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Home , Acute bronchitis, Bronchitis, Croup, Laryngitis, Pharyngitis

COVER ARTICLE PRACTICAL THERAPEUTICS

Diagnosis and Management of 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. show considerable variability in describing the necessary O A patient informa- to its diagnosis. Because most often has a viral cause, symptomatic tion handout on acute bronchitis, written by treatment with protussives, antitussives, or is appropriate. However, the authors of this studies indicate that many physicians treat bronchitis with . These drugs have article, is provided on generally been shown to be ineffective in patients with uncomplicated acute bronchitis. page 2046. Furthermore, antibiotics often have detrimental side effects, and their overuse con- tributes to the increasing problem of resistance. Patient satisfaction with the treatment of acute bronchitis is related to the quality of the -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.)

cute bronchitis, one of tomatic therapy and the role of antibi- the most common diag- otics in treatment. noses in ambulatory care medicine, accounted for Pathophysiology and Etiology approximately 2.5 million Acute bronchitis was originally de- Avisits to U.S. physicians in 1998.1 This scribed in the 1800s as of the condition consistently ranks as one of the bronchial mucous membranes. Over the top 10 diagnoses for which patients seek years, this inflammation has been shown to medical care, with being the most be the result of a sometimes complex and frequently mentioned symptom necessi- varied chain of events. An infectious or tating office evaluation.1 In the United noninfectious trigger leads to bronchial States, treatment costs for acute bronchitis epithelial injury, which causes an inflam- are enormous: for each episode, patients matory response with airway hyperrespon- receive an average of two prescriptions siveness and production.6 Selected and miss two to three days of work.2 triggers that can begin the cascade leading Even though acute bronchitis is a com- to acute bronchitis are listed in Table 1.3,7,8 mon diagnosis, its definition is unclear. Acute bronchitis is usually caused by a The diagnosis is based on clinical find- viral .9 In patients younger than ings, without standardized diagnostic one year, respiratory syncytial , signs and sensitive or specific confirma- parainfluenza virus, and are Members of various family tory laboratory tests.3 Consequently, the most common isolates. In patients practice departments physicians exhibit extensive variability in one to 10 years of age, parainfluenza develop articles for "Practi- cal Therapeutics." This arti- diagnostic requirements and treatment. virus, , respiratory syncytial cle is one in a series coordi- Antibiotic therapy is used in 65 to 80 per- virus, and predominate. In nated by the Department cent of patients with acute bronchitis,4,5 patients older than 10 years, of Family Medicine at Ohio but a growing base of evidence puts this virus, respiratory syncytial virus, and State University College of practice into question. This article exam- adenovirus are most frequent. Medicine and Public Health, Columbus. Guest ines the diagnosis and treatment of acute Parainfluenza virus, enterovirus, and editor of the series is Doug bronchitis in otherwise healthy, non- rhinovirus most commonly Knutson, M.D. patients, with a focus on symp- occur in the fall. Influenza virus, respira-

MAY 15, 2002 / VOLUME 65, NUMBER 10 www.aafp.org/afp AMERICAN FAMILY PHYSICIAN 2039 tory syncytial virus, and coronavirus infections are most frequent in the winter and spring.7 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 and , and often use the same constellation of symptoms pulmonary signs such as wheezing, rhonchi, as diagnostic criteria.10-14 and prolonged expiration. Evidence of consol- Cough is the most commonly observed idation must be absent.7 Fever may be present symptom of acute bronchitis. The cough 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 prompt consideration of or for less than two weeks; however, 26 percent influenza.7 are still coughing after two weeks, and a few Recommendations on the use of Gram cough for six to eight weeks.15 When a staining and culture of 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- Although most physicians consider cough 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. tum production, dyspnea, wheezing, chest In more than two thirds of these patients, a pain, fever, hoarseness, , rhonchi, and 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- leukocytes in sputum causes the color nology, no routinely performed studies diag- changes; hence, color alone should not be nose acute bronchitis. Chest radiography considered indicative of bacterial infection.17 should be reserved for use in patients whose physical examination suggests pneumonia or heart failure, and in patients who would be at TABLE 1 high risk if the diagnosis were delayed.7 Selected Triggers of Acute Bronchitis Included in the latter group are patients with advanced age, chronic obstructive pulmonary : adenovirus, coronavirus, , enterovirus, influenza virus, disease, recently documented pneumonia, parainfluenza virus, respiratory syncytial virus, rhinovirus malignancy, , and immunocom- : Bordatella pertussis, Bordatella parapertussis, Branhamella catarrhalis, promised or debilitated status.7 , pneumoniae, atypical bacteria (e.g., , , Legionella species) Office spirometry and pulmonary function Yeast and fungi: Blastomyces dermatitidis, , Candida tropicalis, testing are not routinely used in the diagnosis Coccidioides immitis, Cryptococcus neoformans, Histoplasma capsulatum of acute bronchitis. These tests are usually Noninfectious triggers: , air pollutants, ammonia, , tobacco, performed only when underlying obstructive trace metals, others pathology is suspected or when patients have repeated 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

2040 AMERICAN FAMILY PHYSICIAN www.aafp.org/afp VOLUME 65, NUMBER 10 / MAY 15, 2002 Acute Bronchitis

rule out bronchitis, asthma, pneumonia, or other specific diagnoses. BRONCHODILATORS Acute bronchitis and asthma have similar Treatment symptoms. Consequently, attention has PROTUSSIVES AND ANTITUSSIVES recently been given to the use of bronchodila- Because acute bronchitis is most often 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 acute bronchitis who used an albuterol more effective (protussive therapy).18 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- who received placebo. 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 a single 100-mg dose was evaluated.19 Common TABLE 2 preparations (e.g., Duratuss) contain guaifen- Selected Nonspecific Antitussive Agents esin in doses of 600 to 1,200 mg. Antitussive therapy is indicated if cough is Preparation Dosage Side effects creating significant discomfort and if sup- Hydromorphone- 5 mg per 100 mg Sedation, nausea, vomiting, pressing the body’s protective mechanism for per 5 mL (one respiratory depression airway clearance would not delay healing. (e.g., Hycotuss) teaspoon)* Studies have reported success rates ranging 30 mg every Rarely, gastrointestinal upset or from 68 to 98 percent.18 Antitussive selection is (e.g., Delsym) 12 hours sedation based on the cause of the cough. For example, Hydrocodone 5 mg every 4 to Gastrointestinal upset, nausea, an would be used to treat cough (e.g., in Hycodan 6 hours drowsiness, constipation associated with allergic , a decongestant syrup or tablets) or an antihistamine would be selected for Codeine (e.g., in 10 to 20 mg every Gastrointestinal upset, nausea, cough associated with postnasal drainage, and Robitussin A-C) 4 to 6 hours drowsiness, constipation a would be appropriate for Carbetapentane 60 to 120 mg Drowsiness, gastrointestinal upset cough associated with asthma exacerbations. (e.g., in Rynatuss) every 12 hours Nonspecific antitussives, such as hydrocodone 100 to 200 mg Hypersensitivity, gastrointestinal (e.g., in Hycodan), dextromethorphan (e.g., (Tessalon) three times daily upset, sedation 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 Economics, 2002. their dosages are listed in Table 2.20

MAY 15, 2002 / VOLUME 65, NUMBER 10 www.aafp.org/afp AMERICAN FAMILY PHYSICIAN 2041 TABLE 3 Reviews and Meta-analyses of Antibiotic Therapy for Acute Bronchitis

Investigators End points Results

MacKay24 Various Some studies showed statistical differences with antibiotic therapy, but there was no clinical significance. Fahey, et al.25 Productive cough, lack of Antibiotic therapy did not improve cough or clinical improvement, side effects 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 subjective ill feeling, activity cough and decreased likelihood of continued cough. limitations, less likely to show no improvement on follow-up assessment Bent, et al.27 Cough, sputum production, Antibiotic therapy decreased duration of cough by days lost from work 12 hours. Smucny, et al.28 Cough, improved assessment, Antibiotic-treated patients were less likely to have pulmonary findings, subjective cough, be unimproved, or have abnormal ill feeling, activity limitations 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 otic side effects were similar. and meta-analyses used many of the same 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 provided no improvement in patients with addition, the patients diagnosed with acute acute bronchitis, whereas others, including bronchitis who also had symptoms of the the Cochrane review,28 showed a slight bene- and had been ill for less than one week generally did not benefit from antibiotic therapy.28 The Authors 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 at Ohio State University School of Medicine and Public Health, Columbus, where he of these antibiotics in the treatment of acute earned his medical degree. Dr. Knutson completed a family practice residency at River- bronchitis are in progress. side Methodist Hospital, Columbus, Ohio.

CHAD BRAUN, M.D., is clinical assistant professor and associate residency director in the Alternatives to Antibiotics Department 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 of Medicine and completed a family practice residency at Riverside Methodist Hospital. uncomplicated acute bronchitis. However, pa- tient satisfaction does not depend on receiving Address correspondence to Doug Knutson, M.D., Department of Family Medicine, Ohio State University College of Medicine and Public Health, 2231 N. High St., Colum- an antibiotic. Instead, it is related to the qual- bus, OH 43201 ([email protected]). Reprints are not available from the authors. ity of the physician-patient visit.

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Physicians should make sure that they ex- to consider the issue of antibiotic resistance. plain the diagnosis and treatment of acute Although the mechanisms leading to anti- 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 within a community can reduce the preva- are probably not going to be beneficial and lence of antibiotic-resistant bacteria.30,31 that treatment with these drugs is associated An algorithm for the treatment of acute 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.” When determining an optimal treatment 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

Patient with cough and chest symptoms consistent with acute bronchitis

Is the bronchitis uncomplicated (no pulmonary disease, no smoking, etc.)?

Yes No

History and physical examination to rule out History and physical examination; consider consolidation or other causes of cough chest radiography, pulmonary function testing, peak flow measurement, sputum culture; consider antibiotic therapy

Acute bronchitis?No Treat cause of cough.

Yes

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.

MAY 15, 2002 / VOLUME 65, NUMBER 10 www.aafp.org/afp AMERICAN FAMILY PHYSICIAN 2043 Acute Bronchitis

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