Bronchitis, Acute

- No testing needed unless concerned about pneumonia - CXR - Lungs normal, if uncomplicated - Helps to rule out other diseases (pneumonia) or complications

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
ImmunosuppressionImmunoglobulin deficiencyHIV infectionAlcoholism
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 differentialSputum 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
CXRLungs normal, if uncomplicatedHelps 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 suspectedQuinolone 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.

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.