''BRONCHITIS''

We have at least once in a lifetime encounter the cough which produced phlegm and
caused discomfort. Coughing is a reflex action to protect the respiratory system by
getting rid of irritants and secretions. In majority cases, cough is caused by respiratory
infections such as in influenza, bronchitis, tuberculosis and pneumonia.

A cross-sectional survey was carried out between the ages of 11-15 years in one of the
middle schools in Seattle, 7.2% of the students suffered from chronic productive cough.

THE PHYSIOLOGY OF LUNGS

The lungs are among the hardest working organs in the body. The elasticity of the lungs
allows them to expand and contract up to 20 times a minute in order to supply oxygen
to tissues all over the body and expel carbon dioxide that has been created as a waste
product.

Lungs consist of a complex set of branching tubes, the bronchi further dividing into
smaller tubules called the bronchioles, and further into alveolar ducts where the
exchange of gasses takes place. The alveoli make up most of the lung volume and they
are made up of a thin membrane which allows the exchange of gasses with nearby blood
vessels.

The bronchi are lined with column line (columnar) epithelial cells, which produce mucus
and have hairlike structures that extend from the surface called cilia.

FUNCTION OF CILIA AND MUCUS.

The cilia beat in an upward direction, to move the mucus away from the lungs. The
particles such as pollutants, pollen, and other larger particles are also pushed away, in
the air away from the lungs in order to protect the lungs from damaging effects.
The function of mucus is to trap the harmful particulates before they reach the delicate
alveoli, therefore, making it easier for the cilia to push these particles upwards and into
the throat and/or nose, hence getting rid of them.

Often due to a reaction to injury or infection, the lining of the bronchi becomes inflamed
and irritated, this inflammation of the bronchi is called ''BRONCHITIS''.

We have always looked up to the causes, treatment, prevention of the diseases.

Did we ever wonder when was the disease discovered?

HISTORY

Bronchitis was discovered in 1814 by a British Physician named Charles

Badham, who described bronchitis as inflammatory changes in the mucous
membrane of the bronchi after a series of experiments between 1808 and 1814.

Later, in 1821, the stethoscope was invented by the father of chest medicine
called Dr. Rene Laennec, which helped to discover the relation between
emphysema and chronic bronchitis, both associated with shortness of breath. By
the year 1870, these both entities were clearly regarded as related diseases
which caused inflammation of lung tissues.

Types of BRONCHITIS include ACUTE and CHRONIC. These two types present with the
same symptoms, but with varying durations.

SYMPTOMS OF BRONCHITIS:

Cough. It occurs as the tubes swell up.

Production of mucus (sputum).

The sputum can be either clear, white, yellowish-gray or green in color moreover, it may
be streaked with blood in rare cases.

Tiredness.

Shortness of breath.
 Slight fever and chills.

Chest discomfort.

Wheezing.

Based on the survey conducted National Health and Nutrition Examination, 2007-
2012, more than one-half, which is approximately (55.7%) of adults aged 40-70
years with CHRONIC BRONCHITIS presented with these symptoms out of which
shortness of breath (dyspnea) was the most commonly reported symptoms
(43.6%).

How to differentiate CHRONIC FROM ACUTE BRONCHITIS?

Acute bronchitis occurs commonly and it takes about two to three weeks to resolve. The
onset of acute bronchitis follows three to four days after infection of upper respiratory
tract.

On the other hand, chronic bronchitis, which also result in 'smoker's cough' occurs
commonly in smokers. It recurs or doesn't go away for a long time. It is persistent for
most days of the month, three months out of the year.

Chronic bronchitis is most prevalent; comprising the current third leading cause of global
mortality and responsible for 2.9 million deaths in 2010.

Statistics were obtained from the US Centers for Disease Control and Prevention
(CDC) that suggested that about 49% of smokers develop chronic bronchitis
whereas 24% of the adults develop emphysema/COPD.

COPD is the umbrella term that also includes emphysema and chronic bronchitis.

In 2010, WHO Global Burden of Disease measures 1.1 million deaths related to COPD,
which was allocated to tobacco smoking and 850,000 to indoor pollution, but in women,
slightly more deaths were estimated due to indoor pollution than to smoking (445,000
vs. 417000 deaths). According to estimates of deaths related to COPD due to smoking
are rising and deaths related to indoor pollution are decreasing.

HOW IS BRONCHITIS DEVELOPED?

Acute bronchitis is 90% of the time caused by a virus, but bacteria can also be
responsible for the inflammation along with various other irritants such as fumes
or smoke. The membrane of the bronchi becomes inflamed in response to
external pathogens, hence it swells and grows thicker. The airway narrows,
which results in a cough accompanied by phlegm and shortness of breath. In a
healthy individual its symptoms will resolve over a period of a few days, but in
cases where the patient is a smoker, the symptoms become persistent and
severe resulting in chronic bronchitis.

There is no vector from bronchitis, it is spread from person to person by

coughing.

Chronic bronchitis is diagnosed usually at after the age of 45. According to a

survey conducted (2007-2012) by the National Health and Nutrition Examination,
it was revealed that about 15% of U.S. adults aged between 40-79 years suffered
from lung obstruction,

9.4% adults had a mild lung obstruction.

5.3% had moderate or worse lung obstruction.

Data collected from a survey in 2007-2012 of the National Health and Nutrition
Examination stated that 46.2% of adults aged 40-79 years of age suffered from
Lung obstructive disease were current smokers.

Did the ratio differ from men to women?

42.6% of women were a current tobacco smoker, which was slightly less as
compared to men (49.3%), this data was collected among adults of age 40-79.
ACUTE BRONCHITIS

It is one of the most common diseases which affects 5%of adults and 6% of
children with at least one episode a year. It mostly occurs in winters.

Approximately 10 million people in the United States visit a doctor with acute
bronchitis and 70% of patients are prescribed antibiotics as a course of
treatment.

CHRONIC BRONCHITIS

Chronic bronchitis is defined as a productive cough which lasts for three or more
months over a period of years or two. The main cause of chronic bronchitis (i.e.
90% of the times) is smoking cigarettes or other forms of tobacco, such as
second-hand tobacco smoke exposure.

Other risk factors include air pollutants, irritating fumes or dust from harmful
exposures in the occupational field such as in coal mining and metal molding. It
may also be caused due to long-term inhalation of organic substances such hay
dust and acid vapors and gastric reflux content.

CHRONIC BRONCHITIS IN SMOKERS.

If you continue smoking, the function of cilia is compromised and the mucous
membrane lining the airways stays inflamed this increases chance to develop
chronic bronchitis. The airway is clogged with mucus, the lungs are then
vulnerable to viral and bacterial infections, which over time distorts and
permanently damage the lungs' airways.

According to the survey in 2007-2012 conducted by the National Health and

Nutrition Examination, in patients with Pulmonary Obstructive Disease, the rate
of smoking cigarettes has declined with increasing levels of education and
awareness. Among the age group 40-79 years, two out of three with less than a
high school degree were currently smoking compared with 53.2% of high school
graduates and 36% of those with some college education.

The obstruction also varies in severity, adults with mild COPD, 55% with less
than a high school degree smoked tobacco and the ones with moderate or
severe COPD, 74% with less than a high school degree smoked cigarettes.

Does the ratio vary with Ethnicity?

There is a notable difference in 40-79 years adults with chronic bronchitis who
smoke tobacco, a significantly greater percentage of non-Hispanic black adults
smoke cigarettes compared with the other race and Hispanic origin groups.

The percentages when compared between the ages of 40-79 years of age,
adults having mild lung obstruction, the results were as follows:

Non-Hispanic white adults (16.3%)

Non-Hispanic black adults (13.5%)

Hispanic Adults (7.7%)

For moderate or worse lung obstruction, both non-Hispanic white which were
(5.9%) and non-Hispanic black which were (5.6%) adults had higher rates than
Hispanic adults (1.9%).

DIAGNOSIS

Diagnosis: Acute Bronchitis

Acute bronchitis does not require a test, it can be detected by physical

examination where the doctor places the stethoscope on the chest and listen for
any abnormal sounds produced within the lungs when you breathe.

Diagnosis: Chronic Bronchitis

The Doctor may require a chest X-ray along with physical examination, the X-ray
will reveal the extent of lung damage. Moreover, pulmonary function test like
spirometry will be performed to measure how well the lungs are functioning.

Additional tests such as complete blood count, arterial blood gas measurement
and CT scan of the chest may also be carried out to exclude other conditions like
tuberculosis, asthma, lung cancer or any other lung infection.

According to the survey, NHANES, 2007-2012, lung function value was

determined from a pre-bronchodilator spirometry examination. It defined lung
obstruction as a ratio less than the lower limit of normal of forced expiratory
volume in the first second (FEV1) to forced vital capacity (FVC).

The severity was then module as follows:

MILD LUNG OBSTRUCTION: FEV1 greater than 70% of the predicted value.

MODERATE OR WORSE LUNG OBSTRUCTION: FEV1 less than or equal to

70% of predicted adults with lung obstruction.

RELEVANT STUDY:

AIR QUALITY AND BRONCHITIS SYMPTOMS IN CHILDREN

DR. KIROS BERHANE, Professor at the department of preventive medicine, at

the University of Southern California, compared the level of air quality and
bronchitis based on the studies conducted in children with asthma and without
asthma.

Chronic respiratory symptoms are of great and significant public health and
clinical concern. A number of research studies have shown that air pollution is
associated with respiratory health problems in children, as manifested by more
diagnosis of asthma or more respiratory symptoms or impaired lung
development, especially when children live in colony environments. It is also
observed in the last twenty some years that the air pollution levels are going
down steadily in the southern California region. So, researchers wanted to see if
this reduction of air pollution level has translated into health benefits for children
as manifested by respiratory symptom reduction in the southern California
region. This investigation was based on the Southern California children's health
study, which was initiated in 1993 and had about 11500 children from 16000
California communities in this investigation which was to focus on 8 communities
which had participants from 3 different groups of children. The first group
followed from 1993-2001, the second one followed from 1996-2004, and the third
one followed from 2003-2012. There were about 4600 children in this
investigation and about 50% of them came from the latest cohort and the other
two contributed to about 25% each. Air quality was also monitored in each one of
these 8 communities. It was decided to consider children with asthma and
children without asthma. The comparison was made between three groups of
children if levels of air pollutions went down with the level of bronchitis symptoms
at the same time period. It was found that in children with asthma as the air
pollution level went down the symptoms of bronchitis also went down. The
reductions were larger in children with asthma or equally significant in children
without asthma. And in all these subgroups of children, there was a significant
reduction in symptoms of bronchitis, so this proves the findings are robust and
available also seen in all these sub-groups of children. All children are impacted
by this reduction in air pollution and are benefiting as a result. The children are
followed up along with other groups of children to monitor the changes. The
children would preferably also be followed to their young adult age or even old
age to see what the life course of these children and how air pollution affects
their growth. Other groups of researchers should replicate these studies in
another part of the United States or even other parts of the world because even
though it is well-designed and carefully conducted study, it is still an
observational study. This should be replicated in many settings so that there is a
credibility and solidified the evidence in order to say that there is a causal
relationship between air pollution and symptoms of bronchitis.
Joel Schwartz, AIR POLLUTION AND CHILDREN HEALTH,
http://pediatrics.aappublications.org/content/pediatrics/113/Supplement_3/1037.f
ull.pdf

COMPLICATIONS WITH COPD include:

Arrhythmia; irregular heartbeats.

Cor pulmonale; Right sided heart failure due to pulmonary hypertension and
high blood pressure in the right ventricle of the heart.

Pneumonia

Pneumothorax

Loss of appetite resulting in severe weight loss.

Osteoporosis; thinning of bones.

Anxiety.

TREATMENT

Treatment: Acute Bronchitis

Symptomatic treatment is carried out for the relief of symptoms which include
drinking plenty of water, resting and avoiding smoke and fumes. The patient is
prescribed paracetamol and NSAIDs that help to relieve body aches. An
expectorant may also be given in order to loosen mucus so it can be easily
coughed up. Certain bronchodilators can be inhaled to open up the airway to
relieve bronchospasm, such as IPRATROPIUM BROMIDE.
Medications generally prescribed are Antibiotics, but since 90% of the times the
cause is viral, then they may not be effective.

Cough Suppressants should be avoided, since coughing helps bring the mucus
to the surface, removing irritants from the lungs and air passage.

Treatment: Chronic Bronchitis

Since this is mostly related to smoking, the patient should quit smoking to
prevent further damage to the lungs. Pneumococcal vaccine and an annual flu
vaccine are also advised.

Treatment may include bronchodilators such as albuterol and steroids such as

prednisone or methylprednisolone for inhalation.

The bronchodilators work by relaxing the smooth muscles, therefore allowing

expansion of the airway. The steroids reduce the inflammation and swelling
encouraging better airflow.

PULMONARY REHABILATION may be performed which include education

(encouraging the patient to cease smoking) and graded physical exercises. The
aim is to optimize the functional capacity of lungs for the conditioning of the
respiratory muscles. The graded exercises include aerobic exercises such as
walking or bicycle and progressively increasing the duration, at least thrice a
week. With these practices, one must call for deep breaths and breathe out
through pursed lips slowly and gradually to allow lungs to relax.

Certain over the counter cough suppressant are also available, the alternate
method includes home remedies such has herbal teas, high doses of vitamin C,
avoiding cold air, eucalyptus oil inhalation therapy.

PROGNOSIS OF CHRONIC BRONCHITIS

This is chronic and progressive, but if patient ceases smoking and/or avoids
exposure to harmful fumes and smokes, this gives a chance for the membrane of
the bronchi to heal hence better prognosis.

Third National Health and Nutrition Examination Survey revealed the reduction in
life expectancy of patients with COPD who smoked tobacco. At age 65, the life
expectancies are as follows:

Stage 1 (mild) - 0.3 years

Stage 2 (mild- moderate) - 2.2 years

Stage 3 or 4 (moderate-severe) - 5.8 years.

These following are in addition to the 3.5 years lost due to smoking cigarettes.

In patients who have ceased smoking the reduction are 1.4 years for stage 2 and
5.6 years for stage 3 or 4.

In patients who are non-smokers, their expectancy is reduced to 0.7 years for
stage 2 COPD and 1.3 years for stage 3 or 4 COPD.

SMOKING CESSATION

In patients, with chronic bronchitis, the single most efficient path to lower the risk
of future morbidity is to give up smoking. It was documented that the FEV1 rate
declined rapidly in smokers as compared to non-smokers, which was 30ml/year
in non-smokers.

PREVENTION

CIGARETTE CESSATION- various medicines are available which helps to quit

smoking. These include Nicotine replacement theory and non-nicotine
medication.

In Nicotine Replacement Theory- this includes replacing cigarettes with another

nicotine substitute can be used such to overcome withdrawal symptoms
gradually. These include nicotine patches and nicotine gums.
Non-nicotine medicines- such as bupropion, these help to reduce cravings and
overcome withdrawal symptoms.

Getting flu vaccine yearly to prevent viral infection.

Wash your hands adequately. Make a habit of using hand Sanitizers.

Wearing surgical mask, i.e. if you already suffer from chronic bronchitis, you
should consider wearing it in order to prevent further exposure to harmful
antigens.