The document discusses lower respiratory tract infections (LRTIs) with a focus on bronchitis, its types (acute and chronic), and management strategies. It highlights the pathogenesis, common pathogens, risk factors, symptoms, and treatment options for both acute and chronic bronchitis, emphasizing the importance of symptomatic care and when antibiotics may be necessary. Additionally, it addresses the role of vaccinations in preventing complications related to these infections.

1. LOWER RESPIRATORY TRACT INFECTIONS
BRONCHITIS
ARWA M. AMIN MOSTAFA
PHD, M.PHARM CLINICAL PHARM, DIP MANGT, B.PHARM.

2. Arwa M. Amin
What We will Discuss Today?
 What are the Lower Respiratory Tract Infections (LRTIs)?
 What is Bronchitis and what are the different types of
Bronchitis?
 What are the pathogenesis, common pathogens, risk factors
and symptoms of Acute Bronchitis?
 How to manage Acute Bronchitis?
 What are the pathogenesis, risk factors, common bacterial
pathogens, and clinical presentation of Chronic Bronchitis?
 What is Acute Exacerbated Chronic Bronchitis (AECB)?
 How to manage Chronic Bronchitis?

3. Arwa M. Amin
Lower Respiratory Tract Infections (LRTIs)
 LRTIs are infections which affect the Lower respiratory tract
System, i.e. the Trachea, bronchi (airways) and Lungs.
 LRTIs include:
 Bronchitis
Acute Bronchitis
Chronic Bronchitis
 Bronchiolitis
 Pneumonia
Community Acquired Pneumonia (CAP)
Hospital Acquired Pneumonia (HAP)

4. Arwa M. Amin
Bronchitis
 Bronchitis is an Inflammation of the tracheobronchial tree lining
which is commonly associated with respiratory infection.
 Acute Bronchitis
Transient inflammation
Begins as URTIs
Short-term symptoms
Occurs in All Ages
Adults and Children
 Chronic Bronchitis
Long-term conditions
Symptoms > 3 months
Affects primarily Adults
URTIs: upper respiratory tract infections

5. Arwa M. Amin
Pathogenesis of Acute Bronchitis
Transient Inflammation and Swelling of the tracheobronchial tree
tissues due to infection.
This leads to:
• ↑↑ Mucus production
• Edema of the bronchus
• Mild to extensive destruction of
the epithelium
• Narrowing of the airways
• Difficultness of breathing
• Productive cough

6. Arwa M. Amin
Acute Bronchitis: Common Pathogens
 Mostly Viral Infection
Common cold viruses
Rhinovirus
Coronavirus
LRT viruses
Influenza virus
Adenovirus
Respiratory Syncytial Virus (RSV)
 Some Bacterial infection
Mycoplasma pneumoniae. G (-)
Chlamydia pneumoniae. G (-)
Bordetella pertussis. G (-)
Coronavirus Influenza virus
RSV
Chlamydia pneumoniae*
Micrograph of Chlamydophila (Chlamydia) pneumoniae in an epithelial cell in acute bronchitis: 1 – infected epitheliocyte,
2 – uninfected epitheliocytes, 3 – chlamydial inclusion bodies in cell, 4 – cell nuclei,

7. Arwa M. Amin
Risk factors of Acute Bronchitis
 Close contact with infected patient
Inhalation of infecting droplets
 Cold climate (Winter months).
 Smoking
 Exposure to tobacco smoke
 Air pollution & dust

8. Arwa M. Amin
Symptoms of Acute Bronchitis
 Begins with URTIs symptoms such as runny
and stuffy nose with sore-throat.
 Fever
 Headache
 Chest discomfort
 Shortness of breath
 Coughing
 Initially Non-productive
 Progress with mucus production
 May be clear-yellow or green
 Fatigue & Tired
 Wheezing
URTIs: upper respiratory tract infections

9. Arwa M. Amin
Management of Acute Bronchitis
 Treatment of Acute Bronchitis is mainly Symptomatic and
Supportive:
Bed Rest
Encourage patient to drink fluids
 To prevent dehydration
Mist therapy (or using of vaporizer)
 To promote loosening of respiratory secretions
 Goal of Treatment:
Mild case: To provide comfort to the patient
Severe case: To treat dehydration and respiratory compromise

10. Arwa M. Amin
Management of Acute Bronchitis
 Cough Suppressants:
 Persistent, Mild cough: Dextromethorphan
 Severe Cough: Intermittent codeine
Analgesics-Antipyretic Therapy:
 Aspirin, Acetaminophen and Ibuprofen
 Use Acetaminophen in children
 Avoid using Aspirin in children; why?
 Taking Aspirin in viral infected children may ↑↑ the risk of Reye’s
syndrome development

11. Arwa M. Amin
Management of Acute Bronchitis
 No Antibiotic (AB) Treatment for Acute Bronchitis unless Bacterial
Infection is suspected or confirmed.
 Acute Bronchitis is Self Limiting. The infection usually goes away
within one week by it self.
 If Bacterial Infection is suspected or confirmed, AB can be used.
 E.g. Mycoplasma pneumonia
Azithromycin
Fluoroquinolone such as Levofloxacin (Adults only)

12. Arwa M. Amin
Pathogenesis and Risk factors of Chronic Bronchitis
 Chronic Inflammation of the bronchi with hypersecretion of mucus which
causes mucus plugging and smaller airways.
 Chronic smoking and heavy exposure to pollutants compromises
bronchial mucosa.
 Chronic Bronchitis is characterized by cough with excessive mucus
production, most of the days for at least 3 consecutive months for at least
2 consecutive years.
 Often coexist with COPD* & Emphysema**
 Risk Factors:
 Smoking cigarette
 Exposure to Air pollution
 Bacterial and (possibly viral) infection
 Genetic factors
• COPD: chronic obstructive pulmonary disease
** Emphysema: Destruction and enlargement of air-space

13. Arwa M. Amin
Common Bacterial Pathogens of Chronic Bronchitis
 Most common Bacterial Pathogens:
 Haemophilus influenzae. G (-)
 Moraxella catarrhalis. G (-)
 Streptococcus pneumoniae. G (+)
 Escherichia coli. G (-)
 Enterobacter species. G (-)
 Klebsiella. G (-)
 Pseudomonas aeruginosa. G (-)
Gram stain Streptococcus
pneumonia
E. coli
Pseudomonas aeruginosa

14. Arwa M. Amin
Clinical Presentations & Diagnosis of Chronic Bronchitis
Signs and Symptoms
 Bronchospasm (Constriction of bronchial airways)
 Mild to severe productive Cough with excessive sputum
 ↑↑ Sputum Quantity in the morning
 Tenacious sputum
 White to yellow-green sputum
Diagnosis
 Diagnosis mainly depends on clinical assessment and history
(productive cough > 3 consecutive months for > 2 consecutive
years)

15. Arwa M. Amin
Chronic Bronchitis with Acute Exacerbation
 Acute Exacerbation of Chronic Bronchitis (AECB) is associated
with increased Purulent Sputum Production.
 Diagnosis of AECB is achieved by Cardinal Symptoms:
 ↑↑ Dyspnea
 ↑↑ Cough
 ↑↑ Sputum production/purulence
 Change in patient “normal” routine

16. Arwa M. Amin
Management of Chronic Bronchitis
Non-Pharmacological Treatment of Chronic Bronchitis:
↓↓ Exposure to irritants (air-pollution and cigarette
smoke)
↓↓ or Eliminate cigarette smoking (Smoking cessation
programs)
Humidification of inspired air
 To promote hydration (liquefaction) of tenacious
secretions
Goal of Therapy:
To reduce the severity of symptoms.
To ameliorate acute exacerbations (i.e. AECB).
To achieve prolonged infection-free intervals.

17. Arwa M. Amin
Management of Chronic Bronchitis
Pharmacological Therapy
 Symptomatic Treatment:
 Bronchodilators such as short acting β2 agonist (e.g. Albuterol) –
Oral or aerosolized, particularly during AECB.
 Chronic inhalation of long-acting β2 agonist and inhaled
corticosteroid combination (e.g. Salmeterol/Fluticasone) can
improve pulmonary function and quality of life.
 Long term inhalation of Ipratropium:
 ↓↓ Frequency of cough
 ↓↓ Severity of cough
 ↓↓ Volume of expectorated sputum
 Treatment of Chronic Bronchitis co-existing with COPD
 Long acting β2 agonist + Inhaled corticosteroids

18. Arwa M. Amin
Management of Chronic Bronchitis
Antibiotic (AB) treatment:
AB treatment in Chronic Bronchitis is Effective if 2 or 3 of the following
symptoms are present:
 ↑↑ Dyspnea
 ↑↑ Sputum volume
 ↑↑ Production of Purulent sputum
Commonly used AB for AECB:
Ampicillin & Amoxicillin
Amoxicillin-Clavulanate
Fluoroquinolones: Ciprofloxacin, Levofloxacin, Moxifloxacin
Tetracyclines: Doxycycline, Minocycline, Tetracycline
Trimethoprim-sulfamethoxazole

19. Arwa M. Amin
Management of Chronic Bronchitis
Vaccination:
Influenza Vaccine (October – December, every year)
Pneumonia vaccine for older adults (> 65 years old) and high risk patients

20. Arwa M. Amin