II. Definition

  1. Infection of trachea, Bronchi, or Bronchioles
  2. Acute Bronchitis is most often of viral etiology
    1. Contrast with Chronic Bronchitis exacerbation (COPD exacerbation) which is often Bacterial

III. Epidemiology

  1. Acute Bronchitis is most common cause of acute cough
    1. Cough is most common presenting symptom in primary care

IV. Etiology: Most common causes by age

  1. Age under one year
    1. Respiratory Syncytial Virus (winter to spring)
    2. Parainfluenza Virus (fall)
    3. Coronavirus (winter to spring)
  2. Age one to 10 years
    1. Parainfluenza Virus (fall)
    2. Enterovirus (fall)
    3. Respiratory Syncytial Virus (winter to spring)
    4. Rhinovirus (fall)
  3. Age over 10 years
    1. Influenza Virus (winter to spring)
    2. Respiratory Syncytial Virus (winter to spring)
    3. Adenovirus

V. Etiology: By Category

  1. Viral Causes (represent >90% of causes)
    1. Adenovirus
    2. Coronavirus
    3. Influenza
    4. Metapneumovirus
    5. Parainfluenza virus
    6. Respiratory Syncytial Virus (RSV)
    7. Rhinovirus
  2. Bacterial causes (1-10% of causes)
    1. Streptococcus Pneumoniae (Pneumococcus)
    2. HaemophilusInfluenzae
    3. Moraxella catarrhalis (Branhamella catarrhalis)
    4. Atypical Bacterial causes
      1. Bordetella pertussis (and parapertussis)
        1. Accounts for 10% of cough lasting >2 weeks
        2. More prevalent in children during outbreaks
      2. Mycoplasma pneumoniae
      3. Chlamydia pneumoniae
      4. Legionella
  3. Yeast or fungi
    1. Blastomyces dermatitidis
    2. Candida albicans (and tropicalis)
    3. Coccidioides immitis
    4. Cryptococcus neoformans
    5. Histoplasma capsulatum
  4. Environmental irritants (noninfectious triggers)
    1. Air Pollution
    2. Ammonia
    3. Marijuana
    4. Tobacco smoke

VI. Symptoms

  1. Respiratory symptoms
    1. Cough (onset within 2 days in 85% of Acute Bronchitis)
      1. Cough often dry, non-productive
      2. Productive cough of variable color Sputum is common (and does not distinguish from Pneumonia)
    2. Dyspnea
    3. Wheezing
    4. Chest Pain
    5. Hoarseness
    6. Nasal congestion
  2. Constitutional and other symptoms
    1. Low-Grade Fever (one third of patients)
      1. In fever (>100-101 F), consider Influenza or Pneumonia
    2. Myalgias
    3. Fatigue
    4. Headache

VII. Signs

  1. Low grade fever
    1. High fever suggests Pneumonia or Influenza
  2. Lung auscultation
    1. Rhonchi variably present (clear with coughing)
    2. Wheezing
    3. Prolonged expiration
    4. No signs of consolidation (Pneumonia)
      1. Lung sounds symmetric
      2. No focal rales

VIII. Diagnostics: Optional

  1. Approach
    1. Testing is not typically performed in Acute Bronchitis
    2. Consider diagnostics when red flag findings are present
  2. Sputum exam
    1. Not indicated unless Pneumonia suspected
  3. Pulse Oximetry
    1. Consider in Dyspnea, Tachypnea or ill appearance
  4. Peak Flow values
    1. Consider in Asthma history
  5. C-Reactive Protein (CRP)
    1. CRP <50 mcg/ml suggests Acute Bronchitis (instead of Pneumonia), especially if no daily fever or Dyspnea
    2. Held (2012) BMC Infect Dis 12:355 [PubMed]
    3. Hopstaken (2003) Br J Gen Pract 53:358-64 [PubMed]
  6. Other specific organism testing
    1. Pertussis PCR
    2. Rapid Influenza Test

IX. Imaging: Chest XRay Indications

  1. Chest XRay is not required in young, otherwise healthy patients without red flag findings
    1. Pneumonia is unlikely with normal Vital Signs and normal Lung Exam
  2. Red flag history findings
    1. Significant Dyspnea
    2. Bloody Sputum or rust colored Sputum
  3. Red flag exam findings
    1. Fever >100-101 F
    2. Tachypnea (adult Respiratory Rate >24/min)
    3. Hypoxia
    4. Tachycardia
    5. Asymmetric lung sounds (e.g. focal decreased breath sounds)
    6. Ill appearance
  4. Pulmonary cause of cough suspected
    1. Pneumonia
    2. Congestive Heart Failure
  5. Older patient or serious comorbid condition
    1. Elderly patient (Pneumonia may present without fever, Tachycardia or Tachypnea)
    2. Chronic Obstructive Lung Disease
    3. Immunocompromised patient
    4. Malignancy history
    5. Recent history of pulmonary process
      1. Pneumonia
      2. Tuberculosis

X. Differential Diagnosis

  1. See Acute Cough Causes
  2. Obstructive Lung Disease
    1. Asthma
    2. Acute Exacerbation of Chronic Bronchitis (COPD)
  3. Other infection
    1. Rhinitis or Sinusitis with post-nasal drainage
    2. Influenza
    3. Pneumonia
      1. Predictors
        1. C-Reactive Protein >20
        2. Erythrocyte sedimentaion rate increased
        3. Dry cough with Diarrhea, Nausea
        4. Temperature >38 C (>100.4 F)
      2. References
        1. Hopstaken (2003) Br J Gen Pract 53:358-64 [PubMed]
  4. Other conditions
    1. Congestive Heart Failure

XI. Management: Symptomatic

  1. Precautions
    1. Cough Suppression risks worsening bronchospasm (esp. Asthma and COPD)
    2. Avoid Albuterol Syrup (Not helpful and potentially harmful)
      1. Littenberg 1996 J Fam Pract 42:49-53) [PubMed]
    3. Although found beneficial in some trials, high dose Inhaled Corticosteroids are not used in standard Acute Bronchitis
      1. McKean (2000) Cochrane Database Syst Rev CD001107 [PubMed]
    4. Avoid Systemic Corticosteroids in Acute Bronchitis (aside from acute COPD or Asthma Exacerbation)
      1. Hay (2017) JAMA 318(8): 721-30 [PubMed]
  2. Supportive care for viral illness
  3. Inhaled Bronchodilator (e.g. Albuterol)
    1. More recent reviews suggest no benefit in Bronchitis unless Wheezing (or Asthma or COPD history)
      1. Direct use to those with Wheezing on examination
      2. Schroeder (2004) Cochrane Database Syst Rev CD001831
    2. Initial review suggested benefit in shortening Bronchitis course
      1. Hueston (1994) J Fam Pract 39:437-40 [PubMed]
  4. Symptomatic relief of cough (especially nighttime)
    1. See Cough Suppressant (Antitussive)
    2. Adults
      1. Guaifenesin (Cough Expectorant)
        1. Smith (2014) Cochrane Database Syst Rev (11):CD001831 [PubMed]
      2. Dextromethorphan (Cough Suppressant)
        1. Smith (2014) Cochrane Database Syst Rev (11):CD001831 [PubMed]
      3. Benzonatate (Tessalon, Cough Suppressant)
        1. Effective when used with Guaifenesin in small study
        2. Dicpingaitis (2009) Respir Med 103(6): 902-6 [PubMed]
    3. Children
      1. Honey appears effective in reducing cough in children
        1. Do not use in age <1 year (Botulism risk)
        2. Oduwole (2014) Cochrane Database Syst Rev (12):CD007094 +PMID:22419319 [PubMed]
      2. Dextromethorphan is not effective in children with Bronchitis
        1. Paul (2004) Pediatrics 114(1):e85-90 [PubMed]
  5. Pelargonium sidoides (herbal product)
    1. Decreases overall symptoms and return to work time compared with Placebo
    2. However, low quality evidence
    3. Matthys (2003) Phytomedicine 10:7-17 [PubMed]

XII. Management: Specific Circumstances

  1. Treat suspected underlying cause of cough
    1. See Cough Management
    2. See Chronic Cough
  2. Persistent post-Bronchitic cough
    1. Bronchodilators reduce symptom severity and duration
    2. Consider Inhaled Corticosteroid (e.g. Azmacort)

XIII. Management: Antibiotics

  1. Most cases are viral and do not require antibiotics
    1. Most studies show minimal if any antibiotic benefit
      1. No benefit with Azithromycin
      2. Evans (2002) Lancet 359:1648-54 [PubMed]
    2. Patients with cough under 1 week showed no benefit
    3. Most patients improve with or without antibiotics
    4. See Antibiotic Resistance for Patient Education
  2. Productive cough short duration (<1 week)
    1. Avoid antibiotics
    2. Treat symptomatically as above
  3. Productive cough longer than 1-2 weeks
    1. Evaluate for treatable and serious causes of cough
      1. Pneumonia (consider Chest XRay)
      2. Acute Sinusitis
      3. Bordatella Pertussis
      4. Influenza A (treat within first 36 hours of symptoms)
      5. Tuberculosis (consider PPD or Quantiferon-TB)
    2. Reassurance
      1. Observation is reasonable if otherwise healthy
      2. Bronchitis often lasts >2 weeks (see course below)
      3. Consider Inhaled Corticosteroid (not typically used)
      4. Even Pertussis course is not significantly modified with antibiotics (esp. at >2 weeks of symptoms)
        1. However, antibiotics do decrease transmission risk (Infectivity)
    3. Antibiotic protocol
      1. Consider delayed antibiotic strategy
        1. Prescription given that may be filled at a later date if not improving
        2. Results in similar outcomes to other strategies, with less antibiotic use, and fewer return visits
        3. Little (2017) BMJ 357:j2148 +PMID:28533265 [PubMed]
        4. Little (2014) BMJ 248:g1606 [PubMed]
      2. Consider using acute phase reactant markers to distinguish higher risk cases
        1. Procalcitonin
          1. Christ-Crain (2004) Lancet 363(9409):600-7 [PubMed]
        2. C-Reactive Protein
          1. Cals (2009) BMJ 338: b1374 [PubMed]
      3. Consider treating high risk groups
        1. Age over 65 years
        2. Chronic Obstructive Lung Disease
          1. See Acute Exacerbation of Chronic Bronchitis
      4. Antibiotics have no benefit empirically in Bronchitis
        1. Evans (2002) Lancet 359(9318): 1648-54 [PubMed]
        2. Smucny (1998) J Fam Pract 47(6): 453-60 [PubMed]
      5. Antibiotic selection (empiric use not recommended)
        1. Adult under age 50 years
          1. Macrolide antibiotic or
          2. Doxycycline
        2. Adult over age 50 years
          1. Third Generation Fluoroquinolone (e.g. Levaquin)

XIV. Precautions

  1. Avoid suppressing cough if possible (esp. during daytime hours)
    1. Cough intended to clear lungs, protect from Pneumonia

XV. Course

  1. Cough persists for >2 weeks in 25% of patients (median duration 18 days)
  2. Cough may persist as long as 8 weeks in some patients

XVI. Resources: Patient Education

  1. Information from your Family Doctor
    1. http://www.familydoctor.org/handouts/677.html

Images: Related links to external sites (from Bing)

Related Studies

Ontology: Bronchitis (C0006277)

Definition (MSH) Inflammation of the large airways in the lung including any part of the BRONCHI, from the PRIMARY BRONCHI to the TERTIARY BRONCHI.
Definition (NCI) An acute or chronic inflammatory process affecting the bronchi.
Definition (NCI_NCI-GLOSS) Inflammation (swelling and reddening) of the bronchi.
Definition (NCI_CTCAE) A disorder characterized by an infectious process involving the bronchi.
Concepts Disease or Syndrome (T047)
MSH D001991
ICD9 490
ICD10 J40
SnomedCT 266354009, 195936003, 155616009, 195940007, 32398004
LNC LA16983-1
English Bronchitides, Bronchitis, Bronchitis, not specified as acute or chronic, Bronchitis NOS, Bronchitis unspecified, bronchitis (diagnosis), bronchitis, Bronchitis [Disease/Finding], Bronchitis unspecified (disorder), Bronchitis: [unspecified (& chest infection)] or [recurrent wheezy], Bronchitis NOS (disorder), Recurrent wheezy bronchitis, Bronchitis: [unspecified (& chest infection)] or [recurrent wheezy] (disorder), Inflammation of bronchus, Bronchial infection, BRONCHITIS, Bronchitis (disorder), Bronchitis, NOS
French BRONCHITE, Bronchite, non précisée comme aiguë ou chronique, Bronchite SAI, Bronchite
Portuguese BRONQUITE, Bronquite NE se aguda ou crónica, Bronquite NE, Bronquite
Spanish BRONQUITIS, Bronquitis NEOM, Bronquitis no especificada como aguda o crónica, bronquitis no especificada, bronquitis, SAI (trastorno), Bronchitis NOS, bronquitis no especificada (trastorno), bronquitis, SAI, bronquitis (trastorno), bronquitis, Bronquitis
German BRONCHITIS, Bronchitis NNB, Bronchitis, nicht spezifiziert als akut oder chronisch, Bronchitis, nicht als akut oder chronisch bezeichnet, Bronchialkatarrh, Bronchitis
Dutch bronchitis NAO, bronchitis, niet-gespecificeerd als acuut of chronisch, Bronchitis, niet gespecificeerd als acuut of chronisch, bronchitis, Bronchitis
Italian Bronchite NAS, Bronchite, non specificata se acuta o cronica, Bronchite
Japanese 気管支炎、急性または慢性不明, 気管支炎NOS, 気管支炎, キカンシエン, キカンシエンNOS, キカンシエンキュウセイマタハマンセイフメイ
Swedish Luftrörskatarr
Czech bronchitida, průdušky - zánět, zánět průdušek, Bronchitida NOS, Bronchitida, neurčená jako akutní nebo chronická, Bronchitida
Finnish Keuhkoputkitulehdus
Korean 급성인지 만성인지 명시되지 않은 기관지염
Polish Zapalenie oskrzeli
Hungarian bronchitis, bronchitis, nem meghatározva, hogy acut vagy chronicus, bronchitis k.m.n.
Norwegian Bronkitt, Luftrørskatarr

Ontology: Acute bronchitis (C0149514)

Definition (MEDLINEPLUS)

Bronchitis is an inflammation of the bronchial tubes, the airways that carry air to your lungs. It causes a cough that often brings up mucus, as well as shortness of breath, wheezing, and chest tightness. There are two main types of bronchitis: acute and chronic.

The same viruses that cause colds and the flu often cause acute bronchitis. These viruses spread through the air when people cough, or through physical contact (for example, on unwashed hands). Being exposed to tobacco smoke, air pollution, dusts, vapors, and fumes can also cause acute bronchitis. Bacteria can also cause acute bronchitis, but not as often as viruses.

Most cases of acute bronchitis get better within several days. But your cough can last for several weeks after the infection is gone. If you think you have acute bronchitis, see your healthcare provider.

Treatments include rest, fluids, and aspirin (for adults) or acetaminophen to treat fever. A humidifier or steam can also help. You may need inhaled medicine to open your airways if you are wheezing. You probably do not need antibiotics. They don't work against viruses - the most common cause of acute bronchitis. If your healthcare provider thinks you have a bacterial infection, he or she may prescribe antibiotics.

NIH: National Heart, Lung, and Blood Institute

Definition (NCI) Acute inflammation and edema of the larger bronchi caused by viruses or bacteria. Signs and symptoms include cough, sputum production, shortness of breath, and wheezing.
Definition (CSP) sudden inflammation of the tracheobronchial tree, which comprises the trachea, or windpipe, and the bronchi; typically associated with a viral upper respiratory tract infection, such as the common cold, and is usually mild; in patients with chronic lung or heart disease, acute bronchitis is more severe, and can become chronic and progress to pneumonia.
Concepts Disease or Syndrome (T047)
ICD9 466.0
ICD10 J20 , J20.9
SnomedCT 266380005, 155512004, 195713004, 155515002, 195733000, 10509002, 35301006
English Acute bronchitis, Acute bronchitis NOS, Acute bronchitis, unspecified, Bronchitis acute NOS, Bronchitis acute, acute bronchitis (diagnosis), acute bronchitis, acute tracheobronchitis, acute tracheobronchitis (diagnosis), Bronchitis;acute, Acute Bronchitis, Bronchitis - acute, Acute bronchitis NOS (disorder), Tracheobronchitis - acute, Acute chest infections, Acute tracheobronchitis, Acute bronchitis (disorder), Acute tracheobronchitis (disorder), bronchitis, bronchitis; acute, acute; bronchitis, acute; tracheobronchitis, Acute bronchitis, NOS, Tracheobronchitis, acute
Dutch acute tracheobronchitis, acute bronchitis, bronchitis acuut, bronchitis acuut NAO, acuut; bronchitis, acuut; tracheobronchitis, bronchitis; acuut, Acute bronchitis, niet gespecificeerd, Acute bronchitis
French Trachéobronchite aiguë, Bronchite aiguë, Bronchite aiguë SAI
German akute Tracheobronchitis, akute Bronchitis, Bronchitis akut NNB, Akute Bronchitis, nicht naeher bezeichnet, Akute Bronchitis
Italian Tracheobronchite acuta, Bronchite acuta, Bronchite acuta NAS
Portuguese Traqueobronquite aguda, Bronquite aguda NE, Bronquite aguda
Spanish Traqueobronquitis aguda, Bronquitis aguda NEOM, Bronquitis aguda, bronquitis aguda, SAI (trastorno), bronquitis aguda, SAI, Acute bronchitis NOS, bronquitis aguda (trastorno), bronquitis aguda, traqueobronquitis aguda (trastorno), traqueobronquitis aguda
Japanese 急性気管気管支炎, キュウセイキカンシエン, 急性気管支炎, 急性気管支炎NOS, キュウセイキカンシエンNOS, キュウセイキカンキカンシエン
Czech Akutní bronchitida NOS, Akutní tracheobronchitida, Bronchitida akutní, Akutní bronchitida
Korean 급성 기관지염, 상세불명의 급성 기관지염
Hungarian Acut bronchitis, Acut tracheobronchitis, acut bronchitis k.m.n., acut bronchitis

Ontology: Lower respiratory tract infection (C0149725)

Definition (NCI) An acute or chronic, viral or bacterial infectious process that affects the lower respiratory tract.
Concepts Disease or Syndrome (T047)
SnomedCT 155625003, 266339003, 155626002, 419502003, 195744008, 266340001, 195745009, 50417007
English Chest infection, Chest infection NOS, Infection lower respirat tract, Infection of lower respiratory tract, Lower respiratory tract infection, Lower respiratory tract infections, LOWER RESP. TRACT INFECTION, CI - Chest infection, LRTI - Lower resp tract infect, Lower resp tract infec, Lower resp. tract infection, Lower respiratory tract infection NOS, LRTI, lrti, Infection;chest, chest colds, infections lower respiratory, chest cold, cold chest, lower respiratory infection, Chest infection (& NOS) (disorder), Chest infection NOS (disorder), Infection of lower respiratory tract (disorder), Chest infection (disorder), Chest infection (& NOS), Lower resp tract infection, respiratory tract infection lower, Lower respiratory tract infection (diagnosis), Chest cold, Lower respiratory infection, LRTI - Lower respiratory tract infection, Lower respiratory tract infection (disorder), Chest cold, NOS, Lower respiratory infection, NOS, Lower respiratory tract infection, NOS, Lower Respiratory Tract Infection, Infection;lower resp tract, lower resp tract infection, chest infection
Italian Infezione delle basse vie aeree, Infezione delle basse vie aeree NAS, Infezione del torace, Infezione delle vie respiratorie inferiori
Dutch borstkasinfectie, lagere luchtweginfectie, onderste luchtweginfectie NAO, onderste luchtweginfectie
French Infec des voies resp inf, Infection des voies resp inf, IVRI, Infection des voies aériennes inférieures SAI, Infection thoracique, INFECTION PULMONAIRE, Infection des voies respiratoires inférieures
German Infekt der unteren Atemwege, LRTI, Infektion der unteren Atemwege NNB, Bronchieninfektion, INFEKTION DER UNTEREN ATEMWEGE, Infektion der unteren Atemwege
Portuguese Infecção das vias respiratórias inferiores NE, Infecção torácica, INFECCAO DO TRACTO RESP. INFERIOR, Infecção das vias respiratórias inferiores
Spanish Infección del tracto respiratorio bajo, Infección de las vías respiratorias bajas NEOM, Infección torácica, infección del tórax (trastorno), infección torácica, infección torácica, SAI (trastorno), infección del tórax, infección torácica, SAI, infección de vías respiratorias inferiores (trastorno), infección de vías respiratorias inferiores, Infección del tracto respiratorio inferior
Japanese 胸部感染, 下気道感染, 下気道感染NOS, カキドウカンセン, キョウブカンセン, カキドウカンセンNOS
Czech Infekce dolních cest dýchacích, Hrudní infekce, Infekce dolních dýchacích cest NOS, Infekce dolních dýchacích cest
Hungarian alsó légúti fertőzés k.m.n., mellkasi fertőzés, Alsó respiratorikus rendszer infectio, Alsó respiratorikus rendszer fertőzés, LRTI, alsó légúti fertőzés