitis in an uncomplicated form lasts about two weeks and ends with complete recovery. In case of concomitant chronic diseases cardiovascular system there is a prolonged course of the disease (a month or more). The chronic form of bronchitis has a long course, alternating periods of exacerbations and remissions.
Prevention
Preventive measures to prevent many bronchopulmonary diseases, including acute and chronic bronchitis, include: eliminating or reducing the effect on the respiratory system harmful factors(dust, air pollution, smoking), timely treatment chronic infections, prevention of allergic manifestations, increased immunity, healthy image life.
The causative agents of the disease are influenza virus, parainfluenza, respiratory syncytial virus, adenovirus, mycoplasma pneumoniae, streptococcus, pathogenic staphylococcus, pneumococcus, Afanasyev-Pfeiffer bacillus or a combination of virus and microbes. It is important to consider the role of endogenous microbial invasion, especially staphylococcal invasion, which occurs most often against the background of influenza or adenoviral infection.Bronchitis or tracheobronchitis may be the initial manifestation of measles, and less commonly, whooping cough and other childhood infections.
Predisposing factors to the occurrence of bronchitis are the following: hypothermia, defects in care (insufficient exposure of the child to fresh air, clothing inappropriate for the weather, etc.), atmospheric air pollution with industrial dust and the premises in which children are located, tobacco smoke.
Pathomorphology of acute bronchitis
Depending on the etiological factors, more or less pronounced pathomorphological changes occur. Thus, tracheobronchitis with influenza is characterized by hemorrhages in the bronchial mucosa and the presence of fibrinous effusion. With parainfluenza, pillow-shaped growths of the epithelium are found, mainly in small bronchi, narrowing their lumen. With adenovirus infection, mucus deposits on the mucous membrane are observed. Round cell infiltrates form in the bronchial wall. With respiratory syncytial infection, the most pronounced changes are in the small and medium bronchi and bronchioles. Characterized by an abundance of foamy, semi-liquid sputum. Microscopically, a slight increase in epithelial cells is detected, their reproduction with the formation of multinuclear papillary growths occupying a significant part of the bronchial lumen. In bacterial bronchitis, infiltration of the mucous membrane with polynuclear cells and lymphocytes is detected microscopically, and in severe cases, the formation of a fibrinous film.Acute bronchitis clinic
The beginning is acute. The temperature rises to low-grade fever, but a short-term (1-2 days) increase to 38-39 °C is often observed. The main symptom is a cough that gets worse at night. At the beginning of the disease, the cough is dry, sometimes paroxysmal, and may be accompanied by vomiting. On the 3rd - 4th day of the disease, the release of mucous sputum begins, later giving way to purulent sputum. Older children complain of pain and tightness in the chest, headache, and sleep disturbances.In acute (non-spastic) bronchitis, scattered dry wheezing is heard in the first days of the disease; on the 3rd to 5th day the wheezing becomes moist. Sometimes moist wheezing can be heard at a distance both during inhalation and exhalation; you can also listen to fine-bubble wheezing, which differs from wheezing with pneumonia in its diffuse nature. The localization of changes in bronchitis is predominantly bilateral. With unilateral auscultatory changes, pneumonia should be excluded, although unilateral bronchitis is also observed even in young children (S. V. Rachinsky et al., 1978). There are usually no percussion changes.
On the 6th - 8th day of the disease, the cough decreases, body temperature normalizes, wheezing in the lungs disappears; recovery begins.
Bronchitis can occur not only from the first days of an acute respiratory viral infection, but at a later date due to the addition of a secondary bacterial infection. The clinical picture of the disease in such cases changes: the general condition worsens, the body temperature rises, the cough intensifies, and moist large- and medium-bubble rales appear in the lungs. In infants and young children, the disease can be complicated by pneumonia. With uncomplicated bronchitis, there is no significant shortness of breath. In infants, breathing can increase up to 60 times per minute, accompanied by a slight participation of the pliable parts of the chest in the act of breathing in the absence of cyanosis.
Radiologically, in acute bronchitis, a symmetrical increase in the pattern of the lungs is detected, mainly in the hilar and inferomedial zones. An intensification of the pattern is also determined along the bronchovascular structures, which is a consequence of vascular hyperemia and increased lymph production, mainly in the peribronchial spaces. These reactive changes in the lungs last longer than the clinical manifestations of bronchitis.
A separate clinical type of acute bronchitis is spastic bronchitis (bronchitis spastica).
The main pathogenetic essence of spastic bronchitis is a narrowing of the lumen of the bronchi, a violation of their patency, caused by vasocretory changes that occur under the influence of ARVI. Due to inflammatory changes, the mucous membrane of the bronchi thickens, becomes swollen and edematous, and in the lumen of the bronchi there is an abundant accumulation of mucus, sometimes viscous. These changes are the cause of the development of obstructive syndrome. It is possible that viral-bacterial allergies play a role in the mechanism of occurrence of spastic bronchitis, since 5-30% of such patients subsequently develop bronchial asthma.
Due to obstructive disorders, tracheobronchial resistance to air flow increases, especially on exhalation, with subsequent retention in the lungs and the development of functional emphysema, determined radiographically in the form of swelling of the lungs.
Spastic bronchitis is most common in children in the second half of life and differs from bronchiolitis in a lesser degree of respiratory impairment due to damage to the larger bronchi. Breathing becomes moderately rapid. The clinical picture of the disease is dominated by signs of expiratory difficulty breathing, although in infants there is a retraction of the pliable parts of the chest into the act of breathing, which may also indicate difficulty in inhaling.
In addition to expiratory difficulty breathing, cough and wheezing noisy breathing are observed. Auscultation reveals dry wheezing. Percussion in connection with the phenomena of emphysema - a boxy tone of sound.
Spastic bronchitis in most cases ends with recovery within 5 - 10 days, simultaneously with ARVI, sometimes it drags on for up to 2 - 3 weeks. More severe forms of spastic bronchitis may be complicated by bronchiolitis.
Significant differential diagnostic difficulties, especially in infants and young children, arise between spastic bronchitis, caused by obstruction of the airways as a result of a reaction to infection, and the asthmatic component, complicating pneumonia. For these purposes, it is important to take into account anamnestic data indicating the manifestation of allergies during acute respiratory viral infections in the past, the presence of drug allergies, exudative diathesis, hereditary allergies, etc.
The diagnosis of acute bronchitis is established based on the diffuseness of the lesion (physical changes on both sides). Pneumonia is characterized by the presence of physical changes over a limited area of the lung. If pneumonia occurs against the background of diffuse bronchitis or simultaneously with it, the deterioration of the child’s general condition, identification of limited areas of shortening of percussion sound and changes in auscultation data are taken into account. X-ray examination of pneumonia reveals infiltrative changes in the lung tissue.
Treatment of acute bronchitis
In case of acute bronchitis, it is necessary to systematically ventilate the ward or room in which the patient is located. Considering that the disease can be caused by a viral-bacterial or bacterial infection, antibiotics are indicated for children, especially young and infants (ampicillin, oxacillin, methicillin, ampiox, carbenicillin, kefzol - p. 232). In case of bronchitis of viral etiology, the use of antibiotics is less justified, although in such cases they can be effective in preventing bacterial complications.Children over three years old and with mild acute bronchitis can be prescribed Bactrim, erythromycin, oleandomycin phosphate, sulfonamide drugs (0.15 - 0.1 g/kg/day for 4 or 6 doses).
When using symptomatic therapy, it is important to take into account that in patients with copious sputum, antitussives can make it difficult to evacuate it and worsen bronchial obstruction.
If there is a thick viscous secretion in the tracheobronchial tract, measures are indicated to promote its liquefaction and evacuation. To thin sputum and reduce inflammatory swelling of the bronchial mucosa, inhalations of 1 - 2% sodium bicarbonate solution are prescribed 2 - 3 times a day. Humidification and warming of inhaled air is indicated, best with the help of ultrasonic humidifiers, aeroionizers, and aerosol devices. If they are not available to humidify the air in the room where the patient is located, winter time use central heating radiators, covering them with a wet thick cloth.
Therapeutic baths are used for 5 - 10 minutes, daily the water temperature is increased from 37 ° C to 40 ° C, warm wraps, distractions (mustard plasters, cups, mustard foot baths), warm drinks, expectorant mixtures, etc.
If there is an abundance of sputum, postural drainage is prescribed to facilitate its outflow from the affected bronchi. The patient is in the Quincke position (with the head end down) for 15 to 20 minutes (with breaks). In this position, coughing movements are desirable. The procedure is repeated 2 - 3 times a day. The effectiveness of drainage increases when combined with vibration massage, which in older children is performed by patting the chest over the affected area with a cupped palm. In young children, this procedure is performed by applying rhythmic blows with the ends of the fingers of one hand to the chest or to a finger of the other hand located along the intercostal space.
To relieve bronchospasm, aminophylline and ephedrine are used. Eufillin is prescribed orally in a single dose of 2 - 4 mg/kg 2 - 3 times a day, intravenously in the form of a 2.4% solution at the rate of 0.1 - 0.15 ml/kg, but not more than 5 - 7.5 ml in 150 - 200 ml of 5% glucose solution. Ephedrine is prescribed orally for children under 1 year of age - 0.002 - 0.003 g; 2 - 5 years - 0.003 - 0.01 g; 6 - 12 years - 0.15 - 0.02 g; older - 0.025 g 2 - 3 times a day. Combined powders of ephedrine, diphenhydramine and aminophylline are prescribed in age-specific doses.
Forecast Acute bronchitis is favorable, but complications are possible - bronchiolitis, pneumonia.
Prevention acute bronchitis comes down to preventing acute respiratory viral infections and increasing the body’s nonspecific resistance through hardening, proper child care, compliance with indoor air conditions, balanced nutrition, etc.
