Leukemia (Blood Cancer)

 

Bronchitis means inflammation of the bronchial tubes in the lung, and it’s said to be chronic when it causes a productive cough—which means producing mucus—for at least 3 months each year for 2 or more years. Chronic bronchitis is actually lumped under the umbrella of chronic obstructive pulmonary disease (or COPD), along with emphysema. These two are different in that chronic bronchitis is defined by clinical features, like a productive cough, whereas emphysema is defined by structural changes—specifical enlargement of the air spaces. That being said, they often coexist, probably because they share the same major risk factor — smoking.

Other risk factors for chronic bronchitis include exposure to air pollutants like sulfur and nitrogen dioxide, exposure to dust and silica, as well as genetic factors like having a family history of chronic bronchitis. With COPD, the airways become obstructed, and the lungs don’t empty properly, which leaves air trapped inside the lungs. For that reason, the maximum amount of air people with COPD can breathe out in a single breath, known as the FVC, or forced vital capacity, is lower. This reduction is especially noticeable in the first second of air breathed out in a single breath, called FEV1—forced expiratory volume (in one second), which typically is reduced even more than the FVC. A useful metric, therefore, is the FEV1 to FVC ratio, which, since the FEV1 goes down even more than FVC, causes the FEV1 to FVC ratio to go down as well.

Alright so say normally your FVC is 5L, and your FEV1 is 4L, your FEV1 to FVC ratio would end up being 80%. Now, someone with COPD’s FVC might be 4L instead, which is lower than normal, but the volume of air that he or she can expire in the first second is only 2L, so not only are both these values lower, but their ratio is lower as well—and this is a hallmark of COPD.

All that had to do with air breathed outright?

Conversely, for air going in, the TLC, or total lung capacity, which is the maximum volume of air that can be taken in or inspired into the lungs, is actually often higher because of the air trapping. Alright, so chronic bronchitis is a type of COPD that’s diagnosed based on clinical symptoms, specifically coughing up a lot of mucus.

But why does this happen? Well, first off, in the lungs, the walls of normal airways have a couple layers to think about. Lining the lumen of the airways you’ve got the epithelium, composed of ciliated pseudo-stratified columnar epithelial cells, which are named that because these epithelial cells have hair-like projections called cilia, their nuclei don’t align so it looks like they’re more than one layer even though they’re not, hence, pseudo-stratified, and because the cells are mostly tall and narrow - or columnar in shape. This layer also contains the occasional Goblet cell which makes some of the mucus that lines the airway. Going deeper past that layer you’ve got the basement membrane and loose connective tissue called the lamina propria—which together with the epithelium makes up the mucosa. Beyond the mucosa, there is smooth muscle followed by more connective tissue, and together, these two layers make up the sub-mucosa and this is where the bronchial mucinous glands live.

These are the glands that secrete the majority of the mucus into the lumen of the bronchi, helping to catch and filter out particles and pathogens. Finally, in the bronchi, but not the bronchioles, there is also a layer of cartilage below the sub-mucosa which stiffens the bronchus and helps to keep it open. Alright, so people who smoke expose their airways to all sorts of irritants and chemicals. Whatever the irritants are, their effect is to stimulate hypertrophy and hyperplasia of the mucinous glands in the main bronchi, as well as the goblet cells in the smaller airways - the bronchioles, which increases mucus production in both locations.

Since the bronchioles are smaller, even a slight increase in mucus can lead to airway obstruction, so this contributes to the majority of the air trapping. To make matters worse, though, smoking makes the cilia short and less mobile, making it harder to move mucus up and out of bronchioles towards the back of the throat to get swallowed. As a result of having too much mucus and poorly functioning cilia, people with chronic bronchitis end up relying on coughing to get rid of their mucus plugs. One measurement, typically done post-mortem, is called the Reid index, which is the ratio of the thickness of the bronchial mucinous glands, relative to the total thickness of the airway - from the epithelium to the cartilage. Normally, this ratio should be less than 40%, but it can be over 40% for people with chronic bronchitis, because of the hyperplasia and hypertrophy of the glands. Even though an increased Reid index goes along with chronic bronchitis, the diagnosis is still done clinically and this measurement is not usually used diagnostically.

All this mucus in the lungs causes people with chronic bronchitis to wheeze due to the narrowing of the passageway available for air to move in and out, these people also have crackles or rales caused by the popping open of small airways. People with chronic bronchitis also often present with hypoxemia, low oxygen in the blood, and hypercapnia, increased carbon dioxide in the blood.

This is because the mucus plugs in the airways block airflow, Which causes the partial pressure of CO2 to increase in the lungs? Increased PCO2 means that the partial pressure of O2 in the lungs goes down, and a lower PO2 means less oxygen gets to the blood, causing hypoxemia. This trapped CO2 in the lungs also makes it harder for CO2 to get out of the bloodstream, which also explains the hypercapnia. The increased CO2 levels in the blood can get so bad that some people develop cyanosis, which is a blue discoloration of the skin, and this is why patients with chronic bronchitis are sometimes referred to as blue bloaters. This is compared to the term pink puffers which describe patients with emphysema.

Alright so in addition to those things, in the areas with decreased gas exchange, blood vessels undergo vasoconstriction in an attempt to shunt blood to an area with better exchange; which, if it’s localized to one area of the lungs, would work pretty well, but when a large proportion of the lungs aren’t exchanging oxygen effectively, a large proportion of blood vessels start to clamp down. And this has the effect of increasing pulmonary vascular resistance, and to maintain pulmonary blood flow the body responds by developing pulmonary hypertension. Over time, this increases the work needed by the right side of the heart to pump blood to the lungs, and eventually, the right side enlarges, leading to right-sided heart failure, a process called cor-pulmonale.

And finally, another consequence of mucus plugging in chronic bronchitis is that people can develop lung infections behind the mucus blockages in the airway, and these infections can worsen the pulmonary and cardiac symptoms. Treatment of chronic bronchitis largely involves reducing risk factors, like as example stopping smoking, but also managing associated illnesses. Supplemental oxygen, as well as certain medications like bronchodilators, inhaled steroids, and antibiotics to control secondary infections might also be used. Okay, to recap, chronic bronchitis is a type of chronic obstructive pulmonary disease or COPD, where exposure to chemicals and irritants—like with smoking—stimulates increased mucus production in the airways, which causes a productive cough that lasts for at least 3months each year for at least 2 years.