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Treatment of Acute Bronchitis in Adults Without Underlying Lung Disease Donald N

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Treatment of Acute Bronchitis in Adults Without Underlying Lung Disease Donald N JGIM CLINICAL REVIEW Treatment of Acute Bronchitis in Adults Without Underlying Lung Disease Donald N. MacKay, MD OBJECTIVE: To determine whether antibiotic and bronchodi- a 1976 survey of family practitioners, acute bronchitis lator treatment of acute bronchitis in patients without lung was the fifth most common cause of office visits. 2 The Na- disease is efficacious. tional Center for Health Statistics found that in 1989 DESIGN: A MEDLINE search of the literature from 1966 to bronchitis (unfortunately, not specified as acute or 1995 was done, using "Bronchitis" as the key word. Papers chronic) was the seventh most common diagnosis for of- addressing acute bronchitis in adults were used as well as fice visits to internists and general and family practi- several citations emphasizing pediatric infections. A manual tioners, accounting for 2.2% of all visits to internists and search of papers addressing the microorganisms causing 2.3% of all visits to general and family practitioners, a This acute bronchitis was also done. Data were extracted manu- review summarizes what is known about the etiology and ally from relevant publications. clinical management of acute bronchitis, and then fo- SETTING: All published reports were reviewed. Papers dealing cuses on the treatment of acute bronchitis in adults with- with exacerbations of chronic bronchitis were excluded in out underlying chronic lung disease. Data regarding the this review. efficacy of specific treatments for patients with acute RESULTS: Although acute bronchitis has multiple causes, the bronchitis are presented. large majority of cases are of viral etiology. Mycoplasma pneumoniae, Chlamydia pneumoniae, and Bordetella pertus- sis are the only bacteria identified as contributing to the METHODS cause of acute bronchitis in otherwise healthy adults. Nine A MEDLINE search of the English language literature double-blind, placebo-controlled trials were reviewed. Four from 1966 to 1995 was done, using "Bronchitis" as the studies showed no advantage for doxycycline and one study showed no advantage for erythromycin. One study using key word. A few more sources were found in the bibliogra- erythromycin and one study using trimethoprim and sul- phies of other papers. Nine double-blind studies using famethoxazole showed that these antibiotics were slightly antibiotics versus placebo or albuterol in the treatment of better than placebo. Two other studies showed an impressive acute bronchitis were analyzed and described. All nine superiority for liquid or inhaled albuterol when compared studies used cough with sputum (several used purulent with erythromycin. sputum) as the major entry criterion. Reports addressing CONCLUSIONS: Most studies showed no significant difference chronic bronchitis were excluded, although several of the between drug and placebo, and the two studies that did nine studies included smokers. Although all the studies showed only small clinical differences. Albuterol had an im- stated that chronic obstructive pulmonary disease (COPD) pressive advantage over erythromycin. Antibiotics should was an exclusion criteria, chest x-rays were used in only not be used in the treatment of acute bronchitis in healthy three studies to exclude underlying lung disease, 4-6 and persons unless convincing evidence of a bacterial infection is two studies used chest x-rays only if fever or signs of con- present. solidation were present, or "at the discretion of the pri- KEY WORDS: acute bronchitis, bronchitis; bronchitis treat- mary provider. ''7,s Pulmonary function tests were not pre- ment. sented in any of the studies in this review. J GEN INTERN MED 1996; 11:557-562. Reviews describing the epidemiology and clinical course of viral and mycoplasma, chlamydia, and borde- tella pertussis respiratory infections were utilized to deter- cute bronchitis is one of the more common condi- mine if m~ etiologic diagnosis could be suspected when the tions seen in ambulatory medicine. In the 1970s a A patient was first seen. As most of the treatment studies survey of an emergency department in Madison, Wiscon- had relatively few patients, and outcome measures dif- sin, including all four seasons, showed that bronchitis, fered between studies, a meta-analysis was not attempted. dough, and laryngitis accounted for 12% of visits1; and in ETIOLOGY Received from the Division of General Internal Medicine, Stan- ford University Medical School, 900 Blake Wilbur Dr., Suite Acute bronchitis, characterized by inflammation of W2080, Stanford University, Stanford, CA 94305. the trachea and bronchi, can be caused by microbial in- 557 558 MacKay, Treatment of Acute Bronchitis JGIM fection or noninfectious assaults on the bronchial tree the adult population is left without antibody to B pertus- such as allergy or air pollution. 9 The presence of a cough, sis, as the protection of childhood immunization wanes with or without fever, cold symptoms, or sputum produc- by 4 to 12 years. 24,25 tion is the symptom that usually leads to a diagnosis of In an epidemic situation, pertussis has an attack rate acute infectious bronchitis, after other causes of cough of 23% to 100% if 12 or more years has passed since the such as bacterial sinusitis, allergies, atmospheric pollu- last pertussis immunization and an adult is exposed to a tion, or other lung diseases have been reasonably ex- family member with whooping cough. 24,26 In one epidemic cluded. Viral infections are thought to be the predomi- in rural Wisconsin, young children were more likely to ac- nant cause of acute bronchitis in otherwise healthy quire whooping cough from teenagers or adults, rather adults, but the precise ratio of viral causes to bacterial than the converse. 24 The cough is usually preceded by causes is not known. Numerous viruses have been impli- rhinorrhea, conjuctivitis, and a low-grade fever. Unfortu- cated as causing acute bronchitis, including influenza vi- nately, the characteristic "whoop" is usually lacking in ruses and adenoviruses,10.l i respiratory syncytial virus adults, 17 so pertussis is rarely considered as causing (RSV}, u,12 and the common cold viruses such as rhinovi- bronchitis unless the patient gives a history of contact ruses, 11 and (less frequently) coronaviruses.13 Measles14 with a known case of pertussis. It is probable that pertus- and herpes simplex virus la may also cause bronchitis, sis is a more common cause of bronchitis than is cur- and are associated with particularly severe cases. rently realized. In children, treatment with erythromycin The only bacteria known to contribute significantly to in the catarrhal stage, and sometimes in the paroxysmal the etiology of acute bronchitis are Mycoplasma pneumo- stage, may be of benefit. 27 However, as adults do not have niae, 1° Chlamydia pneumoniae {formerly known as the usual whoop, it would be difficult to determine if they TWAR), 16 and Bordetella pertussis. ~7 Other bacteria, such had pertussis unless there was contact with a known as Streptococcus pneumoniae, HaemophiIus influenzae, case. The author is unaware of studies of antibiotic use in and Moraxella catarrhalis, have been suggested as etio- adults with pertussis, but it might be reasonable to use logic agents in acute bronchitis in otherwise healthy pa- erythromycin in adults if there is recent contact (within tients, but there is little evidence to support this conten- less than 2 weeks} with a person known to have pertussis. tion, as these bacteria are part of the usual upper respiratory tract flora in many patients. CLINICAL FINDINGS The usual presenting symptoms of bronchitis are EPIDEMIOLOGY cough, frequently accompanied by rhinitis or other cold Enteroviruses such as coxsackieviruses and echovi- symptoms such as pharyngitis and laryngitis. Fever may ruses may cause acute bronchitis during the summer or may not be present. Infection with the three bacteria, months, rhinovirus is present during all seasons, but influenza viruses, and adenoviruses generally cause fever, most other viruses cause bronchitis between early fall while rhinovirus infection usually does not. The patient and spring.iS Influenza generally occurs from late Novem- may or may not give a history of producing sputum, ber through March, and measles bronchitis can be seen which if present can be clear or colored. The presence of during a measles outbreak. RSV may cause bronchitis colored sputum is due to release of peroxidases by neu- (and pneumonia) in elderly adults, 12 as well as in younger trophilic or eosinophilic leukocytes or both and should adults having frequent contact with young children, such not be considered definite evidence of bacterial infec- as pediatric hospital personnel and parents or other care- tion. ~ givers of young children.~9 Alnmst all the viral causes of The initial physical examination may reveal nothing acute bronchitis have relatively brief incubation periods, more than a low-grade fever, rhinitis, and pharyngitis. from 1 day (influenza) to 5-7 days (RSV). Usually the lung examination is normal, although rales M pneumoniae infections occur throughout the year and ronchi may be present in influenza, adenoviral, and with occasional epidemics occurring every 4 to 7 years. 2° C pneumoniae infections, and occasionally with M pneu- C pneumoniae infections appear to have a higher inci- moniae bronchitis. Wheezing may be present, as viruses dence every 4 years. 21 Both Mpneumoniae and C pneumo- and the three bacteria that cause bronchitis are the only niae infections have relatively long incubation periods,
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