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Acute Bronchitis
Aka: Acute Bronchitis, Bronchitis, Chest Cold
- See Also
- Chronic Bronchitis
- Acute Exacerbation of Chronic Bronchitis
- Chronic Cough
- Acute Cough Causes
- Upper Respiratory Infection
- Definition
- Infection of trachea, Bronchi, or Bronchioles
- Acute Bronchitis is most often of viral etiology
- Contrast with Chronic Bronchitis exacerbation (COPD exacerbation) which is often Bacterial
- Epidemiology
- Acute Bronchitis is most common cause of acute cough
- Cough is most common presenting symptom in primary care
- Etiology: Most common causes by age
- Age under one year
- Respiratory Syncytial Virus (winter to spring)
- Parainfluenza Virus (fall)
- Coronavirus (winter to spring)
- Age one to 10 years
- Parainfluenza Virus (fall)
- Enterovirus (fall)
- Respiratory Syncytial Virus (winter to spring)
- Rhinovirus (fall)
- Age over 10 years
- Influenza Virus (winter to spring)
- Respiratory Syncytial Virus (winter to spring)
- Adenovirus
- Etiology: By Category
- Viral Causes (represent >90% of causes)
- Adenovirus
- Coronavirus
- Influenza
- Metapneumovirus
- Parainfluenza virus
- Respiratory Syncytial Virus (RSV)
- Rhinovirus
- Bacterial causes (1-10% of causes)
- Streptococcus Pneumoniae (Pneumococcus)
- HaemophilusInfluenzae
- Moraxella catarrhalis (Branhamella catarrhalis)
- Atypical Bacterial causes
- Bordetella pertussis (and parapertussis)
- Accounts for 10% of cough lasting >2 weeks
- More prevalent in children during outbreaks
- Mycoplasma pneumoniae
- Chlamydia pneumoniae
- Legionella
- Yeast or fungi
- Blastomyces dermatitidis
- Candida albicans (and tropicalis)
- Coccidioides immitis
- Cryptococcus neoformans
- Histoplasma capsulatum
- Environmental irritants (noninfectious triggers)
- Air Pollution
- Ammonia
- Marijuana
- Tobacco smoke
- Symptoms
- Respiratory symptoms
- Cough (onset within 2 days in 85% of Acute Bronchitis)
- Cough often dry, non-productive
- Productive cough of variable color Sputum is common (and does not distinguish from Pneumonia)
- Dyspnea
- Wheezing
- Chest Pain
- Hoarseness
- Nasal congestion
- Constitutional and other symptoms
- Low-Grade Fever (one third of patients)
- In fever (>100-101 F), consider Influenza or Pneumonia
- Myalgias
- Fatigue
- Headache
- Signs
- Low grade fever
- High fever suggests Pneumonia or Influenza
- Lung auscultation
- Rhonchi variably present (clear with coughing)
- Wheezing
- Prolonged expiration
- No signs of consolidation (Pneumonia)
- Lung sounds symmetric
- No focal rales
- Diagnostics: Optional
- Approach
- Testing is not typically performed in Acute Bronchitis
- Consider diagnostics when red flag findings are present
- Sputum exam
- Not indicated unless Pneumonia suspected
- Pulse Oximetry
- Consider in Dyspnea, Tachypnea or ill appearance
- Peak Flow values
- Consider in Asthma history
- C-Reactive Protein (CRP)
- CRP <50 mcg/ml suggests Acute Bronchitis (instead of Pneumonia), especially if no daily fever or Dyspnea
- Held (2012) BMC Infect Dis 12:355 [PubMed]
- Hopstaken (2003) Br J Gen Pract 53:358-64 [PubMed]
- Other specific organism testing
- Pertussis PCR
- Rapid Influenza Test
- Imaging: Chest XRay Indications
- Chest XRay is not required in young, otherwise healthy patients without red flag findings
- Pneumonia is unlikely with normal Vital Signs and normal Lung Exam
- Red flag history findings
- Significant Dyspnea
- Bloody Sputum or rust colored Sputum
- Red flag exam findings
- Fever >100-101 F
- Tachypnea (adult Respiratory Rate >24/min)
- Hypoxia
- Tachycardia
- Asymmetric lung sounds (e.g. focal decreased breath sounds)
- Ill appearance
- Pulmonary cause of cough suspected
- Pneumonia
- Congestive Heart Failure
- Older patient or serious comorbid condition
- Elderly patient (Pneumonia may present without fever, Tachycardia or Tachypnea)
- Chronic Obstructive Lung Disease
- Immunocompromised patient
- Malignancy history
- Recent history of pulmonary process
- Pneumonia
- Tuberculosis
- Differential Diagnosis
- See Acute Cough Causes
- Obstructive Lung Disease
- Asthma
- Acute Exacerbation of Chronic Bronchitis (COPD)
- Other infection
- Rhinitis or Sinusitis with post-nasal drainage
- Influenza
- Pneumonia
- Predictors
- C-Reactive Protein >20
- Erythrocyte sedimentaion rate increased
- Dry cough with Diarrhea, Nausea
- Temperature >38 C (>100.4 F)
- References
- Hopstaken (2003) Br J Gen Pract 53:358-64 [PubMed]
- Other conditions
- Congestive Heart Failure
- Management: Symptomatic
- Precautions
- Cough Suppression risks worsening bronchospasm (esp. Asthma and COPD)
- Avoid Albuterol Syrup (Not helpful and potentially harmful)
- Littenberg 1996 J Fam Pract 42:49-53) [PubMed]
- Although found beneficial in some trials, high dose Inhaled Corticosteroids are not used in standard Acute Bronchitis
- McKean (2000) Cochrane Database Syst Rev CD001107 [PubMed]
- Avoid Systemic Corticosteroids in Acute Bronchitis (aside from acute COPD or Asthma Exacerbation)
- Hay (2017) JAMA 318(8): 721-30 [PubMed]
- Supportive care for viral illness
- Inhaled Bronchodilator (e.g. Albuterol)
- More recent reviews suggest no benefit in Bronchitis unless Wheezing (or Asthma or COPD history)
- Direct use to those with Wheezing on examination
- Schroeder (2004) Cochrane Database Syst Rev CD001831
- Initial review suggested benefit in shortening Bronchitis course
- Hueston (1994) J Fam Pract 39:437-40 [PubMed]
- Symptomatic relief of cough (especially nighttime)
- See Cough Suppressant (Antitussive)
- Adults
- Guaifenesin (Cough Expectorant)
- Smith (2014) Cochrane Database Syst Rev (11):CD001831 [PubMed]
- Dextromethorphan (Cough Suppressant)
- Smith (2014) Cochrane Database Syst Rev (11):CD001831 [PubMed]
- Benzonatate (Tessalon, Cough Suppressant)
- Effective when used with Guaifenesin in small study
- Dicpingaitis (2009) Respir Med 103(6): 902-6 [PubMed]
- Children
- Honey appears effective in reducing cough in children
- Do not use in age <1 year (Botulism risk)
- Oduwole (2014) Cochrane Database Syst Rev (12):CD007094 +PMID:22419319 [PubMed]
- Dextromethorphan is not effective in children with Bronchitis
- Paul (2004) Pediatrics 114(1):e85-90 [PubMed]
- Pelargonium sidoides (herbal product)
- Decreases overall symptoms and return to work time compared with Placebo
- However, low quality evidence
- Matthys (2003) Phytomedicine 10:7-17 [PubMed]
- Management: Specific Circumstances
- Treat suspected underlying cause of cough
- See Cough Management
- See Chronic Cough
- Persistent post-Bronchitic cough
- Bronchodilators reduce symptom severity and duration
- Consider Inhaled Corticosteroid (e.g. Azmacort)
- Management: Antibiotics
- Most cases are viral and do not require antibiotics
- Most studies show minimal if any antibiotic benefit
- No benefit with Azithromycin
- Evans (2002) Lancet 359:1648-54 [PubMed]
- Patients with cough under 1 week showed no benefit
- Most patients improve with or without antibiotics
- See Antibiotic Resistance for Patient Education
- Productive cough short duration (<1 week)
- Avoid antibiotics
- Treat symptomatically as above
- Productive cough longer than 1-2 weeks
- Evaluate for treatable and serious causes of cough
- Pneumonia (consider Chest XRay)
- Acute Sinusitis
- Bordatella Pertussis
- Influenza A (treat within first 36 hours of symptoms)
- Tuberculosis (consider PPD or Quantiferon-TB)
- Reassurance
- Observation is reasonable if otherwise healthy
- Bronchitis often lasts >2 weeks (see course below)
- Consider Inhaled Corticosteroid (not typically used)
- Even Pertussis course is not significantly modified with antibiotics (esp. at >2 weeks of symptoms)
- However, antibiotics do decrease transmission risk (Infectivity)
- Antibiotic protocol
- Consider delayed antibiotic strategy
- Prescription given that may be filled at a later date if not improving
- Results in similar outcomes to other strategies, with less antibiotic use, and fewer return visits
- Little (2017) BMJ 357:j2148 +PMID:28533265 [PubMed]
- Little (2014) BMJ 248:g1606 [PubMed]
- Consider using acute phase reactant markers to distinguish higher risk cases
- Procalcitonin
- Christ-Crain (2004) Lancet 363(9409):600-7 [PubMed]
- C-Reactive Protein
- Cals (2009) BMJ 338: b1374 [PubMed]
- Consider treating high risk groups
- Age over 65 years
- Chronic Obstructive Lung Disease
- See Acute Exacerbation of Chronic Bronchitis
- Antibiotics have no benefit empirically in Bronchitis
- Evans (2002) Lancet 359(9318): 1648-54 [PubMed]
- Smucny (1998) J Fam Pract 47(6): 453-60 [PubMed]
- Antibiotic selection (empiric use not recommended)
- Adult under age 50 years
- Macrolide antibiotic or
- Doxycycline
- Adult over age 50 years
- Third Generation Fluoroquinolone (e.g. Levaquin)
- Precautions
- Avoid suppressing cough if possible (esp. during daytime hours)
- Cough intended to clear lungs, protect from Pneumonia
- Course
- Cough persists for >2 weeks in 25% of patients (median duration 18 days)
- Cough may persist as long as 8 weeks in some patients
- Resources: Patient Education
- Information from your Family Doctor
- http://www.familydoctor.org/handouts/677.html
- References
- Albert (2010) Am Fam Physician 82(11): 1345-50 [PubMed]
- Kinkade (2016) Am Fam Physician 94(7): 560-5 [PubMed]
- Knutson (2002) Am Fam Physician 65(10):2039-44 [PubMed]