Acute Bronchitis – Causes, Symptoms, Diagnosis, Treatment and Ongoing care

Basics

Description

  • Inflammation of trachea, bronchi, and bronchioles resulting from a respiratory tract infection or chemical irritant (1,2)
  • Cough is the predominant symptom (3).
  • Generally self-limited, with complete healing and full return of function
  • Most infections are viral if no underlying cardiopulmonary disease is present.
  • Synonym(s): Tracheobronchitis, chest cold

Geriatric Considerations

Can be serious, particularly if part of influenza, with underlying chronic obstructive pulmonary disease (COPD) or congestive heart failure (CHF) (3)

Pediatric Considerations

  • Usually occurs in association with other conditions of upper and lower respiratory tract (trachea usually involved) (4)
  • If repeated attacks occur, child should be evaluated for anomalies of the respiratory tract, including immune deficiencies or for chronic asthma.
  • When acute bronchitis is caused by respiratory syncytial virus (RSV), it may be fatal.

Epidemiology

  • Predominant age: All ages
  • Predominant gender: Male = Female.

Incidence

  • ∼5% of adults per year (3)
  • A common cause of infection in children (4)

Prevalence

Results in 10–12 million office visits per year (3)

Risk Factors

  • Infants
  • Elderly
  • Air pollutants
  • Smoking
  • Secondhand smoke
  • Environmental changes
  • Chronic bronchopulmonary diseases
  • Chronic sinusitis
  • Tracheostomy
  • Bronchopulmonary allergy
  • Hypertrophied tonsils and adenoids in children
  • Immunosuppression:
    • Immunoglobulin deficiency
    • HIV infection
    • Alcoholism
  • Gastroesophageal reflux disease (GERD)

Genetics

No known genetic pattern

General Prevention

  • Avoid smoking.
  • Control underlying risk factors (i.e., asthma, sinusitis, and reflux).
  • Avoid exposure, especially day care.
  • Pneumovax, influenza immunization

Pathophysiology

Acute bronchitis causes an injury to the epithelial surfaces, resulting in an increase in mucous production (2) and thickening of the bronchiole wall (1).

Etiology

  • Viral infections, such as adenovirus, influenza A and B, parainfluenza virus, coxsackievirus, RSV, rhinovirus, coronavirus (types 1–3), herpes simplex virus
  • Bacterial infections, such as Chlamydia pneumoniae [Taiwan acute respiratory (TWAR) agent], Mycoplasma, Bordetella pertussis, Haemophilus influenzae, Streptococcus pneumoniae, Moraxella catarrhalis, and Mycobacterium tuberculosis
  • Secondary bacterial infection as part of an acute upper respiratory infection
  • Possibly fungal infections
  • Chemical irritants

Commonly Associated Conditions

  • Allergic rhinitis
  • Sinusitis
  • Pharyngitis
  • Epiglottitis (rare but can be rapidly fatal)
  • Coryza
  • Croup
  • Influenza
  • Pneumonia
  • Asthma
  • COPD/emphysema
  • GERD

Chronic obstructive pulmonary disease, Sinusitis, Acute bronchitis, Common cold, Gastroesophageal reflux disease, Chlamydophila pneumoniae, tonsils and adenoids, influenza immunization, cardiopulmonary disease, bronchioles, tracheobronchitis, hiv infection,

Diagnosis

History

  • Sudden onset of cough and no evidence of pneumonia, asthma, exacerbation of COPD, or the common cold (3)
  • Cough is initially dry and unproductive, then productive; later, mucopurulent sputum, which may indicate secondary infection
  • Dyspnea, wheeze, fever, and fatigue may occur.
  • Possible contact with others who have respiratory infections (1)

Physical Exam

  • Fever
  • Tachypnea
  • Pharynx injected
  • Rales, rhonchi, wheezing
  • No evidence of pulmonary consolidation

Diagnostic Tests & Interpretation

Lab

Initial lab tests

  • Sputum culture/sensitivity if purulent
  • Influenza titers (if appropriate for time of year)
  • White blood cell (WBC)

Follow-Up & Special Considerations

  • Arterial blood gases: Hypoxemia (rarely)
  • Pulmonary function tests (seldom needed during acute stages): Increased residual volume, decreased maximal expiratory rate (2)

Imaging

Initial approach

Chest radiograph:

  • Lungs normal if uncomplicated
  • Helps to rule out other diseases (pneumonia) or complications

Differential Diagnosis

  • Common cold
  • Acute sinusitis
  • Bronchopneumonia
  • Influenza
  • Bacterial tracheitis
  • Bronchiectasis
  • Asthma
  • Reactive airways dysfunction syndrome (RADS)
  • Allergy
  • Eosinophilic pneumonitis
  • Aspiration
  • Retained foreign body
  • Inhalation injury
  • Cystic fibrosis
  • Bronchogenic carcinoma
  • Heart failure
  • GERD

Treatment

Medication

Alert

Antibiotics are usually not recommended (1,3,5)[A] unless a treatable pathogen has been identified or significant comorbidities are present.

First Line

  • Amantadine or rimantadine therapy if influenza A is suspected; most effective if started within 24–48 h of development of symptoms [also consider oseltamivir (Tamiflu) or zanamivir (Relenza)]
  • Decongestants if accompanied by sinus condition (1)
  • Antipyretic analgesic, such as aspirin, acetaminophen, or ibuprofen
  • Antibiotics if a treatable cause (i.e., pertussis) is identified (5)[A]:
    • Amoxicillin 500 mg q8h or trimethoprim-sulfamethoxazole DS q12h for routine infection
      • Penicillins and trimethoprim-based regimens seem to be equivalent in terms of effectiveness and toxicity for acute bacterial exacerbations of chronic bronchitis (ABECB) (6)[B].
      • Clarithromycin (Biaxin) 500 mg q12h or azithromycin (Zithromax) Z-pack for penicillin allergy or Mycoplasma infection: In patients with acute bronchitis of a suspected bacterial cause, azithromycin tends to be more effective in terms of lower incidence of treatment failure and adverse events than amoxicillin or amoxycillin-clavulanicacid (7)[B].
    • Doxycycline 100 mg/d × 10 days if Moraxella, Chlamydia, or Mycoplasma suspected
    • Quinolone for more serious infections or other antibiotic failure or in elderly or patients with multiple comorbidities
    • Macrolide for pertussis (1)[A]
  • Cough suppressant for troublesome cough (not with COPD); guaifenesin with codeine or dextromethorphan (3)[A]
  • Inhaled beta agonist (e.g., albuterol) or in combination with steroids for cough with bronchospasm (2,3)[B]
  • Consider steroids for bronchospasm
  • Contraindication(s): Doxycycline should not be used during pregnancy or in children.
  • Precautions:
    • Watch for theophylline toxicity with macrolides and quinolones.
    • Multiple antibiotics have the potential to interfere with the effectiveness of oral contraceptives.

Second Line

  • Other antibiotics if indicated by sputum culture (Moraxella needs a different set of antibiotics)
  • Antivirals
  • Other macrolides or quinolones based on pathogen and sensitivity

Additional Treatment

General Measures

  • Rest
  • Stop smoking/avoid smoke.
  • Steam inhalations
  • Vaporizers
  • Adequate hydration
  • Antitussives
  • Antibiotics are usually not recommended (1,3,5)[A].
  • Treat associated illnesses (e.g., GERD).

Issues for Referral

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  • Complications, such as pneumonia or respiratory failure
  • Comorbidities, such as COPD
  • Cough lasting longer than 3 months

Additional Therapies

Antipyretic for fever (e.g., acetaminophen, aspirin, or ibuprofen)

Complementary and Alternative Medicine

Throat lozenges for pharyngitis

In-Patient Considerations

Initial Stabilization

  • Outpatient, unless elderly or complicated by severe underlying disease
  • May require supplemental oxygen in selected patients
  • Bronchodilators if patient is bronchospastic

Admission Criteria

  • Hypoxia
  • Severe bronchospasm
  • Exacerbation of underlying disease

IV Fluids

May be helpful if patient is dehydrated

Nursing

  • Ensure patient comfort and monitor for signs of deterioration, especially if underlying lung disease exists.
  • May need to follow oxygen saturation in patients with underlying lung disease

Discharge Criteria

Improvement in symptoms and comorbidities

Ongoing Care

Follow-Up Recommendations

  • Usually a self-limited disease not requiring follow-up
  • Cough may linger for several weeks.
  • In children, if recurrent, need to consider other diagnoses, such as asthma (4)

Patient Monitoring

  • Oximetry until no longer hypoxemic
  • Recheck for chronicity.

Diet

Increased fluids (3–4 L/d) while febrile

Patient Education

  • For patient education materials favorably reviewed on this topic, contact the American Lung Association, 1740 Broadway, New York, NY 10019, (212) 315-8700; www.lungusa.org.
  • American Academy of Family Physicians: www.familydoctor.org

Prognosis

  • Usual: Complete resolution
  • Can be serious in the elderly or debilitated
  • Cough may persist for several weeks after an initial improvement (1,2).
  • Postbronchitic reactive airways disease (rare)
  • Bronchiolitis obliterans and organizing pneumonia (rare)

Complications

  • Superinfection such as bronchopneumonia
  • Bronchiectasis
  • Hemoptysis
  • Acute respiratory failure
  • Chronic cough

References

1. Wenzel RP, Fowler AA. Clinical practice. Acute bronchitis. N Engl J Med. 2006;355:2125–30.

2. Knutson D, Braun C. Diagnosis and management of acute bronchitis. Am Fam Physician. 2002;65:2039–44.

3. Braman SS. Chronic cough due to acute bronchitis: ACCP evidence-based clinical practice guidelines. Chest. 2006;129:95S–103S.

4. Fleming DM, Elliot AJ. The management of acute bronchitis in children. Expert Opin Pharmacother. 2007;8:415–26.

5. Fahey T, et al. Antibiotics for acute bronchitis. Cochrane Database Syst Rev. 2004;4:CD000245. DOI:10.1002/14651858.CD000245.pub2.

6. Korbila IP, Manta KG, Siempos II, et al. Penicillins vs trimethoprim-based regimens for acute bacterial exacerbations of chronic bronchitis: Meta-analysis of randomized controlled trials. Can Fam Physician.2009;55:60–7.

7. Panpanich R, Lerttrakarnnon P, Laopaiboon M. Azithromycin for acute lower respiratory tract infections. Cochrane Database Syst Rev. 2008;CD001954.

Additional Reading

See Also (Topic, Algorithm, Electronic Media Element)

Asthma; Chronic Obstructive Pulmonary Disease and Emphysema

Algorithm: Cough

Codes

ICD9

466.0 Acute bronchitis

Snomed

10509002 Acute bronchitis (disorder)

Clinical Pearls

  • Acute bronchitis is a common and generally self-limited disease.
  • Usually does not require treatment with antibiotics
  • Cough may linger for several weeks.
  • Recurrent or seasonal episodes may suggest another disease process, such as asthma.

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