Bronchitis

Definition

Bronchitis is an inflammation of the air passages between the nose and the lungs, including the windpipe or trachea and the larger air tubes of the lung that bring air in from the trachea (bronchi). Bronchitis can either be of brief duration (acute) or have a long course (chronic). Acute bronchitis is usually caused by a viral infection, but can also be caused by a bacterial infection and can heal without complications. Chronic bronchitis is a sign of serious lung disease that may be slowed but cannot be cured.

Description

Although acute and chronic bronchitis are both inflammations of the air passages, their causes and treatments are different. Acute bronchitis is most prevalent in winter. It usually follows a viral infection, such as a cold or the flu, and can be accompanied by a secondary bacterial infection. Acute bronchitis resolves within two weeks, although the cough may persist longer. Acute bronchitis, like any upper airway inflammatory process, can increase a person's likelihood of developing pneumonia.

Anyone can get acute bronchitis, but infants, young children, and the elderly are more likely to get the disease because people in these age groups generally have weaker immune systems. Smokers and people with heart or other lung diseases are also at higher risk of developing acute bronchitis. Individuals exposed to chemical fumes or high levels of air pollution also have a greater chance of developing acute bronchitis.

Chronic bronchitis is a major cause of disability and death in the United States. The American Lung Association estimates that about 14 million Americans suffer from the disease. Like acute bronchitis, chronic bronchitis is an inflammation of airways accompanied by coughing and spitting up of phlegm. In chronic bronchitis, these symptoms are present for at least three months in each of two consecutive years.

Chronic bronchitis is caused by inhaling bronchial irritants, especially cigarette smoke. Until recently, more men than women developed chronic bronchitis, but as the number of women who smoke has increased, so has their rate of chronic bronchitis. Because this disease progresses slowly, middle-aged and older people are more likely to be diagnosed with chronic bronchitis.

KEY TERMS

Acute— Disease or condition characterized by the rapid onset of severe symptoms.

Bronchi— The larger air tubes of the lung that bring air in from the trachea.

Chronic— Disease or condition characterized by slow onset over a long period of time.

Chronic obstructive pulmonary disease (COPD)— A term used to describe chronic lung diseases, like chronic bronchitis, emphysema, and asthma.

Emphysema— One of the several diseases called chronic obstructive pulmonary diseases, emphysema involves the destruction of air sac walls to form abnormally large air sacs that have reduced gas exchange ability and that tend to retain air within the lungs. Symptoms include labored breathing, the inability to forcefully blow air out of the lungs, and an increased susceptibility to respiratory tract infections.

Chronic bronchitis is one of a group of diseases that fall under the name chronic obstructive pulmonary disease (COPD). Other diseases in this category include emphysema and chronic asthmatic bronchitis. Chronic bronchitis may progress to emphysema, or both diseases may be present together.

Causes and symptoms

Acute bronchitis

Acute bronchitis usually begins with the symptoms of a cold, such as a runny nose, sneezing, and dry cough. However, the cough soon becomes deep and painful. Coughing brings up a greenish yellow phlegm or sputum. These symptoms may be accompanied by a fever of up to 102°F (38.8°C). Wheezing after coughing is common.

In uncomplicated acute bronchitis, the fever and most other symptoms, except the cough, disappear after three to five days. Coughing may continue for several weeks. Acute bronchitis is often complicated by a bacterial infection, in which case the fever and a general feeling of illness persist. To be cured, the bacterial infection should be treated with antibiotics.

Chronic bronchitis

Chronic bronchitis is caused by inhaling respiratory tract irritants. The most common irritant is cigarette smoke. The American Lung Association estimates that 80-90% of COPD cases are caused by smoking. Other irritants include chemical fumes, air pollution, and environmental irritants, such as mold or dust.

Chronic bronchitis develops slowly over time. The cells that line the respiratory system contain fine, hair-like outgrowths from the cell called cilia. Normally, the cilia of many cells beat rhythmically to move mucus along the airways. When smoke or other irritants are inhaled, the cilia become paralyzed or snap off. When this occurs, the cilia are no longer able to move mucus, and the airways become inflamed, narrowed, and clogged. This leads to difficulty breathing and can progress to the life-threatening disease emphysema.

A mild cough, sometimes called smokers' cough, is usually the first visible sign of chronic bronchitis. Coughing brings up phlegm, although the amount varies considerably from person to person. Wheezing and shortness of breath may accompany the cough. Diagnostic tests show a decrease in lung function. As the disease advances, breathing becomes difficult and activity decreases. The body does not get enough oxygen, leading to changes in the composition of the blood.

Diagnosis

Initial diagnosis of bronchitis is based on observing the patient's symptoms and health history. The physician will listen to the patient's chest with a stethoscope for specific sounds that indicate lung inflammation, such as moist rales and crackling, and wheezing, that indicates airway narrowing. Moist rales is a bubbling sound heard with a stethoscope that is caused by fluid secretion in the bronchial tubes.

A sputum culture may be performed, particularly if the sputum is green or has blood in it, to determine whether a bacterial infection is present and to identify the disease-causing organism so that an appropriate antibiotic can be selected. Normally, the patient will be asked to cough deeply, then spit the material that comes up from the lungs (sputum) into a cup. This sample is then grown in the laboratory to determine which organisms are present. The results are available in two to three days, except for tests for tuberculosis, which can take as long as two months.

Occasionally, in diagnosing a chronic lung disorder, the sample of sputum is collected using a procedure called a bronchoscopy. In this procedure, the patient is given a local anesthetic, and a tube is passed into the airways to collect a sputum sample.

A pulmonary function test is important in diagnosing chronic bronchitis and other variations of COPD. This test uses an instrument called a spirometer to measure the volume of air entering and leaving the lungs. The test is done in the doctor's office and is painless. It involves breathing into the spirometer mouthpiece either normally or forcefully. Volumes less than 80% of the normal values indicate an obstructive lung disease.

To better determine what type of obstructive lung disease a patient has, the doctor may do a chest x ray, electrocardiogram (ECG), and blood tests. An electrocardiogram is an instrument that is used to measure the electrical activity of the heart and is useful in the diagnosis of heart conditions. Other tests may be used to measure how effectively oxygen and carbon dioxide are exchanged in the lungs.

Treatment

Acute bronchitis

When no secondary infection is present, acute bronchitis is treated in the same way as the common cold. Home care includes drinking plenty of fluids, resting, not smoking, increasing moisture in the air with a cool mist humidifier, and taking acetaminophen (Datril, Tylenol, Panadol) for fever and pain. Aspirin should not be given to children because of its association with the serious illness, Reye's syndrome.

Expectorant cough medicines, unlike cough suppressants, do not stop the cough. Instead they are used to thin the mucus in the lungs, making it easier to cough up. This type of cough medicine may be helpful to individuals suffering from bronchitis. People who are unsure about what type of medications are in over-the-counter cough syrups should ask their pharmacist for an explanation.

If a secondary bacterial infection is present, the infection is treated with an antibiotic. Patients need to take the entire amount of antibiotic prescribed. Stopping the antibiotic early can lead to a return of the infection. Tetracycline or ampicillin are often used to treat adults. Other possibilities include trimethoprim/sulfamethoxazole (Bactrim or Septra) and the newer erythromycin-like drugs, such as azithromycin (Zithromax) and clarithromycin (Biaxin). Children under age eight are usually given amoxicillin (Amoxil, Pentamox, Sumox, Trimox), because tetracycline discolors permanent teeth that have not yet come in.

Chronic bronchitis

The treatment of chronic bronchitis is complex and depends on the stage of chronic bronchitis and whether other health problems are present. Lifestyle changes, such as quitting smoking and avoiding secondhand smoke or polluted air, are an important first step. Controlled exercise performed on a regular basis is also important.

Drug therapy begins with bronchodilators. These drugs relax the muscles of the bronchial tubes and allow increased air flow. They can be taken by mouth or inhaled using a nebulizer. A nebulizer is a device that delivers a regulated flow of medication into the airways. Common bronchodilators include albuterol (Ventolin, Proventil, Apo-Salvent) and metaproterenol (Alupent, Orciprenaline, Metaprel, Dey-Dose).

Anti-inflammatory medications are added to reduce swelling of the airway tissue. Corticosteroids, such as prednisone, can be taken orally or intravenously. Other steroids are inhaled. Long-term steroid use can have serious side effects. Other drugs, such as ipratropium (Atrovent), are given to reduce the quantity of mucus produced.

As the disease progresses, the patient may need supplemental oxygen. Complications of COPD are many and often require hospitalization in the latter stages of the disease.

Alternative treatment

Alternative practitioners focus on prevention by eating a healthy diet that strengthens the immune system and practicing stress management. Bronchitis can become serious if it progresses to pneumonia, therefore, antibiotics may be required. In addition, however, there are a multitude of botanical and herbal medicines that can be formulated to treat bronchitis. Some examples include inhaling eucalyptus or other essential oils in warm steam. Herbalists recommend a tea made of mullein (Verbascum thapsus ), coltsfoot (Tussilago farfara ), and anise seed (Pimpinella anisum ). Homeopathic medicine and traditional Chinese medicine may also be very useful for bronchitis, and hydrotherapy can contribute to cleaning the chest and stimulating immune response.

Prognosis

When treated, acute bronchitis normally resolves in one to two weeks without complications, although a cough may continue for several more weeks. The progression of chronic bronchitis, on the other hand, may be slowed, and an initial improvement in symptoms may be achieved. Unfortunately, however, there is no cure for chronic bronchitis, and the disease can often lead to or coexist with emphysema. Taken together, all forms of COPD are a leading cause of death.

Prevention

The best way to prevent bronchitis is not to begin smoking or to stop smoking. Smokers are ten times more likely to die of COPD than non-smokers. Smokers who stop show improvement in lung function. Other preventative steps include avoiding chemical and environmental irritants, such as air pollution, and maintaining good overall health. Immunizations against certain types of pneumonia (as well as influenza ) are an important preventative measure for anyone with lung or immune system diseases.

Resources

ORGANIZATIONS

American Lung Association. 1740 Broadway, New York, NY 10019. (800) 586-4872. 〈http://www.lungusa.org〉.

National Heart, Lung and Blood Institute. P.O. Box 30105, Bethesda, MD 20824-0105. (301) 251-1222. 〈http://www.nhlbi.nih.gov〉.

National Jewish Center for Immunology and Respiratory Medicine. 1400 Jackson St., Denver, CO 80206. (800) 222-5864. 〈http://www.nationaljewish.org/main.html〉.

Bronchitis

Definition

Bronchitis is an inflammation of the air passages between the nose and the lungs, including the windpipe, or trachea, and the larger air tubes called bronchi that bring air into the lungs from the trachea. When bronchitis is mild and brief in duration, it is called acute. Chronic bronchitis is recurrent, has a prolonged course, and is often a sign of a serious underlying lung disease.

Description

Acute bronchitis

Bronchitis is an inflammation of the breathing airways accompanied by coughing and spitting up of phlegm. It can be caused by exposure to a cold or the flu, infection, or irritants. Although the symptoms of acute and chronic bronchitis are similar, their causes and treatments are different. Acute bronchitis is most common in winter. It usually follows an upper respiratory infection, and may be accompanied by a secondary bacterial infection. Acute bronchitis usually resolves within two weeks, although the cough may persist longer. Like any upper airway inflammatory process, acute bronchitis can increase a person's likelihood of developing pneumonia .

Anyone can get acute bronchitis, but infants, young children, and the elderly are more likely to come down with the disease. Smokers and people with heart or lung diseases are at a higher risk of developing acute bronchitis. Individuals exposed to chemical fumes or high levels of air pollution also have a greater chance of developing acute bronchitis.

Chronic bronchitis

Chronic bronchitis is one of a group of diseases that fall under the name chronic obstructive pulmonary disease (COPD). Other diseases in this category include emphysema and chronic asthmatic bronchitis. Chronic bronchitis is a major cause of disability and death in the United States. The American Lung Association estimates that about 14 million Americans suffer from the disease. Chronic bronchitis shows symptoms similar to acute bronchitis, but it recurs and is present for at least three months a year. Until recently, more men than women developed chronic bronchitis, but as the number of women who smoke has increased, so has their rate of chronic bronchitis. Because this disease progresses slowly, middle-aged and older people are more likely to be diagnosed with chronic bronchitis.

Causes & symptoms

Acute bronchitis

Acute bronchitis usually begins with the symptoms of a cold, such as a runny nose, sneezing , and dry cough. However, the cough soon becomes deep and painful. Coughing brings up a greenish yellow phlegm or sputum. These symptoms may be accompanied by a fever of up to 102°F

(38.8°C). Wheezing after coughing is common. About 90% of acute bronchitis is caused by a bacterial infection.

In uncomplicated acute bronchitis, the fever and most other symptoms, except the cough, disappear after three to five days. Coughing may continue for several weeks. Acute bronchitis is often complicated by a bacterial infection, in which case the fever and a general feeling of illness persist.

Chronic bronchitis

Chronic bronchitis is caused by inhaling respiratory tract irritants; it may also be due to recurrent bouts of acute bronchitis. The most common cause, however, is the irritation of cigarette smoke. The cells that line the respiratory system contain fine, hair-like outgrowths called cilia. Normally, the cilia of many cells beat rhythmically to move mucus along the airways. When smoke or other irritants are inhaled or when there is irritation from repeated dry coughing, the cilia become paralyzed or snap off and the airways become inflamed, narrowed, and clogged. This leads to difficulty breathing and can progress to the life-threatening disease emphysema. A mild cough is usually the first visible sign of chronic bronchitis. Coughing brings up phlegm, and wheezing and shortness of breath may accompany the cough.

Diagnosis

General

Initial diagnosis of bronchitis is based on observing the patient's symptoms and health history. The physician will do chest examination with a stethoscope for specific sounds that indicate lung inflammation and airway narrowing. A sputum culture may be performed, particularly if the sputum is green or has blood in it, to determine whether a bacterial infection is present and to identify the disease-causing organism so that an appropriate antibiotic can be selected. Occasionally, in diagnosing a chronic lung disorder, the sample of sputum is collected using a procedure called a bronchoscopy.

Chronic bronchitis

A pulmonary function test is important in diagnosing chronic bronchitis and other variations of COPD. This test uses an instrument called a spirometer to measure the volume of air entering and leaving the lungs. The doctor may do a chest x ray, an electrocardiogram (ECG), and blood tests as well. Other tests may be used to measure how effectively oxygen and carbon dioxide are being exchanged in the lungs.

Treatment

The treatment of chronic bronchitis is complex and depends on the stage of chronic bronchitis and whether other health problems are present. Lifestyle changes, such as quitting smoking and avoiding secondhand smoke or polluted air, are an important first step. Controlled exercise performed on a regular basis is also important.

There are a multitude of botanical and herbal medicines that can be used to treat bronchitis. Examples from aromatherapy include essential oils of any of the following: benzoin, Styrax benzoin; camphor, Cinnamomum camphora; eucalyptus , Eucalyptus globulus; lavender , Lavandula officinalis; pine, Pinus sylvestris; sandalwood, Santalum album; or thyme , Thymus vulgaris. Any one or combination of these oils should be added to water and inhaled in a warm steam. They can also be dabbed on to a cloth, and the aroma can be breathed in deeply through the nose. A mixture of the essential oils of clove, Eugenia aromaticum; cinnamon, Cinnamomum zeylanicum; lemon balm , Melissa officianalis; and lavender, Lavandula officinalis, is reported to be particularly effective when taken as a steam inhalation.

Herbalists recommend taking a tea, syrup or tincture of any of the following: mullein , Verbascum thapsus; coltsfoot , Tussilago farfara; aniseed, Pimpinella anisum; hyssop , Hyssopus officinalis; elecampane, Inula helenium; and garlic , Allium sativum. The Chinese herb ephedra , also called ma huang or Ephedra sinica, may be recommended as long as heart disease or high blood pressure is not a problem. Ephedra is only used in herbal combinations and when coughing and wheezing are present. There are many remedies in traditional Chinese medicine for coughing and phlegm.

Recommended homeopathic remedies include Aconite 6c, Kali bichromicum 6c, and Phosphorus 6c.

Acupuncture can be useful in preventing chronic bronchitis attacks and in resolving colds that lead to acute attacks.

For a mild case of acute bronchitis over-the-counter remedies of homeopathic medicine, traditional Chinese medicine, and Ayurveda are widely available and quite helpful. Practitioners of these disciplines can be very effective and should be consulted in dealing with more severe or chronic cases. Hydrotherapy and massage with tapping and cupping is also recommended in bronchitis to loosen mucus, improve breathing, and heighten the immune response to the condition.

The juice of a lemon squeezed into a cup of water should be consumed to clear out mucus. Hot, spicy foods can help open the air passages. These foods include garlic, onions, chili peppers, and horseradish, and should be consumed liberally.

Allopathic treatment

Acute bronchitis

When no secondary infection is present, acute bronchitis is treated in the same way as the common cold . Home care includes drinking plenty of fluids, resting, not smoking, increasing moisture in the air with a cool mist humidifier, and taking acetaminophen (Datril, Tylenol, Panadol) for fever and pain . Aspirin should not be given to children because of its association with seizures in children. Cough syrups are recommended to reduce coughing, soothe irritation, and increase expectoration of mucus.

It is important for mucus to be cleared from the lungs. The use of cough suppressants should be limited because when coughing is suppressed, the mucus accumulates in the plugged airways and may become a breeding ground for pneumonia bacteria. If the patient is coughing up phlegm, the cough should be allowed to continue to bring up mucus and irritants from the lungs. Cough medicines with expectorants may, therefore, be helpful. Expectorant cough medicines are used to thin the mucus in the lungs, making it easier to cough up and expel. People who are unsure about what type of medications are in over-the-counter cough syrups should ask their pharmacist for an explanation.

If a secondary bacterial infection is present, the infection may be treated with an antibiotic. Patients need to take the entire amount of antibiotic prescribed. However, in 2002, a new study showed that antibiotics really don't do anything to help acute bronchitis. The drug is mostly prescribed to make the physician and the patient feel like they are "doing something." Inn a double blind study, treatment with cough suppressant medication and inhaled albuterol reported the same improvement as those patients who took antibiotics.

Chronic bronchitis

Drug therapy uses bronchodilators to relax the muscles of the bronchial tubes and allow increased airflow. They can be taken by mouth or inhaled using a nebulizer. Common bronchodilators include albuterol (Ventolin, Proventil, Apo-Salvent) and metaproterenol (Alupent, Orciprenaline, Metaprel, Dey-Dose). Anti-inflammatory medications are added to reduce swelling of the airway tissue. Corticosteroids, such as prednisone, can be taken orally or intravenously. Other steroids are inhaled. Medications are also given to reduce the quantity of mucus. As the disease progresses, the patient may need supplemental oxygen. A one-time pneumonia vaccination may also be recommended.

In 2002, a new drug therapy was approved to treat chronic bronchitis, as well as other pulmonary diseases. Called Severent Diskus, or salmeterol, it is a long-acting bronchodilator that can be inhaled twice a day and will last for 12 hours. It works well for patients with the chronic form of bronchitis, but is not intended for use in acute episodes.

Expected results

When treated, acute bronchitis normally resolves in one to two weeks without complications, although a cough may continue for several more weeks. Unfortunately, there is no cure for chronic bronchitis, and the disease can often lead to or coexist with emphysema. On the whole, all forms of COPD are a leading cause of death.

Prevention

The best way to prevent bronchitis is not to begin smoking or to stop smoking. Smokers are 10 times more likely to die of COPD than non-smokers. Smokers who stop show improvement in lung function. Other preventative steps include avoiding chemical and environmental irritants, such as air pollution, and maintaining good overall health.

Supplementation with vitamins A, C, and E, zinc and bioflavonoids may also be helpful in preventing recurrence and secondary infections . Dairy products, sugar foods and eggs should be avoided, as they may increase the tendency to form mucus in the lungs.

Resources

BOOKS

The Burton Goldberg Group. Alternative Medicine: The Definitive Guide. Washington: Future Medicine Publishing, 1995.

The Editors of Time-Life Books. The Medical Advisor: The Complete Guide to Alternative and Conventional Treatments. VA: Time-Life, Inc., 1996.

PERIODICALS

Evans, AT, S Husain, and L Durairaj. "Antibiotics Won't Do Anything for Acute Bronchitis." Formulary (June 2002): 286.

Mechcatie, Elizabeth. "New & Approved." Family Practice News (May 15, 2002):18–21.

Tiep, Brian L. "Disease Management of COPD with Pulmonary Rehabilitation." Chest (December 1997).

ORGANIZATIONS

National Heart, Lung, and Blood Institute Information Center. P.O. Box 30105, Bethesda, MD 20824-0105.

National Jewish Center for Immunology and Respiratory Medicine. 1400 Jackson Street, Denver, CO 80206.

Patience Paradox

Teresa G. Odle

Bronchitis

Definition

Bronchitis is inflammation of the walls that line the tube-like bronchial passages (bronchi, bronchioles) that carry air in and out of the lungs.

Description

Inflammation of the bronchial tubes in the lungs means that the lining of the bronchials (mucous membrane) is swollen and tender, usually occurring after an acute cold or respiratory infection in the nasal passageways, sinuses, or throat. Bronchitis occurs most often as a single illness (acute bronchitis), but it can sometimes become chronic bronchitis in which the inflammation occurs several months during the year for at least two consecutive years. Smoking cigarettes or being frequently exposed to other irritants may cause acute bronchitis to develop into a chronic condition. In both acute and chronic bronchitis, inflammation is accompanied by infection, resulting in reduced airflow and causing a cough. The source of infection can be bacterial or viral.

Acute bronchitis can usually be treated effectively in people who are otherwise healthy. Chronic bronchitis is a more serious and potentially long-term illness in which the individual will have a mucus-producing cough for most days in three or four months out of each year. It may act like a cold that will not clear up, but the inflammation gradually scars the lining of the bronchi and bronchioles so that mucus production is continuous and the condition develops again and again. As a result the walls that line the bronchial tubes become thicker, reducing airflow and causing constant inflammation, mucus production and coughing. This may become the permanent condition of the lungs, especially in smokers. Chronic bronchitis may also lead to emphysema , a condition that reduces the lungs' ability to exhale air. Both chronic bronchitis and em-physema are classified as chronic obstructive pulmonary disease (COPD) and often occur together.

Demographics

Acute bronchitis occurs commonly among people of both sexes and all ages, with as many as 34 million doctor visits each year by people seeking care for bronchitis or upper respiratory infection (URI). Acute bronchitis develops in 60% of individuals who have the flu (influenza ). More than 12 million individuals are reported to have chronic bronchitis. Among adults, chronic bronchitis occurs twice as often in men than in women and most often in smokers.

Causes and symptoms

Breathing (respiration) is the main function of the lungs on either side of the chest, each composed of lobes, three in the right lung and two in the left. They exchange oxygen and carbon dioxide, bringing in oxygen from the outside environment into the blood, and releasing carbon dioxide from blood that has circulated. Between the lungs is a central airway, the trachea, which then branches into the two larger bronchi that lead into each lung and divide again into smaller bronchi called bronchioles. Finally, the branching ends in small tube-like passages, the terminal bronchioles, which are composed of air-filled sacs (alveolar sacs) that contain even smaller air sacs (alveoli) that exchange oxygen and carbon dioxide through tiny blood vessels surrounding them. Moisture levels inside the lungs make it a perfect environment for bacterial growth, one of the reasons for development of bacterial and viral infections in lungs that are compromised by disease

Acute bronchitis

Acute bronchitis usually follows a cold or viral infection, especially flu virus, and typically lasts no more than six weeks. In acute bronchitis, passageways that are inflamed during an infection return to normal fairly quickly in normally healthy individuals after the infection is treated. However, acute bronchitis can become worse or recur if the individual smokes.

The first symptom of acute bronchitis after having a cold or upper respiratory infection will be a sore throat that leads to a cough, either dry or with coughing up of sputum. Symptoms may also include tightness in the chest and some mild difficulty breathing. Usually there is no fever and symptoms subside in a week or so, except for a lingering cough.

Chronic bronchitis

Smoking cigarettes is the most common cause of chronic bronchitis. When someone smokes, bronchitis recurs frequently, becoming a chronic condition because the lining of the bronchial tract is continuously

irritated. Likewise, when chronic bronchitis is accompanied by smoking, the lining of the bronchial tract stays inflamed and small fibers (cilia) that normally move irritants and mucus out of the passage-ways stop functioning. Because the lungs are then filled with mucus most of the time, they are more subject to bacterial and viral infections. This cycle of inflammation and infection can cause permanent damage to the lungs and severely limit lung function. At this point the condition becomes chronic obstructive lung disease (COPD), which requires regular medical care and treatment to help maintain lung function.

Other irritants that may cause chronic bronchitis include environmental pollutants (e.g., sulfur dioxide) and industrial pollutants found in certain occupations such as coal mining, metal work, and work in grain mills.

Chronic cough is the most noticeable symptom of chronic bronchitis. Symptoms will also include coughing up (expectoration) of significant amounts of sputum, wheezing and difficulty breathing. Sputum is typically thick, yellow to green, and may have tinges of blood. Coughing and expectoration are worse on arising from sleep. Breathing difficulty may be worse after physical activity. The most characteristic pattern includes severe colds and upper respiratory infections, especially in cold weather months, followed by periods of sputum-producing cough with difficult breathing. Several months may pass before another acute infection occurs, but coughing persists in between. Symptoms become progressively worse with each year.

Diagnosis

A comprehensive history will be taken by the doctor, including childhood illnesses such as asthma , injuries, and medications taken; use of drugs, alcohol and tobacco; and any known pattern of coughs, colds or flu followed by a lasting cough. The doctor may ask if anyone in the family has a history of lung disease. Examination of nose, sinuses and throat may reveal signs of recent infection or irritation. A stethoscope may reveal wheezing or crackling sounds in the chest related to excess production of mucus. If sputum is present, it will be tested for the presence of blood and cultured to identify the presence of specific types of bacteria. Testing for viruses may be done as well. Blood tests, including complete blood count and blood chemistries, may be done to investigate overall health, immune system status, and presence of other possible diseases or conditions. Pulmonary function tests will be performed to measure air volume released by the lungs (forced expiratory volume or FEV) and air capacity of the lungs (forced vital capacity or FVC). X rays may also be ordered to check for increased lung volume, which can occur due to inflation of the lungs. The heart may also be enlarged in individuals with advanced chronic bronchitis.

Treatment

In acute bronchitis, the only treatment is to relieve symptoms. Anti-inflammatory drugs may be prescribed as well a decongestants and drugs to thin bronchial secretions and assist in removing material from the lungs (expectorant). Antibiotics are only given when an individual does not respond to treatment of symptoms and when specific bacteria have been identified in sputum.

For chronic bronchitis, the most important treatment for smokers is to stop smoking. Doctors will often recommend nicotine patches or counseling to help an individual stop smoking. Otherwise, specific treatment is not usually effective. Antibiotics may be given when acute flare-ups of infection occur and specific bacterial causes have been identified. Drug therapy may be used to reduce bronchial secretions and reduce inflammation in the airways. Medications may be given by nebulizers that allow

QUESTIONS TO ASK YOUR DOCTOR

• What caused this condition to develop?
• Can I prevent my symptoms from getting worse?
• Are there things I can do for myself to decrease coughing and to breath more easily?
• How many of your patients have chronic bronchitis?
• What medication or treatment has worked best for your patients with chronic bronchitis?

inhalation of a mist, or by metered dose inhalers (MDIs) that are easy for the individual to carry with them at all times. Types of medication will differ from patient to patient, depending on which medication produces the best response. Sometimes inhaled steroids (corticosteroid drugs) are most effective in reducing inflammation in the bronchial passages, helping to reduce secretions and improve breathing. Corticosteroids have numerous side effects in some individuals, however, including osteoporosis , obesity and problems with glucose (sugar) metabolism. If side effects can be controlled, inhaled steroids can continue to be used to relieve symptoms. In advanced cases, regular testing of oxygen levels may be necessary to determine if oxygen administration should be part of treatment, either at night only or continuously.

Prognosis

Acute bronchitis in otherwise healthy individuals is usually short-term. Chronic bronchitis is long-term, with progressive worsening of symptoms. Respiratory failure can occur in chronic bronchitis that has become severe obstructive lung disease, resulting in a life-threatening situation. Death and disability from chronic bronchitis occur primarily in adults over age 55; some deaths are due directly to complications of COPD and others are due to associated heart and/or lung failure.

Prevention Although any adult can develop acute bronchitis due to colds or flu, preventing repeated infections in the bronchial tract from becoming chronic bronchitis is possible. Preventive measures include:

• Don't smoke.
• Avoid inhaled irritants such as second-hand smoke, chemical fumes and environmental toxins.
• Take supplements to support the immune system (Vitamin C with bioflavanoids), destroy harmful toxins (Vitamin E), heal and improve tissues (Vitamin A) and improve circulation and breathing (Coenzyme Q10).
• Include garlic and onions in meals. Both have an anti-inflammatory enzyme and garlic has natural antibiotic properties against infection.
• Maintain good fluid balance in the body (hydration) by drinking plenty of water and other clear fluids.
• Treat any cold or respiratory infection immediately.

KEY TERMS

Bacterial culture —Planting samples of body fluids (e.g., blood, urine or sputum) in a special broth to determine if bacteria are present. Bacteria will then be stained and identified to help select proper antibiotic treatment.

Bronchi —Larger tubular divisions stemming from the main airway (trachea) into the lungs. Bronchi help carry air to and from the lungs and branch into smaller tubular divisions of the lung.

Bronchial —Any function or condition relating to the bronchi.

Corticosteroid drug —A medication that acts like a type of hormone (cortisol) produced by the adrenal gland of the body. Corticosteroids produced by the body stimulate specific types of functional activity. As a drug, a corticosteroid (sometimes just called steroid) provides extra cortisol, which helps treat infection or trauma to the body.

Emphysema —A chronic obstructive pulmonary disease (COPD) characterized by respiratory airspace enlargement that affects lung function and breathing ability.

Nebulizer —A device that holds and dispenses medications in mist-form. Nebulizers help deliver medication to break up congestion in airways or lungs and to improve breathing ability.

Respiratory failure —Loss of lung (pulmonary) function, which can be an acute or chronic disturbance of breathing ability.

Caregiver concerns

An adult with acute bronchitis will not need special care. Individuals with chronic bronchitis may need assistance with nebulizers or other devices that dispense medications or oxygen. The caregiver must be especially alert to breathing difficulty and understand what actions to take if breathing becomes seriously labored. If the individual has advanced chronic bronchitis, the caregiver must be aware of signs and symptoms of lung and heart failure and understand when to call for help since hospitalization may be needed.

Resources

BOOKS

“Bronchitis.” Infectious Diseases, 2nd ed. J. Cohen et al. eds. Philadelphia: Mosby, 2004.

“Pulmonary Disorders: Bronchitis.” The Merck Manual of Diagnosis and Therapy, Section 6. R.S. Porter, ed. White House Station, NJ: Merck Research Laboratories, 2007. Available at www.merck.com. Accessed Feb 1, 2008.

Balch P A. “Bronchitis.” Prescription for Nutritional Healing. Garden City Park, NY: Avery, 1997.

OTHER

“Bronchitis Causes, Symptoms, Diagnosis, Treatment, and Prevention.” MedicineNet. Available at http://www.medicinenet.com. Accessed Feb.3, 2008.

ORGANIZATIONS

American Lung Association, 61 Broadway, 6th floor, New York, NY, 10006, 212-315-8700, 800-LUNG-USA (800-586-4872), www.lungusa.org.

L. Lee Culvert

BRONCHITIS

DEFINITION

Bronchitis (pronounced brong-KIE-tis) is an inflammation of the air passages between the nose and the lungs. It affects the trachea (pronounced TRAY-kee-uh), or windpipe, and the bronchi. The bronchi (pronounced BRON-kee) are air tubes through which air flows into and out of the lungs.

Bronchitis can be either acute (of brief duration) or chronic (longlasting). Acute bronchitis is usually caused by a viral or bacterial infection. It usually heals fairly quickly without complications. Chronic bronchitis is a sign of more serious lung disease. It can often be slowed, but it cannot be cured.

DESCRIPTION

Acute and chronic bronchitis are both inflammations of the air passages. However, their causes and treatments are different. Acute bronchitis occurs most frequently during the winter. It often follows a viral infection, such as a cold (see common cold entry) or the flu (see influenza entry), and may accompany a bacterial infection.

A person who has acute bronchitis is usually better within two weeks. The cough that accompanies the disease may last longer, however. As with similar infections of the airways, pneumonia (see pneumonia entry) may also develop.

Anyone can get acute bronchitis. However, people with weak immune systems, such as infants and the elderly, are more prone to the disease. Smokers and people with heart or lung disease are also at higher risk for acute bronchitis, as are people who are exposed to chemical fumes or high levels of air pollution.

Chronic bronchitis is a major cause of disability and death. The American Lung Association estimates that about fourteen million Americans suffer from the disease. Like acute bronchitis, chronic bronchitis is accompanied by severe coughing and spitting up of phlegm (pronounced FLEM). Chronic bronchitis is characterized by the presence of these symptoms for a period of at least three months in each of two consecutive years. Chronic bronchitis develops slowly. As a result, the disease is seen more often among older people than among the young and middle-aged.

Bronchitis: Words to Know

Bronchi:

The larger air tubes of the lung that bring air in from the trachea.

Cilia:

Fine, hair-like projections that line the trachea and bronchi. Cilia wave back and forth, carrying mucus through the airways.

Emphysema:

A serious and usually fatal disease of the lungs.

Trachea:

The windpipe, a tube that brings air from the back of the throat to the bronchi.

CAUSES

Chronic bronchitis is caused by inhaling substances that irritate the trachea and bronchi. The most common substance is cigarette smoke. The American Lung Association estimates that 80 to 90 percent of all cases of chronic bronchitis are caused by smoking. Until recently, chronic bronchitis occurred more frequently among men than women because traditionally more men smoked than women. That trend is changing and the number of women suffering from chronic bronchitis is also increasing. Other substances

that can irritate the trachea and bronchi include chemical fumes, air pollution, and other materials in the air, such as mold and dust.

Chronic bronchitis develops slowly over time. It is caused by changes in the cilia (pronounced SIL-ee-uh) that line the trachea and bronchi. Cilia are fine, hair-like projections that wave back and forth, carrying mucus through the airways. Smoke and other irritants can damage cilia, causing them to lose their ability to move mucus normally. The airways become narrow and clogged with mucus. The patient has difficulty breathing because he or she cannot get enough air into the lungs. Eventually chronic bronchitis leads to an even more serious and life-threatening disease, emphysema (pronounced em-fi-SEE-muh; see emphysema entry).

SYMPTOMS

Acute bronchitis usually begins with cold-like symptoms, such as a runny nose, sneezing, and dry cough. However, the cough soon becomes deep and painful. Coughing produces a greenish-yellow phlegm or sputum (pronounced SPYOO-tum). Phlegm and sputum are substances coughed up from the inflamed airways. They include blood, mucus, dead cells, and other materials. A fever with temperatures of up to 102°F (39°C) are common. The coughing may also be accompanied by wheezing.

In simple cases of acute bronchitis, most symptoms disappear in three to five days. The cough remains and may continue for several weeks. Acute bronchitis is often accompanied by a bacterial infection that causes its own symptoms, including fever and a general feeling of illness. The bacterial infection can be treated with antibiotics. Drugs are usually not effective against the original viral infection, however.

The first sign of chronic bronchitis is often a mild cough, sometimes called smokers' cough. This coughing may bring up small or greater amounts of phlegm. Wheezing and shortness of breath may accompany the cough. As the disease develops, breathing becomes more difficult. The patient finds it necessary to become less active. The body no longer gets enough oxygen, leading to changes in the composition of the blood.

DIAGNOSIS

To diagnose bronchitis, the doctor first takes the patient's health history and observes his or her symptoms. The doctor then listens to the patient's chest with a stethoscope. Certain sounds indicate narrowing of the airways. These sounds include moist rales, crackling, and wheezing. Moist rales is a bubbling sound caused when fluids are present in the bronchial tubes.

A sputum culture may be performed, especially if the sputum is green or has blood in it. The culture allows the doctor to determine what kinds of bacteria are present in the sputum. He or she can then decide what kind of drugs to use in killing the bacteria.

The first step in taking a sputum culture is to have the patient cough up a small amount of sputum (material from the lungs). The sample is then placed in a warm environment for two to three days. Under these conditions, bacteria grow rapidly and are easy to identify. Sputum can also be collected by means of a bronchoscopy. In this procedure, the patient is first given a local anesthetic. A tube is then passed down the airway to collect a sputum sample.

Another step in diagnosing bronchitis is a lung function test. This step requires the use of a spirometer, which is a device that measures the amount of air entering and leaving the lungs. The test is performed by having the patient breathe into the spirometer, first normally and then with force. The test is quick, easy, and painless. It is usually done in the doctor's office. A lung

function of less than 80 percent can be the sign of bronchitis or a related lung disease.

Many lung diseases have similar symptoms. To tell them apart, a doctor may order other tests, such as a chest X ray, electrocardiogram (ECG; pronounced ih-LEK-tro-KAR-dee-o-gram), or blood tests. An ECG measures electrical activity in the heart. Other tests may be used to measure how effectively oxygen and carbon dioxide are being exchanged in the lungs.

TREATMENT

Simple cases of acute bronchitis are treated like a common cold. The patient is told to drink plenty of fluids, to rest, and to avoid smoking. An air humidifier should be used to increase moisture in the air. Acetaminophen (pronounced uh-see-tuh-MIN-uh-fuhn, trade names Datril, Tylenol, Panadol) should be taken for fever and pain. Aspirin should not be given to children because it may cause the serious illness Reye's syndrome (see Reye's syndrome entry).

Coughing that brings up phlegm should not be treated because it helps remove mucus and other harmful materials from the lungs. If not removed, they collect in the lungs and block airways. Cough suppressants can be used with dry coughs, however.

People with bronchitis may get some relief from expectorant cough medicines. While these medicines do not reduce coughing, they do thin mucus in the lungs, which makes the mucus easier to cough up.

Bacterial infections may accompany acute bronchitis. These infections can be treated with antibiotics. The most important rule about antibiotics is to take the full amount prescribed. Failure to do so can cause the infection to return. A variety of antibiotics is available for use with adults, including trimethoprim/sulfamethoxazole (pronounced tri-METH-o-prim/SULL-fuhmeth-OCK-suh-zole, trade names Bactrim or Septra), azithromycin (pronounced uh-zith-ro-MISE-uhn, trade name Zithromax), and clarithromycin (pronounced kluh-rith-ruh-MISE-uhn, trade name Biaxin). Children under the age of eight are usually given amoxicillin (pronounced uh-MOK-sih-SIL-in, trade names Amoxil, Pentamox, Sumox, Trimox).

Chronic Bronchitis

The treatment of chronic bronchitis is complex. It depends on the stage of the disease and whether other health problems are present. An important first step is giving up smoking and avoiding second-hand smoke (smoke from other people's cigarettes) and air pollutants. A regular program of controlled exercise is also important.

Drug therapy begins with bronchodilators (pronounced brong-ko-die-LATE-urs). These drugs relax the muscles of the bronchial tubes and allow air to flow more freely. Common bronchodilators include albuterol (pronounced al-BYOO-tuh-rol, trade names Ventolin, Proventil, Apo-Salvent) and metaproterenol (pronounced met-uh-pro-TER-uh-nol, trade names Alupent, Orciprenaline, Metaprel, Dey-Dose). They can be taken by mouth or inhaled with a nebulizer. A nebulizer is a device that delivers a carefully measured amount of medication to the airways.

Anti-inflammatory medications are used to reduce swelling of airway tissues. Corticosteroids (pronounced kor-tih-ko-STIHR-oids), such as prednisone (pronounced PRED-nih-zone), can be taken by mouth or by injection. Other steroids are inhaled. Long-term steroid use can have serious side effects and should be avoided.

Drugs are available to reduce the amount of mucus produced. Ipratropium (pronounced ip-ruh-TRO-pee-uhm, trade name Atrovent) is one such drug. In the late stages of the disease, patients may need extra oxygen supplied from an oxygen tank through a mask. Hospitalization may also be required to provide the medical care needed in the last stages of the disease.

Alternative Treatment

The focus of alternative treatments is a healthy diet that strengthens the immune system. A number of herbal medicines have also been recommended for the treatment of bronchitis. These treatments include the inhaling of eucalyptus (pronounced yoo-kuh-LIP-tus) or certain other oils in warm steam and drinking a tea made of mullein, coltsfoot, and anise seed. Hydrotherapy, the use of water and water vapors, may also help clean out the chest and stimulate the immune system.

PROGNOSIS

With treatment, acute bronchitis usually clears up in one to two weeks. The cough that accompanies the disease may last for several more weeks, however. By contrast, chronic bronchitis is a progressive disease. Brief improvements may be seen, but in the long term, no cure is available. The disease often develops into emphysema or other lung diseases, all of which are eventually fatal.

PREVENTION

The best way to prevent bronchitis is not to begin smoking or to stop smoking. Smokers are ten times more likely to die of bronchitis and other lung disorders than are nonsmokers. Other irritants in the environment, such as chemicals and air pollutants, should also be avoided. Immunizations (shots) can also help protect against certain diseases of the lungs, such as pneumonia and the flu.

FOR MORE INFORMATION

Books

Adams, Francis V. The Breathing Disorders Sourcebook. Los Angeles, CA: Lowell House, 1998.

Haas, Francois, and Sheila Sperber Haas. The Chronic Bronchitis and Emphysema Handbook. New York: John Wiley & Sons, 1990.

Shayevits, Myra, Berton Shayevits, and the editors of Consumer Reports Books. Living Well with Chronic Asthma, Bronchitis, and Emphysema. Yonkers, NY: Consumer Report Books, 1991.

Smolley, Laurence A., Debra Fulghum Bruce, and Rob Muzzio. Breathe Right Now : A Comprehensive Guide to Understanding and Treating the Most Common Breathing Disorders. New York: W. W. Norton & Company, 1998.

Organizations

American Lung Association. 1740 Broadway, New York, NY. (800) LUNGUSA. http://www.lungusa.org

National Heart, Lung, and Blood Institute Information Center. PO Box 30105, Bethesda, MD 20824–0105. (301) 251–1221.

National Jewish Center for Immunology and Respiratory Medicine. 1400 Jackson Street, Denver, CO 80206. (800) 222–5864.

Bronchitis

Definition

Bronchitis is an inflammation of the air passages between the nose and the lungs, including the windpipe or trachea and the larger air tubes of the lung that bring air in from the trachea (bronchi). Bronchitis can either be of brief duration (acute) or have a long course (chronic). Acute bronchitis is usually caused by a viral infection but can also be caused by a bacterial infection and can heal without complications. Chronic bronchitis is a sign of serious lung disease that may be slowed but cannot be cured. This form is found almost exclusively in adult smokers. Bronchitis in children is often misdiagnosed as asthma .

Description

Acute bronchitis is most prevalent in winter. It is most often caused by a viral infection and may be accompanied by a secondary bacterial infection. Acute bronchitis resolves within two weeks, although the cough may persist longer. Acute bronchitis, like any upper airway inflammatory process, can increase a child's likelihood of developing pneumonia .

Demographics

Acute bronchitis is one of the more common illnesses affecting preschool and school-age children. It is more commonly diagnosed among children under age five than any other age group. It occurs more often in young males. It can occur anytime but is more frequent during the winter months. In otherwise healthy children complications are few.

Causes and symptoms

Acute bronchitis usually begins with the symptoms of a cold, such as a runny nose, sneezing, and dry cough. However, the cough soon becomes deep and painful. Coughing brings up a greenish yellow phlegm or sputum. These symptoms may be accompanied by a fever of up to 102°F (38.8°C). Wheezing after coughing is common.

In uncomplicated acute bronchitis, the fever and most other symptoms, except the cough, disappear after three to five days. Coughing may continue for several weeks. Acute bronchitis is often complicated by a bacterial infection, in which case the fever and a general feeling of illness persist. To be cured, the bacterial infection should be treated with antibiotics . A cough that does not go away may be a sign of another problem such as asthma or pneumonia.

Physical findings of acute bronchitis vary with the age of the child, and the stage of the disease, but may include the following:

• runny nose
• dry, hacking unproductive cough that may change to a loose cough with increased mucus
• sore throat
• back and other muscle pains
• chills and low grade fever
• headache and general malaise (feeling unwell)

Diagnosis

Initial diagnosis of bronchitis is based on observing the child's symptoms and health history. The physician will listen to the child's chest with a stethoscope for specific sounds that indicate lung inflammation, such as moist rales and crackling, and wheezing, that indicate airway narrowing. Moist rales is a bubbling sound heard with a stethoscope that is caused by fluid secretion in the bronchial tubes.

A sputum culture may be performed, particularly if the sputum is green or has blood in it, to determine whether a bacterial infection is present and to identify the disease-causing organism so that an appropriate antibiotic can be selected. Normally, the patient will be asked to cough deeply then spit the material that comes up from the lungs (sputum) into a cup. This sample is then grown in the laboratory to determine which organisms are present. The results are available in two to three days.

Occasionally, in diagnosing a chronic lung disorder, the sample of sputum is collected using a procedure called a bronchoscopy. In this procedure, the patient is given a local anesthetic, and a tube is passed into the airways to collect a sputum sample.

To better determine what type of obstructive lung disease a patient has, the doctor may do a chest x ray and order blood tests. Other tests may be used to measure how effectively oxygen and carbon dioxide are exchanged in the lungs.

Treatment

When no secondary infection is present, acute bronchitis is treated in the same way as the common cold . Home care includes drinking plenty of fluids, resting, not smoking , increasing moisture in the air with a cool mist humidifier, and taking acetaminophen (Datril, Tylenol, Panadol) for fever and pain . Aspirin should not be given to children because of its association with the serious illness Reye's syndrome .

Cough suppressants are used only when the cough is dry and produces no sputum. If the patient is coughing up phlegm, the cough should be allowed to continue. The purpose of the cough is to bring up extra mucus and irritants from the lungs. When coughing is suppressed, the mucus accumulates in the plugged airways and can become a breeding ground for pneumonia bacteria.

Expectorant cough medicines, unlike cough suppressants, do not stop the cough. Instead they are used to thin the mucus in the lungs, making it easier to cough up. This type of cough medicine may be helpful to individuals suffering from bronchitis. People who are unsure about what type of medications are in over-the-counter cough syrups should ask their pharmacist for an explanation.

If a secondary bacterial infection is present, the infection is treated with an antibiotic. Patients need to take the entire amount of antibiotic prescribed. Stopping the antibiotic early can lead to a return of the infection. Tetracycline or ampicillin is often used to treat adults. Other possibilities include trimethoprim/sulfamethoxazole (Bactrim or Septra) and the newer erythromycin-like drugs, such as azithromycin (Zithromax) and clarithromycin (Biaxin). Children under age eight are usually given amoxicillin (Amoxil, Pentamox, Sumox, Trimox) because tetracycline discolors permanent teeth that have not yet come in.

For some children with acute bronchitis, doctors may prescribe medicines often used to treat asthma. These medicines can help open the bronchial tubes and clear out mucus. Bronchial dilators are usually given with an inhaler. An inhaler sprays the medicine right into the bronchial tree.

Prognosis

When treated, acute bronchitis normally resolves in one to two weeks without complications, although a cough may continue for several more weeks. The progression of chronic bronchitis, on the other hand, may be slowed, but an initial improvement in symptoms may be achieved.

Prevention

Parents should make sure their children are getting adequate nutrition and rest to boost their immunity during cold and flu season. Children should be taught to wash their hands regularly to avoid spreading bacteria and viruses. Other preventative steps include avoiding chemical and environmental irritants, such as air pollution. Immunizations against certain types of pneumonia (as well as influenza ) are an important preventative measure for the very young or those children with chronic diseases.

Parental concerns

Parents should encourage fluids by frequent offers of small amounts of the child's favorite liquids. Humidifiers should produce moist air to keep mucus from drying and to make it easier for the child to breathe. The child should be checked for signs of dehydration , including daily weights. Acetaminophen is given for temperatures over 101°F (38.3°C). Quiet activity provides a diversion for the sick child.

In caring for a child with acute bronchitis, parents should make the following observations:

• Is there a decrease in coughing and mucus production?
• Does the child have periods of rest and sleep?
• Is the child's intake enough for his or her age?
• Has the child kept a normal body temperature for 24 hours?

Parents should be aware that there is a significant association between high levels of air pollution, smoking, and increased incidence of chronic bronchitis. Air pollutants aggravate chronic pulmonary disease in children and cause decreased pulmonary performance in exercising children and teenagers. Teenagers should be questioned and taught about the ill effects of smoking either tobacco or marijuana. Teenagers should also be questioned about industrial fumes or automobile exhaust exposure at school or work.

KEY TERMS

Acute —Refers to a disease or symptom that has a sudden onset and lasts a relatively short period of time.

Bronchi —Singular, bronchus; the large tubular passages that carry air to the lung and allow air to be expelled from the lungs.

Chronic —Refers to a disease or condition that progresses slowly but persists or recurs over time.

Resources

BOOKS

Acute Bronchitis: A Medical Dictionary, Bibliography, and Annotated Research Guide to Internet References. San Diego, CA: Icon Group International, 2004.

Bronchitis: A Medical Dictionary, Bibliography, and Annotated Research Guide to Internet References. San Diego, CA: Icon Group International, 2003.

Ivker, Robert S. Sinus Survival: The Holistic Medical Treatment for Allergies, Bronchitis, Colds, and Sinus. East Rutherford, NJ: Penguin Group, 2000.

Wright, Jill. Asthma and Bronchitis. Northfield, IL: How to Books, 2004.

ORGANIZATIONS

American Lung Association. 1740 Broadway, New York, NY 10019. Web site: <www.lungusa.org>.

National Heart, Lung, and Blood Institute. PO Box 30105, Bethesda, MD 20824–0105. Web site: <www.nhlbi.nih.gov>.

National Jewish Center for Immunology and Respiratory Medicine. 1400 Jackson St., Denver, CO 80206. Web site: <www.nationaljewish.org/main.html>.

WEB SITES

"Bronchitis." MedlinePlus. Available online at <www.nlm.nih.gov/medlineplus/bronchitis.html> (accessed December 17, 2004).

Aliene Linwood, RN, DPA, FACHE

Tish Davidson, AM