Acute Bronchitis


Article Author:
Anumeha Singh
Akshay Avula


Article Editor:
Elise Zahn


Editors In Chief:
David Wood
Andrew Wilt
Hajira Basit


Managing Editors:
Avais Raja
Orawan Chaigasame
Khalid Alsayouri
Kyle Blair
Radia Jamil
Erin Hughes
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Navid Mahabadi
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beenish Sohail
Hajira Basit
Phillip Hynes
Sandeep Sekhon


Updated:
7/29/2019 8:34:08 PM

Introduction

Acute bronchitis is an inflammation of the large airways of the lung. It is a common clinical presentation to an emergency department, urgent care center, and primary care office. About 5% of adults have an episode of acute bronchitis each year. An estimated 90% of these seek medical advice for the same. In the United States, acute bronchitis is among the top ten most common illness among outpatients.[1][2][3]

Etiology

Acute bronchitis is caused by infection of the large airways commonly due to viruses and is usually self-limiting. Bacterial infection is uncommon. Approximately 95% of acute bronchitis in healthy adults are secondary to viruses. It can sometimes be caused by allergens, irritants, and bacteria. Irritants include smoke inhalation, polluted air inhalation, dust, among others.[4] 

Epidemiology

Acute bronchitis is one of the common presentations in any healthcare setting. It is estimated that every year, 5% of the general population reports an episode of acute bronchitis, accounting for more than 10 million office visits yearly. [5] Like most of the viral diseases of the respiratory tract, acute bronchitis is commonly seen during the flu season. In the United States, flu season is common during autumn and winter. It can follow any viral upper respiratory infection (URI). The common pathogens are a respiratory syncytial virus, Influenza virus A and B, Parainfluenza, rhinovirus, and similar viruses.

Factor like a history of smoking, living in a polluted place, crowding, and a history of asthma, are all risk factors for acute bronchitis. In some people, acute bronchitis can be triggered by particular allergens like pollens, perfume, and vapors.

When the infection is bacterial, the isolated pathogens are usually the same as those responsible for community-acquired pneumonia, for example, Streptococcus pneumonia and Staphylococcus aureus.[6][7]

Pathophysiology

Acute bronchitis is the result of acute inflammation of the bronchi secondary to various triggers, most commonly viral infection, allergens, pollutants, etc. Inflammation of the bronchial wall leads to mucosal thickening, epithelial-cell desquamation, and denudation of the basement membrane. At times, a viral upper respiratory infection can progress to infection of the lower respiratory tract resulting in acute bronchitis. [8]

History and Physical

An acute bronchitis patient presents with a productive cough, malaise, difficulty breathing, and wheezing. Usually, their cough is the predominant complaint and is clear or yellowish, although sometimes it can be purulent. Purulent sputum does not correlate with bacterial infection or antibiotic use. [9] Cough after acute bronchitis typically persists for 10 to 20 days but occasionally may last for 4 or more weeks. The median duration of cough after acute bronchitis is 18 days[10] Paroxysms of cough accompanied by inspiratory whoop or post-tussive emesis should raise concerns for pertussis. A prodrome of URI symptoms like runny nose, sore throat, fever, and malaise are common. A low-grade fever may be present as well. High-grade fevers in the setting of acute bronchitis are unusual and further diagnostic workup is required.

On physical exam, lung auscultation may be significant for wheezing; pneumonia should be suspected when rales, rhonchi or egophony are appreciated. Tachycardia can be present reflecting fever as well as dehydration secondary to the viral illness. Rest of the systems are typically within normal limits.

Evaluation

Acute bronchitis is a clinical diagnosis based on history, past medical history, lung exam, and other physical findings. Oxygen saturation plays an important role in judging the severity of the disease along with the pulse rate, temperature, and respiratory rate. No further workup is needed if vital signs are normal, no exam findings suggestive of pneumonia. An exception to this rule is elderly patients >75 years old.  Also, further workup is needed when pneumonia is suspected, clinical diagnosis is in question or in cases of high suspicion for influenza or pertussis. 

Chest x-ray findings are not specific and are typically normal. Occasionally, chest x-ray demonstrates increased interstitial markings consistent with thickening of bronchial walls. A chest x-ray differentiates pneumonia from acute bronchitis when infiltrates are seen. Evidence-based guidelines from the American College of Chest Physicians(ACCP) recommends obtaining a CXR only when heart rate > 100/min, respiratory rate >24 breaths/min, oral body temperature > 38 degree C and chest examination findings of egophony or fremitus.[5]

Complete blood count and chemistry may be ordered as a workup for fever. White blood count might be mildly elevated in some cases of acute bronchitis. Blood chemistry can reflect dehydration changes.

Routine use of rapid microbiological testing is not cost-effective and would not change management except during influenza season and in cases with high suspicion of pertussis or other bacterial infection. Gram stain and bacterial sputum cultures are specifically discouraged bacteria is rarely the causative agent. 

Spirometry, when performed, demonstrates transient bronchial hyperresponsiveness in 40% of patients with acute bronchitis. Reversibility of FEV1 >15% is reported in 17% of patients. [5] Airflow obstruction and bronchial hyperresponsiveness typically resolve in 6 weeks. 

Treatment / Management

Acute bronchitis is self-limiting and treatment is typically symptomatic and supportive therapy. For cough relief, nonpharmacological and pharmacological therapy should be offered. Nonpharmacological therapy includes hot tea, honey, ginger, throat lozenges, etc. No clinical trials evaluated the efficacy of these interventions. Antitussive agents like dextromethorphan, codeine or guaifenesin are frequently used in clinical practice to suppress cough based on their effectiveness in chronic bronchitis and studies on cough in common cold. No randomized trials exist to evaluate their effectiveness in acute bronchitis. Codeine should be avoided for the addictive potential. Data on the use of a mucolytic agent is conflicting. 

Beta-agonists are routinely used in acute bronchitis patients with wheezing. Small Randomized control trials on beta agonists for cough in acute bronchitis had mixed results. A Cochrane review of five trials demonstrated no significant benefit of beta-agonists on daily cough except for a small benefit in a subgroup of patients with wheezing and airflow obstruction at baseline.[11] A more recent Cochrane review demonstrated similar results [12] 

Analgesic and antipyretic agents may be used to treat associated malaise, myalgia, and fever. Prednisone or other steroids can be given to help with the inflammation as well. Although there is not enough evidence showing their benefit, it is useful in patients with underlying chronic obstructive pulmonary disease (COPD) or asthma. Typically steroid is used as short-term burst therapy. Sometimes longer tapering dose of steroid might be warranted, especially in patients with underlying asthma or COPD. [13][14]

ACCP guidelines recommend against antibiotic use in simple acute bronchitis in otherwise healthy adults. A Cochrane review of nine randomized, controlled trials of antibiotic agents showed a minor reduction in the total duration of cough (0.6 days). The decrease in the number of days of illness was not significant per this review.[15] Hence antibiotic use should be avoided in simple cases considering the cost of antibiotic, the growing global problem of antibiotic resistance and the possible side effects of antibiotic usage. Multiple other international medical societies recommend against antibiotic use in viral acute bronchitis. Despite these recommendations, a large proportion of patients with acute bronchitis are prescribed antibiotics. No data exist to justify the prospect of cough being less severe or less prolonged with antibiotic therapy. Antimicrobial therapy is recommended when a treatable pathogen is identified as with influenza or pertussis. In patients with influenza infection, oseltamivir or Zanamivir should be promptly started. Macrolides are the treatment of choice for Pertussis along with 5 days of isolation. It is interesting to note that whooping cough is only present in a minority of patients with pertussis. 

Procalcitonin might be useful in deciding on antibiotic use when the diagnosis of acute bronchitis is uncertain. A meta-analysis demonstrated procalcitonin-guided antibiotic therapy reduced antibiotic exposure and improved survival. [16]

Lifestyle modification like smoking cessation and the avoidance of allergens and pollutants play an important role in the avoidance of recurrence and complications. Flu vaccine and pneumonia vaccine are especially recommended in special groups including adults older than 65, children younger than two years (older than six months), pregnant women, and residents of nursing homes and long-term care facilities. People with asthma, COPD, and other immunocompromised adults are also at higher risk of developing complications. Recurrence is seen in up to a third of the cases of acute bronchitis.

In summary, the data for the use of beta-agonists, steroids, and mucolytic agent, especially in patients with no underlying COPD and asthma, is lacking. Treatment should be guided by the individual response to them and reported benefit, as well as, weighing risk and benefit in each case.

Differential Diagnosis

Other causes of acute cough should be considered especially when a cough persists for longer than 3 weeks. 

  • Asthma: Acute asthma is misdiagnosed as acute bronchitis in approximately one-third of the patients who present with acute cough.
  • Acute/chronic sinusitis
  • Bronchiolitis
  • COPD
  • GERD
  • Viral pharyngitis
  • Heart Failure
  • Pulmonary Embolism

Prognosis

Acute bronchitis is self-limiting and resolves with symptomatic treatment in most of the instances. Secondary pneumonia is possible. Rare cases of acute respiratory distress syndrome and respiratory failure have been reported in the literature. [17][18]

Pearls and Other Issues

Sometimes secondary pneumonia can develop. This is usually indicated by worsening symptoms, productive cough and fever. In such cases, a chest x-ray is indicated. This is especially important in immunocompromised adults, elderly population, infants and newborns, and smokers. Pulmonary emboli should always be in differentials in a patient with a cough and shortness of breath. Sometimes aggressive coughing can lead to spontaneous pneumothorax and or spontaneous pneumomediastinum. Hence any acute worsening of symptoms usually requires a chest x-ray.

Enhancing Healthcare Team Outcomes

Acute bronchitis is a very common disorder that frequently presents to the emergency department or the primary provider's office. It is a very common cause of absenteeism from work/school. The condition is best managed by an interprofessional team that includes a primary care provider, a nurse, a pharmacist, and a pulmonologist. The key is coordinating patient education. The nursing staff should be tasked to work with patients to stop smoking and avoid exposure to secondhand smoke. The nurses should encourage individuals to get influenza and pneumococcal vaccines to reduce morbidity. The nurses should monitor patients for compliance and report back to the clinical team leader patients that are non-compliant with smoking cessation. In addition, the nurse and pharmacist should encourage hand washing to limit the spread of micro-organisms.

For those patients whose cough persists, the nurses should monitor for the possibility of atypical pneumonia or pneumonia that requires antibiotic therapy. In these cases, the nurse should arrange a follow-up visit with the clinical team for re-assessment. If an antibiotic is deemed necessary, the pharmacist should evaluate for drug-drug interaction and allergy prior to filling the prescription. If there are any concerns, the pharmacist should make the clinical team aware of potential problems before the drug is dispensed.

The outcomes of patients with acute bronchitis are good; however, it is a common reason for absenteeism from work. In some patients with underlying COPD and other lung problems, acute bronchitis can have high morbidity. Patients whose symptoms persist for more than six weeks need to be re-evaluated to ensure that the diagnosis is correct.[19][20] (Level V)


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Acute Bronchitis - Questions

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A patient presents with vesicular breath sounds, moderate vocal resonance, and localized crackles. What is a likely diagnosis?



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A 30-year-old male with insignificant past medical history presents to the emergency department with complaints of shortness of breath, coughing, and intermittent wheezing. His symptoms started two days before presentation and progressively worsened. On further questioning, he reveals a history of runny nose, sore throat, nasal congestion, low-grade fever before the onset of current symptoms. His niece was sick with similar complaints as well. Vital signs were within normal limits except for tachypnea. Physical exam was significant for bilateral wheezing on lung auscultation. What is the most common cause of the diagnosis?



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Which of the following antibiotics is the most appropriate choice for an individual with an acute exacerbation of chronic bronchitis?



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What is the imaging study of choice for uncomplicated, acute bronchitis?



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What is the treatment of choice for uncomplicated acute bronchitis?



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A 65-year-old female with a past medical history of hypertension and high cholesterol presents to the emergency department in winter with a six-day history of cough and a fever. The maximum temperature was 101 F on the day before the presentation. She denies any sick contacts or recent illness. Vital signs on presentation were significant for a heart rate of 102/min, blood pressure 130/84 mmHg, pulse oximetry of 90%, and temperature 99.1 F. The physical exam was notable for an ill-looking female with scattered rhonchi on lung auscultation. The patient reports recent travel on an airplane back from England. She has a dry cough and muscle aches and no other complaints. What is the most appropriate management for the probable condition?



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A 45-year-old female with a past medical history of HIV on antiretroviral therapy presents with complaints of shortness of breath, fevers, chills, and coughing. Her complaints started 1 day prior to the presentation and are persistent. She denies chest pain or hemoptysis. Vital signs are significant for fever of 101 F, tachycardia, and tachypnea. The physical exam, on presentation, is significant for respiratory distress and wheezing. She has been compliant with her medications. Her most recent CD4 count was above 200 cell/ul. Blood work and chest x-ray are within normal limits. What is the next best step in the management of this patient?



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A 28-year-old male patient with a past medical history significant for asthma presents to the primary care office for complaints of cough, shortness of breath for 24 hours duration. His symptoms started abruptly and are progressively worsening. He denies fevers or chills and has had no known exposure to sick contacts. Vital signs are within normal limits. Physical examination is significant for mild expiratory wheezing. His asthma is well controlled, and he has not used any inhalers for a few years. What is the next best step in the management of this patient?



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A 35-year-old otherwise healthy male presents for a follow up of a cough of three weeks duration. He was seen two weeks prior for a runny nose, low-grade fever, cough, and myalgias. He was treated symptomatically with antipyretics and antitussives. Vital signs and physical exam are within normal limits. The patient is requesting for antibiotics to be prescribed as the cough has been prolonged. What is the most appropriate course of action?



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Acute Bronchitis - References

References

Pulia M,Redwood R,May L, Antimicrobial Stewardship in the Emergency Department. Emergency medicine clinics of North America. 2018 Nov     [PubMed]
Saust LT,Bjerrum L,Siersma V,Arpi M,Hansen MP, Quality assessment in general practice: diagnosis and antibiotic treatment of acute respiratory tract infections. Scandinavian journal of primary health care. 2018 Oct 8     [PubMed]
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Ward JI,Cherry JD,Chang SJ,Partridge S,Lee H,Treanor J,Greenberg DP,Keitel W,Barenkamp S,Bernstein DI,Edelman R,Edwards K, Efficacy of an acellular pertussis vaccine among adolescents and adults. The New England journal of medicine. 2005 Oct 13     [PubMed]
Smucny J,Becker L,Glazier R, Beta2-agonists for acute bronchitis. The Cochrane database of systematic reviews. 2006 Oct 18     [PubMed]
Becker LA,Hom J,Villasis-Keever M,van der Wouden JC, Beta2-agonists for acute cough or a clinical diagnosis of acute bronchitis. The Cochrane database of systematic reviews. 2015 Sep 3     [PubMed]
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