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Bronchitis - Uncomplicated Acute Overview

Contents

Overview
Follow-Up
Evaluation
Diagnosis
Pharmacological Therapy
Patient Education
Guideline References

OVERVIEW

Acute uncomplicated bronchitis is characterized by the inflammation of the bronchi. Patients

usually presents w/ cough lasting for more than 5 days w/c may be associated w/ sputum
production
Other symptoms of acute bronchitis include:

Sore throat
Rhinorrhea
Hoarseness
Dyspnea
Fatigue

Refer to Symptoms for more information.

Symptoms
Signs & Symptoms

Cough &/or increase in sputum production

Breathlessness/wheeze
Chest pain/aches
Sweats &/or sore throat
Increase in temperature
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Diagnosis

Diagnosis is based on patient history & clinical presentation

Studies such as sputum analysis & culture, chest radiograph, pulmonary function
tests, etc are not routinely requested unless to rule out other pulmonary diseases such
as pneumonia

Refer to Diagnosis for more information.

Diagnosis

Uncomplicated Acute Bronchitis

A self-limiting acute respiratory tract infection (RTI) characterized by the sudden

onset of cough, w/ or w/o sputum production, in an otherwise healthy individual
o Diagnosis is based on clinical findings

Pathogenesis

An inflammatory response to infections of the bronchial epithelium of the large

airways of the lungs
o Begins w/ mucosal injury, epithelial cell damage & release of
proinflammatory mediators
o Transient airflow obstruction & bronchial hyperresponsiveness
Purulence can result from either bacterial or viral infection

Etiology
Viral

The most common cause (90% of cases) of bronchial inflammation in otherwise

healthy adults presenting w/ acute bronchitis
o Influenza A & B, parainfluenza 3 & resp syncytial virus produce primarily
lower resp tract disease
o Corona virus, adenovirus & rhinoviruses more commonly produce upper resp
tract symptoms

Non-viral

Mycoplasma pneumoniae, Chlamydia pneumoniae, Bordetella pertussis (5-10% of

cases)
Environmental cough triggers (eg dust, dander, toxic fume inhalation)

Typical Clinical Presentation

Signs & Symptoms
 Predominant symptom: Cough that is usually productive that persists <3 wk
o The cough generally lasts 7-10 days but occasionally persists for >1 mth
o Influenza (flu) virus typically causes a nonproductive cough
o If cough has been >3 wk, consider investigation of other diagnoses (eg
tuberculosis in endemic areas)
Sputum may be clear, white, yellow, green or even tinged w/ blood
o Green/yellow (purulent) sputum production is indicative of an inflammatory
reaction & it can result from either viral or bacterial infection
Cough may be accompanied by clinical features that suggest an acute RTI (eg sore
throat, rhinorrhea, hoarseness)
Patient may also present w/ retrosternal chest pain on coughing, dyspnea, wheezing,
fever, fatigue or night cough

History

Perform a complete & detailed medical history including tobacco use

Physical Exam

Wheezing, rhonchi, coarse rales, a prolonged expiratory phase or other obstructive

signs may be present
o Forced expiration may be done to detect wheezing

Diagnostic Studies

No available test can provide a definitive diagnosis of acute bronchitis

In patients presumed to have acute bronchitis, viral cultures, serologic assays &
sputum analyses should not be done routinely because the responsible organism is
rarely identified in clinical practice
Gram stain or sputum culture in the healthy adult w/ acute bronchitis is not helpful as
most cases are caused by a virus
Transient pulmonary function abnormalities (very similar to those of mild asthma)
may occur in acute bronchitis but diagnostic pulmonary function testing need not be
performed in previously healthy patients
Chest x-ray is typically unnecessary
o Purulent sputum is not an indication for a chest x-ray
o Consider performing a chest x-ray if vital signs show a heart rate of >100
beats/min, respiratory rate of >24 breaths/min, & an oral temperature of
>100.4F (>38C), & if focal pulmonary consolidation is present on exam

Differential Diagnoses
Pertussis

An uncommon cause of uncomplicated acute bronchitis

May be present in up to 10-20% of adults w/ cough lasting >2-3 wk
o Adults immunized as children but no longer having effective immunity may
be a reservoir of B pertussis
o No classic features of pertussis in adults (as there are in children) but generally
presents as severe bronchitis
 Pertussis may be considered in children suffering from severe spasmodic coughing,
esp if terminated by vomiting or associated w/ redness of the face & catching of the
breath
o The incidence of pertussis in children has decreased due to widespread
pertussis vaccination
Physicians should limit suspicion & treatment of adult pertussis to patients w/ a high
probability of exposure (during outbreak in the community or if there is history of
contact w/ a patient who has a known case)
If pertussis is suspected, a diagnostic test should be performed & antimicrobial
therapy initiated
o Diagnosis may be difficult to establish because of delay in suspicion of disease
(cultures of nasopharyngeal secretions are usually negative after 2 wk &
reliable serologic tests may not be available)
o Polymerase chain reaction (PCR) of nasopharyngeal swabs or aspirates
improves detection

Asthma

Should be considered in patients w/ repetitive episodes of acute bronchitis

o Full spirometric testing w/ bronchodilatation or provocative testing w/ a
Methacholine challenge test can be given to help differentiate asthma from
recurrent bronchitis
Acute bronchitis may cause transient pulmonary abnormalities & the diagnosis of
asthma should be considered if abnormalities in pulmonary function persist after the
acute phase of the illness

Influenza (Flu)

Flu viruses are the most common pathogens found in patients w/ uncomplicated acute
bronchitis
During times of outbreak, diagnosis by clinical presentation is as accurate as rapid
diagnostic tests
o Patient may benefit from anti-influenza agents if treated w/in 48 hr of
symptom onset

For more detailed diagnosis & treatment of influenza, see Influenza Disease Management
Chart
Pneumonia

Potentially the most serious cause of acute cough illness & should be ruled out
In healthy, non-elderly adults, the absence of vital sign abnormalities (eg HR 100
beats/min, resp rate >24 breaths/min, oral body temp 38C & signs of focal
consolidation on chest exam) sufficiently reduces the likelihood of pneumonia to
eliminate the need for a chest x-ray

For more detailed diagnosis of pneumonia, see Pneumonia - Community Acquired Disease
Management Chart
Upper Respiratory Tract Infection (URTI)

In these settings, cough is not a predominant symptom (eg common cold)

Non-pulmonary Causes

Chronic heart failure (CHF) in elderly patients, gastroesophageal reflux disease

(GERD) & bronchogenic tumor

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Treatment

Routine treatment of uncomplicated acute bronchitis w/ antibiotics is not recommended,

regardless of cough duration
Options for symptomatic therapy include:

Analgesics & Antipyretics

Bronchodilator: Beta2-agonist (inhaled)
Cough & Cold Preparation

Refer to Treatment for more information.

Below is the overview of disease management of Bronchitis - Uncomplicated Acute:

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Treatment
Pharmacological Therapy

1. Symptomatic Therapy
Choice of therapy depends on which symptoms are most bothersome to the patient
1.1. Analgesics (Non-Opioid) & Antipyretics

Eg Paracetamol, Ibuprofen
Beneficial when influenza symptoms eg malaise & fever are prominent
Avoid salicylates in children 18 yr of age because of the risk of Reye Syndrome

1.2. Bronchodilators: Beta2-Agonists

May be used to reduce the duration & severity of cough in some patients, but routine
use for cough palliation is not recommended
Use should be individualized to those who are most likely to benefit
o Eg use is justified in patients w/ clinical evidence of airflow obstruction or
bronchial hyperresponsiveness eg wheezing or bothersome cough
Effects: Studies have shown that more patients report decrease in cough after 7 days
of inhaled bronchodilator as compared to placebo or antibiotic

1.3. Cough & Cold Preparations

Codeine or Dextromethorphan
o May be justified for a nonproductive irritating cough, given short term for
cough relief
o Patients w/ cough lasting >2-3 wk are the most likely to benefit
o Suppress the cough reflex by a direct action on the cough center in the medulla
of the brain
o Modest effect on severity & duration of cough
o Typically not very effective in patients w/ acute or early cough due to colds or
other viral URTI
Mucolytic agents are not advised

Adverse Reactions:
o GI disturbances, N/V; hypersensitivity reactions (bronchospasm, rashes);
Other effect (hypotension)
Special Instruction:
o Use w/ caution in patients w/ gastric or duodenal ulcer
Dosage Guidelines

a. Acetylcysteine (N-acetylcysteine)

o 200 mg PO 8 hrly

b. Ambroxol

o 60-120 mg PO divided 8-12 hrly

 o Extended-release: 75 mg PO 24 hrly

c. Bromhexine

o 8-16 mg PO 6-8 hrly

d. Carbocisteine (Carbocysteine)

o Initial dose: 750 mg PO 6-8 hrly, then 1.5 g/day PO in divided doses
Adverse Reactions:
o GI effect (stomach pain); hypersensitivity reaction (rashes)
Special Instruction:
o Use w/ caution in patients w/ renal failure
Dosage Guidelines

a. Cyclidrol (Sobrerol)

o 200 mg PO 12 hrly or up to 800 mg daily in divided doses

Adverse Reactions:
o GI disturbances (GI discomfort, rarely taste alterations); Other effects (rarely,
headache, dyspnea, urticaria, erythema, dermatitis)
Special Instruction:
o Contraindicated in patients w/ hepatic cirrhosis,
hepatic impairment, cystathionine-synthetase enzyme deficiency & severe
renal failure
Dosage Guidelines

a. Erdosteine

o 300 mg PO 8-12 hrly

Adverse Reactions:
o GI disturbances (GI discomfort, N/V)
Special Instruction:
o Use w/ caution in patients w/ persistent or chronic cough, asthma, chronic
bronchitis or emphysema
o Discontinue use if cough persists for >7 days w/ fever, rash or persistent
headache
Dosage Guidelines

a. Guaifenesin

o 600 mg PO 12 hrly or 200 mg 4 hrly

o Max dose: 1200 mg in 24 hr
Adverse Reactions:
o CNS effect (somnolence, faintness, clouding of consciousness, dizziness,
headache); Other effects (palpitation, GI disturbance)
Special Instructions:
o Use w/ caution in patients w/ excessive mucus discharge, limited mucociliary
function, hepatic dysfunction, renal insufficiency, & diabetes
 Dosage Guidelines

a. Levodropropizine

o 60 mg PO 8 hrly

2. Antibiotics for Pertussis

Use is supported only for confirmed or suspected B pertussis cases when there is a
high probability of exposure or during an outbreak
Erythromycin is the drug of choice for treatment & prophylaxis of pertussis in people
of all ages
Two small comparative studies suggest that Clarithromycin & Azithromycin are at
least as effective as Erythromycin for pertussis treatment
Co-trimoxazole may be used as an alternative when macrolides cannot be given
Antibiotics are primarily used to decrease shedding of the pathogen & therefore
decrease the spread of the disease
o Patient isolation for 5 days from the start of treatment is a necessary
precaution
o Antibiotic therapy does not appear to resolve symptoms if it is initiated 7-10
days after the onset of illness but does prevent spread to others

2.1. Antibacterial combination

Adverse Reactions:
o GI effects (N/V, anorexia, diarrhea, rarely antibiotic-associated
diarrhea/colitis, glossitis); Dermatologic effects (rash, pruritus,
photosensitivity); Hypersensitivity reactions can range from mild (eg rash) to
severe/life-threatening (eg Stevens-Johnson syndrome); Urogenital
(crystallization in the urine)
o Rarely hematologic effects which may be more common if given for long
periods or w/ high doses; rarely hepatic effects, renal effects; aseptic
meningitis has occurred
Special Instructions:
o Maintain adequate fluid intake
o Contraindicated in patients allergic to sulfonamides
o Use w/ extreme caution or not at all in patients w/ hematological disorders esp
megaloblastic anemia due to folic acid deficiency
o Use w/ caution in patients w/ renal impairment or severe hepatic dysfunction
& w/ caution in patients w/ folate deficiency (may consider administration of
Folinic acid)
Dosage Guidelines

a. Co-trimoxazole [Sulfamethoxazole (SMZ) & Trimethoprim (TM)]

o SMZ 800 mg & TM 160 mg PO 12 hrly x 14 days

2.2. Macrolides

Adverse Reactions:
 o
GI effects (N/V, abdominal discomfort, diarrhea & other GI disturbances,
antibiotic-associated diarrhea/colitis); Other (candidal infections)
o Hypersensitivity reactions are uncommon (urticaria, pruritus, rash, rarely
anaphylaxis); rarely cardiotoxicity, hepatotoxicity; dose-related
tinnitus/hearing loss have occurred w/ some macrolides
o Azithromycin & Clarithromycin tend to cause less GI disturbances than
Erythromycin
Special Instructions:
o May take w/ food to decrease gastric distress
o Use w/ caution in patients w/ hepatic dysfunction
Dosage Guidelines

a. Erythromycin

o Childn: 40-50 mg/kg/day PO divided 6-12 hrly x 14 days

o Adults: 500 mg PO 6 hrly x 14 days

b. Roxithromycin

oChildn >40 kg: 5-8 mg/kg/day PO divided 12 hrly x 7-10 days

oAdults: 150 mg PO 12 hrly x 7-10 days or 300 mg PO 24 hrly x 7-10 days
Advanced Macrolides

a. Azithromycin

o Childn: 10 mg/kg PO 24 hrly x 5-7 days

o Adults: 500 mg PO 24 hrly x 3 days or 500 mg PO 24 hrly x 1 day followed by
250 mg PO 24 hrly x 4 days

b. Clarithromycin

o Childn: 7.5 mg/kg PO 12 hrly x 5-10 days

o Adults: 500 mg PO 12 hrly x 7-14 days
o Extended-release: 1000 mg PO 12 hrly x 7-14 days

All dosage recommendations are for non-pregnant & non-breastfeeding women, non-elderly
adults w/ normal renal & hepatic function unless otherwise stated.

Not all products are available or approved for above use in all countries.

Products listed above may not be mentioned in the disease management chart but have
been placed here based on indications listed in regional manufacturers product information.

Click the link below for specific prescribing information of products available in respective
countries.

Brands available in: Hong

Kong Indonesia Malaysia Philippines Singapore Thailand Vietnam
Follow-Up

Routine follow-up is not usually necessary

Consider alternate diagnoses, if symptoms worsen
Further investigation is recommended if:
Symptoms recur >3x/yr
If symptoms persist for >1 mth

Evaluation

Patients w/ Comorbidity

Comorbid conditions: Chronic obstructive pulmonary disease (COPD), CV diseases,

neurological diseases, diabetes mellitus (DM), chronic liver or renal failure, recent
viral infection, immunodeficiency, etc
Evaluation & management must be tailored in light of the patients comorbid
condition
o Eg see Bronchitis - Chronic in Acute Exacerbation Disease Management Chart
if patient has underlying COPD

Elderly Patients

Require a more careful evaluation & management

o Eg chest x-ray, sputum culture, ECG
o Appropriate antibiotic therapy should not be withheld since clinical features
are less reliable & pneumococcal infection is common in these patients

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Bronchitis - Uncomplicated Acute Symptoms

Version: 3 Sep 2014

Guideline References:

1. Alberta Medical Association. Guideline for the management and treatment of acute
bronchitis. http://www.albertadoctors.com/resources/cpg/acute-
bronchitisguideline.Pdf. 2000
2. Braman SS. Chronic cough due to chronic bronchitis: ACCP evidence-based clinical
practice guidelines. Chest. 2006 Jan;129(1)(Suppl):95S-103S. PMID: 16428698
3. European Respiratory Society. ERS Task Force Report. Guidelines for management
of adult community-acquired lower respiratory tract infections. Eur Respir J. 1998
Apr;11(4):986-991. PMID: 9623709
4. Gerberding JL. General principles and diagnostic approach. In: Mason RJ, Murray JF,
Broaddus VC, et al. eds. Murray and Nadels Textbook of Respiratory Medicine. 3rd
ed. Philadelphia: Lippincott Williams & Wilkins; 2000
5. Gonzales R, Bartlett JG, Besser RE, et al. Principles of appropriate antibiotic use for
treatment of uncomplicated acute bronchitis: background. Ann Intern Med. 2001
Mar;134(6):521-529. PMID: 11255532
6. Guide JK. Acute bronchitis. Conn's Current Therapy. 55th ed: Saunders, an imprint of
Elsevier; 2003
7. Gwaltney Jr JM. Section C: acute bronchitis. In: Mandell GL, Bennett JE, Dolin R,
eds. Mandell, Douglas and Bennetts principles and practice of infectious diseases.
5th ed. Philadelphia: Elsevier Churchill Livingstone, Inc; 2000
8. Hirschmann JV. Antibiotics for common respiratory tract infections in adult. Arch
Intern Med. 2002 Feb;162(3):256-264. PMID: 11822917
9. Hueston WJ, Mainous AG 3rd. Acute bronchitis. Am Fam Physician. 1998
Mar;57(6):1270-1276,1281-1282. PMID: 9531910
10. Knutson D, Braun C. Diagnosis and management of acute bronchitis. Am Fam
Physician. 2002 May;65(10):2039-2044. PMID: 12046770
11. Macfarlane J, Holmes W, Gard P, et al. Reducing antibiotic use for acute bronchitis in
primary care: blinded, randomised controlled trial of patient information leaflet. BMJ.
2002 Jan;324(7329):91-94. PMID: 11786454
12. Massie RJ, Altunaji S, Kukurozovic R, et al. Pertussis: adults as a source in healthcare
settings [letters]. Med J Aust. 2003 Feb;178(4):191. PMID: 12580755
13. McCormack JG, Spearing NM, Horvath RL. Pertussis: adults as a source in healthcare
settings [in reply to letters]. Med J Aust. 2003 Feb;178(4):191
14. Ministry of Health Singapore. Clinical Practice Guidelines: use of antibiotics in
adults. MOH (Singapore). http://www.moh.gov.sg/content/moh_web/home.html. Jan
2002
15. National Guideline Clearinghouse (NGC). Guideline summary: Management of
uncomplicated acute bronchitis in adults. National Guideline Clearinghouse.
http://www.guideline.gov/content.aspx?id=38688&search=Bronchodilator+. Sep
2012. Accessed 10 Oct 2013
16. Ressel G; Centers for Disease Control and Prevention; American College of
Physicians-American Society of Internal Medicine; American Academy of Family
Physicians; Infectious Diseases Society of America. Principles of appropriate
antibiotic use: part V. Acute bronchitis. Am Fam Physician. 2001 Sep;64(6):1098-
1100. PMID: 11578027
17. Scottish Intercollegiate Guidelines Network. Community management of lower
respiratory tract infections in adults: a national clinical guideline. SIGN.
http://www.sign.ac.uk/pdf/sign59.pdf. 2002
18. Snow V, Mottur-Pilson C, Gonzales R; American Academy of Family Physicians;
American College of Physicians-American Society of Internal Medicine; Centers for
Disease Control; Infectious Diseases Society of America. Principles of appropriate
antibiotic use for treatment of acute bronchitis in adults. Ann Intern Med. 2001
Mar;134(6):518-520. PMID: 11255531
19. Spearing NM, Horvath RL, McCormack JG. Pertussis: adults as a source in healthcare
settings. Med J Aust. 2002 Nov;177(10):568-569. PMID: 12429009
20. Wenzel RP, Fowler AA. Acute bronchitis. N Engl J Med. 2006 Nov;355(20):2125-
2130. PMID: 17108344