Chronic bronchitis: diagnosis

Laboratory data

1. General blood test without significant changes. With severe exacerbation of chronic purulent bronchitis, a small neutrophilic leukocytosis and a moderate increase in ESR are possible.
2. Sputum analysis is a macroscopic study. Sputum can be mucous (white or transparent) or purulent (yellow or yellow-green). With a small admixture of pus to mucus, sputum is considered mucopurulent. Black color of sputum is possible if it contains particles of coal dust. Blood veins are characteristic for hemorrhagic bronchitis. Sometimes in the sputum, mucous and purulent plugs and bronchial molds are found. For fibrinous bronchitis is characterized by the presence of sputum in the sputum, "bronze models". NV Syromyatnikova and OA Strashinina (1980) propose to determine the rheological properties of sputum, its viscosity and elasticity. Rheological properties of phlegm depend on the content of protein, fibrin, sialic acids, nucleic acids, immunoglobulins, cellular elements. Purulent sputum is characterized by increased viscosity and decreased elasticity, for mucous sputum - a decrease in viscosity and increased elasticity.

When microscopic examination of purulent sputum, a large number of neutrophilic leukocytes are found, often cells of the bronchial epithelium, macrophages, bacterial cells are found. Bacteriological examination of sputum reveals different types of infectious agents and their sensitivity to antibacterial agents. The most reliable are the results of bacteriological examination of sputum obtained from bronchoscopy (aspirates and flushes from the bronchi).

Blood chemistry. Based on the definition of biochemical indicators of the activity of the inflammatory process, it is judged of its severity.

Instrumental research

Bronchoscopy. Bronchoscopically distinguish diffuse and limited bronchitis and the degree of inflammation of the bronchi. With diffuse bronchitis, the inflammatory process extends to all endoscopically visible bronchi - the main, lobar, segmental, subsegmental. Primary chronic bronchitis is characterized by diffuse bronchial lesions. Partial diffuse bronchitis is characterized by the fact that the upper frontal bronchi are intact, while the remaining bronchi are inflamed. With severely restricted bronchitis, the inflammation seizes the main and lobar bronchi, and the segmental bronchi of the upper and lower lobes are not altered.

The intensity of inflammation is estimated as follows.

• I degree - the bronchial mucosa is pale pink, covered with mucus, does not bleed. Radiative vessels are visible under the thin mucous membrane.
• II degree - bronchial mucosa bright red, thickened, often bleeds, covered with pus.
• III degree - the mucous membrane of the bronchi and the trachea is thickened, purple-cyanotic, bleeds easily, is covered with a purulent secret.

Bronchography should be performed after the sanation of the bronchial tree, otherwise such signs as breakage, thinning, deformation of the bronchi can be caused not by true changes, but by congestion in the bronchi of a thick, viscous secretion.

The most regular bronchial symptoms of chronic bronchitis are as follows:

• bronchi IV, V, VI, VII orders of magnitude are cylindrically expanded, their diameter does not decrease to the periphery, as in the norm; the lateral branches are obliterated, the distal ends of the bronchi blindly terminate ("amputated");
• in a number of patients, the enlarged bronchi in some areas are narrowed, their contours are changed (the shape of the "beads"), the inner contour of the bronchi is jagged, the architectonics of the bronchial tree is broken.

Bronchoscopy and bronchography are not mandatory research methods for chronic bronchitis, they are used usually for differential diagnosis with other bronchopulmonary diseases (tuberculosis, bronchocarcinoma, congenital anomalies, bronchiectasis, etc.). Preference is given to fibrobronchoscopy, if necessary, a bronchial mucosa biopsy is performed.

X-ray and radiography of the lungs. X-ray signs of chronic bronchitis can be seen only in long-term patients, with characteristic strengthening and deformation of the pulmonary pattern along the loop-cellular type, increasing the transparency of the pulmonary fields, expanding the shadows of the roots of the lungs. In a number of cases, one can see a thickening of the bronchial walls due to peribronchial pneumosclerosis.

Examination of the function of external respiration. Spirographic study, as well as pneumotachometry, peakflowmetry do not reveal violations of bronchial patency with chronic non-obstructive bronchitis. However, in approximately 30% of the patients, an increase in the residual volume of the lungs, a decrease in MOC w and MOS "(maximal space velocity at the level of 50 or 75% of the forced LEL) is revealed with normal values of the LEL, peak space velocity.

Investigation of the gas composition of blood. In chronic non-obstructive bronchitis, there is usually no disturbance in the gas composition of the blood, with a pronounced clinical picture, especially in the period of exacerbation, moderate arterial hypoxemia is possible due to violations of gas exchange conditions in the lungs due to regional changes in the ratio of alveolar ventilation and pulmonary blood flow.

The above changes in the parameters of external respiration and gas composition of the blood indicate a lesion of predominantly peripheral parts of the bronchi, instability of their lumen and a decrease in the elasticity of the lungs.

Diagnostics

Diagnostic criteria for chronic bronchitis can be considered the following:

1. 1. Persistent cough with sputum production for at least 3 months for 2 consecutive years or more (WHO criteria). If the duration of productive cough does not meet WHO criteria, and cough repeatedly recurs, it is necessary to take into account the possibility of the following situations:
   • • The smoker's cough;
   • • cough due to irritation of the respiratory tract with industrial hazards (gases, vapors, fumes, etc.);
   • • cough due to pathology of the nasopharynx;
   • • lingering or relapsing course of acute bronchitis;
   • • respiratory discomfort and cough due to exposure to volatile irritants;
   • • a combination of these factors. All these states are named by the Institute of Pulmonology of the RAMS "prebronchitis".
2. A typical auscultative picture is a rough rigid vesicular breathing with an extended exhalation, scattered dry and wet rales.
3. Inflammatory changes in the bronchi according to bronchoscopy (the method is used primarily for differential diagnosis).
4. Elimination of other diseases manifested by long-term productive cough, i.e. Bronchiectasis, chronic lung abscess, tuberculosis, pneumoconiosis, congenital pathology of the bronchopulmonary system, diseases of the cardiovascular system, which occur with stagnation of blood in the lungs.
5. Absence of violations of bronchial patency in the study of the function of external respiration.

Diagnosis of exacerbation

The following signs indicate the active inflammatory process in the bronchi:

• increased general weakness, the appearance of malaise, a decrease in overall performance;
• the appearance of severe sweating, especially at night (a symptom of a "wet pillow or sheets");
• increased cough;
• increase in the number and "purulence" of phlegm;
• subfebrile body temperature;
• tachycardia at normal temperature;
• the appearance of biochemical signs of inflammation;
• shift in the leukocyte formula to the left and increase in ESR to moderate figures;
• increased activity of alkaline and acidic phosphatases of leukocytes (cytochemical study).

Differential diagnosis

Chronic non-obstructive bronchitis should be differentiated with:

• acute lingering and relapsing bronchitis; for the protracted course of acute bronchitis is characterized by the existence of symptoms more than 2 weeks, recurrent acute bronchitis characterized by repeated but brief episodes of the disease three times a year or more. Thus, the protracted and recurrent course of acute bronchitis does not correspond to the temporary criteria for chronic bronchitis proposed by WHO;
• bronchiectasis (especially with coughing up of purulent or mucopurulent sputum); for bronchiectasis is characterized by the appearance of cough from early childhood, the withdrawal of a large amount of purulent sputum ("full mouth"), the connection of sputum production with a certain position of the body, thickening of the end phalanges in the form of "drumsticks" and nails in the form of "watch glasses", local purulent endobronchitis with fibrobronchoscopy, detection of bronchial dilations in bronchography;
• bronchus tuberculosis - it is characterized by symptoms of tuberculous intoxication (night sweats, anorexia, weakness, subfebrile body temperature), hemoptysis, absence of "purulence" of sputum, presence of Koch bacilli in sputum and bronchial irrigation waters, tuberculosis family history, positive tuberculin tests, local endobronchitis with scars and fistulas with fibrobronchoscopy, a positive effect of treatment with tuberculostatic drugs;
• cancer of the bronchus - it is more common in men who smoke and is characterized by a cough with an impurity of blood, atypical cells in sputum, in far-reaching stages - pains in the chest, emaciation, hemorrhagic exudative pleurisy. A crucial role in the diagnosis of bronchial cancer is played by fibrobronchoscopy and biopsy of the bronchial mucosa;
• expiratory collapse of the trachea and major bronchi (tracheobronchial dyskinesia), with expiratory stenosis due to prolapse of the membrane part. The basis of clinical diagnosis is the analysis of cough. Its characteristic features: dry, paroxysmal, "trumpet", "barking", "rattling", rarely - bitonal; provoked by sharp slopes, head turns, forced breathing, laughter, cold, straining, physical exertion; accompanied by dizziness, sometimes fainting, urinary incontinence, a feeling of suffocation. With forced expiration, a characteristic "notch" is seen on the spirogram. The diagnosis is specified in fibrobronchoscopy. MI Perelman (1980) distinguishes three degrees of expiratory stenosis: 1 degree - narrowing of the lumen of the trachea or major bronchi by 50%, 2 degree - up to 2/3, 3 degree - more than 2/3 or complete overlap of the lumen of the trachea.

[1], [2], [3], [4], [5], [6], [7], [8]