Acute bronchitis: diagnosis, differential diagnosis, rational therapy

Treatment methods

In the vast majority of cases, bronchitis is a minor illness that goes away on its own after a few days. Since this disease is most often caused by viruses, antibiotics are not recommended for bronchitis. Antibiotics act against bacteria, so giving them in case of a viral infection is not only unnecessary, but also harmful.

However, in rare cases, your doctor may decide to prescribe an antibiotic for treatment. One such situation is a cough that lasts for more than 3 weeks, which is a symptom of whooping cough. An appropriate examination will confirm the diagnosis, after which the doctor may prescribe an antibiotic.

The basis of treatment for bronchitis is symptomatic treatment. This means using medications that directly target and relieve the symptoms of the disease. It is also necessary to monitor the progression of the disease and, if symptoms worsen or persist, consult a doctor. If you have shortness of breath, your doctor may recommend a bronchodilator.

Bronchitis is often accompanied by an increase in body temperature. So you can use antipyretics. Ibuprofen, aspirin, or acetaminophen are quite effective. For children, paracetamol is considered the safest drug for fever. Remember that aspirin should not be taken by people under 12 years of age. Symptoms of bronchitis are most often associated with a cough. You can use over-the-counter cough medicine to help clear any remaining secretions. Effective drugs for wet cough include, but are not limited to: ambroxol, bromhexine and acetylcysteine.

Among herbal preparations that facilitate mucus discharge, you can use, for example, ivy syrups and tablets. Ivy syrup is safe even for small children. Medicines for wet cough that can be used to treat bronchitis: ACC, Phlegamine, Lazolvan and Hederasal.

Bronchitis may initially begin with a dry, debilitating cough. To relieve it, you can use over-the-counter dry cough medications. Popular antitussives include butamirate, levodropropizine, dextromethorphan and codeine. Cough suppressants reduce the cough reflex, its intensity and frequency. The last two substances are opioids. They help to get rid of cough quickly and effectively, but can also be addictive. Opioids for cough should not be given to children under 12 years of age. Therefore, drugs with butamirate and levodropropizine, such as Supremin, Sinekod and Levopront, are a safer choice in case of dry cough, which is a symptom of bronchitis. Herbal cough medicines are also an alternative. Using marshmallow syrup is common. Throat moisturizers may also provide relief.

Main symptoms

The main symptoms of chronic bronchitis are cough with expectoration of sputum. In addition, distant wheezing, heaviness and congestion in the chest, and shortness of breath during exercise may appear. People who smoke often have a cough with sputum all year round, and against this background, exacerbations of bronchitis periodically develop3.

Initially, cough occurs mainly in the autumn-winter period, significantly decreasing or completely disappearing in the warm season. In the absence of treatment, the cough progresses over the years and becomes year-round, exacerbations with the appearance of purulent sputum occur more often, last longer and are more severe, and shortness of breath gradually develops during physical exertion.

During exacerbations, the cough usually intensifies, the volume of sputum increases, although in the first days it may decrease; At the same time, coughing becomes difficult. During an exacerbation, the color of sputum often changes to darker: yellow, green or brown. Exacerbations of bronchitis may be accompanied by shortness of breath on exertion or a feeling of chest congestion or heaviness, even in those patients who do not experience such sensations in a stable condition4.

Causes and mechanism of development

To understand what kind of chronic disease this is, you need to understand its causes and mechanism of development. The pathogenesis of bronchitis in smokers is based on the inflammatory reaction of the mucous membrane of the bronchial wall in response to constant irritation by the combustion products of tobacco. Chronic obstructive bronchitis is characterized by a progressive decrease in airflow in the respiratory tract, which is not completely reversible.

The cause of chronic inflammation of the bronchi is considered to be the negative and irritating effects of the following substances:

• nicotine;
• hydrocyanic acid;
• carbon monoxide;
• cadmium;
• polonium;
• resin;
• soot.

Harmful substances contained in cigarettes

In the pathogenesis of smoker's bronchitis, an important role is played by oxidative stress and a decrease in the antioxidant function of blood plasma, as well as an imbalance between enzymes that break down proteins and their inhibitors.

In response to the arrival of irritating components to the bronchial mucosa, a large number of neutrophils (a type of leukocyte) are activated, which try to phagocytose the particles. This continues for several years, and infiltration of leukocytes manifests itself in the form of a productive cough. Next, T-lymphocytes and macrophages are included in the process, which produce proteolytic enzymes that melt tissue.

Destruction of mucosal areas leads to disruption of the pulmonary structure and obstruction - narrowing of the bronchi. The accumulating resin does not undergo full phagocytosis and does not melt, aggravating the progression of obstruction.

Online test: assessing the degree of nicotine addiction

The course of chronic obstructive bronchitis is described by exacerbations and remissions. Relapse and worsening of symptoms are ensured by:

• hypothermia;
• frequent ARVI;
• unfavorable environmental factors;
• industrial hazards;
• malnutrition and hypovitaminosis;
• burdened hereditary history;
• bronchial hyperreactivity;
• prematurity.

Treatment of exacerbations

For exacerbation of bronchitis, antibiotics, inhaled bronchodilators, expectorants and sputum thinners (mucolytics), and antitussives are used. If inhalation and mucolytic therapy was used regularly as a basic therapy, then with exacerbation of bronchitis it usually intensifies.

For severe dry cough that disrupts sleep and daytime activity, antitussive medications are recommended. They are usually prescribed during the initial period of treatment for faster cough relief. Modern antitussive drugs have a fairly weak effect and even in the presence of a small amount of sputum in adult patients they cannot have a negative effect on coughing up, therefore, if necessary, antitussive drugs can be combined with expectorants and sputum-thinning drugs13.

Expectorants and phlegm thinners (mucolytics) can be used in different forms: either as tablets, capsules or syrups, or as inhalations through a nebulizer. Inhalations have their advantages over tablet forms, since during inhalation the medicine enters directly into the respiratory tract, creating a high concentration in them, while the risk of side effects is reduced, since the medicine does not pass through the stomach, liver, kidneys and other organs.

Antibiotics are not always needed during exacerbation of bronchitis, since not all exacerbations are of an infectious nature. Antibiotics are preferred in older people with serious concomitant diseases, such as diabetes mellitus, chronic heart failure, etc., as well as in patients who are often (more than twice a year) treated in hospitals, regardless of the reason for hospitalization, or who are constantly taking medications , which suppress the immune system (immunosuppressants).

In exacerbations of chronic bronchitis, antibiotics are recommended when shortness of breath increases along with the appearance of yellow or green (purulent) sputum14.

With frequent (more than two episodes per year) exacerbations of bronchitis, some types of mucolytics, for example N-acetylcysteine ​​or carbocysteine, can be taken for a long time - up to 1 year, especially in winter, since data have been obtained that in patients with chronic bronchitis, these drugs, when used for a long time, can reduce the risk of exacerbations15.

Forecast. With timely cessation of smoking and initiation of therapy, the prognosis of patients with smoker’s bronchitis is favorable2. In later stages of the disease, in patients with chronic obstructive pulmonary disease, the main task of the doctor is not so much improvement (which is not always achievable), but rather inhibition of disease progression and prevention of serious exacerbations and the development of chronic respiratory failure4.

Prevention. An important component of the prevention of smoker's bronchitis is patient education, that is, conversations about the negative consequences of smoking, the need to quit smoking, and eliminating contact with other adverse environmental factors, including occupational factors; about vaccination, about the prevention of exacerbations of bronchitis, etc. 3.5

Bibliography

1. Global Initiative for Chronic Obstructive Lung Disease. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. Bethesda, MD, USA: GOLD, 2013.
2. Respiratory medicine: manual: in 3 volumes / ed. A. G. Chuchalina. — 2nd ed., revised. and additional M.: Litterra, 2022. T. 1. P. 543.
3. Global Initiative for Chronic Obstructive Lung Disease. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. Bethesda, MD, USA: GOLD, 2010.
4. Global Initiative for Chronic Obstructive Lung Disease. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. Bethesda, MD, USA: GOLD, 2022.
5. Chuchalin A.G., Aisanov Z.R., Chikina S.Yu. and others. Federal clinical recommendations of the Russian Respiratory Society on the use of spirometry. Pulmonology. 2014; 6:11–23.
6. Chuchalin A.G., Aisanov Z.R., Avdeev S.N. and others. Russian Respiratory Society. Federal clinical guidelines for the diagnosis and treatment of chronic obstructive pulmonary disease. M.: RRO; 2014
7. Sukhovskaya O.A. A practical algorithm for quitting smoking. Practical pulmonology. 2022. No. 2. pp. 30-32.
8. Chikina S.Yu. Mucolytics: current role in the management of patients with chronic obstructive pulmonary disease. // Practical pulmonology. 2015. No. 4. pp. 18-22.
9. Chuchalin A.G., Briko N.I., Avdeev S.N. and others. Federal clinical recommendations for vaccine prevention of pneumococcal infection in adults. Pulmonology 2022. T. 29. No. 1. pp. 19-34. DOI: 10.18093/0869-0189-2019-29-1-19-34.
10. Bolser DC Cough suppressant and pharmacologicprotussive therapy. Chest 2006;129; 238S-249S. DOI 10.1378/chest.129.1_suppl.238S.
11. Stey C., Steurer J., Bachmann S. et al. The effect of oral N-acetylcysteine ​​in chronic bronchitis: a quantitative systematic review. Eur. Respira. J. 2000; 16:253–262.

Diagnostics

Most often, chronic obstructive bronchitis of a smoker is diagnosed after 40 years. Determining the stage of bronchitis in a smoker is based on the global initiative Global Strategy for Diagnosis, Management and Prevention of COPD - GOLD, 2011-2014. In turn, the severity can be determined based on spirometry data. The method is based on measuring the speed of air flow in the lungs and its volume. The patient performs special breathing maneuvers, based on which they determine how much air and at what speed penetrates into the lungs during inhalation, is expelled during exhalation, and remains after it.

X-rays and other tests are of an auxiliary nature.

Complications and prognosis

With an exacerbation, a smoker's bronchitis can be complicated by pneumonia, pleurisy, the outcome of which can be pneumosclerosis, bronchiectasis, pneumothorax. The consequences include the development of respiratory failure, polycythemia (blood thickening), chronic pulmonary heart disease, and congestive heart failure.

Expert opinion

Anna Sandalova

Pulmonologist, doctor of the highest category

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We can talk about a favorable prognosis only at the initial stage of obstructive bronchitis in a smoker, subject to smoking cessation. Starting from stage 2, the disease is irreversible and has a poor prognosis. Respiratory failure increases and inevitably leads to increased pressure in the pulmonary circulation. The result is chronic pulmonary heart disease and its failure, and the whole body begins to suffer.

More details about severity levels can be found in a separate article.

Pathogenesis

Smoking disrupts the functioning of the cilia that cover the inner lining of the bronchi (bronchial epithelium) and causes excessive mucus formation in the bronchial wall, and it does not matter what exactly the patient smokes: pipe tobacco, cigarettes or marijuana. Thus, under the influence of tobacco smoke components, non-infectious inflammation develops in the bronchi. In addition, nicotine causes spasm of the muscular lining of the bronchi (bronchospasm). These processes are expressed in the appearance of a cough with phlegm, and sometimes shortness of breath or a feeling of chest congestion or “heavy breathing.” The accumulation of sputum in the bronchi can cause distant wheezing, which the patient hears himself when inhaling or exhaling4.

Similar changes in the bronchial tree can occur not only with smoking, but also with prolonged exposure to other unfavorable factors: long-term inhalation of industrial smoke, for example, during welding, soldering, contact with combustion products, etc.5, therefore, before making a diagnosis, a detailed conversation between the doctor and the patient to find out all the possible causes of bronchitis.