Bronchitis (Chest Cold), Acute

Perform a complete history and physical examination; document which of the aforementioned signs and symptoms are present; rule out any other underlying ailment; and note any sign of bacterial superinfection of the ears, sinuses, pharynx, tonsils, epiglottis, bronchi, or lungs, which might require antibiotics or other therapy. In the absence of significant comorbid conditions or asthma, the primary objective when evaluating patients who have acute cough illness is to exclude pneumonia.

The absence of abnormal vital signs (heart rate greater than 100 beats/minute, respiratory rate greater than 24 breaths/minute, oral temperature greater than 100.4° F [38° C], hypoxemia), along with the absence of abnormalities on chest examination (focal consolidation, e.g., rales, egophony, fremitus), reduces the likelihood of pneumonia sufficiently to render further diagnostic testing unnecessary.

Abnormalities in these “pneumonia clinical prediction rules” should prompt the ordering of a chest radiograph. These rules have limited application in the elderly, because they may present with atypical manifestations of pneumonia (and without vital sign or examination abnormalities). Conversely, during the influenza season, many patients will have fever or tachycardia but not pneumonia.

The presence or absence of purulent sputum is a poor predictor of bacterial infections.

In settings where chest radiography is not readily available, elderly patients who have cough illness or those with clinical findings consistent with pneumonia may be prescribed antibiotics to safeguard against missing a case of pneumonia.

Routine antibiotic treatment of acute bronchitis has no consistent effect on either the duration or the severity of illness, and has potential side effects.

Patients who have a cough accompanied by the sudden onset of high fever (greater than 101° F), headache, moderate to severe myalgias, and fatigue should be suspected of having influenza in the face of a negative chest radiograph. Laboratory testing to make the diagnosis is not necessary during an outbreak; otherwise, rapid influenza testing can be performed on a nasopharyngeal specimen. If it has been less than 48 hours since the onset of symptoms, consider treating with oseltamivir (Tamiflu), 75 mg bid × 5 days (2 mg/kg bid × 5 days in children). In patients younger than 65 years, who are otherwise healthy and not pregnant, treatment is not necessary but may shorten the duration of illness if initiated promptly. For unvaccinated or high-risk vaccinated patients (elderly, children younger than 2 years old, pregnant women, immunosuppressed patients, or those with underlying lung disease), treatment should be initiated regardless of time from onset of symptoms. Local and national influenza surveillance data should be reviewed to determine appropriate treatment and provide further guidance in choice of antiviral agent.

Explain the course of the viral illness and the inadvisability of indiscriminate use of antibiotics. Provide the patient with realistic expectations for the duration of the cough (typically 10 to 14 days) and the ineffectiveness and potential adverse side effects of antibiotics. In addition, inform them that their condition could worsen, because resistant bacteria may be produced. Let them know that you want to hold antibiotics in reserve in case they develop a true bacterial infection. Try to avoid using the term bronchitis, and instead, refer to their illness as a “chest cold.” Positive rapid influenza tests in children can help foster parental acceptance of a management strategy that does not include antibiotics.

Tailor drug treatment to the patient’s specific complaint as follows:

For fever, headache, and myalgia, prescribe acetaminophen, 650 mg q4h, or ibuprofen, 600 mg q6h (adjust dose for age and weight).

For bronchitis with suspected bronchospasm, treat the cough using inhaled bronchodilators, such as albuterol, two puffs q1-8h prn cough.

Zinc and vitamin C have been shown to be beneficial in reducing the duration and severity of the common cold when taken within 24 hours of onset of symptoms.

Recommend comforting regimens, such as using a vaporizer in a dry environment, drinking tea and honey, and eating mother’s chicken soup. There appears to be no evidence in the literature to support the recommendation to drink extra fluids during a respiratory infection. Also, parents of children with an acute cough resulting from URI should be advised that there is almost no meaningful evidence regarding the effectiveness of over-the-counter (OTC) cough preparations, and that the available evidence does not support such treatment.

Patients with chronic obstructive pulmonary disease (COPD) who have an acute bacterial exacerbation of chronic bronchitis (increased sputum volume or purulence and difficulty breathing) may benefit from antibiotic therapy. For mild to moderate disease, either no treatment or doxycycline or trimethoprim/sulfamethoxazole (TMP/SMX) can be prescribed. For severe disease, amoxicillin/clavulanate (AM/CL), azithromycin, or a respiratory quinolone may be given for a period of 3 to 7 days. If the patient is at risk for Pseudomonas (i.e., severe COPD, recent hospitalization, or requiring antibiotics frequently), consider treatment with ciprofloxacin.

Consider gastroesophageal reflux disease as a possible etiology of new cough, and treat accordingly.

Arrange for follow-up if symptoms persist or worsen or if new problems develop.

What Not To Do:

Do not prescribe antibiotics inappropriately. In recent years, patient expectations for antibiotic treatment for URIs have decreased somewhat. It should not be assumed that most patients with a URI want to be treated with antibiotics; when they request one, however, personalize the risks of taking inappropriate antibiotics. Inform them that previous antibiotic use increases their personal risk for carriage of and infection with antibiotic-resistant infections. In addition, antibiotics cause frequent side effects, especially of the gastrointestinal tract.

Do not obtain sputum for Gram stains and cultures. They have no clinical usefulness in patients with acute bronchitis. Peroxidase released by the leukocytes in sputum causes the color changes.

Discussion

Data from the National Health Interview Survey suggest that 4% to 5% of all adults experience one or more episodes of acute bronchitis each year. Furthermore, more than 90% of acute bronchitis episodes will come to medical attention.

Acute bronchitis is a clinical diagnosis applied to otherwise healthy adults with acute respiratory illness of 1 to 3 weeks’ duration. Acute bronchitis usually is distinguished from other acute respiratory infections by the predominance of a cough and the absence of findings suggestive of pneumonia. A cough lasting longer than 3 weeks should be considered a “persistent” or “chronic” cough. The diagnostic considerations, under these circumstances, are significantly different from those of acute bronchitis.

The underlying pathophysiology of acute bronchitis is hypersensitivity of the tracheobronchial epithelium and airway receptors (reactive airway disease). Recurrent episodes of “acute bronchitis” may suggest underlying asthma, but a workup for asthma should be reserved for patients with a cough that lasts longer than 3 weeks.

In epidemiologic studies, respiratory viruses seem to cause or serve as a co-pathogen in most cases of acute bronchitis. Mycoplasma pneumoniae and Chlamydia pneumoniae have been recognized as possible bacterial causes of acute bronchitis. In several studies in which these pathogens were present (as determined by antibody titer or gene amplification), however, treatment with antibiotics appropriate to atypical pathogens did not change the outcome.

Adults with pertussis generally present with a persistent cough, with a mean duration of 36 to 48 days. The cough is mostly paroxysmal and often disturbs sleep. Choking or vomiting and whooping can be present, but less commonly than in children or previously unimmunized adults. The diagnosis is made by swabbing the posterior nasopharynx and sending the specimen for polymerase chain reaction (PCR) testing. Antibiotic therapy does not seem to decrease duration of symptoms for pertussis, unless it is initiated within 7 to 10 days of the onset of illness. Macrolide prophylaxis during outbreaks and after intrafamilial contact seems effective, however, and decreases spread of disease.

The societal cost of inappropriate antibiotic use is the rapid emergence of antibiotic resistance among bacterial pathogens and unnecessary prescription expenditures, estimated to be $726 million. On an individual level, a person’s risk for carriage and transmission of, and invasive infection with, antibiotic-resistant bacteria is associated strongly with previous antibiotic use. There is ongoing research on using serum levels of procalcitonin as a surrogate biomarker of bacterial infection to help guide the need for antibiotic therapy in acute bronchitis. Further research is needed before this is incorporated into standard clinical practice.

Evidence suggests that physicians and patients are more likely to believe that antibiotics are appropriate if purulent secretions are present or if the patient is a smoker, despite significant evidence to the contrary. Patients frequently expect to receive antibiotics for uncomplicated acute bronchitis, and patients or parents who expect antibiotics are more likely to receive them. Communication elements associated with the issuance of antibiotic prescriptions for acute respiratory infections include patient appeals to specific life circumstances (e.g., a pressing social engagement), identification of a previous positive experience with antibiotic use, or the disease being labeled as “acute bronchitis” rather than a “chest cold.”

Despite physician concerns about patient expectations, most studies find that satisfaction with care for acute respiratory infections is tied more closely to how much time the physician spent explaining the illness rather than receipt of antibiotics. High patient satisfaction was associated with positive responses to the following statements: “The doctor spent enough time with me”; “the doctor explained the illness to me”; and “the doctor treated me with respect.”

Influenza is the most common cause of acute bronchitis, and influenza vaccination is the most effective strategy for preventing influenzal illness. Cough and fever are positive predictors of influenza, whereas severe sore throat is a negative predictor. Prophylactic treatment for high-risk exposed individuals is indicated. Amantadine, rimantadine, zanamivir, and oseltamivir decrease illness duration by approximately 1 day and lead to a half-day quicker return to normal activities. The primary difference between the agents is that the neuraminidase inhibitors are effective against influenza A and B, whereas amantadine and rimantadine are effective only against influenza A, and there is high viral resistance to amantadine. The cost and side effects of these drugs are also significantly different. The relative proportion of cases caused by each type of influenza virus varies from year to year and is determined best through consultation with local public health agencies. Because each of these therapies is effective only if initiated within the first 48 hours (preferably the first 30 hours) of symptom onset, rapid diagnosis is key. During documented influenza outbreaks, the positive predictive value of clinical diagnosis based on clinical judgment is good (correct approximately 70% of the time) and compares favorably with rapid diagnostic tests for influenza (sensitivities of 63% to 81%). Diagnosis of influenza in a non-outbreak period is more difficult, and diagnostic testing should be considered.

The effectiveness of antitussive therapy seems to depend on the cause of a cough illness. An acute or early cough caused by colds and other URIs does not seem to respond to dextromethorphan or codeine. Coughs lasting longer than 3 weeks and coughs associated with underlying lung disease seem to respond to these agents.

An herbal extract from the Pelargonium sidoides root has been shown to alleviate symptoms of acute bronchitis, including cough and sputum production. In the United States, P. sidioides is marketed under the trade name Umcka (4-ounce bottle) 1 tsp, 4 to 5 times per day continued for 48 hours after symptoms subside (Nature’s Way, Springville, Utah).