ORL38: 178 186 (1976)
Chronic Bronchitis A Bronchologic Evaluation
K. Jokinen, T. Paha and J. Nuutinen Department of Otolaryngology, University of Oulu, Oulu; Ear, Nose and Throat Hospital, Helsinki University, and Paivarinne Chest Hospital, Helsinki
Key Words. Chronic bronchitis • Bronchoscopy • Bronchography Abstract. 214 patients with chronic bronchitis were subjected to bronchial studies at Paivarinne Chest Hospital during the period 1967 1973. Bronchoscopy alone gave a fre quency of 30 % for bronchiectases while the information from bronchography increased this figure to 44%. In addition, 24% of the patients showed bronchographic changes in the form of naked filling or mucus obstruction. Sputum specimens were less reliable indicators of infection than bronchial aspirates in patients with chronic bronchitis. Tracheobroncho malacia was found in 50 patients and greatly increased the gravity of the disease.
Introduction
Received; October 27, 1975; accepted: November 28, 1975.
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/5/2018 9:06:32 AM
The definition of chronic bronchitis is based on clinical and functional manifestations of the disease (The Medical Research Council’s Committee on the Aetiology of Chronic Bronchitis, 1961). Simple chronic bronchitis is defined as chronic or recurrent increase in the volume of mucoid bronchial secretion suffi cient to cause expectoration. The bronchial tree is usually colonized by bacteria that are normally found in the upper respiratory passages {Palva et al., 1957). In chronic or intermittent mucopurulent bronchitis, sputum is persistently muco purulent. The patients may have anatomical changes, e.g. dilatation of bronchi, and the bronchial tree is often colonized by pathogenic bacteria {Fletcher, 1960). In chronic obstructive bronchitis, persistent narrowing of the intrapulmonary airways, at least on expiration, can be seen. Bronchoscopy, especially when combined with bronchography, gives valu able information in the diagnosis of chronic bronchitis. Added information may
Jokinen/Palva/Nuutinen
179
be obtained with bronchial biopsies, bacterial cultures of bronchial aspirates, and cytologic studies with smears of bronchial aspirates. We have presently analyzed a series of 2,150 bronchoscopies and chosen for this report those cases (214 pa tients) in which a diagnosis of chronic bronchitis was reached with these exami nation methods.
Material and Methods
Fig. 1. Age and sex distribution of 214 patients with chronic bronchitis.
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/5/2018 9:06:32 AM
The present material consists of 214 cases in which the final diagnosis was chronic bronchitis, subjected to bronchoscopy at Pàivàrinne Chest Hospital during the period 1967 1973. 53 of these patients were admitted to the hospital at least twice during this period. The age distribution ranged from 14 to 79 years (average 51 years). 51 were female and 163 male (fig. 1), and while the curve for the former was nearly flat, the curve for the latter showed a remarkably high increase in the age groups between 45 and 65 years. 73 % of the patients were heavy smokers, 10% ex-smokers and 17% non-smokers, the latter consisting of the female patients. All bronchoscopies were performed by one highly experienced member of the team in local anaesthesia. Bronchography was done on the more affected side through the broncho scope with duodenal sounds at the termination of bronchoscopy, using 12 15 cm3 of Dionosil Aqueous (Glaxo). Smears for cytologic examination of bronchial aspirates as well as of sputum were stained by the Papanicolaou technique. Bacteriological cultures were made on blood agar, chocolate agar and lactose agar plates, and on thioglycolate broth. Sabouraud’s medium was used for fungi.
Jokinen /Palva /Nuutinen
180
Results Chronic cough with expectorata, dyspnoea, haemoptysis and recurrent fever were the most common symptoms on admission (table I). In addition to chronic bronchitis, 23 % of the patients were suffering from marked emphysema, 16 % from sinusitis, 14 % from coronary artery disease, 7 % from cardiac insufficiency and 6 % from hypertension. Their hospital stay varied from 2 to 240 days (aver age 35 days). Seven patients died during the control time, 4 of cor pulmonale, 2 of bronchopneumonia and 1 of coronary thrombosis. Indications for the 266 bronchoscopies performed during the observation period are seen in table II. Tumour suspicion, suspected bronchiectases, and haemoptysis were the most common indications. Mucosal changes in the tra cheobronchial tree in the form of redness, inflammatory oedema, or atrophy were noted in 70 % of cases. Widening or fixation of the carina occurred in 33 %, obstructive changes in 6 % and increased thick secretion in 76 % of cases (fig. 2). Tracheobronchomalacia (fig. 3), often in very severe form, was diagnosed in 50 patients (23 %) and tracheopathia osteochondroplastica in 2 patients (1 %).
Table I. The main symptoms of 214 patients with chronic bronchitis at admission
Chronic cough and sputum Dyspnoea Haemoptysis Recurrent fever Poor general condition Thoracal pains
Number of cases
%
190 94 73 67 31 31
39 19 15 14 6.5 6.5
Number of cases
%
Table II. Indication for bronchoscopy
Total
93 60 55 42 15 1 266
35 22.5 20.5 16 5.5 0.5 100 Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/5/2018 9:06:32 AM
Tumour suspicion Bronchiectasis suspicion Haemoptysis Chronic bronchitis Tuberculosis suspicion Bronchial lavation
Fig. 4. Bronchiectases in the basal segments of the left lower lobe of a patient with chronic bronchitis. Fig. 5. Bronchographic picture in chronic bronchitis of the left bronchial tree. Typical naked filling in the small bronchi and mucus obstructions in the larger bronchi are seen in all lobes.
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/5/2018 9:06:32 AM
Fig. 2. Bronchoscopie view into the left lower lobe of a man, aged 69, with chronic bronchitis. The thickening of the spur between basal bronchial orifices and mucus obstruc tion of anterior basal segmental bronchus (arrows) is seen. Fig. 3. Bronchoscopie view of lower trachea and main bronchi of a patient with a moderate-degree tracheobronchomalacia. The posterior wall of trachea and main bronchi is bulging inwards in quiet respiration.
182
Jokinen /Paha /Nuutinen Table III. Cytologic findings of sputum and bronchial aspirates Sputum
Bronchial aspiration
Number of cases %
Number of cases %
1 11 111
349 69 3
159 39 1
Total
421
Papanicolaou group
83 16 1
80 19.5 0.5
199
Table IV. Bacteriological findings in sputum and bronchial aspiration Bronchial aspiration
Sputum Number of cases
Negative Haemophilus influenzae Diplococcus pneumoniae Klebsiella Pseudomonas aeruginosa Staphylococcus aureus Alcaligenes faecalis Streptococcus ß-hemolyticus Escherichia coli Streptococcus viridans Proteus mirabilis Neisseria catarrhalis Streptococcus a-hemolyticus Staphylococcus albus Neisseria meningitides Aerob acter aerogenes Hafnia
87 39 19 9 8 6 5 4 4 3 3 2 -
Total
191
-
1 1
%
46 20 10 5 4 3 3 2 2 1.5 1.5 1 -
0.5 0.5
Number of cases 93 2 1 5 4 9 2 3 2 5 2 6 6 1 1 1 -
%
65 1.5 0.5 3.5 3 6 1.5 2 1.5 3.5 1.5 4 4 0.5 0.5 0.5 -
143
Bronchography was combined with bronchoscopy 195 times. 94 patients (44 %) had bronchiectases (fig. 4). In 57 cases (60 %) the left lung was the more affected side; in 65 % the bronchiectases were located in the lower lobe, in 25 % in the lower lobe and lingula, in 5 % in the upper lobe, and in 5 % in the whole left lung. On the right side, 40.5 % of the bronchiectases were found in the lower lobe, 35 % in the lower and middle lobe, 13.5 % in the middle lobe, and 11 % in
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/5/2018 9:06:32 AM
Bacteriological findings
Chronic Bronchitis
183
the whole right lung. The difference between right and left lung is statistically significant (p < 0.05). Bronchoscopically, bronchiectases in the lower lobes, or middle lobe and lingula, were obvious already in 65 patients. Typical bronchographical changes for uncomplicated chronic bronchitis with naked filling, mucus-obstructed smaller bronchi but without clear bronchiectases (fig. 5) were found in 52 patients (24 %). Only 49 times (22 %) was the bronchography with in normal limits. Cytologic findings of sputum and bronchial aspirates were quite similar (table III), most samples in both groups being classified into Papanicolaou’s first group. A somewhat greater number of bronchial samples than of sputum samples was classified into second Papanicolaou group. Bacteriological studies of the bronchial aspirates and sputum were negative in 65 and 46 %, respectively (table IV). Haemophilus influenzae and Diplococcus pneumoniae were clearly more usual in sputum than in bronchial aspiration. On the other hand, Staphylococcus aureus was seen more often in bronchial aspira tions. From cultures for fungi, Candida was found as the only organism in sputum 18 times (8 %) and in bronchial aspirates 12 times (6 %). 140 patients (65 %) had broad spectrum antibiotics during treatment in the hospital. Most of the patients had used them earlier intermittently during exacer bations, about 10% using them continuously. Ten patients were vaccinated using multi-bacteria vaccines but without obvious success. 18 patients (8 %) were operated because of marked bronchiectases. Resec tion of the left lower lobe was made on 7 patients, left lower lobe and lingula on 4, and left lung on one patient. On the right side, the middle and lower lobe were resected on 2 and subsegments of the lower lobe on 3 patients. The final result was satisfactory in 15 patients (83 %) and moderate in 3 patients. All patients were advised to stop smoking but only about 10% could achieve this. All cases with maxillary sinusitis were treated by puncture and antibiotics and chronic cases by Caldwell-Luc operation. 37 patients (17 %) were already receiving a pension because of chronic bronchitis before first admission during this study period, and 13 new patients were pensioned during the obser vation time.
Chronic bronchitis is not an unambiguous entity but consists of syndromes with cough and expectoration which are called ‘bronchitis’ by clinicians. Its prevalence in general is high and of great economic importance. In this country, Huhti (1965) found an incidence of 28.2 % among middle-aged men and 30% among men aged 70 years. To establish the diagnosis and assess the working capacity, patients with chronic bronchitis should be examined, in addition to
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/5/2018 9:06:32 AM
Discussion
184
bronchoscopy, also with a bronchogram and cytologic and bacteriological studies of the bronchial aspirate (Palva etal., 1957\Lemoine, 1971). In addition to the symptomatic diagnosis of chronic bronchitis, additional indications for bronchoscopy were suspicion of tumour (35 %) and haemoptysis (20.5 %). In this selected material with final diagnosis of chronic bronchitis the tumours are excluded but the figures show that many either parenchymal infil trates or enlarged paratracheal or parabronchial lymphonodes may mimic a tumour which can only be excluded by thorough bronchial studies. As to haemoptysis, it was most often caused by infection combined with frequent and sometimes persistent attacks of cough. None of these cases of haemoptysis proved really serious as often occurs in tuberculosis or malignancies, large arte ries being eroded. Without exception, all these cases had various degrees of either bronchiectases or tracheobronchomalacia or both. Tuberculosis was suspected in 5.5 % of cases. According to Tevola (1974), studies of bronchial aspirates increase the number of bacteriologically confirmed cases by about 30%. On the other hand, it should be remembered that in endobronchial tuberculosis bronchoscopy can be the only way to obtain a cor rect diagnosis. However, bronchial reddening and some oedema cannot as such be accepted as tuberculous if evidence in the form of positive biopsies is lacking {Palva, 1958), and all biopsies in the present cases showed only thick mucosa without specific changes. In our experience, it is very important to combine bronchography with bronchoscopy either separately or, as we prefer, in the same sitting. In the present material, bronchography increased the incidence of diagnosed bronchiec tases to 44 % of patients from the figure of 30 % based on bronchoscopy alone. In 24 % of patients typical bronchographical findings for chronic bronchitis were found, namely, naked filling of the bronchial tree in the small bronchi, and mucus obstructions in the larger bronchi. That the left lung was more often the more involved side can be explained by the upward shift of the main bronchus with subsequent kinking of the lower lobe bronchi, making drainage more diffi cult. Also for diagnosis of tracheobronchomalacia, bronchoscopy is of special importance. In none of our cases could this disease be diagnosed before bron choscopy, and bronchoscopy under local anaesthesia is the best way to do it. The flaccid tracheal or bronchial posterior wall forms in quiet respiration the typical half-moon type lumen which during coughing may become almost totally occluded. During the introduction of the bronchoscope and particularly in slightly incomplete anaesthesia, the wheezing sounds and the patient’s distress during the tracheal passage can be quite alarming to an inexperienced bronchoscopist. The choking sensation, however, passes as the bronchoscope tip has passed the carina and anaesthesia complemented. The presence of tracheobron chomalacia can be the cause of the patient’s incapacity to continued manual
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/5/2018 9:06:32 AM
Jokinen /Palva/Nuutinen
Chronic Bronchitis
185
work and should be particularly looked for when pension compensations are being considered. Bronchography in these cases may be non-yielding and often difficult to make succesfully, due to the patient’s tendency to cough and dyspnoea. The cytologic picture of sputum and bronchial aspirates showed only mini mal differences. The relatively greater number of aspirate specimens in the second group of Papanicolaou is probably due to the fact that bronchial aspirate contains more squamous-like metaplastic cells originating from the infected area. The advantage with sputum specimens is their ease of take, repeatedly if needed, but in nonproductive cough the specimens may be unsatisfactory. The screening of sputum is also more difficult. The bronchial aspirate, on the other hand, contains always cells from the bronchial epithelium and the aspirate can be taken directly from the specific area {Liu, 1964). The relatively high number of negative bronchial bacterial specimens is apparently due to the fact that most of the patients were on antibiotics before and at admission. In the sputum, Haemophilus influenzae and Diplococcus pneumoniae were more frequent than in the bronchial aspirates, as can be ex pected from these frequent upper respiratory system invaders. Staphylococcus aureus was the most often found bacterium in bronchial aspirates (6 %). As grave staphylococcal infections were missing, this finding apparently reflects the great ly lowered resistance of these patients to infections. In general, our data (tab le IV) agree with the results of Kortekangas (1959) that bacterial cultures of sputum specimens are not true indicators of the incidence and nature of the bacterial flora of the tracheobronchial tree in patients with pulmonary disease. On the other hand, antibiotic treatment based on bronchial aspirates is on a firmer basis even if the susceptibility of these patients to infections cannot be cured with antibiotics (Tager and Speizer, 1975). To stop cigarette smoking should always be strongly advised in all cases of chronic bronchitis in order to get rid of one of the major irritants. However, we have succeeded in this only moderately, since no more than 10% have stopped smoking. In these patients best results were obtained in cases with only naked filling picture, while cases with established bronchiectases seemed to continue with the infections even when not smoking. Better success with stopping ciga rette smoking should be the aim before the disease has progressed into an irrepa rable stage. The high incidence of chronic bronchitis in the male population in the age groups between 45 and 65 years is, in all probability, due to heavy smoking that has lasted several decades.
214 an chronischer Bronchitis leidende Patienten wurden während des Zeitraums 1967- 1973 am Krankenhaus für Lungenerkrankungen in Päivärinnc bronchologischen Stu
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Zusammenfassung
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186
dien unterzogen. Bronchoskopie allein ergab eine Häufigkeit von 30 % für Bronchiektasien, während mittels Bronchographie gewonnene Informationen diese Zahl auf 44 % erhöhten. Ausserdem zeigten 24 % der Patienten bronchographische Veränderungen in Form von Schleim-Obstruktionen. Sputum-Untersuchungen waren als Indikatoren für eine Infektion weniger zuverlässig als bronchiale Absaugungen bei Patienten mit chronischer Bronchitis. Tracheobronchomalazie wurde bei 50 Patienten gefunden und verschlimmerte das Krank heitsbild wesentlich.
Résumé 214 patients affectés d’une bronchite chronique ont été l’objet d’une étude des bron ches au Sanatorium de Pâivàrinne durant la période 1967-1973. La bronchoscopie ellemême a donné une fréquence de 30 % pour la bronchiectasie, tandis que les informations fournies par la bronchographie ont porté ce pourcentage à 44 %. En plus, 24 % des patients ont montré des changements bronchographiques sous la forme d’obstruction par mucus. Les expectorations sont comme indicateurs d’infection moins certaines que les aspirations bronchiales chez les patients atteints d’une bronchite chronique. La trachéobronchomalacia a été dépistée chez 50 patients et a largement augmenté la gravité de la maladie.
References Fletcher, C.M.: Definition and classification of bronchitis, asthma and emphysema. Bronchi tis. An international symposium. (Orie & Sluiter, Netherlands 1960). Huhti, E.: Prevalence of respiratory symptoms, chronic bronchitis and pulmonary emphy sema in a Finnish rural population. Acta tuberc. scand., suppl. 61 (1965). Kortekangas, A.E.: Investigations of the bacterial flora of the respiratory tract. Acta otolar., suppl. 150 (1959). Lemoine, J.M.: Endoscopische Befunde der wesentlichen bronchopulmonalcn Krankheiten. Internist 12: 430-436 (1971). Liu, W.: An introduction to respiratory cytology (Thomas, Springfield 1964). Medical Research Council: Standardised questionnaire on respiratory symptoms. Br. med. J. ii: 973 (1961). Palva, T.: Tuberculous bronchitis in the light of bronchial biopsies. Acta tuberc. scand. 35: 157 165 (1958). Palva, T.: Elo, R., and Saloheimo, M.: The role of bronchial studies in the differential diagnosis of pulmonary diseases in sanatoria. Acta tuberc. scand. 33: 265 275 (1957). Tager, I. and Speizer, F.E.: Medical progress. Role of infection in chronic bronchitis. New Engl. J. Med. 292: 563-571 (1975). Tevola, K.: Bronchial aspiration in the diagnosis of pulmonary tuberculosis. Scand. J. resp. Dis., suppl. 89, p. 151 (1974).
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Kalevi Jokinen, MD, Department of Otolaryngology, University of Oulu, 90220 Oulu 22 (Finland)
Chronic Bronchitis A Bronchologic Evaluation
K. Jokinen, T. Paha and J. Nuutinen Department of Otolaryngology, University of Oulu, Oulu; Ear, Nose and Throat Hospital, Helsinki University, and Paivarinne Chest Hospital, Helsinki
Key Words. Chronic bronchitis • Bronchoscopy • Bronchography Abstract. 214 patients with chronic bronchitis were subjected to bronchial studies at Paivarinne Chest Hospital during the period 1967 1973. Bronchoscopy alone gave a fre quency of 30 % for bronchiectases while the information from bronchography increased this figure to 44%. In addition, 24% of the patients showed bronchographic changes in the form of naked filling or mucus obstruction. Sputum specimens were less reliable indicators of infection than bronchial aspirates in patients with chronic bronchitis. Tracheobroncho malacia was found in 50 patients and greatly increased the gravity of the disease.
Introduction
Received; October 27, 1975; accepted: November 28, 1975.
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/5/2018 9:06:32 AM
The definition of chronic bronchitis is based on clinical and functional manifestations of the disease (The Medical Research Council’s Committee on the Aetiology of Chronic Bronchitis, 1961). Simple chronic bronchitis is defined as chronic or recurrent increase in the volume of mucoid bronchial secretion suffi cient to cause expectoration. The bronchial tree is usually colonized by bacteria that are normally found in the upper respiratory passages {Palva et al., 1957). In chronic or intermittent mucopurulent bronchitis, sputum is persistently muco purulent. The patients may have anatomical changes, e.g. dilatation of bronchi, and the bronchial tree is often colonized by pathogenic bacteria {Fletcher, 1960). In chronic obstructive bronchitis, persistent narrowing of the intrapulmonary airways, at least on expiration, can be seen. Bronchoscopy, especially when combined with bronchography, gives valu able information in the diagnosis of chronic bronchitis. Added information may
Jokinen/Palva/Nuutinen
179
be obtained with bronchial biopsies, bacterial cultures of bronchial aspirates, and cytologic studies with smears of bronchial aspirates. We have presently analyzed a series of 2,150 bronchoscopies and chosen for this report those cases (214 pa tients) in which a diagnosis of chronic bronchitis was reached with these exami nation methods.
Material and Methods
Fig. 1. Age and sex distribution of 214 patients with chronic bronchitis.
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/5/2018 9:06:32 AM
The present material consists of 214 cases in which the final diagnosis was chronic bronchitis, subjected to bronchoscopy at Pàivàrinne Chest Hospital during the period 1967 1973. 53 of these patients were admitted to the hospital at least twice during this period. The age distribution ranged from 14 to 79 years (average 51 years). 51 were female and 163 male (fig. 1), and while the curve for the former was nearly flat, the curve for the latter showed a remarkably high increase in the age groups between 45 and 65 years. 73 % of the patients were heavy smokers, 10% ex-smokers and 17% non-smokers, the latter consisting of the female patients. All bronchoscopies were performed by one highly experienced member of the team in local anaesthesia. Bronchography was done on the more affected side through the broncho scope with duodenal sounds at the termination of bronchoscopy, using 12 15 cm3 of Dionosil Aqueous (Glaxo). Smears for cytologic examination of bronchial aspirates as well as of sputum were stained by the Papanicolaou technique. Bacteriological cultures were made on blood agar, chocolate agar and lactose agar plates, and on thioglycolate broth. Sabouraud’s medium was used for fungi.
Jokinen /Palva /Nuutinen
180
Results Chronic cough with expectorata, dyspnoea, haemoptysis and recurrent fever were the most common symptoms on admission (table I). In addition to chronic bronchitis, 23 % of the patients were suffering from marked emphysema, 16 % from sinusitis, 14 % from coronary artery disease, 7 % from cardiac insufficiency and 6 % from hypertension. Their hospital stay varied from 2 to 240 days (aver age 35 days). Seven patients died during the control time, 4 of cor pulmonale, 2 of bronchopneumonia and 1 of coronary thrombosis. Indications for the 266 bronchoscopies performed during the observation period are seen in table II. Tumour suspicion, suspected bronchiectases, and haemoptysis were the most common indications. Mucosal changes in the tra cheobronchial tree in the form of redness, inflammatory oedema, or atrophy were noted in 70 % of cases. Widening or fixation of the carina occurred in 33 %, obstructive changes in 6 % and increased thick secretion in 76 % of cases (fig. 2). Tracheobronchomalacia (fig. 3), often in very severe form, was diagnosed in 50 patients (23 %) and tracheopathia osteochondroplastica in 2 patients (1 %).
Table I. The main symptoms of 214 patients with chronic bronchitis at admission
Chronic cough and sputum Dyspnoea Haemoptysis Recurrent fever Poor general condition Thoracal pains
Number of cases
%
190 94 73 67 31 31
39 19 15 14 6.5 6.5
Number of cases
%
Table II. Indication for bronchoscopy
Total
93 60 55 42 15 1 266
35 22.5 20.5 16 5.5 0.5 100 Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/5/2018 9:06:32 AM
Tumour suspicion Bronchiectasis suspicion Haemoptysis Chronic bronchitis Tuberculosis suspicion Bronchial lavation
Fig. 4. Bronchiectases in the basal segments of the left lower lobe of a patient with chronic bronchitis. Fig. 5. Bronchographic picture in chronic bronchitis of the left bronchial tree. Typical naked filling in the small bronchi and mucus obstructions in the larger bronchi are seen in all lobes.
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/5/2018 9:06:32 AM
Fig. 2. Bronchoscopie view into the left lower lobe of a man, aged 69, with chronic bronchitis. The thickening of the spur between basal bronchial orifices and mucus obstruc tion of anterior basal segmental bronchus (arrows) is seen. Fig. 3. Bronchoscopie view of lower trachea and main bronchi of a patient with a moderate-degree tracheobronchomalacia. The posterior wall of trachea and main bronchi is bulging inwards in quiet respiration.
182
Jokinen /Paha /Nuutinen Table III. Cytologic findings of sputum and bronchial aspirates Sputum
Bronchial aspiration
Number of cases %
Number of cases %
1 11 111
349 69 3
159 39 1
Total
421
Papanicolaou group
83 16 1
80 19.5 0.5
199
Table IV. Bacteriological findings in sputum and bronchial aspiration Bronchial aspiration
Sputum Number of cases
Negative Haemophilus influenzae Diplococcus pneumoniae Klebsiella Pseudomonas aeruginosa Staphylococcus aureus Alcaligenes faecalis Streptococcus ß-hemolyticus Escherichia coli Streptococcus viridans Proteus mirabilis Neisseria catarrhalis Streptococcus a-hemolyticus Staphylococcus albus Neisseria meningitides Aerob acter aerogenes Hafnia
87 39 19 9 8 6 5 4 4 3 3 2 -
Total
191
-
1 1
%
46 20 10 5 4 3 3 2 2 1.5 1.5 1 -
0.5 0.5
Number of cases 93 2 1 5 4 9 2 3 2 5 2 6 6 1 1 1 -
%
65 1.5 0.5 3.5 3 6 1.5 2 1.5 3.5 1.5 4 4 0.5 0.5 0.5 -
143
Bronchography was combined with bronchoscopy 195 times. 94 patients (44 %) had bronchiectases (fig. 4). In 57 cases (60 %) the left lung was the more affected side; in 65 % the bronchiectases were located in the lower lobe, in 25 % in the lower lobe and lingula, in 5 % in the upper lobe, and in 5 % in the whole left lung. On the right side, 40.5 % of the bronchiectases were found in the lower lobe, 35 % in the lower and middle lobe, 13.5 % in the middle lobe, and 11 % in
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/5/2018 9:06:32 AM
Bacteriological findings
Chronic Bronchitis
183
the whole right lung. The difference between right and left lung is statistically significant (p < 0.05). Bronchoscopically, bronchiectases in the lower lobes, or middle lobe and lingula, were obvious already in 65 patients. Typical bronchographical changes for uncomplicated chronic bronchitis with naked filling, mucus-obstructed smaller bronchi but without clear bronchiectases (fig. 5) were found in 52 patients (24 %). Only 49 times (22 %) was the bronchography with in normal limits. Cytologic findings of sputum and bronchial aspirates were quite similar (table III), most samples in both groups being classified into Papanicolaou’s first group. A somewhat greater number of bronchial samples than of sputum samples was classified into second Papanicolaou group. Bacteriological studies of the bronchial aspirates and sputum were negative in 65 and 46 %, respectively (table IV). Haemophilus influenzae and Diplococcus pneumoniae were clearly more usual in sputum than in bronchial aspiration. On the other hand, Staphylococcus aureus was seen more often in bronchial aspira tions. From cultures for fungi, Candida was found as the only organism in sputum 18 times (8 %) and in bronchial aspirates 12 times (6 %). 140 patients (65 %) had broad spectrum antibiotics during treatment in the hospital. Most of the patients had used them earlier intermittently during exacer bations, about 10% using them continuously. Ten patients were vaccinated using multi-bacteria vaccines but without obvious success. 18 patients (8 %) were operated because of marked bronchiectases. Resec tion of the left lower lobe was made on 7 patients, left lower lobe and lingula on 4, and left lung on one patient. On the right side, the middle and lower lobe were resected on 2 and subsegments of the lower lobe on 3 patients. The final result was satisfactory in 15 patients (83 %) and moderate in 3 patients. All patients were advised to stop smoking but only about 10% could achieve this. All cases with maxillary sinusitis were treated by puncture and antibiotics and chronic cases by Caldwell-Luc operation. 37 patients (17 %) were already receiving a pension because of chronic bronchitis before first admission during this study period, and 13 new patients were pensioned during the obser vation time.
Chronic bronchitis is not an unambiguous entity but consists of syndromes with cough and expectoration which are called ‘bronchitis’ by clinicians. Its prevalence in general is high and of great economic importance. In this country, Huhti (1965) found an incidence of 28.2 % among middle-aged men and 30% among men aged 70 years. To establish the diagnosis and assess the working capacity, patients with chronic bronchitis should be examined, in addition to
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/5/2018 9:06:32 AM
Discussion
184
bronchoscopy, also with a bronchogram and cytologic and bacteriological studies of the bronchial aspirate (Palva etal., 1957\Lemoine, 1971). In addition to the symptomatic diagnosis of chronic bronchitis, additional indications for bronchoscopy were suspicion of tumour (35 %) and haemoptysis (20.5 %). In this selected material with final diagnosis of chronic bronchitis the tumours are excluded but the figures show that many either parenchymal infil trates or enlarged paratracheal or parabronchial lymphonodes may mimic a tumour which can only be excluded by thorough bronchial studies. As to haemoptysis, it was most often caused by infection combined with frequent and sometimes persistent attacks of cough. None of these cases of haemoptysis proved really serious as often occurs in tuberculosis or malignancies, large arte ries being eroded. Without exception, all these cases had various degrees of either bronchiectases or tracheobronchomalacia or both. Tuberculosis was suspected in 5.5 % of cases. According to Tevola (1974), studies of bronchial aspirates increase the number of bacteriologically confirmed cases by about 30%. On the other hand, it should be remembered that in endobronchial tuberculosis bronchoscopy can be the only way to obtain a cor rect diagnosis. However, bronchial reddening and some oedema cannot as such be accepted as tuberculous if evidence in the form of positive biopsies is lacking {Palva, 1958), and all biopsies in the present cases showed only thick mucosa without specific changes. In our experience, it is very important to combine bronchography with bronchoscopy either separately or, as we prefer, in the same sitting. In the present material, bronchography increased the incidence of diagnosed bronchiec tases to 44 % of patients from the figure of 30 % based on bronchoscopy alone. In 24 % of patients typical bronchographical findings for chronic bronchitis were found, namely, naked filling of the bronchial tree in the small bronchi, and mucus obstructions in the larger bronchi. That the left lung was more often the more involved side can be explained by the upward shift of the main bronchus with subsequent kinking of the lower lobe bronchi, making drainage more diffi cult. Also for diagnosis of tracheobronchomalacia, bronchoscopy is of special importance. In none of our cases could this disease be diagnosed before bron choscopy, and bronchoscopy under local anaesthesia is the best way to do it. The flaccid tracheal or bronchial posterior wall forms in quiet respiration the typical half-moon type lumen which during coughing may become almost totally occluded. During the introduction of the bronchoscope and particularly in slightly incomplete anaesthesia, the wheezing sounds and the patient’s distress during the tracheal passage can be quite alarming to an inexperienced bronchoscopist. The choking sensation, however, passes as the bronchoscope tip has passed the carina and anaesthesia complemented. The presence of tracheobron chomalacia can be the cause of the patient’s incapacity to continued manual
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/5/2018 9:06:32 AM
Jokinen /Palva/Nuutinen
Chronic Bronchitis
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work and should be particularly looked for when pension compensations are being considered. Bronchography in these cases may be non-yielding and often difficult to make succesfully, due to the patient’s tendency to cough and dyspnoea. The cytologic picture of sputum and bronchial aspirates showed only mini mal differences. The relatively greater number of aspirate specimens in the second group of Papanicolaou is probably due to the fact that bronchial aspirate contains more squamous-like metaplastic cells originating from the infected area. The advantage with sputum specimens is their ease of take, repeatedly if needed, but in nonproductive cough the specimens may be unsatisfactory. The screening of sputum is also more difficult. The bronchial aspirate, on the other hand, contains always cells from the bronchial epithelium and the aspirate can be taken directly from the specific area {Liu, 1964). The relatively high number of negative bronchial bacterial specimens is apparently due to the fact that most of the patients were on antibiotics before and at admission. In the sputum, Haemophilus influenzae and Diplococcus pneumoniae were more frequent than in the bronchial aspirates, as can be ex pected from these frequent upper respiratory system invaders. Staphylococcus aureus was the most often found bacterium in bronchial aspirates (6 %). As grave staphylococcal infections were missing, this finding apparently reflects the great ly lowered resistance of these patients to infections. In general, our data (tab le IV) agree with the results of Kortekangas (1959) that bacterial cultures of sputum specimens are not true indicators of the incidence and nature of the bacterial flora of the tracheobronchial tree in patients with pulmonary disease. On the other hand, antibiotic treatment based on bronchial aspirates is on a firmer basis even if the susceptibility of these patients to infections cannot be cured with antibiotics (Tager and Speizer, 1975). To stop cigarette smoking should always be strongly advised in all cases of chronic bronchitis in order to get rid of one of the major irritants. However, we have succeeded in this only moderately, since no more than 10% have stopped smoking. In these patients best results were obtained in cases with only naked filling picture, while cases with established bronchiectases seemed to continue with the infections even when not smoking. Better success with stopping ciga rette smoking should be the aim before the disease has progressed into an irrepa rable stage. The high incidence of chronic bronchitis in the male population in the age groups between 45 and 65 years is, in all probability, due to heavy smoking that has lasted several decades.
214 an chronischer Bronchitis leidende Patienten wurden während des Zeitraums 1967- 1973 am Krankenhaus für Lungenerkrankungen in Päivärinnc bronchologischen Stu
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Zusammenfassung
Jo kinen /PaIva/Nun tinen
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dien unterzogen. Bronchoskopie allein ergab eine Häufigkeit von 30 % für Bronchiektasien, während mittels Bronchographie gewonnene Informationen diese Zahl auf 44 % erhöhten. Ausserdem zeigten 24 % der Patienten bronchographische Veränderungen in Form von Schleim-Obstruktionen. Sputum-Untersuchungen waren als Indikatoren für eine Infektion weniger zuverlässig als bronchiale Absaugungen bei Patienten mit chronischer Bronchitis. Tracheobronchomalazie wurde bei 50 Patienten gefunden und verschlimmerte das Krank heitsbild wesentlich.
Résumé 214 patients affectés d’une bronchite chronique ont été l’objet d’une étude des bron ches au Sanatorium de Pâivàrinne durant la période 1967-1973. La bronchoscopie ellemême a donné une fréquence de 30 % pour la bronchiectasie, tandis que les informations fournies par la bronchographie ont porté ce pourcentage à 44 %. En plus, 24 % des patients ont montré des changements bronchographiques sous la forme d’obstruction par mucus. Les expectorations sont comme indicateurs d’infection moins certaines que les aspirations bronchiales chez les patients atteints d’une bronchite chronique. La trachéobronchomalacia a été dépistée chez 50 patients et a largement augmenté la gravité de la maladie.
References Fletcher, C.M.: Definition and classification of bronchitis, asthma and emphysema. Bronchi tis. An international symposium. (Orie & Sluiter, Netherlands 1960). Huhti, E.: Prevalence of respiratory symptoms, chronic bronchitis and pulmonary emphy sema in a Finnish rural population. Acta tuberc. scand., suppl. 61 (1965). Kortekangas, A.E.: Investigations of the bacterial flora of the respiratory tract. Acta otolar., suppl. 150 (1959). Lemoine, J.M.: Endoscopische Befunde der wesentlichen bronchopulmonalcn Krankheiten. Internist 12: 430-436 (1971). Liu, W.: An introduction to respiratory cytology (Thomas, Springfield 1964). Medical Research Council: Standardised questionnaire on respiratory symptoms. Br. med. J. ii: 973 (1961). Palva, T.: Tuberculous bronchitis in the light of bronchial biopsies. Acta tuberc. scand. 35: 157 165 (1958). Palva, T.: Elo, R., and Saloheimo, M.: The role of bronchial studies in the differential diagnosis of pulmonary diseases in sanatoria. Acta tuberc. scand. 33: 265 275 (1957). Tager, I. and Speizer, F.E.: Medical progress. Role of infection in chronic bronchitis. New Engl. J. Med. 292: 563-571 (1975). Tevola, K.: Bronchial aspiration in the diagnosis of pulmonary tuberculosis. Scand. J. resp. Dis., suppl. 89, p. 151 (1974).
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Kalevi Jokinen, MD, Department of Otolaryngology, University of Oulu, 90220 Oulu 22 (Finland)
