Muller, Hendrik

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South African Medical Journal Suid-Afrikaanse Tydskrif vir GeneeskundeCape Town, 26 September 1959General Practice SeriesVolume 33 No, 39 Deel 33 Kaapstad, 26 September 1959CHRO lC BRO JCHlTlS AND EMPHYSEMAHENDRlK MULLER, B.M. (OXON), M.R.C.P. (LOND.,) Cape TownChronic bronchitis has been defined by Scadding as 'thecondition of those patients suffering from chronic recurrentcough and expectoration, and usually effort dyspnoea, inwhom these symptoms are not caused by disease of thelungs, by localized disease of the bronchi, trachea or upperrespiratory tract, or by primary cardiovascular disease'. InGreat Britain and other countries where climate and in-dustrial air pollution together produce the ideal conditionsfor its development, chronic bronchitis and the later de-velopment of emphysema cause a heavy mortality andmorbidity. In South Africa, fortunately, the disease is muchless common, but still occurs often enough to make it animportant illness to guard against by prophylactic measures,and to recognize and treat during the early stages of itsdevelopment.CLINICAL PICTUREMost typically the condition begins with recurrent attacksof winter bronchitis, each attack being more persistent andmore productive of cough and expectoration than the pre-ceeding bout. These attacks may start in early childhood andmay then clear up for some years, or persist and progressyear by year. The onset may, however, occur at almost anyage; but there is always a heavier incidence in men thanin women.After a varying number of winters tightness and wheezingin the chest become noticeable, at first only during thebronchial attack, but later between attacks also. As thecondition progresses this becomes a major feature of thedisease, causing dyspnoea on effort and even at rest, some-times with obvious attacks of 'bronchial asthma', while atthe same time the cough tends to persist through the wholeyear with acute exacerbations during the time of the previous'winter bronchitis' and also during any respiratory infection.Between these acute attacks the expectoration may beminimal and mainly mucoid, but with the superimposedinfections the sputum increases in amount and becomesfrankly mucopurulent.Gradually the picture of emphysema develops, with thedeep barrel-shaped chest, the hyperresonant note on percus-sion (obliterating the normal cardiac and liver dullness),noisy, wheezing and prolonged expiration associated withrhonchi over the lungs, and marked dyspnoea. In the pre-terminal stage polycythaemia and 'central' cyanosis developand, almost inevitably, failure of the right heart follows,with increased jugular venous pressure, hepatomegaly andoedema of the feet. This is one type of heart disease towhich the term 'cor pulmonale' is correctly applied, but inthe past it has often been recorded on the death certificateas 'myocarditis', 'myocardial degeneration', etc. These casesshow 'central' cyanosis, i.e., cyanosis of the tongue andmucous membranes in addition to blueness of the extremi-ties, as opposed to the usual peripheral cyanosis of mostcases of heart failure. The term' 'black cardiac' has beencoined for the most extreme cases of this type. Finally,the onset of drowsiness and confusion indicates that, unlesstreatment is effective, the end is near.AETIOLOGY(a) Climate and Air PollutionAs is to be expected, bronchitis occurs most frequentlyand severely where the winter is damp and cold, and inSouth Africa it is probably most seen at the Cape, althougheven here the winters cannot be judged severe as comparedwith countries such as England and Northern Europe. Itmust also be accepted that not only climate is importantbut also the heavy pollution of the atmosphere with industrialetlluents and smoke and, where climatic and industrialconditions are combined, chronic bronchitis and emphysemahave their highest incidence. During every fog, or moreespecially 'smog', there is always a sharp rise in hospitaladmissions for chronic bronchitis and respiratory illnesses,and also in the mortality from bronchitis and emphysema.Fortunately, heavy atmospheric pollution is also not commonin South Africa, so that the combined effect of climate andindustrial factors is seldom seen here. In highly indus-trialized countries such as England this association is com-mon and both the incidence and the mortality of bronchitisare much higher in London and Manchester and in the in-dustrial areas generally than in the countryside.(b) SmokingVarious surveys of the effect of smoking have indicatedthat it bears a definite aetiological relationship to this dis-ease. Even in the United Kingdom, where climate and airpollution are the major factors in the production of theillness, Doll and Bradford Hill found that in male doctorsover the age of 35 heavy smoking caused a 6-fold increasein the mortality from bronchitis. The incidence of chronicbronchitis closely parallels that of carcinoma of the bronchus,which must be accepted as being associated with heavycigarette smoking. Finally, duodenal ulceration, anotherdisease of smokers, has a significant association with chronicbronchitis. That smoking produces bronchitis is not sur-prising; it is indeed so widely recognized by the laity, whohave coined the term 'smoker's cough', that it is acceptedas normal. One may presume that in the Union, where con-sumption of cigarettes per unit of population is exception-"805806 S.A. MEDICAL JOURNAL 26 September 1959ally heavy, and where the climatic and air-pollution factorsin the production of chronic bronchitis are minimal, theaetiological significance of smoking is greatly increased.It is indeed unusual in this country to find chronic bron-chitis and emphysema in non-asthmatic patients who arealso non-smokers. It is surprising how little attention ispaid to this factor both by patients and their medical advisers.(c) ConstitutionConstitutional factors undoubtedly are of very greatimportance in chronic bronchitis. These patients usuallyhave a long history of cough, even dating back to childhood,or recurrent respiratory infections, nasal catarrh and repeatedbouts of bronchitis can be traced, this tendency to 'weakchests' often being a familial one. Asthma and other respira-tory allergies undoubtedly do tend to predispose to chronicbronchitis at a later period of life.(d) InfectionThe role of infection is also of considerable importance.These patients seem to develop respiratory infections veryreadily, and these infections are more persistent and severethan in other subjects. Exacerbations of established chronicbronchitis occur when respiratory infections are rife; butno particular organism. can be incriminated, a variety oforganisms being obtained from the sputum during exacer-bations. Naturally enough, antibiotics ·have been employedfor years in treating these acute infections, but more recentlytheir use in prophylaxis has been under trial, with promisingresults.PATHOLOGYThe nature of the essential lesions in chronic bronchitisis not clearly understood. Various authors have suggested.that a primary disturbance of the mucus-secreting cells ofthe respiratory tract is the basic factor, the resulting swellingof the mucous membrane causing obstruction to the airway,especially in expiration. This expiratory obstruction, possiblyin conjunction with a constitutional weakness of the alveolarwalls of the lungs, causes breakdown of the alveolar parti-tions, which is the basic feature of emphysema. As a directresult, the pulmonary capillary bed is diminished and in-c;:reased work is demanded from the right heart in the circula-tion of the blood through the lungs. The healthy myo-cardium of the right ventricle usually has no difficulty inmaintaining a moderate increase in the pulmonary arterialpressure, and it is commonly only with the aging of themyocardium (around the age of 50-55) that embarrassmentof the right ventricle becomes apparent. By this time alveolardestruction has reached an advanced state; at the sametime ventilation of these damaged alveolar spaces is restrictedby bronchial and bronchiolar obstruction, and impairedoxygenation of the arterial blood, with central cyanosis,results. Parallel· with the reduction in oxygen tension inthe alveoli, CO2 retention occurs, so that the CO. tensionin the arterial blood rises as the oxygen tension falls.It must be emphasized that the cause of the arterial oxygendesaturation and the CO2 retention is the impaired ventila-tion of the alveolar spaces, and that shunting of blood fromLhe pulmonary artery to pulmonary vein by anastomosesis of little importance. Nor is a diffusion defect across thealveolar-eapillary barrier demonstrable. With the deficientoxygenation of the blood, reflex pulmonary arteriolar con-traction occurs, with a further rise in the pulmonary arterialpressure, further aggravated in many cases by secondarypolycythaemia and increased viscosity of the blood, so thatthe stage is now set for failure of the overburdened rightheart. Any respiratory infection, by causing further limita-tion of alveolar ventilation, may acutely precipitate thecondition of central cyanosis, CO 2 retention and right heartfailure, which, under favourable circumstances, may be asrapidly reversible if infection and spasm can be overcome.The chronic termjnal condition, however, is more resistantto treatment, and chronic CO2 retention ultimately causesthe drowsiness, confusion and coma which, with fallureof the right heart, is the main cause of death in these cases.TREATMENTProphylaxis(a) In patients who are subject to recurrent respiratoryinfections and winter bronchitis, the ultimate developmentof chronic bronchitis and emphysema is always to be feared,so that measures to prevent infection and irritation of therespiratory passages should be instituted at an early stagebefore irreversible damage has been done. As far as infec-tion is concerned, avoidance of crowded, stuffy places,particularly during the season of respiratory infections,should be advised, but it usually is almost impossible toenforce this in patients who have to travel in buses to work,or who work in close proximity to others who may carryinfections. Vaccines have been recommended and may beworth a trial, although convincing evidence of effectivenessis still lacking. Long-term prophylactic treatment withantibiotics, such as the tetracyclines in doses of 0·25 orO' 5 g. per day, has shown considerable promise. In care-fully controlled experiments convincing' evidence of a re-duction in the frequency of attacks of bronchitis, and evenan improvement in the condition of the lungs, have beenobtained. Unfortunately, expense alone is likely to makethis unacceptable to the majority of patients, and occasionaltoxic reactions also are a hazard. It seems likely that earlytreatment of acute bronchitis is a more acceptable methodof prevention of further lung damage.(b) Avoidance of bronchial irritation by smoke, dust orfumes is an obvious step, but may be difficult to implementin certain trades; consideration may then have to be givento the advisability of a change of work or residence, whenthis is possible. The obvious importance of a completeban on smoking is unfortunately usually either overlookedor insufficiently stressed by the medical attendant, andnearly always meets with considerable resistance on thepart of the patient. Frequently patients who have smokedheavily for years are ultimately forced to give up smokingwhen bronchitis with emphySema has already reached acrippling stage, but unfortunately it is then too late to expectmore than slight relief of symptoms. It must be emphasizedagain that, especially in this country, smoking is one of themajor causes of chronic bronchitis and emphysema.(c) In the various geographical areas of South Africathere is a wide range of climatic conditions, so that sufferers,26 September 1959 S.A. TYDSKRIF VIR GENEESKUNDE 807or potential sufferers, from chronic bronchitis and emphys-ema can practically always find some part of the countrywhere the climate factor can be eliminated; the cold andwet winters of the Western Province, particularly the CapePeninsula, is obviously unsuited to these patients, and theclimate of the Karroo or high veld, or possibly the . latalCoast, is much to be preferred. It is often difficult to per-suade patients that such a major upheaval in their lives isjustified or necessary, but where the condition is progressingyear by year, there can be no doubt that such a changeshould be seriously considered.Acute BronchitisTreatment of the acute attack of bronchitis follows theordinary accepted measures, namely, rest in bed in a warm,well-ventilated room, antispasmodics (such as ephedrine,aminophylline or a combination of the two, and a sedative);and expectorant cough mixtures ami inhalations. Expec-torants have a time-honoured role but are of doubtful value,and inhalations of menthol, etc., also are mainly psycho-logical in value; but a linctus containing codeine, heroin,opium, etc., is often necessary to ensure a reasonable night'srest from the distressing cough. Antibiotics are usually ofthe greatest value, especially when the sputum is muco-purulent in character, and preference should be given tothe broad-spectrum antibiotics of the tetracycline group,or to novobiocin or chloramphenicol. Adequate dosageis essential during the severe phase of the cough, and atleast 500 mg. 6-hourly should be given until a good re-sponse is obtained, when the dosage may be reduced tohalf this amount. Penicillin, or penicillin combined withstreptomycin, is not usually as effective as the broad-spectrumantibiotics and, as the sufferer from chronic bronchitis isoften also an allergic subject, the danger of penicillin re-actions is very real. Steroids, suCh as cnrtisone, hydro-cortisone, prednisone, etc., play little part in the treatmentof bronchitis in the ordinary case, but where there is anallergic background they may be of definite value in speedingrecovery. If a steroid is going to give relief, improvementis noticeable within 24-48 hours of its exhibition, and ifthis is not evident after 48 hours its use should be discon-tinued. Prednisone, 10-15 mg. 6-hourly, is a favouredpreparation and, if effective, it can be maintained in slowlyreducing doses for 10-14 days as necessary. Patients shouldbe made to understand that any respiratory infection, evena minor cold, should be regarded as a major illness andshould justify a period of treatment in bed, while the fullroutine outlined above should be instituted if any evidenceof bronchitis develops.Chronic BronchitisThe more prolonged the chronic bronchitis, and themore severe the emphysematous changes in the lungs, themore severe the effects of each attack of acute bronchitis.Patients with advanced disease are usually willing to co-operate to the fullest extent in their treatment (except forthe question of giving up smoking) but it is impossible toreverse the structural damage to the lungs, so that the resultsof treatment cannot be really satisfactory; obviously It ISof great importance to insist on adequate prophylacticmeasures in younger patients before the full-blown pictureof chronic bronchitis and emphysema develops.Cor PulmonaleIn patients who are already cyanosed, an acute bronchialattack is a major illness which may terminate fatally, andtreatment is a matter of urgent importance. Cardiac failuremay develop, producing a rise in jugular venous pressure,hepatomegaly, and oedema of the legs. Increased cyanosis,so that the tongue becomes a dark blue colour, is then tobe expected, while consciousness becomes dulled .and thepatient drowsy and stuporose. The development of comais usually a pre-terminal event. Treatment here is the sameas for any acute attack of bronchitis, and a response toantibiotics offers the best hope of recovery. In addition,mersalyl, 2 c.c: every 2nd or 3rd day, may be of great value,or chlorothiazide, 2-4 tablets (I to 2 g.) daily, may be sub-stituted. Diamox may be especially useful, because it hassome effect in lowering the CO 2 tension of the blood inproducing its diuretic effect. It certainly is worth a trialin severely ill patients. Full digitalization is recommended,but may have disappointingly little effect on the degree ofheart failure. The administration of oxygen is obviouslysuggested by the cyanosis, but it should be used with cautionbecause it may cause deepening of the stupor and evencoma and death. In these patients the prolonged and exces-sive degree of CO2 retention leads to a blunting of its normalstimulating effect on the respiratory centre, and lowered.oxygen tension of the arterial blood is the main respiratorystimulus; if this is removed by free administration of oxygen(as in an oxygen tent), the respiratory efforts are diminishedand the patient rapidly becomes more comatosed owingto a rise in the arterial CO2 tension although, paradoxicallyhis colour improves and cyanosis may be absent. Oxygentherefore should be given only by nasal catheter, preferablyintermittently, and at the first sign of increased unconscious-ness it should be stopped until consciousness is again re-stored. Where facilities are available for assisted respiration,oxygen may naturally be given freely with much benefitto the patient. Ideally, in the comatosed case a tracheotomyshould be performed, and IPPR (intermittent positivepressure respiration) can then be applied with considerablebenefit, and at the same time secretions can be aspiratedfrom the trachea and bronchi. Aminophylline, 0·25 or 0·5 g.,should be given by intravenous injection, and 'solucortef'should be given at the same time (100 mg. intravenously).It has recently been suggested that large doses of amiphena-zole, e.g. 150 mg. intravenously per hour, may be usefulbecause of a specific stimulating effect on the brain andrespiratory centre, and in promoting cough and expectora-tion. It is clear, however, that the prognosis is poor, andthat treatment should be undertaken only in a hospitalwhere full facilities are available. Even then, in spite ofthe best possible treatment, failure to respond is commonenough, while improvement can of necessity only be tem-porary.

Chronic bronchitis and emphysema

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Chronic bronchitis and emphysema

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