Topic Editor: Grant E. Fraser, M.D., FRACGP, FACRRM, ASTEM

Review Date: 10/7/2012

Defination

Acute bronchitis is inflammation of the trachea and bronchi most commonly caused by respiratory viral infection or irritants

Description

• Acute bronchitis is an illness characterized by cough and excess production of mucus and in some cases bronchospasm
• The most common cause of bronchitis is a viral infection. It is rarely caused by bacteria
• Treatment is primarily symptomatic. Although antibiotics are have been commonly prescribed in the past, there is little to no evidence of benefit, with most authorities indicating antibiotics are not indicated in most cases
• The majority of patients recover within 6 weeks. It is rare to have complications with most common being post-bronchitis syndrome

Epidemiology

Incidence/Prevelence

• Occurs in approximately 5% of adults yearly
• Results in 10-12 million physician visits/year

Age

• Occurs among all age ranges; however, the highest incidence is in older adults, smokers, and young children during the winter months

Gender

• Occurs more commonly in males than females

Risk factors

• Air pollutants
• Bronchopulmonary allergy
• Chronic bronchopulmonary diseases
• Chronic sinusitis
• Cigarette smoking
• Elderly
• Environmental changes
• Exposure to others who have bronchitis (rapidly spread through respiratory secretions when due to viral infection)
• Gastroesophageal reflux
• Hypertrophied tonsils and adenoids in children
• Immunosuppression (HIV patients/alcoholics/Immunodeficient patients)
• Infants
• Tracheostomy

Etiology

• The most common cause of bronchitis is a virus infections: Respiratory Syncytial Virus, Rhinovirus, Influenza virus, Adenovirus
• Rarely due to bacterial causes with the most common being Mycoplasma pneumoniae or Chlamydia pneumoniae. More rarely being due Streptococcus pneumoniae, Haemophilus influenzae, Bordetella pertussis, or Moraxella catarrhalis with typical bacterial causes being more common in patients who have chronic lung disease
• Irritants (Tobacco smoke, pollution, chemicals)

[Outline]

• Defination
• Description
• Epidemiology
• Etiology

History

• Productive cough for 30 days
• Duration of cough 30 days
• Purulent sputum
• No history of chronic respiratory illnesslung diseases
• Dyspnea
• Fatigue
• Myalgia
• Pyrexia (generally in first days of onset of illness)
• Nasal congestion
• Sore throat

Physical Findings on examination

• May have fever at onset of illness, however this typically abates within the first 2 days
• Wheezing (more common in patients with asthma). Note that focal wheeze may indicate need for further investigation (pneumonia, aspiration, foreign body)
• Rhonchi may require further investigations for potential pneumonia
• Tachypnea is unusual unless there is significant inflammation leading to wheezing or other airway obstruction
• Acute bronchitis generally results in a normal lung examination or has diffuse findings without focal abnormalities. Chest percussion should be normal

[Outline]

• History
• Physical Findings on examination

Other laboratory test findings

• Usually no blood or other tests are needed to successfully evaluate and treat patients who have bronchitis
• In rare cases specific testing for suspected viral or bacterial etiologic agents may be indicated:
  • Nasal swab for respiratory viruses (Influenza, RSV, Parainfluenza and Adenovirus)
  • Nasal Pharyngeal Aspirate (NPA) for Pertussis
  • Serologies for Mycoplasma pneumoniae or Chlamydia pneumoniae
  • Sputum culture and gram stain in cases where suspected bacterial pathogen is causative

Radiographic findings

• Chest X-ray is generally not indicated in patients with:
  • No focal findings on chest auscultation
  • Normal respiratory rate and oxygen saturation
  • Any abnormal findings completely accounted for by reactive airways or asthma
• In the event if a chest x ray is ordered, this would usually to evaluate for focal consolidation or other cause of the patients symptoms

Other diagnostic test findings

• Pulmonary function test is not recommended for the diagnosis of acute bronchitis. It is usually performed in the suspected case of underlying obstructive pathology or in the repeated episodes of bronchitis

[Outline]

• Other laboratory test findings
• Radiographic findings
• Other diagnostic test findings

Differential diagnosis of patients presenting with typical acute bronchitis includes:

• Allergies
• Bronchiectasis
• Congestive heart failure
• Cough secondary to medications most commonly ACE inhibitors and more rarely angiotensin II receptor blockers
• Eosinophilic pneumonitis
• Gastroesophageal reflux
• Inhalation injury
• Sinusitis
• Viral upper respiratory tract infections

Other conditions which do not particularly have symptoms classic for acute bronchitis but can mimic some degree include:

• Allergic aspergillosis
• Aspiration
• Asthma
• Bacterial tracheitis
• Bronchiolitis
• Bronchopneumonia
• Croup
• Cystic fibrosis
• Eosinophilic pneumonitis
• Neoplasm
• Pertussis
• Retained foreign body
• Asthma
• Bronchiolitis
• Aspiration
• Cystic fibrosis
• Neoplasm
• Allergic aspergillosis
• Bronchopneumonia
• Bacterial tracheitis
• Croup
• Eosinophilic pneumonitis
• Retained foreign body
• Pertussis

General treatment items

First line:

• Symptomatic relief for fever or aches can include antipyretics/analgesics such as acetaminophen or ibuprofen
• In the event of sinus congestion, decongestants may be used (nasal spray or oral)
• Albuterol has been shown effective in bronchitis for treatment of irritant cough
• Cough suppressants: dextromethorphan and guaifenesin with or without codeine
• Cough suppressants: dextromethorphan and guaifenesin with or without codeine
• There is no indication for steroids in bronchitis
• Note (regarding antibiotics): In the event that a bacterial pathogen is believed to be a cause, this decision should generally be guided by sputum culture, with therapy guided to the most appropriate narrow spectrum antimicrobial. Most studies examining efficacy of antibiotics for bronchitis have shown little difference in bronchitis outcomes with or without antibiotics. Judicious use of antibiotics would indicate that bronchitis should only rarely be treated with antibiotics
• In the event that influenza is suspected, appropriate diagnostic testing is reasonable and treatment with appropriate antiviral (oseltamivir or zanamavir) may be indicated in appropriate cases
• In the case of empiric use of antibiotics, common choices include amoxicillin, azithromycin, clarithromycin, doxycycline, trimethoprim/sulfamethoxazole, orand cephalexin

Additional treatment:

• Hydration
• Smoking cessation
• Antitussives

IV fluids:

• Use of IV fluids is only recommended in cases where the patient is unable to stay appropriately hydrated orally

Medications with specific doses

• Oseltamivir
  • Adult Dosing
  • Pediatric Dosing
• Zanamivir [Inhaled]
  • Adult Dosing
  • Pediatric Dosing
• Acetaminophen
  • Adult Dosing
  • Pediatric Dosing
• Ibuprofen
  • Adult Dosing
  • Pediatric Dosing
• Albuterol [Inhaled]
  • Adult Dosing
  • Pediatric Dosing
• Dextromethorphan
  • Adult Dosing
  • Pediatric Dosing
• Guaifenesin
  • Adult Dosing
  • Pediatric Dosing
• Azithromycin
  • Adult Dosing
  • Pediatric Dosing
• Clarithromycin
  • Adult Dosing
  • Pediatric Dosing
• Doxycycline
  • Adult Dosing
  • Pediatric Dosing
• Sulfamethoxazole/trimethoprim
  • Adult Dosing
  • Pediatric Dosing
• Cephalexin
  • Adult Dosing
  • Pediatric Dosing

Dietary or Activity restrictions

• During fever fluid intake should be increased up to 3 to 4 liters per day for adults and well over maintenance fluid levels for children

[Outline]

• General treatment items
• Medications with specific doses
• Dietary or Activity restrictions

Monitoring

• This is a common acute illness which typically resolves within a few weeks, hence long term monitoring is usually not required. Patients should be warned that if they become persistently febrile, increasingly short breath or are feeling much worse; especially after already starting to recover than an urgent healthcare provider visit is indicated as this commonly indicates a secondary pneumonia
• It case of recurrent bronchitis in children, evaluate for other causes such as asthma

Assessment of therapy

• Patients who are prescribed albuterol must receive information on the appropriate use of a metered dose inhaler (MDI)

Complications

• Bronchiectasis
• Chronic cough
• Hemoptysis
• Pneumonia
• Chronic cough
• Pneumonia
• Bronchiectasis
• Hemoptysis

[Outline]

• Monitoring
• Assessment of therapy
• Complications

Prevention

• Smokers should be advised to discontinue use of cigarettes

Prognosis

• Usually complete resolution is achieved
• After initial improvement, cough may persist for several weeks
• Debilitated or elderly patients may be more likely to develop secondary infections such as bacterial pneumonia
• Recurrence is common, especially in smokers
• Postbronchitic reactive airways disease, bronchiolitis obliterans and organizing pneumonia may develop in rare cases

Pregnancy/Pediatric effects on condition

• Some studies suggest that acute respiratory conditions such as bronchitis during pregnancy may cause premature rupture of the membranes (PROM), especially in African Americans
• Do not use doxycycline during pregnancy and in children below 8 years of age
• Do not use quinolones during pregnancy

Synonyms

• Chest cold

ICD9-CM

• 466.0 Acute bronchitis

ICD-10-CM

• J20 Acute bronchitis

[Outline]

• Prevention
• Prognosis
• Pregnancy/Pediatric effects on condition
• Synonyms
• ICD9-CM
• ICD-10-CM

1. Wenzel RP, Fowler AA. Clinical practice. Acute bronchitis. N Engl J Med. 2006;355(20):2125-30.
2. Braman SS. Chronic cough due to acute bronchitis: ACCP evidence-based clinical practice guidelines. Chest. 2006:129;95s-103s.
3. Williamson HA Jr. Pulmonary function tests in acute bronchitis: evidence for reversible airway obstruction. J Fam Pract. 1987;25:251-6.
4. Walsh EE. Acute bronchitis. In: Mandell GL, Bennett JE, Dolin R, eds. Principles and Practice of Infectious Diseases. 7th ed. Philadelphia, PA: Elsevier Churchill Livingstone; 2010:873-876.61
5. Hueston WJ. A comparison of albuterol and erythromycin for the treatment of acute bronchitis. J Fam Pract. 1991;33(5):476-80.
6. Fahey T, Stocks N, Thomas T. Quantitative systematic review of randomised controlled trials comparing antibiotic with placebo for acute cough in adults. BMJ. 1998;316(7135):906-10.
7. Getahun D, Ananth CV, Oyelese Y, et al. Acute and chronic respiratory diseases in pregnancy: associations with spontaneous premature rupture of membranes. J Matern Fetal Neonatal Med. 2007;20(9):669-75.
8. MacFarlane J, Holmes W, Gard P, et al. Prospective study of the incidence, aetiology and outcome of adult lower respiratory tract illness in the community. Thorax. 2001;56:109-14.
9. Gonzales R, Bartlett JG, Besser RE, et al. Principles of appropriate antibiotic use for treatment of uncomplicated acute bronchitis: background. Ann Intern Med. 2001;134:521-9.
10. Smucny JJ, Becker LA, Glazier RH, et al. Are antibiotics effective treatment for acute bronchitis? A meta-analysis. J Fam Pract. 1998;47:453-60.
11. Knutson D, Braun C. Diagnosis and management of acute bronchitis. Am Fam Physician. May 15 2002;65(10):2039-44.
12. Braman SS. Chronic cough due to acute bronchitis: ACCP evidence-based clinical practice guidelines. Chest. 2006;129(1 Suppl):95s-103s.
13. Smucny J, Becker L, Glazier R. beta2-agonists for acute bronchitis. Cochrane Database Syst Rev. 2006;(4):CD001726.
14. Aagaard E, Gonzales R. Management of acute bronchitis in healthy adults. Infect Dis Clin North Am. 2004;18(4):919-37.