Diagnosis and management of acute bronchitis -- american family physician

Diagnosis and Management
of Acute Bronchitis
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 by treatment 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 Acute Bronchitis
rule out bronchitis, asthma, pneumonia, orother specific diagnoses.
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 ANTIBIOTICS
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 (knutson.1@osu.edu). 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
16. Mufson MA. Viral pharyngitis, laryngitis, croup and bronchitis. In: Goldman L, Bennett JC, eds. Cecil 1. Slusarcick AL, McCaig LF. National hospital ambu- Textbook of medicine. 21st ed. Philadelphia: Saun- latory medical care survey: 1998 outpatient depart- ment summary. Hyattsville, Md.: U.S. Dept. of 17. Chodosh S. Acute bacterial exacerbations in bron- Health and Human Services, Centers for Disease chitis and asthma. Am J Med 1987;82(4A):154-63.
Control and Prevention, National Center for Health 18. Irwin RS, Boulet LP, Cloutier MM, Fuller R, Gold Statistics, 2000; DDHS publication no. (PHS) 2000- PM, Hoffstein V, et al. Managing cough as a defense mechanism and as a symptom. A consen- 2. Oeffinger KC, Snell LM, Foster BM, Panico KG, sus panel report of the American College of Chest Archer RK. Diagnosis of acute bronchitis in adults: Physicians. Chest 1998;114(2 suppl managing): a national survey of family physicians. J Fam Pract 19. Irwin RS, Curley FJ, Bennett FM. Appropriate use of 3. Hueston WJ, Mainous AG III. Acute bronchitis. Am antitussives and protussives. A practical review.
Fam Physician 1998;57:1270-6,1281-2.
4. Gonzales R, Steiner JF, Sande MA. Antibiotic pre- 20. Physicians’ desk reference. 56th ed. Montvale, N.J.: scribing for colds, upper respiratory tract infec- tions, and bronchitis by ambulatory care physi- 21. Hueston WJ. Albuterol delivered by metered-dose inhaler to treat acute bronchitis. J Fam Pract 1994; 5. Mainous AG III, Zoorob RJ, Hueston WJ. Current management of acute bronchitis in ambulatory 22. Snow V, Mottur-Pilson C, Gonzales R. Principles of care: the use of antibiotics and bronchodilators.
appropriate antibiotic use for treatment of acute bronchitis in adults. Ann Intern Med 2001;134: 6. Treanor JJ, Hayden FG. Viral infections. In: Murray JF, ed. Textbook of respiratory medicine. 3d ed.
23. Arroll B, Kenealy T. Antibiotics for acute bronchitis Philadelphia: Saunders, 2000:929-84.
7. Blinkhorn RJ Jr. Upper respiratory tract infections.
24. MacKay DN. Treatment of acute bronchitis in adults In: Baum GL, ed. Textbook of pulmonary diseases.
without underlying lung disease. J Gen Intern Med 6th ed. Philadelphia: Lippincott-Raven, 1998:493- 25. Fahey T, Stocks N, Thomas T. Quantitative system- 8. Boldy DA, Skidmore SJ, Ayres JG. Acute bronchitis atic review of randomised controlled trials compar- in the community: clinical features, infective factors, ing antibiotic with placebo for acute cough in changes in pulmonary function and bronchial reac- tivity to histamine. Respir Med 1990;84:377-85.
26. Smucny JJ, Becker LA, Glazier RH, McIsaac W. Are 9. Marrie TJ. Acute bronchitis and community antibiotics effective treatment for acute bronchitis? acquired pneumonia. In: Fishman AP, Elias JA, eds.
A meta-analysis. J Fam Pract 1998;47:453-60.
Fishman’s Pulmonary diseases and disorders. 3d ed.
27. Bent S, Saint S, Vittinghoff E, Grady D. Antibiotics New York: McGraw-Hill, 1998:1985-95.
in acute bronchitis: a meta-analysis. Am J Med 10. Scherl ER, Riegler SL, Cooper JK. Doxycycline in acute bronchitis: a randomized double-blind trial. J Ky 28. Smucny J, Fahey T, Becker L, Glazier R, McIsaac W.
Antibiotics for acute bronchitis. Cochrane Data- 11. Franks P, Gleiner JA. The treatment of acute bronchi- tis with trimethoprim and sulfamethoxazole.
29. Gonzales R, Barrett PH Jr, Crane LA, Steiner JF. Fac- tors associated with antibiotic use for acute bron- 12. Williamson HA Jr. A randomized, controlled trial of chitis. J Gen Intern Med 1998;13:541-8.
doxycycline in the treatment of acute bronchitis.
30. Stephenson J. Icelandic researchers are showing the way to bring down rates of antibiotic-resistant 13. Brickfield FX, Carter WH, Johnson RE. Erythromycin in the treatment of acute bronchitis in a commu- 31. Seppala H, Klaukka T, Vuopio-Varkila J, Muotiala A, nity practice. J Fam Pract 1986;23:119-22.
Helenius H, Lager K, et al. The effect of changes in 14. Dunlay J, Reinhardt R, Roi LD. A placebo-con- the consumption of macrolide antibiotics on eryth- trolled, double-blind trial of erythromycin in adults romycin resistance in group A streptococci in Fin- with acute bronchitis. J Fam Pract 1987;25:137-41.
land. Finnish Study Group for Antimicrobial Resis- 15. Chesnutt MS, Prendergast TJ. Lung. In: Tierney LM, ed. Current medical diagnosis & treatment, 2002.
32. Hueston WJ. Antibiotics: neither cost effective nor 41st ed. New York: McGraw-Hill, 2002:269-362.
“cough” effective. J Fam Pract 1997;44:261-5.

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