What are the symptoms and treatment options for a patient with bronchial tube constriction, especially those with asthma or COPD?

Symptoms of Bronchial Tube Constriction

Primary Symptoms

Bronchial tube constriction manifests with a characteristic constellation of respiratory symptoms that vary in severity depending on the underlying disease (asthma or COPD) and degree of obstruction.

Cardinal Respiratory Symptoms

• Dyspnea (shortness of breath) is the most characteristic and disabling symptom, causing significant anxiety and activity limitation 1
• Wheezing occurs due to turbulent airflow through narrowed airways and may vary throughout the day 1
• Chest tightness is commonly reported and can fluctuate in intensity 1
• Chronic cough is often the first symptom to appear, frequently dismissed by patients as a consequence of smoking or environmental exposures 1
• Sputum production may be present, with increased volume and purulence during acute exacerbations 1

Symptoms During Acute Exacerbations

• Increased breathlessness beyond baseline is a key indicator of worsening obstruction 1, 2
• Increased sputum volume signals acute deterioration 1, 2
• Development of purulent (discolored) sputum suggests bacterial infection 1, 2
• Increased wheeze and chest tightness worsen during exacerbations 1

Severe Disease Manifestations

• Fatigue, weight loss, and anorexia occur in patients with more severe forms of COPD 1
• Cyanosis (bluish discoloration) indicates significant hypoxemia 1
• Peripheral edema may develop with cor pulmonale (right heart failure) 1
• Clinical signs of respiratory exhaustion including inability to speak in full sentences, use of accessory muscles, and altered mental status indicate life-threatening obstruction 1

Treatment Approach

Immediate Bronchodilator Therapy

Short-acting inhaled bronchodilators are the first-line treatment for acute bronchial constriction, with the inhaled route strongly preferred over intravenous administration due to superior efficacy and fewer side effects 1, 2, 3.

• Salbutamol (albuterol) 2.5-5 mg via nebulizer every 4-6 hours provides rapid bronchodilation 2
• Ipratropium bromide 500 mcg via nebulizer three times daily should be added for severe symptoms or inadequate response to beta-agonists alone 2
• Combined beta-agonist and anticholinergic therapy provides superior bronchodilation lasting 4-6 hours compared to either agent alone 4
• Dosable aerosols, nebulization, or continuous nebulization are appropriate even for severe obstructive crises requiring mechanical ventilation 3

Systemic Corticosteroids for Acute Exacerbations

Prednisone 30-40 mg orally once daily for exactly 5 days reduces treatment failure by over 50% and should be prescribed for acute COPD exacerbations 2.

• Oral administration is equally effective as intravenous and should be the default route when the patient can tolerate oral medications 2
• Corticosteroids should not be used routinely in the community unless specific criteria are met: patient already on oral corticosteroids, previously documented response, or airflow obstruction failing to respond to increased bronchodilator dose 1

Antibiotic Therapy Indications

Antibiotics should be prescribed only when at least two of three cardinal symptoms are present: increased dyspnea, increased sputum volume, and development of purulent sputum 1, 2.

• Amoxicillin 500 mg orally three times daily for 5-7 days is a recommended first-line regimen 2
• If treatment fails, obtain sputum culture before escalating to fluoroquinolones (levofloxacin 750 mg daily or moxifloxacin 400 mg daily) 4

Oxygen Therapy

• Target SpO₂ of 88-92% to avoid hypercapnic respiratory failure in COPD patients 2
• Start with 2 L/min via nasal cannula or 28% FiO₂ via Venturi mask until arterial blood gases are obtained 2

Critical Pitfalls to Avoid

• Never use intravenous methylxanthines (theophylline) as they increase side effects without added benefit compared to inhaled bronchodilators 1, 4
• Do not use long-acting beta-agonists (LABAs) alone for acute relief—they are not indicated for acute bronchospasm 5
• Paradoxical bronchospasm can occur with any inhaled medication; if it develops, discontinue immediately and use alternative therapy 5
• Ensure proper inhaler technique as inadequate technique is a common cause of treatment failure 1, 6

When to Escalate Care

Endotracheal intubation is indicated for patients presenting with apnea, coma, persistent or increasing hypercapnia, exhaustion, severe distress, or depression of mental status 1.

• Noninvasive positive-pressure ventilation (BiPAP) should be initiated immediately for acute hypercapnic respiratory failure, persistent hypoxemia despite controlled oxygen, or severe dyspnea with respiratory muscle fatigue 4
• Rapid sequence intubation using the largest endotracheal tube available (8-9 mm) decreases airway resistance 1

Follow-Up and Prevention

• Reassess within 48 hours to evaluate treatment response 2
• After recovery, optimize maintenance therapy with long-acting bronchodilators (LAMA/LABA combination) to prevent future exacerbations 2
• Smoking cessation is the single most critical intervention at all stages of disease 6
• Schedule pulmonary rehabilitation within 3 weeks after discharge to reduce hospital readmissions 4