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Acute Bronchitis

 

Acute bronchitis can be described as a self limited inflammation of large airways of the lung that happens in a patient without chronic lung disease.

 

How common – LRTIS -leading infectious cause of death worldwide among children and adults Not well defined ,but from an epidemiological point of view the term LRTI includes pneumonia ( infection of lung parenchyma ) , influenza , bronchitis
( including acute exacerbation in chronic obstructive pulmonary disease -AECOPD ) and bronchiolitis Together they are the Vth leading cause of death exact prevalence of acute bronchitis can be hard to estimate as in primary care often various conditions are clumped together under acute bronchitis None the less it is one of the most common presentation in any healthcare setting data from the US shows that an estimated 5 % of the general population report an episode of acute bronchitis responsible for 10 million visits / year In the UK it is stated that acute bronchitis affects 44/1000 adults ( > 16yrs ) each year in the UK with 82 % of episodes occurring during winter or autumn Most common among young children , affects men and women equally and shows seasonal variation with no racial predilection

 

Causes- Risk factors include smoking , living in a polluted place , crowding and h/o asthma , contact with someone who has a cold , lack of immunization More than 90 % of cases are viral in origin including influenza A & B , parainfluenza ,coronavirus , respiratory syncytial virus , adenovirus , rhinovirus ans human metapneumovirus bacterial causes are less common ( 1% to 10 % ) and include Streptococcus pneumoniae , Staphylococcus aureus , Bordetella pertusis , Chlamydia pneumonia , Mycoplasma pneumonia Studies have shown that about 10 % of patients in whom the cough lasted > 2 wks have evidence of B.pertussis infection Pathogens are found in less than 1/2 the people with acute bronchitis Bacterial strains have been isolated from sputum but bronchial biopsies do not show bacteral invasion Non infectious causes can include noxious agents as inhaled vapors or gases

 

What happens – Acute infection causing transient inflammation of the trachea and bronchial airways Inflammation leads to mucosal thickening , epithelial cell desquamation and denudation of the basement membrane Transient bronchial hyperresonsiveness FEV1 may be reduced in up to 40 % of cases which improves during the following 5-6 weeks

 

Presentation- There is no consensus as to how to define acute bronchitis Cough is the predominant feature ( with or without sputum ) Often preceded by symptoms of URTI Other features noted can include sore throat , nasal congestion , headache ,fever , general fatigue , wheezing , myalgia , hoarseness and malaise Initial tracheitis causes a dry cough with retrosternal soreness Patients often c/o substernal or chest wall pain when coughing Sputum can become mucopurulent and may be flecked with blood BMJ Best Practice suggests that the MacFarlane criteria offers a practical framework for suspecting acute bronchitis- these are
(a) an acute illness of < 21 days
(b) cough as the predominant symptom
(c) atleast 1 other lower respiratory tract symptom as sputum production , wheezing , chest pain
(d) no alternative explanation for the symptoms Studies have shown that cough can last longer than 30 days in about a quarter of patients with acute bronchitis – hence acute bronchitis can be present in patients with coughs lasting > 1 month The diagnosis is clinical based on history , past medical history , lung exam and other physical findings ( further tests are usually not needed unless an alternative diagnosis like pneumonia is suspected ) Clinical findings may reveal localized lymphadenopathy , reddened pharynx , rhinorrhoea and wheezing or rhonchi on auscultation.

 

Fever – most papers quote that fever is not a typical feature presence of fever may indicate pneumonia AAFP paper quotes that fever may be present in about 1/3rd of the patients BMJ best practice quotes that low grade fever may be present presence of high grade fever should prompt consideration of influenza or pneumonia

 

Oxygen saturation – important in judging the severity of the disease hypoxia indicates a more serious diagnosis

 

CXR – normal consider of pneumonia suspected consider in older patients in whom a cough may be the only initial presenting symptom

 

Procalcitonin – infection marker trials have shown that use of procalcitonin led to substantially reduce the use of antibiotics treatment in low risk situations.

 

Pneumonia is unlikely in healthy immunocompetent individuals Consider a diagnosis of pneumonia if pulse > 100 Resp rate > 24 temp > 38 abnormal chest exam e.g rales , egophony ( ask the patient to 
say “Ee “- it will be transformed into “A” with the voice having a nasal bleating quality similar to bleating of a goat suggesting consolidation , pleural effusion and lung cavity ) tactile fremitus or dullness o percussion CXR findings suggest infection.

 

Uncomplicated acute bronchitis is a self limiting illness with complete resolution and return to normal structure and function In primary care the aim is often to rule out more serious causes of cough such as asthma , exacerbation of COPD , heart failure or pneumonia first few days the symptoms may be indistinguishable from common cold sputum production is common and does not correlate with bacterial infection the median duration of cough after acute bronchitis is 18 days

 

Supportive management – Mainstay of management is supportive care and symptom management. Most guidelines advice against use of antibiotics but they are often prescribed for acute bronchitis. Here we discuss several agents which can potentially be used in supportive management

 

Non-pharmacological- hot tea honey , ginger , throat lozenges these have not been evaluated in any clinical trial

 

Anti-tussive- dextromethorphan codeine guaifenesin moguisteine trials show mixed results

 

Beta 2 agonists – may reduce symptoms , including cough , in people with evidence of airflow obstruction Use not supported by NICE unless the patient has an underlying airway disease

 

Antibiotics- Studies have consistently shown only a marginal benefit for use of antibiotics in treatment of uncomplicated acute bronchitis. Despite lack of good evidence antibiotics are widely used in treatment of acute bronchitis and this over prescription constitutes a global problem and is an important factor in increasing the levels of antibiotic resistance

 

NICE guideline on acute cough is a valuable guide for antibiotic prescribing . A summary is presented here for the full guidance see under links

 

Acute bronchitis and
 not systemically very unwell or at risk of complications- Do not offer 
an antibiotic.

 

Higher risk of complications
 ( at face to face examination )

NICE groups the following categories as higher risk people with pre-existing comorbidity young children born prematurely people older than 65 with 2 or more of the following , or older than 80 with one
- hospitalization in previous year
- diabetes ( type 1 or 2 )
- h/o congestive heart failure
- current use of oral corticosteroids
- Consider either an immediate or back-up antibiotic.

 

Systemically very unwell at face 
to face examination. Offer an immediate antibiotic.

 

Symptoms or signs suggest a more 
serious illness or condition for e.g sepsis , PE or lung cancer- Refer to hospital or seek specialist advice.

 

Differentials – URTI / common cold asthma COPD exacerbation pneumonia influenza chronic bonchitis – usually defined as hypersecretion of mucus and chronic productive cough that continues for atleast 3 months of the year for atleast 2 consecutive years allergic rhinitis sinusitis pertussis Tuberculosis bronchogenic carcinoma pulmonary embolism congestive cardiac failure reflux oesophagitis allergic aspergillosis occupational exposures.

 

Complications chronic cough progression to chronic bronchitis or pneumonia

Patient Information Resource

Lung Foundation Australia – concise printable leaflet https://lungfoundation.com.au/wp-content/uploads/2018/09/Factsheet-Acute-Bronchitis-Aug2018.pdf

Chest foundation on acute bronchitis – recently updated https://foundation.chestnet.org/lung-health-a-z/acute-bronchitis/

Family doctor on acute bronchitis https://familydoctor.org/condition/acute-bronchitis/

NI Direct on acute bronchitis https://www.nidirect.gov.uk/conditions/bronchitis-acute

 

References

  1. Evidence-based diagnosis
    and management of acute bronchitis by Ann Marie Hart PhD , FNP
    www.tnpj.com The Nurse Practitioner • September 2014 33
    acute bronchitis https://alliedhealth.ceconnection.com/files/EvidencebasedDiagnosisandManagementofAcuteBronchitis-1415888726241.pdf
  2. Singh A, Avula A, Zahn E. Acute Bronchitis. [Updated 2020 Jun 24]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK448067/
  3. Hueston WJ, Mainous AG 3rd. Acute bronchitis. Am Fam Physician. 1998 Mar 15;57(6):1270-6, 1281-2. PMID: 9531910.
  4. Hueston WJ, Mainous AG 3rd. Acute bronchitis. Am Fam Physician. 1998 Mar 15;57(6):1270-6, 1281-2. PMID: 9531910.
  5. Evidence-based diagnosis and management of acute bronchitis, The Nurse Practitioner: September 18th, 2014 – Volume 39 – Issue 9 – p 39-40 doi: 10.1097/01.NPR.0000453812.05509.98
  6. PRACTICE GUIDANCE FOR JUDICIOUS USE OF ANTIBIOTICS
    Striving for better outcomes for individual patients, improved population health, and lower healthcare costs
    ACUTE UNCOMPLICATED BRONCHITIS (Adults)
    This guideline is not intended for patients with COPD/chronic bronchitis or other serious comorbidities. https://www.doh.wa.gov/Portals/1/Documents/Pubs/420-196-WAAdultBronchitisClinicalGuideline.pdf
  7. Llor CarlMoragas AnaBayona CarolinaMorros RosaPera HelenaPlana-Ripoll Oleguer et al. Efficacy of anti-inflammatory or antibiotic treatment in patients with non-complicated acute bronchitis and discoloured sputum: randomised placebo controlled trial 
  8. Llor CarlMoragas AnaBayona CarolinaMorros RosaPera HelenaPlana-Ripoll Oleguer et al. Efficacy of anti-inflammatory or antibiotic treatment in patients with non-complicated acute bronchitis and discoloured sputum: randomised placebo controlled trial 
  9. . (2020) Use of chest X-ray in the assessment of community acquired pneumonia in primary care – an intervention studyScandinavian Journal of Primary Health Care 38:3, pages 323-329.
  10. Modi P, Nagdev TS. Egophony. [Updated 2020 Jul 10]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK518991/
  11. Cough (acute): antimicrobial prescribing NICE guideline Ng 120 https://www.nice.org.uk/guidance/ng120/resources/visual-summary-pdf-6664861405
  12. Procalcitonin-guided diagnosis and
    antibiotic stewardship revisited Sager et al. BMC Medicine (2017) 15:15
    DOI 10.1186/s12916-017-0795-7 
  13. Seppä Y, Bloigu A, Honkanen PO, Miettinen L, Syrjälä H. Severity Assessment of Lower Respiratory Tract Infection in Elderly Patients in Primary Care. Arch Intern Med. 2001;161(22):2709–2713. doi:10.1001/archinte.161.22.2709
  14. Acute lower respiratory infections European Lung Whitebook https://www.erswhitebook.org/chapters/acute-lower-respiratory-infections/

  15. Acute bronchitis epidemiology and demographics C Michael Gibson et al https://www.wikidoc.org/index.php/Acute_bronchitis_epidemiology_and_demographics

  16. BMJ Best practice acute bronchitis https://bestpractice.bmj.com/topics/en-gb/135/investigations#firstOrder

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