This document discusses chronic bronchitis and asthma. It provides information on the definition, epidemiology, risk factors, signs and symptoms, diagnosis, and treatment of each condition. For chronic bronchitis, key points include that it is progressive airflow obstruction, affects over 16 million Americans, and smoking is the primary risk factor. Asthma affects 7-10% of the population and prevalence has increased in recent decades. Diagnosis involves assessing severity, controlling triggers, and pharmacological management. Treatment focuses on minimizing symptoms and exacerbations through the use of bronchodilators and anti-inflammatory medications.

1. Kristopher R. Maday, MS, PA-C
University of Tennessee Health Science Center
Physician Assistant Program
Chronic
Bronchitis

2. Greek: noisy breathing, panting

3. • Very common disease
– Affects approximately 7-10% of the
population
– More common in male children and female
adults
• (+) genetic predisposition
• Prevalence, hospitalizations, and fatal
asthma exacerbations have all increased in
the past 20 years
– 500,000 hospitalizations each year
– 4500 deaths each year
http://www.aaaai.org/about-the-aaaai/newsroom/asthma-statistics.aspx

5. • Risk Factors
– Atopy
• Hypersensitivity to IgE release
– Obesity
• Precipitants
– Inhaled allergens
• House dust mites, cockroaches, cat dander, seasonal
pollens
– Exercise
– Upper respiratory tract infection
– Tobacco smoke
– Occupational exposures
– GERD
National Asthma Education and Prevention Program: Expert Panel Report III (EPR-3) - 2007

6. • Upper Airway Disorders
– Vocal cord paralysis, vocal cord dysfunction, foreign
body aspiration, laryngotracheal masses, tracheal
narrowing, tracheomalacia, airway edema
• Lower Airway Disorders
– Non-asthmatic COPD, bronchiectasis, cystic fibrosis,
bronchopulmonary dysplasia
• Systemic Vasculitides
– Churge-Strauss, Wegeners granulomatosis
• Psychiatric
– Conversion disorders, emotional laryngeal wheezing
• GERD
National Asthma Education and Prevention Program: Expert Panel Report III (EPR-3) - 2007

7. • Focused history is paramount
– Physical exam is relatively insensitive
– Most patients report episodic wheezing,
dyspnea, chest tightness, productive cough at
some point
– Frequency of these symptoms are highly
variable
– History of rashes
– History of allergies
– History of activity limitations

8. • Physical Exam
– Normal during non-exacerbations
– Coughing paroxysm induced by deep
inhalation or forced expiration
– Nasal mucosal swelling
– Increased nasal secretions
– Nasal polyps
– Rashes

9. • Physical Exam during exacerbation
– Tachypnea and tachycardia are ubiquitous
• 25% may have RR > 30 and HR > 130
– Diffuse musical wheezes
• Begins when peak flow decreased by 25%
• Presence and intensity does not reliably predict severity
• Greater airway obstruction with:
– Wheezing during both inspiration and expiration
– Audible without stethoscope
– High pitched
– Wheezing is absent
– Prolonged expiratory phase
– Chest hyperinflation
– Accessory muscle use or retractions
Mannam P, Siegel MD. J Intensive Care Med. 2010;25(1):3-15.

10. Gas Exchange Abnormalities
Rodriguez-Roisin R. Eur Respir J. 1997;10:1359-1371.

11. • Pulmonary Function Testing
– 2 reasons for testing
• Assess severity
• Assess reversibility
– Spirometry
• Measured before and 20 minutes after bronchodilator
• Measurements
– Forced Expiratory Volume in 1 second (FEV1)
» Increase by 12% and 200mL
– Forced Vital Capacity (FVC)
» Increase by 15% and 200mL
– Peak Expiratory Flow
• Diurnal variation > 20% supports asthma diagnosis
National Asthma Education and Prevention Program: Expert Panel Report III (EPR-3) - 2007

12. • Used in patients with suspected lung
pathology but normal spirometry
measures in the office
• 2 types
– Methacholine challenge
– Exercise challenge
• Exclusion criteria
• Positive test is a reduction of FEV1 > 20%
of baseline
Wilken LA, Joo MJ. Pulmonary Function and Related Tests. In: Basic Skills in Interpreting Laboratory Data. 2009:191-206.

13. • Absolute contraindications
• Severe airflow limitation
• FEV1 < 1.0 L or 60% predicted
• Heart attack or stroke within past 3 months
• Uncontrolled HTN
• SBP > 200 or DBP > 100
• Aortic aneurysm
• Relative contraindications
• Moderate airflow limitation
• FEV1 < 1.5 L or 75% predicted
• Pregnancy or breastfeeding
• Inability to achieve spirometry results of
acceptable quality

14. Methacholine
• Start with nebulized saline
solution
– Established baseline
• Increasing concentration of
methacholine is inhaled (every
5 minutes)
– Spirometry is performed after
each concentration increase
• Recorded as PC20FEV1 (mg/mL)
– Positive test < 8mg/mL
Exercise
• Baseline spirometry
• Can use treadmill or cycle
ergometer
• Increasing intensity of activity
until 80-90% of maximum
heart rate
– Generally takes 6-10 minutes
• Once completed, serial
spirometry is performed every
5 minutes for 30 minutes
Wilken LA, Joo MJ. Pulmonary Function and Related Tests. In: Basic Skills in Interpreting Laboratory Data. 2009:191-206.

15. • 4 components to diagnosis and
management
– Assessing and monitoring asthma severity
– Patient education designed to foster a
partnership for care
• Home monitoring
– Control of environmental factors and
comorbid conditions
– Pharmacologic management
• Prevention medications
• Treatment medicationsNational Asthma Education and Prevention Program: Expert Panel Report III (EPR-3) - 2007

16. National Asthma Education and Prevention Program: Expert Panel Report III (EPR-3) - 2007

19. • Goals of Asthma Therapy
– Minimize chronic symptoms that interfere with
normal activity
– Prevent recurrent exacerbations
– Reduce or eliminate need for emergency
department visits
– Maintain normal or near-normal lung function
National Asthma Education and Prevention Program: Expert Panel Report III (EPR-3) - 2007

20. • Inhaled Short Acting β-agonists
– Can be MDI or nebulizer
– Albuterol, Levalbuterol q4-6hrs
• Anticholinergics
– Can be MDI or nebulizer
– Ipratropium q6hrs
• Systemic Corticosteroids
– Can PO, IM, or IV
– “Burst” course
• 0.5-1mg/kg/d in daily or BID dosing x 3-10 days
– Methylprednisolone, Prednisolone, Prednisone
National Asthma Education and Prevention Program: Expert Panel Report III (EPR-3) - 2007Krishnan JA, et al. Am J Med. 2009;122:977-991.

21. • Anti-Inflammatory Agents
– Inhaled corticosteroids (ICS) preferred
• Beclomethasone, Budesonide, Flunisolide,
Fluticasone, Mometasone
• BID or daily dosing
• Side effects
– Hoarseness, dysphonia, cough, oral candidiasis
National Asthma Education and Prevention Program: Expert Panel Report III (EPR-3) - 2007

22. • Bronchodilators
– Long Acting β-agonist
• Salmeterol, Formoterol
• BID dosing
• Never used as
monotherapy
– Often combined in MDI
with ICS
– Anticholinergic
• Tiotropium
• Similar response to LABA
– Phosphodiesterase
Inhibitor
• Theophylline
• Narrow therapeutic
window
• Mediator Modulators
– Mast Cell Stabilizer
• Cromolyn, Nedocromil
– Leukotriene Modifier
• Montelukast, Zafirlukast,
Zileuton
– Immunomodulator
• Binds free IgE
• SQ injection q2-4 weeks
• Omalizumab
National Asthma Education and Prevention Program: Expert Panel Report III (EPR-3) - 2007

23. National Asthma Education and Prevention Program: Expert Panel Report III (EPR-3) - 2007

24. • Determine severity
• Supplemental oxygen if:
– SaO2 < 95%
– PaO2 < 80 mmHg
• High dose delivery (nebulizer) of:
– Inhaled short acting β-agonist (albuterol)
• Home – 2-4 puffs/1 neb every 20 minutes x 2
• ED/Office - 3 doses in 1 hour or continuous 1 hour treatment
– Anticholinergic (ipratropium)
• Systemic corticosteroids
– 0.5-1mg/kg IM or IV
• Magnesium Sulfate
– 1-2g IV over 30 minutes
Lazarus SC. N Engl J Med. 2010;363:755-764.

25. Evaluation of Asthma Exacerbation Severity (EPR-3 - 2007)
Mild Moderate Severe Imminent
Respiratory Arrest
Symptoms
Breathlessness With exertion At rest At rest
Talks in: Sentences Phrases Words
Alertness Anxious Agitated Agitated Drowsy, Confused
Signs
Respiratory Rate 20-25 25-30 > 30
Accessory muscle use Usually not Commonly Usually Parodoxical
thoracoabdominal
movement
Wheeze End expiratory Throughout expiration Inspiratory and expiratory Absence
Heart Rate < 100 100-120 > 120 < 60
Functional Assessment
Peak Expiratory Flow > 70% 40-69% < 40% < 25%
PaO2 80-100 mmHg 60-80 mmHg < 60 mmHg
PaCO2 < 40 mmHg 40-50 mmHg > 50 mmHg
SaO2 > 95% 90-95% < 90%

26. • Patient not meeting goals after 6 months of
treatment
• Step 4 or higher
• > 2 courses of oral corticosteroids in last 12
months
• Any life-threatening exacerbation or exacerbation
requiring hospitalization in last 12 months
• Suboptimal response to therapy
• Complicating comorbid conditions
– Tobacco use, multiple environmental allergies
• Atypical presentation or uncertain diagnosis

27. Greek: to smoke

28. • Definition
– Progressive airflow obstruction with airway
hyperreactivity that is no longer fully reversible
• Epidemiology
– Greater than 16 million Americans have COPD
• As many afflicted but not diagnosed
– 3rd leading of death in US
– 672,000 hospital admissions per year
– 16 million office visits to physicians per year
– $29.5 billion / year in direct health care costs yearly
– ̴120,000 deaths yearly
– Death rate from COPD increasing past several
decades, especially among women
http://www.lung.org/lung-disease/copd/resources/facts-figures/COPD-Fact-Sheet.html

29. Emphysema
Abnormal permanent
enlargement of air spaces
distal to terminal
bronchioles
Destruction of lung matrix
Loss of elastic recoil
Chronic Bronchitis
Excessive secretion of
mucus with daily
productive cough for 3
months or more in at
least 2 consecutive
years
Peribronchiol fibrosis
Airway narrowing

31. • Risk Factors
– Smoking – 80% of cases
– Occupational exposures
– Environmental Pollution
– Host factors
Rabe KF, et al. AM J Respir Crit Care Med. 2007;176:532-555.

32. • Signs and Symptoms
– Typically present in 5th and 6th decade
• Though symptoms have been present for up to 10
years prior
– Dyspnea
– Cough
– Sputum production

33. • Diagnosis
– Spirometry
• Post-bronchodilator:
– FEV1 < 80% predicted
– FEV1/FVC ratio < 0.7
• Increased lung volumes as evidenced by:
– Increased RV
– Increased TLC
– Increased RV/TLC ratio
– Arterial Blood Gas
• Normal in early disease, but will eventually progress to
chronic hypoxemia and a compensated respiratory acidosis
• Only need to check if:
– Concern for hypoxemia or hypercarbia
– FEV1 < 50%
– Clinical signs of RHF or pulmonary HTN
Rabe KF, et al. AM J Respir Crit Care Med. 2007;176:532-555.

37. • Imaging
– Generally non-diagnostic

38. • Treatment
– Stop smoking
– Stop smoking
– Stop smoking
– Supplemental Oxygen
– Medications
– Pulmonary Rehabilitation
– Surgery

40. • Home Oxygen Therapy
– Only drug therapy that improves the natural history of
COPD
• Increased survival
– After 36 months:
» Continuous – 65% survival
» Nocturnal – 45% survival
• Reduced hospitalization
• Better quality of life
– Medicare Requirements
• PaO2 < 55 mmHg or SaO2 < 88% at rest on room air
• PaO2 56-59 mmHg or SaO2 89% if evidence of:
– Dependent edema
– Pulmonary HTN
– HCT > 56%
Centers for Medicare and Medicaid Services. 1993. 100-3;240.2.Stoller JK, et al. CHEST. 2010;138(1):179-187.

41. • Medications
– Short-Acting Inhaled Therapy
• Do not alter decline in lung function
• Albuterol - less expensive, faster acting
• Ipratropium – preferred first line
– Longer duration and lack of sympathomimetic effects
– Long Acting Inhaled Therapy
• Triple Inhaler Therapy
Rabe KF, et al. AM J Respir Crit Care Med. 2007;176:532-555.

42. • Long Acting Beta Agonist (LABA)
– Formoterol, Salmeterol, Oldaterol
• Long Acting Muscarinic Agent (LAMA)
– Tiotropium
• Inhaled Corticosteroid (ICS)
– Budesonide, Beclomethasone, Fluticasone

43. • Medications
– Theophylline
• 4th line agent without adequate control on
anticholinergic, LABA, and ICS
• Improves dyspnea, exercise performance, and PFT
• Narrow therapeutic index
– Phosphodiaesterase Inhibitors
• Decrease inflammation and relax smooth muscles
• Roflumilast
– Chronic azithromycin
Rabe KF, et al. AM J Respir Crit Care Med. 2007;176:532-555.

44. • Pulmonary Rehabilitation
– Multidisciplinary program that attempts to
return patient to highest function capacity as
possible
– Graded aerobic activity designed to:
• Improved exercise capacity
• Decrease hospitalizations
• Enhance quality of life
Foglio K. Eur Respir J 1999;13:125–132.

45. • Surgery
– Lung Transplantation
• 2 year survival – 75%
• Requirements:
– Severe lung disease, limited ADLs, exhaustion of medical
therapy, adequate other organ function
– Lung Volume Reduction Surgery
• Benefits only a select population
• Bilateral resection of 20-30% of TLV
• Improves functional capacity and exercise
tolerance, but no change in mortality when
compared to medical therapy only
Martinez FJ, Change A. Semin Respir Crit Care Med. 2005;25(2):167-191.

46. Symptoms Risk Treatment
A
Less symptomatic
Mild/infrequent symptoms
CAT < 10
Low
1st – SABA or SAAC
2nd - LABA
B
More symptomatic
Moderate/severe symptoms
CAT ≥ 10
Low 1st – LAMA or LABA with SABA
C
Less symptomatic
Mild/infrequent symptoms
CAT < 10
High
1st – LAMA
2nd – LAMA + LABA or LABA + ICS
3rd – PDE-4 or theophylline
D
More symptomatic
Moderate/severe symptoms
CAT ≥ 10
High
1st – LAMA + LABA/ICS
2nd - PDE-4 or theophylline

47. • Often a prodrome of symptoms up to 7
days before the acute exacerbation
– Leads to a sub-acute decrease in lung function
• Causes
– Respiratory infection
• Most frequent cause
• Viral
– More severe symptoms and longer duration
• Bacterial
– S.pneumoniae, H.influenza, M.catarrhalis
– P.aeruginosa more prevalent in advanced stages
Rabe KF, et al. Global Strategy for Diagnosis, Management, and
Prevention of Chronic Obstructive Pulmonary Disease: GOLD Executive
Summary. AM J Respir Crit Care Med. 2007;176:532-555.

48. • Treatment
– Admission
• Severe symptoms, co-morbidities, advanced disease
– Supplemental oxygen
– Inhaled Medications
• Albuterol and Ipratropium q6hr
– Antibiotics
• Depends on local biotagram
• Needs to cover MRSA, S.pneumoniae, and P.aeruginosa
• Duration of therapy 3-7 days
– Corticosteroids
• IV Solumedrol 125mg BID
– Noninvasive Positive Pressure Ventilation for
hypercapnic respiratory failure
Rabe KF, et al. Global Strategy for Diagnosis, Management, and
Prevention of Chronic Obstructive Pulmonary Disease: GOLD Executive
Summary. AM J Respir Crit Care Med. 2007;176:532-555.
Daniels JM, et al. Antibiotics in Addition to Systemic
Corticosteroids for Acute Exacerbations of Chronic Obstructive
Pulmonary Disease. Am J Respir Crit Care Med.
2010;181:150-157.

49. • Severe (Stage C or D) or rapidly
progressing disease
• COPD before age 40
• 2 or more exacerbation per year despite
optimal therapy
• Symptoms out of proportion to airway
obstruction severity
• Need for long-term oxygen therapy
• Comorbid conditions
– CHF, lung cancer, CAD

50. w w w . p a i n e p o d c a s t . c o m