Definition
A.Chronic bronchitis is excessive mucus secretion with chronic or recurrent productive cough occurring 3 successive months a year for 2 consecutive years.
B.Others limit the definition to a productive cough that lasts more than 2 weeks despite therapy.
C.Patients with chronic bronchitis have more mucus than normal because of either increased production or decreased clearance. Coughing is the mechanism for clearing excess secretion.
Incidence
A.The incidence of chronic bronchitis is uncertain. There is a lack of definitive diagnostic criteria, and there is considerable overlap with asthma. Visits for bronchitis are second only to visits for otitis media and are slightly more common than for asthma.
B.Chronic bronchitis prevalence increases with age.
C.Chronic bronchitis rates are highest in African American and Caucasian ethnicities.
Pathogenesis
A.Mucociliary clearance is delayed because of excess mucus production and loss of ciliated cells, leading to a productive cough.
B.Bacteria most often implicated are Streptococcus pneumoniae, Haemophilus influenzae, Mycoplasma pneumoniae, and Moraxella catarrhalis.
C.Specific occupational exposures are associated with symptoms of chronic bronchitis, including coal, cement, welding fumes, organic dusts, engine exhausts, fire smoke, and secondhand smoke.
Predisposing Factors
A.Cigarette smoking.
B.Cold weather.
C.Acute viral infection.
D.Chronic obstructive pulmonary disease (COPD)/emphysema.
E.Occupational exposure to other airborne irritants.
F.Chronic, recurrent aspiration or gastroesophageal reflux.
G.Allergies.
H.Immunosuppression.
I.Frailty.
Common Complaints
A.Worsening cough: Hacking, harsh, or raspy sounding.
B.Changes in color (yellow, white, or greenish), amount, and viscosity of sputum.
C.Rattling
sound in chest.
D.Dyspnea/breathlessness.
E.Wheezing.
Other Signs and Symptoms
A.Difficulty breathing, retrosternal pain during a deep breath or cough.
B.Rapid respirations.
C.Fatigue.
D.Headache.
E.Loss of appetite.
F.Fever.
G.Myalgias.
H.Arthralgias.
I.Sleep disturbance due to cough.
Subjective Data
A.Determine the onset, course, and duration of illness.
B.Is the patient having trouble breathing?
C.Has there been a fever?
D.How is the patient’s appetite? Is the patient drinking enough fluids?
E.Does the patient smoke, or is the patient exposed to secondhand smoke?
F.Review occupational history to evaluate exposure to irritants.
G.Does the patient have a history of asthma?
Chronic bronchitis has a long history of a productive cough and late-onset wheezing. Patients with asthma with a chronic obstruction have a long history of wheezing with a late onset of productive cough.
H.Chest pain in any certain area?
I.When was the patient’s last illness?
J.Blood glucose levels if diabetic.
K.Frequency of short-acting beta-2 agonists (SABA) inhaler use and effectiveness.
L.Any confusion or lack of appetite (especially in advanced age).
Physical Examination
A.Check temperature, pulse, blood pressure (BP), respirations, and pulse oximetry.
B.Inspect:
1.Observe overall appearance including signs of respiratory distress.
2.Inspect eyes, ears, nose, and throat:
a.Pharynx may be injected.
b.Conjunctivitis suggests adenovirus.
3.Transilluminate sinuses.
4.Assess skin turgor and mucous membranes for dehydration.
C.Auscultation:
1.Auscultate lungs in all fields. Lung sounds may sound normal to scattered, bilateral crackles, rhonchi, or large airway wheezing.
2.Auscultate heart.
D.Percuss chest.
E.Palpate:
1.Anterior/posterior cervical lymph nodes.
2.Maxillary and frontal sinuses.
Diagnostic Tests
A.Patients with uncomplicated respiratory illness need little, if any, laboratory evaluation.
B.Pulse oximetry.
C.Sputum culture to identify bacteria.
D.Chest radiograph (CXR) may help exclude other diseases or complications.
E.Pulmonary function studies may be indicated.
F.ECG and pulmonary function tests (PFTs) may be required for COPD patients.
Differential Diagnoses
A.Chronic bronchitis.
B.Acute bronchitis.
C.Asthma.
D.Sinusitis.
E.Cystic fibrosis (CF).
F.Bronchiectasis.
G.Central airway obstruction.
H.Pneumonia.
I.Lung cancer.
J.Aspiration syndrome.
K.Gastroesophageal reflux.
L.Tuberculosis (TB).
M.Foreign body.
Plan
A.General interventions:
1.Rest during early phase of illness.
2.Encourage stopping smoking and staying away from secondhand smoke.
3.Suggest exercise for patients with COPD.
4.The patient’s goal is to improve symptoms and to decrease cough and production of sputum.
5.Inform patients that increased sputum production may occur after smoking cessation and the patient may have airway reactivity (wheezing), especially seen in asthmatics.
6.Discuss patient’s choices of advance directives preferably before exacerbation occurs.
B. 
See Section III: Patient Teaching Guide Chronic Bronchitis.
C.Dietary management:
1.Increase fluids unless contraindicated.
2.Eat nutritious food.
D.Pharmaceutical therapy:
1.Bronchodilators should be considered for bronchospasm:
a.Albuterol sulfate (Proventil, Ventolin):
i.Adults: Metered-dose inhaler (MDI) actuations (90 mcg/actuation) inhaled every 4 to 6 hours.
2.Analgesics and antipyretics are used to control fever, myalgias, and arthralgias.
3.Consider oral steroids to decrease inflammation:
a.Adults: 5 to 60 mg/d by mouth.
b.Tapering steroids is not necessary with short courses.
4.Inhaled corticosteroid (ICS) may be effective:
a.Beclomethasone (QVAR) available as an MDI that delivers 40 or 80 mcg/actuation:
i.40 to 80 mcg inhaled by mouth twice a day, not to exceed 320 mcg twice a day.
b.Fluticasone (Flovent HFA, Flovent Diskus). Available as MDI (44, 110, or 220 mcg per actuation) and diskus powder for inhalation (50, 100, or 250 mcg per actuation):
i.Adults:
•MDI: 88 mcg inhaled by mouth twice a day, not to exceed 440 mcg twice a day.
•Diskus: 100 mcg inhaled by mouth twice a day, not to exceed 500 mcg twice a day.
5.Antibiotics for bacterial infection (two of the following should be present to consider antibiotics: dyspnea, increased cough, or purulent sputum):
a.Amoxicillin-clavulanic acid (Augmentin):
i.250 to 500 mg by mouth every 8 hours.
b.Doxycyline 100 mg by mouth every 12 hours.
c.Trimethoprim-sulfamethoxazole 80 to 160 mg by mouth every 12 hours.
d.Suspected pseudomonas coverage or 65 or older with cardiac disease: Levofloxacin 500 mg daily.
Follow-Up
A.Follow up if there is no improvement in 3 to 4 days after starting therapy.
B.Recommend yearly influenza vaccinations and vaccinations against pneumonia.
Emergent Issues/Instructions
A.Patient should understand to seek emergency care should their shortness of breath (SOB) worsen, in accordance with the Advance Directive.
Consultation/Referral
A.Refer patients with respiratory distress to a physician. If respiratory failure occurs (rare), hospitalization may be needed.
B.Refer patients with COPD to a physician or pulmonary specialist.
C.Pulmonary rehab should be considered once recovered.
Individual Considerations
A.Geriatrics:
1.Follow-up may be needed every 24 hours to ensure improvement and to assess for septic changes.
2.Use of hand-held bronchodilator should be demonstrated. Older adults who are cognitively intact or mildly impaired may be unable to use standard inhalers. Spacing chambers may be used to assist in proper delivery of inhaled medications. Nebulized treatments should also be considered for the following issues:
a.Decreased manual dexterity due to arthritis or reduced grip strength.
b.Cognitive impairment: Difficulty coordinating the required activation/inhalation steps to achieve proper penetration of medication into the lungs.
3.The patient’s choice for aggressive care, including ventilation, should be noted in the chart, and shared with family members.
Resource
Pulmonary Disease Aerosol Delivery Devices: A Guide for Physicians, Nurses, Pharmacists, and Other Health Care Professionals is available at www.aarc.org/wp-content/uploads/2018/03/aersol-guides-for-hcp.pdf