Practice Session 2.

1. Chronic Bronchitis;
2. Bronchial Asthma

Diagnostic and Therapy of Internal Diseases

For Faculty of Physical Medicine and Rehabilitation
 1. Chronic Bronchitis;

Diagnostic and Therapy of Internal Diseases

For Faculty of Physical Medicine and Rehabilitation
 Definition and Pathology
• Chronic Progressive Inflammatory Disease of Bronchial Tree;

• Progressive disorder of evacuation and defense functions:

― Secretion from Epithelial Layer and muco-ciliary transport;
― Sustainable damaging of deeper layers (Smooth muscle);
― Peri-bronchial inflammation and sclerosis;
― Frequent exacerbation of inflammation of bronchial tree and lung
parenchymal tissues;
― Further development of disorders with vicious cycles related to
• ventilation in obstructive type,
• lung emphysema and diffusion,
• secondary pulmonary hypertension, lung perfusion and cor-
pulmonale
• WHO criteria of definition
— Productive cough i.e., cough with expectoration;
— For at least 3 consecutive months a year for 2 consecutive years.
 Prevalence

• CB prevailed in about 10% of adult population in industrialized countries;

– The most frequently occurred chronic lung disease;
– Men are affected 3 times as often s women;
– Considerably related with the fact that smoking prevalence is much more higher
in men than women
• Muco-ciliary insufficiency resulted by years of exposure numerous exogenous and
endogenous factors
– Primarily occurred with the cilia paralysis and destroy;
 Etiology
Exogenous factors
― Tobacco – 90% of CB patients are smokers, ex-smokers or
passive smokers and influenced by tobacco fume;
 Every second smokers at age of 40 are suffered from CB;
― Ongoing exposure of environmental pollutants on mucous
layer of airways
 Communal and industrial dusts and exhausts
― Frequent recurrent infections
• Endogenous Factors
― Hyper-reactivity of airways;
― Syndrome of Antibody Deficiency e.g. Congenital missing of
IgA, which naturally occur in bronchial secretions ;
― Primary ciliary Diskinezia, e.g. α1-anti-Tripsin Deficiency –
congenital disease, in which ciliated epithelium of airways
does not move;
― Mucoviscidosis – cystic fibrosis – congenital disease
 Pathogenesis
• Damage of bronchial structures due to exogenous and endogenous factors;
• Lesion of mucous and sub-mucous layer
• Lost of ciliary epithelium;
• Hyperplasia and hypertrophy of Coblet epithelial cells
• Abnormalities in secretion, evacuation and defense functions of bronchi
• First, mucous hypertrophy and than Hypercrinia / Dyscrinia
• Deterioration in muco-ciliary clearance;
• Disturbance in local cell immunity and bacterial colonization, infection
• Inflammation of bronchial wall and altered immune response on inflammation
• Cellular – mobilization of neutrophiles and lymphocytes
• Humoral – activation /secretion of inflammatory mediators and proteolytic
enzymes;
• Increased mucous production  Block of airways – “endobronchial Obstruction” 
Atrophy of bronchial mucous layer  Bronchial deformity and colapse  Bronchi-
constriction – “Exobronchial Obstruction”  Forced Expiation
 Clinical Signs

• Cardinal Symptom – First, Persistent Productive Cough, Later Dyspnoe;

― Excessive Expectoration - When mucous-purulent bronchial secrete (sputum) is
produced;
― Nonproductive – when obstruction exists;
― Dyspnoe – when distal part of bronchial three is obstructed.;
― Bloody Sputum – Deeper damaged Epithelial layer, if Bloody Sputum recurrence
- hemorrhagic bronchitis, bronchiectasis , or Airway Tract Cancer
• General Symptoms – Fatigue, Sweating, Fever – sub-febrile
― Occurrence during exacerbation, Infection
 Symptoms
• Inspection
—No Signs
• Percussion
—No Symptoms at the early course
—Symptoms appeared on later stages
• Hyper-resonant – Box-like sounds, when marked obstruction
• Auscultation
—No symptoms at the early course and during remission
• Bronchovesicular – Dense Sound, that can be a variant of norm
—Symptoms appeared during exacerbation or on later stages
• Expiratory wheezes – indicates obstruction at distal bronchi
• Diminished Bronchovesicular Sound – indicates on emphysema
—When bronchi-obstruction auscultation signs can be appeared only during forced
breathing or in lying down position
 Labs/Instrumentals
• Lab Tests
—No specific changes or occurrence
—CBC – Erithrocytosis (Secondary Erithremia) and the Lowest value of
ESR – at later stages of the disease
• Chest X-ray
— No manifested abnormalities. If only increased bronchi-vascular
markings, enlarged vessels, marked appeared in bronchial tree
• Bronchoscopy
—Inflammation - extent , characteristics (fibrin, pus, hemorrhage);
—Bronchial Kinetics /Diskinezia
—Complications – Bronchiectasis, Strictures, Deformity, Tumor
• Spirometry
—FEV1; FVC; Tiffeneau test (FEV1/FVC);
—Obstruction, if Tiffeneau test<80%
• ECG
—Right Axis Deviation;
—Right Ventricle Hypertrophy, R/S<1 in V4-V6 leads
—P- pulmonale (II, III, AVF leads)
 Complications

• Pneumonia and Abscesses;

• Bronchiectasis;
• Chronic Obstructive Pulmonary Disease
(COPD), Emphysema
• Respiratory Insufficiency
• Pulmonary Hypertension and cor-pulmonale
Vicious Spiral in Chronic Bronchitis
 Treatment
• Avoiding impact of etiological Factors;
― Quite Smoking / Communal and Industrial Dusts and Exhausts;
― Controlling of Endogenous Factors (e.g. α1-antitripsin replacement) ;
― Physical Activity, Body weight control;
• Delaying bronchial damage – Treatment in remission;
― Long –term bronchodilator treatment if bronchi-obstruction
 Anti-cholinergic agents - Ipratropium Bromide, Tiotropium Bromide
 Long acting β-agonists (LABA) – salmeterol, formoterol;
• Treatment of exacerbations;
― Mucolitics – for maintaining of muco-ciliary clearance
 Acetylsalicylate, ambroxol.
 Anti-cholinergic agents - Ipratropium Bromide
― Short acting β-agonists (LABA) – albuterol, salbutamol
― Sustain Released Methilxantanes – theophyline, aminophyline
― Etiotrophic Treatment – Antibiotics / Corticosteroids
 2. Bronchial Asthma;

Diagnostic and Therapy of Internal Diseases

For Faculty of Physical Medicine and Rehabilitation
 Definition
• Inflammatory disease of airways supported by bronchial hyper-reactivity that is triggered by
different irritants and occurs by attacks of bronchial obstruction
• Prevalence – 10% among children and 5% among adults;
— The most frequent chronic disease among children;
— Almost half of affected children become asymptomatic after puberty.
• Mechanisms of inflammation are usually triggered by allergic and non-allergic stimuli and
cause bronchial obstruction by:
― Bronchospasm;
― Mucosal Edema;
― Secretion of dense mucous
― Disturbance in mucous-ciliary transport
 Etiology and Forms of Asthma - Allergic
• Allergic Asthma – Allergic Sanitization / “Extrinsic Asthma”;
― Clear Relationships between triggers of allergy in patients history in form of additional
signs of atopia and disease symptoms could be identified
― The most frequent triggers of allergic asthma
 Pollen;
 Household /in-home dust;
 Animal heir;
 Mold.
― Contact with allergens causes a type I reaction ;
 IgE antibodies and mediators such as histamine , prostaglandins, serotonin released
after mast cells degranulation or from other blood cells of first line immunity
leading to bronchospasm with in few minutes;
 An Inflammatory reaction of late phase (release of cytokines, chemokines,
leukotriens) with edema of the bronchial with excessive formation of mucus is
developed in few hours
 Etiology and Forms of Asthma – nonallergic / mixed
• Nonallergic Asthma - Bronchial mucosa response with hyper-reactivity to any kind of other
nonallergic irritants / “intrinsic asthma”.
― The most frequent triggers of nonallergic asthma
 Infection;
 Environmental Pollutants;
 Climatic conditions – cold or hot or ozone;
 Medications;
 Psychological stress
• Mixed forms of Asthma – the most frequent form
― Allergic Asthma – in 10%;
― Nonallergic Asthma – in 10%;
― Mixed Asthma – in 80%
 Clinical Signs
Regular
• Difficult and prolonged exhalation;
• Expiratory breath sounds: whistling,
wheezing, or buzzing;
• Racking and urge cough, sometimes
with dense, glassy expectoration;
• Orthopnea, Using of additional
breathing muscles;
Complications
• Restlessness, tachycardia, tachypnea;
• Respiratory insufficiency;
• Cyanosis;
• Lung hyper-distension (air tapping) with
horizontal position of ribs and diaphragm
depression;
• Asthma attack can last for hours and days. Such
condition is called - status asthmaticus;
– Dispelling β-adrenomimetics are not effective;
– Up-growing respiratory insufficiency can be
life-threatening and requires emergency care
and intensive therapy;
• Rarely pneumothorax and secretory atelectasis
 Symptoms
• Cardinal Symptom – Dyspnoe, with prolonged and difficult expiration, cough with
difficulty of expectoration
• General Symptoms - Restlessness, tachycardia, tachypnea, cyanosis, if complications;
• Inspection - puffed up chest – “barrel-kind”, Orthopneic, Cyanotic (if complicated)
• Percussion – hyper-resonant, “Box-like”, or Timpanitic, if distended lungs – complicated
asthma, or status asthmaticus
• Auscultation
• Polyphonic wheezes (whistling, buzzing), overlapping the basic breath sounds –
bronchial sounds.
• Monophonic wheezes
• Prolongation of Expiration phase and/or appearance of wheezes during forced
breathing or in lying down position
 LABs/Instrumental
• Lab tests and Chest X-ray presents changes in phases of
exacerbation or complications
— CBC – Erithrocytosis (Secondary Erithremia) and the Lowest
value of ESR – at later stages of the disease;
— CBC – elevated level of WBC (Leicocytosis) and/or risen
values of ESR – if complicated: usually pneumonia, or other
bacterial infection;
— Elevated Level of CRP (C-reactive Protein) - if complicated:
usually pneumonia, or other bacterial infection;
• Allergy tests - to evaluate suspicious allergic genesis
— PRICK test – intracutaneous (skin) test – skin reaction on IgE-
mediated sensitization with selected allergen;
— RAST test – to prove specific IgE antibody releasing in
response to the selected allergen (blood test)
 LABs/Instrumental – cont’
• Chest X-ray – No specific changes without:
— Lung hyper-distension from tapping air - emphysema
— Complications – Pneumonia, Pneumothorax
— Right heart stress – pulmonary hypertension and cor-
pulmonale
• Spirometry - to confirm bronchial obstruction and its
reversibility
— FEV1 ↓, FVC↓↑, Tiffeneau test <80%; PEF (peak
expiratory flow)↓;
— Bronchi-spasmolysis test with β–adrenomimetic bronchi-
dilator shows improvement >15%;
• ECG
—Right Axis Deviation;
—Right Ventricle Hypertrophy, R/S<1 in V4-V6 leads
—P- pulmonale (II, III, AVF leads)
 Classification of Asthma Severity
CLASSIFY SEVERITY
Clinical Features Before Treatment

Symptoms Nocturnal FEV1 or PEF

Symptoms
STEP 4 Continuous  60% predicted
Severe Persistent Limited physical activity Frequent Variability > 30%

STEP 3 Daily 60 - 80% predicted

Attacks affect activity > 1 time week Variability > 30%
Moderate
Persistent
STEP 2
> 2 times a month  80% predicted
> 1 time a week , but < 1 time a
Mild Persistent Variability 20 - 30%
day

< 1 time a week

STEP 1  80% predicted
Asymptomatic and normal  2 times a month
Intermittent PEF between attacks Variability < 20%

The presence of one feature of severity is sufficient to place patient in that category.
 Treatment
• Avoiding of Allergens and irritation factors;
• Symptomatic / Reliever Medications;
― Short-acting β-adrenomimetics – Albuterol, Salbutamol;
― Systemic corticosteroids – Prednison, hydrocortison
― Anticholinergics – Ipratropium Bromide
― Methylxanthines - Aminophylline
• Anti-inflammatory Therapy;
― Topical (Inhalation) corticosteroids – Beclometason,
Fluticason, Budesonide, Mometason.
― Systemic corticosteroids – Prednison, Hydrocortison
• Long-Acting Bronchi-dilators
― β-adrenomimetics – Salmeterol, formoterol;
― Methylxanthines - Theophyline, Diaphylline.
• Disease Modifiers;
― Leukotriens Inhibitors - Monetelucast;
• Antibiotics - even if bacterial Infection - bronchial /
pulmonal/ other