Diagnosis and management of acute bronchitis -- american family physician
Diagnosis and Management of Acute Bronchitis DOUG KNUTSON, M.D., and CHAD BRAUN, M.D. Ohio State University School of Medicine and Public Health, Columbus, Ohio Acute bronchitis is one of the top 10 conditions for which patients seek medical care. Physicians show considerable variability in describing the signs and symptoms necessary to its diagnosis. Because acute bronchitis most often has a viral cause, symptomatic tion handout on acutebronchitis, written bytreatment with protussives, antitussives, or bronchodilators is appropriate. However, studies indicate that many physicians treat bronchitis with antibiotics. These drugs have generally been shown to be ineffective in patients with uncomplicated acute bronchitis. Furthermore, antibiotics often have detrimental side effects, and their overuse con- tributes to the increasing problem of antibiotic resistance. Patient satisfaction with the treatment of acute bronchitis is related to the quality of the physician-patient interac- tion rather than to prescription of an antibiotic. (Am Fam Physician 2002;65:2039-44, 2046. Copyright 2002 American Academy of Family Physicians.)
tomatic therapy and the role of antibi-otics in treatment. Pathophysiology and Etiology
the most common diag-noses in ambulatory caremedicine, accounted forapproximately 2.5 million
scribed in the 1800s as inflammation of the
condition consistently ranks as one of the
years, this inflammation has been shown to
States, treatment costs for acute bronchitis
epithelial injury, which causes an inflam-
triggers that can begin the cascade leading
to acute bronchitis are listed in Table 1.3,7,8
mon diagnosis, its definition is unclear.
viral infection.9 In patients younger than
signs and sensitive or specific confirma-
physicians exhibit extensive variability in
diagnostic requirements and treatment.
virus, enterovirus, respiratory syncytial
cal Therapeutics." This arti-cle is one in a series coordi-
Antibiotic therapy is used in 65 to 80 per-
cent of patients with acute bronchitis,4,5
practice into question. This article exam-
ines the diagnosis and treatment of acute
Health, Columbus. Guesteditor of the series is Doug
occur in the fall. Influenza virus, respira-
tory syncytial virus, and coronavirus infectionsare most frequent in the winter and spring.7
Physical Examination and Diagnostic Studies Signs and Symptoms
The physical examination of patients pre-
Classifying an upper respiratory infection
senting with symptoms of acute bronchitis
as bronchitis is imprecise. However, studies of
should focus on vital signs, including the pres-
bronchitis and upper respiratory infections
ence or absence of fever and tachypnea, and
often use the same constellation of symptoms
pulmonary signs such as wheezing, rhonchi,
and prolonged expiration. Evidence of consol-
idation must be absent.7 Fever may be present
in some patients with acute bronchitis. How-
begins within two days of infection in 85 per-
ever, prolonged or high-grade fever should
cent of patients.15 Most patients have a cough
for less than two weeks; however, 26 percent
are still coughing after two weeks, and a few
staining and culture of sputum to direct ther-
patient’s cough fits this general pattern, acute
apy for acute bronchitis vary, because these
bronchitis should be strongly suspected.
tests often show no growth or only normal res-
piratory flora.6,7 In one recent study,8 nasopha-
to be necessary to the diagnosis of acute bron-
ryngeal washings, viral serologies, and sputum
chitis, they vary in additional requirements.
cultures were obtained in an attempt to find
Other signs and symptoms may include spu-
pathologic organisms to help guide treatment.
In more than two thirds of these patients, a
pain, fever, hoarseness, malaise, rhonchi, and
pathogen was not identified. Similar results
rales.16 Each of these may be present in vary-
have been obtained in other studies. Hence, the
ing degrees or may be absent altogether. Spu-
usefulness of these tests in the outpatient treat-
tum may be clear, white, yellow, green, or even
ment of acute bronchitis is questionable.
tinged with blood. Peroxidase released by the
Despite improvements in testing and tech-
nology, no routinely performed studies diag-
changes; hence, color alone should not be
considered indicative of bacterial infection.17
should be reserved for use in patients whosephysical examination suggests pneumonia orheart failure, and in patients who would be at
high risk if the diagnosis were delayed.7
Selected Triggers of Acute Bronchitis
Included in the latter group are patients withadvanced age, chronic obstructive pulmonary
Viruses: adenovirus, coronavirus, coxsackievirus, enterovirus, influenza virus,
parainfluenza virus, respiratory syncytial virus, rhinovirus
Bacteria: Bordatella pertussis, Bordatella parapertussis, Branhamella catarrhalis,Haemophilus influenzae, Streptococcus pneumoniae, atypical bacteria
(e.g., Mycoplasma pneumoniae, Chlamydia pneumoniae, Legionella species)
testing are not routinely used in the diagnosis
Yeast and fungi: Blastomyces dermatitidis, Candida albicans, Candida tropicalis,Coccidioides immitis, Cryptococcus neoformans, Histoplasma capsulatum
of acute bronchitis. These tests are usually
Noninfectious triggers: asthma, air pollutants, ammonia, cannabis, tobacco,
performed only when underlying obstructive
pathology is suspected or when patients haverepeated episodes of bronchitis. Pulse oxime-
Information from references 3, 7, and 8.
try may play a role in determining the sever-ity of the illness, but results do not confirm or
rule out bronchitis, asthma, pneumonia, orother specific diagnoses. BRONCHODILATORS Treatment PROTUSSIVES AND ANTITUSSIVES
recently been given to the use of bronchodila-
tors in patients with acute bronchitis.
caused by a viral infection, usually only symp-
Although relatively few studies have exam-
tomatic treatment is required. Treatment can
ined the efficacy of oral or inhaled beta ago-
focus on preventing or controlling the cough
nists, one study21 found that patients with
(antitussive therapy) or on making the cough
metered-dose inhaler were less likely to be
Protussive therapy is indicated when cough-
coughing at one week, compared with those
ing should be encouraged (e.g., to clear the air-
ways of mucus). In randomized, double-blind,placebo-controlled studies of protussives in
patients with cough from various causes, only
Because of increasing concerns about anti-
terbutaline (Brethine), amiloride (Midamor),
biotic resistance, the practice of giving antibi-
and hypertonic saline aerosols proved success-
otics to most patients with acute bronchitis
ful.19 However, the clinical utility of these
has been questioned.22,23 Clinical trials on the
agents in patients with acute bronchitis is
effectiveness of antibiotics in the treatment of
questionable, because the studies examined
acute bronchitis have had mixed results and
cough resulting from other illnesses. Guaifen-
rather small sample sizes. Attempts have been
esin, frequently used by physicians as an expec-torant, was found to be ineffective, but only asingle 100-mg dose was evaluated.19 Common
preparations (e.g., Duratuss) contain guaifen-
Selected Nonspecific Antitussive Agents
Antitussive therapy is indicated if cough is
creating significant discomfort and if sup-
pressing the body’s protective mechanism for
airway clearance would not delay healing.
Studies have reported success rates ranging
from 68 to 98 percent.18 Antitussive selection is
based on the cause of the cough. For example,
an antihistamine would be used to treat cough
associated with allergic rhinitis, a decongestant
or an antihistamine would be selected for
10 to 20 mg every Gastrointestinal upset, nausea,
cough associated with postnasal drainage, and
a bronchodilator would be appropriate for
cough associated with asthma exacerbations.
Nonspecific antitussives, such as hydrocodone
(e.g., in Hycodan), dextromethorphan (e.g.,
Delsym), codeine (e.g., in Robitussin A-C),carbetapentane (e.g., in Rynatuss), and ben-
*—Doses adjusted per manufacturer’s instructions.
zonatate (e.g., Tessalon), simply suppress
Information from Physicians’ desk reference. 56th ed. Montvale, N.J.: Medical
cough.18 Selected nonspecific antitussives and
their dosages are listed in Table 2.20
TABLE 3 Reviews and Meta-analyses of Antibiotic Therapy for Acute Bronchitis
Some studies showed statistical differences with
antibiotic therapy, but there was no clinical significance.
Antibiotic therapy did not improve cough or clinical
status, and patients had more side effects than those who did not take antibiotics.
Smucny, et al.26 Cough, productive cough,
Antibiotic therapy resulted in shorter duration of
cough and decreased likelihood of continued cough.
limitations, less likely to show no improvement on follow-up assessment
Antibiotic therapy decreased duration of cough by
Smucny, et al.28 Cough, improved assessment,
Antibiotic-treated patients were less likely to have
pulmonary findings; they also had shorter duration of cough and subjective ill feeling. Information from references 24 through 28.
made to quantify and clarify data from the
ficial effect; however, problems with antibi-
studies (Table 3).24-28 Although these reviews
Regardless of the end points evaluated in
studies, they examined different end points
each study, one fact was consistent: improve-
and reached slightly different conclusions.
ment occurred in the vast majority of patients
One analysis25 showed that antibiotic therapy
who were not treated with antibiotics. In
addition, the patients diagnosed with acute
acute bronchitis, whereas others, including
the Cochrane review,28 showed a slight bene-
common cold and had been ill for less thanone week generally did not benefit fromantibiotic therapy.28
None of the studies included newer macro-
lides or fluoroquinolones. Studies on the use
DOUG KNUTSON, M.D., is assistant professor in the Department of Family Medicine
of these antibiotics in the treatment of acute
at Ohio State University School of Medicine and Public Health, Columbus, where heearned his medical degree. Dr. Knutson completed a family practice residency at River-
side Methodist Hospital, Columbus, Ohio. Alternatives to Antibiotics
CHAD BRAUN, M.D., is clinical assistant professor and associate residency director in theDepartment of Family Medicine at Ohio State University School of Medicine and Public
Patients often expect antibiotic therapy for
Health. Dr. Braun received his medical degree from the University of Cincinnati College
uncomplicated acute bronchitis. However, pa-
of Medicine and completed a family practice residency at Riverside Methodist Hospital.
tient satisfaction does not depend on receiving
Address correspondence to Doug Knutson, M.D., Department of Family Medicine,
an antibiotic. Instead, it is related to the qual-
Ohio State University College of Medicine and Public Health, 2231 N. High St., Colum-bus, OH 43201 (email@example.com). Reprints are not available from the authors.Acute Bronchitis
Physicians should make sure that they ex-
to consider the issue of antibiotic resistance.
plain the diagnosis and treatment of acute
bronchitis, and provide realistic expectations
biotic resistance are complex, previous antibi-
about the clinical course. Patients should
otic use is a major risk factor.27,29 Studies have
expect to have a cough for 10 to 14 days after
shown that decreasing the use of antibiotics
the visit. They need to know that antibiotics
are probably not going to be beneficial and
lence of antibiotic-resistant bacteria.30,31
that treatment with these drugs is associated
with significant risks and side effects. It is help-
bronchitis is provided in Figure 1.15,32
ful to refer to acute bronchitis as a “chest cold.”
The authors indicate that they do not have any con-
protocol for acute bronchitis, physicians need
flicts of interest. Sources of funding: none reported.Management of Acute Bronchitis
History and physical examination to rule out
History and physical examination; consider
chest radiography, pulmonary function testing, peak flow measurement, sputum culture; consider antibiotic therapy
Treat with protussives, specific or nonspecific
antitussives, or bronchodilators as symptoms dictate; discuss follow-up.
Symptoms persist for two weeks or more despite appropriate treatment of symptoms.*
*—After two weeks, 26 percent of patients with acute bronchitis are still coughing.15 Some studies recommend waiting 30 days before changing therapy.32
FIGURE 1. Algorithm for the treatment of patients with acute bronchitis. Acute Bronchitis
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