Basics
Description
- Hyperemia and edema of the mucous membranes
- Production of mucopurulent exudates
- Impairment of the productive function of the cilia, lymphatics, and phagocytes
- Airway obstruction from:
- Edema
- Secretions
- Bronchial muscle spasm
Etiology
- Viral infections are the primary cause of bronchitis:
- Parainfluenza
- Influenza A and B
- Respiratory syncytial virus
- Human metapneumovirus
- Echovirus
- Coronavirus
- Adenovirus
- Coxsackievirus
- Rhinovirus
- Measles and herpes viruses (can cause severe viral bronchitis)
- Particularly severe or long-lasting bronchitis:
- Mycoplasma pneumoniae
- Chlamydia pneumoniae
- Bordetella pertussis:
- Rates of pertussis are increasing, even in the fully immunized population (little protection remains after 10 yr).
- Other bacteria have not been conclusively proven to cause bronchitis except in those with chronic lung disease.
Diagnosis
Signs and Symptoms
History
- Complaints that may precede upper respiratory tract infection (URTI) symptoms:
- Malaise
- Chills
- Myalgias
- Coryza (rhinitis)
- Sore throat
- Onset of URTI symptoms:
- Mild dyspnea
- Cough, initially dry and nonproductive
- Cough, later becomes mucoid or mucopurulent
- Chest pain or burning related to cough
- Initial symptoms improve after 3-5 days, with 1-3 wk of residual cough and malaise
Physical Exam
- Fever, not usually above 102 °F (38.5 °C)
- Tachypnea
- Mild hemoptysis
- Ronchi (wheezing)
- Rales (crackles)
Essential Workup
- Influenza A and B testing if identification of these organisms is required for treatment or reporting
- Evaluate for pertussis:
- Acute cough illness lasting 14 days or more in a person with paroxysmal cough, post-tussive vomiting, or inspiratory whoop
- 14 days or more of cough within an outbreak setting
Diagnosis Tests & Interpretation
Lab
- Influenza A and B testing may help immediately confirm clinical suspicion.
- In most cases, no specific test will help make the diagnosis immediately.
- Viral or bacterial cultures are rarely helpful.
- CBC may show leukocytosis, but is a nonspecific finding.
- Pertussis may be confirmed using PCR testing, but diagnosis will be delayed.
Imaging
CXR:
- No evidence of consolidation
- Indications:
- Shortness of breath
- Hypoxia
- Chest pain
- Heart rate >100 beats/min
- Respiratory rate ≥24 breaths/min
- Temperature ≥38 °C
- Focal findings on chest exam
- Elderly patient with multiple comorbid conditions
- Hypoxia
- 14 days or more of cough
Diagnostic Procedures/Surgery
Pulmonary function tests are frequently abnormal.
Differential Diagnosis
- Acute and subacute <8 wk:
- Pneumonia
- Reactive airway disease
- Aspiration
- Acute sinusitis
- Bacterial tracheitis
- Occupational exposure
- Chronic >8 wk:
- Asthma
- GERD
- Chronic bronchitis
- Bronchiectasis
- ACE inhibitor use
- Bronchogenic carcinoma
- Carcinomatosis
- Sarcoidosis
- Left ventricular failure
- Aspiration syndrome
- Psychogenic/habit
Treatment
Pre-Hospital
- Maintain adequate oxygenation
- Bronchodilators if wheezing is present
Initial Stabilization/Therapy
- Aggressive initial management of these patients is seldom required.
- Administer oxygen if the patient is hypoxic.
- Fluids may be administered if the patient is dehydrated.
Ed Treatment/Procedures
- Bronchitis is usually a viral process, but may be bacterial and there is no practical test to distinguish between the 2:
- Because this is usually a viral process, treatment is symptomatic:
- Cough suppressants may be considered.
- β-Adrenergic inhaler for patients with evidence of airflow obstruction
- Amantadine may be used in known outbreaks of influenza A, although local patterns of resistance should be reviewed.
- Oseltamivir (Tamiflu) and zanamivir (Relenza) may be considered in patients with recent onset of influenza.
- Antibiotics:
- Generally, antibiotics are not indicated (even when secretions are purulent).
- In healthy patients with no underlying lung disease, antibiotics may help some patients get better slightly faster, but weighed against the many people it does not help, cost, side effects, and resistance, antibiotics are not recommended.
- Consider use in those patients who have recurrence of fever after initial improvement.
- Symptomatic control with antipyretics and analgesics
- Although patients should be encouraged to stop smoking, the use of tobacco is not an indication for antibiotics unless the patient has a known history of emphysema.
Be aware that respiratory viruses can cause significant morbidity in immunocompromised patients and their care should be discussed with their primary care physician.
- Aggressive initial management of these patients is seldom required.
- Administer oxygen if the patient is hypoxic.
- Fluids may be administered if the patient is dehydrated.
- Repeated bouts in children should lead to referral for complete evaluation of the respiratory tract.
Medication
- Albuterol Inhaler may be used for those with evidence of airflow obstruction.
- Amantadine: 100 mg/d PO, must be given within 48 hr of symptom onset
- Oseltamivir (Tamiflu) and zanamivir (Relenza) within 48 hr of symptom onset for influenza-related bronchitis:
- Zanamivir: 10 mg inhalation q12h (peds: >7 yr 10 mg or 2 inhalations q12h) — 5 d
- Oseltamivir: 75 mg PO BID (peds: 2 mg/kg) — 5 d
- Erythromycin should be given to proven cases of pertussis and to household contacts of those with proven pertussis.
- Yearly influenza vaccinations should be encouraged in health care providers and in the high-risk populations (elderly, immunocompromised, chronic lung disease).
- Use of acetaminophen rather than aspirin for analgesia
- Antibiotic considerations are the same as in adults.
Follow-Up
Disposition
Admission Criteria
- Underlying significant cardiopulmonary compromise
- Significant hypoxia
- Ill patient with unclear diagnosis
Discharge Criteria
- No pulmonary compromise should be present.
- Instruct patients, particularly high-risk patients, to return if no improvement or worsening of symptoms occurs.
- Bed rest
- Fluids
- Aspirin or acetaminophen
Follow-Up Recommendations
- No follow-up is needed in those patients that improved.
- Patients should be instructed to return to the ED for onset of shortness of breath and should see their doctor if not improved after 2-3 wk.
Pearls and Pitfalls
Patients with high fever or significant pulmonary symptoms should be evaluated for pneumonia.
Additional Reading
- Aagaard E, Gonzales R. Management of acute bronchitis. Infect Dis Clinic North Am. 2004;18:919-937.
- Becker LA, Hom J, Villasis-Keever M, et al. Beta2-agonists for acute bronchitis. Cochrane Database of Syst Rev. 2011;(7):CD001726. doi:10.1002/14651858.CD001726.pub4.
- Camargo CA Jr, Rachelefsky G, Schatz M. Managing asthma exacerbations in the emergency department. Summary of the National Asthma Education and Prevention Program Expert Panel Report 3 guidelines for the management of asthma exacerbations. Proc Am Thorac Soc. 2009;6(4):357-366.
- Rollins DR, Beuther DA, Martin RJ. Update on infection and antibiotics in asthma. Curr Allergy Asthma Rep. 2010;10:67-73.
- Smith SM, Fahey T, Smucny J, Becker LA. Antibiotics for acute bronchitis. Cochrane Database of Syst Rev. 2014; Issue 3. Art. No.: CD000245. DOI: 10.1002/14651858.CD000245.pub3.
- Stephens MM, Nashelsky J. Clinical Inquiries. Do inhaled beta-agonists control cough in URIs or acute bronchitis? J Fam Pract. 2004;53:662-663.
See Also (Topic, Algorithm, Electronic Media Element)
- Cough
- Dyspnea
- Pneumonia, Adult
- Pneumonia, Pediatric
Codes
ICD9
- 466.0 Acute bronchitis
- 466.11 Acute bronchiolitis due to respiratory syncytial virus (RSV)
- 490 Bronchitis, not specified as acute or chronic
- 466.19 Acute bronchiolitis due to other infectious organisms
- 466.1 Acute bronchiolitis
ICD10
- J20.4 Acute bronchitis due to parainfluenza virus
- J20.5 Acute bronchitis due to respiratory syncytial virus
- J20.9 Acute bronchitis, unspecified
- J20.8 Acute bronchitis due to other specified organisms
- J20.0 Acute bronchitis due to Mycoplasma pneumoniae
- J20.1 Acute bronchitis due to Hemophilus influenzae
- J20.2 Acute bronchitis due to streptococcus
- J20.3 Acute bronchitis due to coxsackievirus
- J20.6 Acute bronchitis due to rhinovirus
- J20.7 Acute bronchitis due to echovirus
- J20 Acute bronchitis
SNOMED
- 32398004 Bronchitis (disorder)
- 16146001 Viral bronchitis (disorder)
- 79479005 Respiratory syncytial virus bronchitis (disorder)
- 27475006 Parainfluenza virus bronchitis (disorder)
- 195725001 Acute coxsackievirus bronchitis
- 195728004 Acute bronchitis due to rhinovirus
- 195729007 Acute echovirus bronchitis