> Table of Contents > Bronchitis, Acute
Bronchitis, Acute
Alan Cropp, MD, FCCP
Ghazaleh Bigdeli, MD, FCCP
image BASICS
DESCRIPTION
  • Inflammation of trachea, bronchi, and bronchioles resulting from a respiratory tract infection or chemical irritant (1)
  • Cough, the predominant symptom, may last as long as 3 weeks (2,3).
  • Generally self-limited, with complete healing and full return of function (2)
  • Most infections are viral if no underlying cardiopulmonary disease is present (2).
  • Synonym(s): tracheobronchitis
Geriatric Considerations
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
image DIAGNOSIS
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 Consideration
  • 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
image 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).
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MEDICATION
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-Pak 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
image 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)
REFERENCES
1. Wenzel RP, Fowler AA III. Clinical practice. Acute bronchitis. N Engl J Med. 2006;355(20):2125-2130.
2. Albert RH. Diagnosis and treatment of acute bronchitis. Am Fam Physician. 2010;82(11):1345-1350.
3. Braman SS. Chronic cough due to acute bronchitis: ACCP evidence-based clinical practice guidelines. Chest. 2006;129(1)(Suppl):95S-103S.
4. Fleming DM, Elliot AJ. The management of acute bronchitis in children. Expert Opin Pharmacother. 2007;8(4):415-426.
5. Llor C, Moragas A, Bayona C, et al. Efficacy of antiinflammatory or antibiotic treatment in patients with non-complicated acute bronchitis and discoloured sputum: randomised placebo controlled trial. BMJ. 2013;347:f5762.
6. Schuetz P, Amin DN, Greenwald JL. Role of procalcitonin in managing adult patients with respiratory tract infections. Chest. 2012;141(4):1063-1073.
7. 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.
8. 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
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.