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Bronchitis, Acute

para>Can be serious, particularly if part of influenza, with underlying COPD or 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, immune deficiencies, or for chronic asthma.

  • Acute bronchitis caused by RSV may be fatal.

  • Antitussive medication not indicated in patients younger than age 6 years (2).

 

EPIDEMIOLOGY


  • Predominant age: all ages

  • Predominant gender: male = female


Incidence
  • ~5% of adults per year (5)

  • Common cause of infection in children (4)


Prevalence
Results in 10 to 12 million office visits per year  

ETIOLOGY AND PATHOPHYSIOLOGY


  • Viral infections such as adenovirus, influenza A and B, parainfluenza virus, coxsackie virus, RSV, rhinovirus, coronavirus (types 1 to 3), herpes simplex virus, metapneumonia virus (2)

  • Bacterial infections, such as Chlamydia pneumoniae TWAR agent, Mycoplasma, Bordetella pertussis, Haemophilus influenzae, Streptococcus pneumoniae, Moraxella catarrhalis, and Mycobacterium tuberculosis (2)

  • Secondary bacterial infection as part of an acute upper respiratory infection

  • Possibly fungal infections

  • Chemical irritants

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


Genetics
No known genetic pattern  

RISK FACTORS


  • Infants

  • Elderly

  • Air pollutants

  • Smoking

  • Secondhand smoke

  • Environmental changes

  • Chronic bronchopulmonary diseases

  • Chronic sinusitis

  • Tracheostomy or endobronchial intubation

  • Bronchopulmonary allergy

  • Hypertrophied tonsils and adenoids in children

  • Immunosuppression

    • Immunoglobulin deficiency

    • HIV infection

    • Alcoholism

  • Gastroesophageal reflux disease (GERD)


GENERAL PREVENTION


  • Avoid smoking and secondhand smoke.

  • Control underlying risk factors (i.e., asthma, sinusitis, and reflux).

  • Avoid exposure, especially daycare.

  • Pneumovax, influenza immunization


COMMONLY ASSOCIATED CONDITIONS


  • Allergic rhinitis

  • Sinusitis

  • Pharyngitis

  • Epiglottitis (rare but can be rapidly fatal)

  • Coryza

  • Croup

  • Influenza

  • Pneumonia

  • Asthma

  • COPD/emphysema

  • GERD


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 nonproductive, then productive; later, mucopurulent sputum, which may indicate secondary infection

  • Cough lasts more than 5 days (1)

  • Dyspnea, wheeze, and fatigue may occur.

  • Possible contact with others who have respiratory infections (1)

  • Fever is uncommon and may suggest pneumonia or influenza infection (1).


PHYSICAL EXAM


  • Fever

  • Tachypnea

  • Pharynx injected

  • Rales, rhonchi, wheezing

  • No evidence of pulmonary consolidation


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

  • Chronic cough


DIAGNOSTIC TESTS & INTERPRETATION


Initial Tests (lab, imaging)
  • None normally needed; diagnosis is based on history and physical exam showing no postnasal drip or rales (1,3).

  • For a complicated picture, consider the following:

    • WBC with differential

    • Sputum culture/sensitivity if CXR is abnormal (3)

    • Influenza titers (if appropriate for time of year) (1)

    • Viral panel

  • No testing needed unless concerned about pneumonia

  • CXR

    • Lungs normal, if uncomplicated

    • Helps to rule out other diseases (pneumonia) or complications


Follow-Up Tests & Special Considerations
  • Arterial blood gases: hypoxemia (rarely)

  • Pulmonary function tests (seldom needed during acute stages): increased residual volume, decreased maximal expiratory rate (2)

  • Procalcitonin level may influence use on antibiotics (6).

  • Sputum culture in those patients intubated or with tracheostomy


TREATMENT


GENERAL MEASURES


  • Outpatient treatment unless elderly or complicated by severe underlying disease

  • Rest

  • Stop smoking or avoid smoke.

  • Steam inhalations

  • Vaporizers

  • Adequate hydration

  • Antitussives

  • Antibiotics are usually not recommended (1,3,7)[A].

  • Treat associated illnesses (e.g., GERD).


MEDICATION


ALERT

Antibiotics are not recommended (1,3,6)[A] unless a treatable pathogen has been identified or significant comorbidities are present. This should be explained to patients who likely expect an antibiotic to be prescribed (3)[B].

 
First Line
  • Supportive; increased fluids (cough results in increased fluid loss)

  • Antipyretic analgesic such as aspirin, acetaminophen, or ibuprofen

  • Decongestants if accompanied by sinus condition

  • Cough suppressant for troublesome cough (not with COPD); honey, benzonatate (Tessalon), guaifenesin with codeine or dextromethorphan. Not indicated in children younger than age 6 years (2)[C]

  • Mucolytic agents are not recommended (3)[B].

  • Inhaled β-agonist (e.g., albuterol) or in combination with high-dose inhaled corticosteroids for cough with bronchospasm (2)[B]

  • If influenza is highly suspected and symptom onset is <48 hours: oseltamivir (Tamiflu) or zanamivir (Relenza) (2)[B]

  • Antibiotics ONLY if a treatable cause (i.e., pertussis) is identified (2)[A].

    • Clarithromycin (Biaxin): 500 mg q12h or azithromycin (Zithromax) Z-pack for atypical or pertussis infection (1)[A]

    • 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 amoxicillin-clavulanic acid (8)[B].

      • Doxycycline: 100 mg/day — 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

  • Contraindication(s): Doxycycline and quinolones should not be used during pregnancy or in children.

  • Precautions:

    • Multiple antibiotics have the potential to interfere with the effectiveness of PO contraceptives.

    • Antibiotic use can be associated with Clostridium difficile infections.

    • Cough and cold preparations should not be used in children <6 years (2)[B].


Second Line
Other antibiotics if indicated by sputum culture  
ISSUES FOR REFERRAL
  • Complications such as pneumonia or respiratory failure

  • Comorbidities such as COPD

  • Cough lasting >3 months


ADDITIONAL THERAPIES


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

  • Inhaled β-agonist (e.g., albuterol) or in combination with high-dose inhaled corticosteroids for cough with bronchospasm (2)[B]

  • Oral corticosteroids probably not indicated (2)[C]


COMPLEMENTARY & ALTERNATIVE MEDICINE


Throat lozenges for pharyngitis  

INPATIENT CONSIDERATIONS


Admission Criteria/Initial Stabilization
  • Hypoxia-may require supplemental oxygen

  • Respiratory failure that may require CPAP/bilevel ventilation

  • Severe bronchospasm

  • Exacerbation of underlying disease

  • Bronchodilators if patient is bronchospastic.


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 (7)


Patient Monitoring
  • Oximetry until no longer hypoxemic

  • Recheck for chronicity.


DIET


Increased fluids (3 to 4 L/day) 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.

  • Postbronchitic reactive airways disease (rare)

  • Bronchiolitis obliterans and organizing pneumonia (rare)


COMPLICATIONS


  • Superinfection such as bronchopneumonia

  • Bronchiectasis

  • Hemoptysis

  • Acute respiratory failure

  • Chronic cough


REFERENCES


11 Wenzel  RP, Fowler  AAIII. Clinical practice. Acute bronchitis. N Engl J Med.  2006;355(20):2125-2130.22 Albert  RH. Diagnosis and treatment of acute bronchitis. Am Fam Physician.  2010;82(11):1345-1350.33 Braman  SS. Chronic cough due to acute bronchitis: ACCP evidence-based clinical practice guidelines. Chest.  2006;129(1)(Suppl):95S-103S.44 Fleming  DM, Elliot  AJ. The management of acute bronchitis in children. Expert Opin Pharmacother.  2007;8(4):415-426.55 Llor  L, Moragas  A, Bayona  C, et al. Efficacy of anti-inflammatory or antibiotic treatment in patients with non-complicated acute bronchitis and discoloured sputum: randomised placebo controlled trial. BMJ.  2013;347:f5762.66 Schuetz  P, Amin  DN, Greenwald  JL. Role of procalcitonin in managing adult patients with respiratory tract infections. Chest.  2012;141:1063-1073.77 Gonzales  R, Anderer  T, McCulloch  CE, et al. A cluster randomized trial of decision support strategies for reducing antibiotic use in acute bronchitis. JAMA Intern Med.  2013;173(4):267-273.88 Panpanich  R, Lerttrakarnnon  P, Laopaiboon  M. Azithromycin for acute lower respiratory tract infections. Cochrane Database Syst Rev.  2008;(1):CD001954.

SEE ALSO


  • Asthma; Chronic Obstructive Pulmonary Disease and Emphysema

  • Algorithm: Cough, Chronic


CODES


ICD10


  • J20.9 Acute bronchitis, unspecified

  • J68.0 Bronchitis and pneumonitis due to chemicals, gases, fumes and vapors

  • B97.0 Adenovirus as the cause of diseases classified elsewhere

  • J20.1 Acute bronchitis due to Hemophilus influenzae

  • J20.5 Acute bronchitis due to respiratory syncytial virus

  • J20.4 Acute bronchitis due to parainfluenza virus

  • J20.6 Acute bronchitis due to rhinovirus

  • J20.0 Acute bronchitis due to Mycoplasma pneumoniae

  • J20.3 Acute bronchitis due to coxsackievirus

  • J20.8 Acute bronchitis due to other specified organisms

  • J20.2 Acute bronchitis due to streptococcus

  • J20.7 Acute bronchitis due to echovirus


ICD9


  • 466.0 Acute bronchitis

  • 506.0 Bronchitis and pneumonitis due to fumes and vapors

  • 079.0 Adenovirus infection in conditions classified elsewhere and of unspecified site

  • 041.5 Hemophilus influenzae [H. influenzae] infection in conditions classified elsewhere and of unspecified site

  • 074.8 Other specified diseases due to Coxsackie virus

  • 079.3 Rhinovirus infection in conditions classified elsewhere and of unspecified site

  • 041.00 Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, unspecified

  • 079.1 Echo virus infection in conditions classified elsewhere and of unspecified site

  • 079.6 Respiratory syncytial virus (RSV)


SNOMED


  • 10509002 Acute bronchitis (disorder)

  • 54410000 Bronchitis due to fumes AND/OR vapors (disorder)

  • 233603001 Acute bronchiolitis due to adenovirus

  • 195721005 Acute haemophilus influenzae bronchitis (disorder)

  • 195728004 Acute bronchitis due to rhinovirus

  • 195727009 Acute respiratory syncytial virus bronchitis

  • 233601004 Acute viral bronchitis (disorder)

  • 195720006 Acute streptococcal bronchitis (disorder)

  • 195729007 Acute echovirus bronchitis

  • 233599001 Acute mycoplasmal bronchitis

  • 233598009 Acute bacterial bronchitis (disorder)

  • 195726000 Acute parainfluenza virus bronchitis

  • 195725001 Acute coxsackievirus bronchitis


CLINICAL PEARLS


  • Acute bronchitis is a common and generally self-limited disease.

  • It usually does not require treatment with antibiotics. This needs to be explained to patients who expect antibiotics to be prescribed.

  • Cough may linger for several weeks.

  • Recurrent or seasonal episodes may suggest another disease process, such as asthma.

  • Fever is uncommon and should prompt investigation for pneumonia or influenza.

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