Amoxycillin + Bromhexine


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Amoxycillin + Bromhexine

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Amoxycillin + Bromhexine

  1. 1. Amoxycillin +Amoxycillin + BromhexineBromhexine Role in respiratory InfectionsRole in respiratory Infections
  2. 2. Amoxycillin + BromhexineAmoxycillin + Bromhexine  A combination of:A combination of:  Antibacterial + MucolyticAntibacterial + Mucolytic  What is theWhat is the add-vantageadd-vantage of such aof such a combination?combination?  What are the indications where its use wouldWhat are the indications where its use would be superior?be superior?  Let us peep into the background of theLet us peep into the background of the pathophysiology of the respiratory tract topathophysiology of the respiratory tract to understand this …understand this …
  3. 3. RTI OrganismsRTI Organisms  Viruses – influenza, parainfluenza,Viruses – influenza, parainfluenza, measles, varicella-zoster, respiratorymeasles, varicella-zoster, respiratory syncytial virus (RSV). Common, often selfsyncytial virus (RSV). Common, often self limiting but can be complicatedlimiting but can be complicated  BacteriaBacteria  Chlamydia, mycoplasmaChlamydia, mycoplasma  FungiFungi
  4. 4. Respiratory tract defencesRespiratory tract defences  Ventilatory flowVentilatory flow  CoughCough  Mucociliary clearance mechanismsMucociliary clearance mechanisms  Mucosal immune systemMucosal immune system
  5. 5. Lung Clearance What do the Lungs do? Mucus Clearance Effect of Disease Retention Adverse Effects Diagnosis Treatment The Lungs: FunctionThe Lungs: Function Exchange of gasesHow do they do it?
  6. 6. based on Burri & Weibel 1973 Closer understandingCloser understanding
  7. 7. Closer understandingCloser understanding Bronchial Epithelium (seen in cross-section) This is what cilia look like ??? Or like this ??? The cilia on the right side are damaged as occurs in chronic bronchitis, giving rise to decreased clearance of the mucus secretions and difficulty in expectoration
  8. 8. Knowles and Boucher, J Clin Invest, 2002: 109: 571-7 Interaction of cilia and mucusInteraction of cilia and mucus Tarran et al. J Gen Physiol 2001: 118: 223-36 Mucus transport - as seen by time-lapse photos in cell culture experiments
  9. 9. Mucus clearance & retentionMucus clearance & retention  Mucus Clearance is dependent onMucus Clearance is dependent on Mucociliary function & Cough reflex,Mucociliary function & Cough reflex,  Clearance from whole Lung andClearance from whole Lung and Tracheobronchial would be differentTracheobronchial would be different  Dependence on Deposition DistributionDependence on Deposition Distribution  Mucus composition with relation to Salt andMucus composition with relation to Salt and Water or temperature makes a differenceWater or temperature makes a difference  Medication / Physiotherapy effect outcomesMedication / Physiotherapy effect outcomes
  10. 10. Mucus clearance & retentionMucus clearance & retention Pavia 1985
  11. 11. Mucus retention in chronicMucus retention in chronic bronchitisbronchitis Pavia 1985
  12. 12. MucokineticsMucokinetics  Drugs that increase and aid clearance ofDrugs that increase and aid clearance of respiratory tract secretionsrespiratory tract secretions  Hypoviscosity agents (Wetting agents)Hypoviscosity agents (Wetting agents)  MucolyticsMucolytics  Expectorants (Bronchomucotropics)Expectorants (Bronchomucotropics)
  13. 13. Muco-ciliary BlanketMuco-ciliary Blanket  95% water, 2%95% water, 2% glycoproteinsglycoproteins  Gel layer-high viscosityGel layer-high viscosity from goblet cellsfrom goblet cells  Sol layer – low viscositySol layer – low viscosity from submucosalfrom submucosal bronchial glandsbronchial glands
  14. 14. Muco-ciliary BlanketMuco-ciliary Blanket  Both goblet cells and bronchial sub-mucosalBoth goblet cells and bronchial sub-mucosal glands increase secretion when irritated.glands increase secretion when irritated.  Vagal stimulation will also increaseVagal stimulation will also increase bronchial sub-mucosal gland secretion.bronchial sub-mucosal gland secretion.  Increased goblet cell secretion = increasedIncreased goblet cell secretion = increased sputum viscosity.sputum viscosity.  Increased bronchial sub-mucosal glandIncreased bronchial sub-mucosal gland secretion = decreased sputum viscositysecretion = decreased sputum viscosity
  15. 15. Need forNeed for MucokineticsMucokinetics when secretions increase inwhen secretions increase in amount and/or viscosityamount and/or viscosity
  16. 16. MucolyticsMucolytics  AidAid mucokinesismucokinesis by breakingby breaking up bonds inup bonds in mucusmucus  BromhexineBromhexine is an oralis an oral mucolyticmucolytic agent with aagent with a low level oflow level of associatedassociated toxicity.toxicity.
  17. 17. Mucolytics: BromhexineMucolytics: Bromhexine  Causes BronchorrheaCauses Bronchorrhea  It acts on the mucus atIt acts on the mucus at the formative stages inthe formative stages in the glands, within thethe glands, within the mucus-secreting cells.mucus-secreting cells.  Bromhexine disrupts theBromhexine disrupts the structure of acidstructure of acid mucopolysaccharidemucopolysaccharide fibres in mucoid sputumfibres in mucoid sputum and produces lessand produces less viscous mucus, which isviscous mucus, which is easier to expectorate.easier to expectorate.
  18. 18. ExpectorantsExpectorants (Bronchomucotropics)(Bronchomucotropics)  Usually stimulate sol layer production byUsually stimulate sol layer production by direct irritation or indirect through vagaldirect irritation or indirect through vagal stimulationstimulation  Remember, ↑ sol means decreased viscosity!Remember, ↑ sol means decreased viscosity!  Smoke is a bronchomucotropic!Smoke is a bronchomucotropic!  Unfortunately, it’s irritation stimulates theUnfortunately, it’s irritation stimulates the bronchial submcosal glands AND the goblet cellsbronchial submcosal glands AND the goblet cells so there is in ↑ mucus production & viscosityso there is in ↑ mucus production & viscosity  Spicy food ↑ sol due to vagal stimulation!Spicy food ↑ sol due to vagal stimulation!  Expectorants include guaphenesin,Expectorants include guaphenesin, ammonium chlorideammonium chloride
  19. 19. ExpectorantsExpectorants (Bronchomucotropics)(Bronchomucotropics) GuaifenesinGuaifenesin  Vagal stimulation likeVagal stimulation like without foul taste orwithout foul taste or severe side effectssevere side effects  Active ingredient inActive ingredient in many “cough”many “cough” medicines.medicines.  Very effectiveVery effective expectorant for chronicexpectorant for chronic bronchitisbronchitis Ammonium ChlorideAmmonium Chloride  Vagal stimulation onlyVagal stimulation only  Found in many children’sFound in many children’s “cough” syrups because it“cough” syrups because it is easy to flavoris easy to flavor  Side effects are like SSKISide effects are like SSKI and Guaifenesinand Guaifenesin  Also may cause metabolicAlso may cause metabolic acidosisacidosis
  20. 20. Amoxycillin + BromhexineAmoxycillin + Bromhexine  Better than most respiratory antibacterialsBetter than most respiratory antibacterials especially where sensitivity is assured;especially where sensitivity is assured;  Time tested and trusted antibacterial,Time tested and trusted antibacterial,  Bonus effects of mucolyticBonus effects of mucolytic  Eliminates the need for expectorantsEliminates the need for expectorants  2 benefits at the price of 12 benefits at the price of 1  Antibacterial + mucokinesisAntibacterial + mucokinesis