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.