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Diagnosis and Treatment of Acute Bronchitis ROSS H Diagnosis and Treatment of Acute Bronchitis ROSS H. ALBERT, MD, PhD, Hartford Hospital, Hartford, Connecticut Cough is the most common symptom bringing patients to the primary care physician’s office, and acute bronchitis is usually the diagnosis in these patients. Acute bronchitis should be differentiated from other common diagnoses, such as pneumonia and asthma, because these conditions may need specific therapies not indicated for bronchitis. Symp- toms of bronchitis typically last about three weeks. The presence or absence of colored (e.g., green) sputum does not reliably differentiate between bacterial and viral lower respiratory tract infections. Viruses are responsible for more than 90 percent of acute bronchitis infections. Antibiotics are gener- ally not indicated for bronchitis, and should be used only if pertussis is suspected to reduce transmission or if the patient is at increased risk of developing pneumonia (e.g., patients 65 years or older). The typical therapies for managing acute bronchitis symptoms have been shown to be ineffective, and the U.S. Food and Drug Admin- istration recommends against using cough and cold preparations in children younger than six years. The supplement pelargonium may help reduce symptom severity in adults. As patient expectations for antibiotics and therapies for symptom management differ from evi- dence-based recommendations, effective communication strategies are necessary to provide the safest therapies available while main- taining patient satisfaction. (Am Fam Physician. 2010;82(11):1345- 1350. Copyright © 2010 American Academy of Family Physicians.) ILLUSTRATION JOAN BY BECK ▲ Patient information: ough is the most common symp- lasts only seven to 10 days. Symptoms of A handout on treatment tom for which patients present acute bronchitis typically persist for approx- of bronchitis, written by 3 the author of this article, is to their primary care physicians, imately three weeks. provided on page 1353. and acute bronchitis is the most Pneumonia can usually be ruled out in C common diagnosis in these patients.1 How- patients without fever, tachypnea, tachycar- ever, studies show that most patients with dia, or clinical lung findings suggestive of acute bronchitis are treated with inappropri- pneumonia on examination.4 However, cough ate or ineffective therapies.2 Although some may be the only initial presenting symptom physicians cite patient expectations and time of pneumonia in older adults; a lower thresh- constraints for using these therapies, recent old for using chest radiography should be warnings from the U.S. Food and Drug maintained in these patients. The presence or Administration (FDA) about the dangers of absence of colored (e.g., green) sputum does certain commonly used agents underscore not reliably differentiate between bacterial the importance of using only evidence- and viral lower respiratory tract infections.3 based, effective therapies for bronchitis. The causative pathogen for bronchitis is rarely identified (Table 25). In clinical stud- Diagnosis ies, identification of the causative patho- Acute bronchitis is a self-limited infection gen occurs in less than 30 percent of cases.6 with cough as the primary symptom. This Approximately 90 percent of acute bronchi- infection can be difficult to distinguish from tis infections are caused by viruses.7 Because other illnesses that commonly cause cough the yield of viral cultures is typically low and (Table 1). results rarely affect clinical planning, rou- The common cold often causes coughing; tine serologic testing is not recommended however, nasal congestion and rhinorrhea for bronchitis. Testing may be considered are also usually present, and a cold typically for influenza when risk is thought to be Downloaded from the American Family Physician Web site at www.aafp.org/afp. Copyright © 2010 American Academy of Family Physicians. For the private, noncommercial December 1,use 2010 of one ◆ individualVolume user82, ofNumber the Web 11site. All other rights reserved.www.aafp.org/afp Contact [email protected] for copyright questionsAmerican and/or Familypermission Physician requests. 1345 Acute Bronchitis SORT: KEY RECOMMENDATIONS FOR PRACTICE Evidence Clinical recommendation rating References Antibiotics should not be used routinely for the treatment B 10, 12, 13 of acute bronchitis The following therapies may be considered to manage bronchitis-related symptoms: Antitussives (dextromethorphan, codeine, hydrocodone) C 12, 19 in patients six years and older Beta-agonist inhalers in patients with wheezing B 23 High-dose episodic inhaled corticosteroids B 24 Echinacea B 25 Pelargonium B 26-28 Dark honey in children B 28 The following medicines should not be used to manage bronchitis-related symptoms: Expectorants B 22 Beta-agonist inhalers in patients without wheezing B 23 Antitussives in children younger than six years C 20, 21 A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evi- dence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.xml. intermediate and the patient presents within bronchitis may also be considered in select 36 hours of symptom onset. During peak clinical scenarios. Mycoplasma pneumonia influenza season, testing is generally not and Chlamydia pneumonia are bacterial eti- helpful because the pretest probability of ologies that can affect young adults. How- influenza is high. Conversely, the positive ever, trials showing that treatment shortens predictive value is too low to be helpful out- the course of these infections, even when side of influenza season. initiated early, are lacking. Bordetella pertus- Diagnostic testing during outbreaks of sis, the causative agent in pertussis, can also Table 1. Most Common Differential Table 2. Most Common Infectious Diagnosis of Acute Cough Etiologies of Acute Bronchitis Acute bronchitis Viral Allergic rhinitis Adenovirus Asthma Coronavirus Chronic obstructive pulmonary disease Influenza A and B exacerbation Metapneumovirus Common cold Parainfluenza virus Congestive heart failure exacerbation Respiratory syncytial virus Gastroesophageal reflux disease Rhinovirus Malignancy Bacterial Pneumonia Bordetella pertussis Postinfectious cough Chlamydia pneumonia Postnasal drip Mycoplasma pneumonia Sinusitis Viral syndrome Information from reference 5. 1346 American Family Physician www.aafp.org/afp Volume 82, Number 11 ◆ December 1, 2010 Acute Bronchitis lead to acute bronchitis. Testing for pertus- bronchitis showed reduction of cough at sis should be considered in patients who are follow-up (number needed to treat = 5.6) but unvaccinated; patients with a cough that is no change in patients’ activity limitations. paroxysmal, has a “whooping” sound, or has The meta-analysis also showed a number lasted longer than three weeks; and patients needed to harm (based on antibiotic adverse who have been exposed to pertussis or effects) of 16.7.13 In a study of unvaccinated persons. 230 patients diagnosed with acute bronchitis (i.e., presence The duration of office Treatment of cough for two to 14 days) visits for acute respiratory Treatment of acute bronchitis is typically who received azithromycin infection is unchanged or divided into two categories: antibiotic ther- (Zithromax) or a low-dose of only one minute longer apy and symptom management. Physicians vitamin C, more than one half when antibiotics are not appear to deviate from evidence-based med- of patients had fever or puru- prescribed. ical practice in the treatment of bronchitis lent sputum, although none more than in the diagnosis of the condition. had chest findings. Outcomes at days 3 and 7 were no different between ANTIBIOTICS the two groups, and 89 percent of patients in Because of the risk of antibiotic resistance both groups had clinical improvement.14 and of Clostridium difficile infection in the Although antibiotics are not recommended community, antibiotics should not be rou- for routine use in patients with bronchitis, tinely used in the treatment of acute bron- they may be considered in certain situations. chitis, especially in younger patients in When pertussis is suspected as the etiology whom pertussis is not suspected. Although of cough, initiation of a macrolide antibi- 90 percent of bronchitis infections are otic is recommended as soon as possible to caused by viruses, approximately two thirds reduce transmission; however, antibiotics do of patients in the United States diagnosed not reduce duration of symptoms. Antiviral with the disease are treated with antibiotics.8 medications for influenza infection may be Patient expectations may lead to antibiotic considered during influenza season for high- prescribing. A survey showed that 55 per- risk patients who present within 36 hours of cent of patients believed that antibiotics were symptom onset. An argument for the use of effective for the treatment of viral upper antibiotics in acute bronchitis is that it may respiratory tract infections, and that nearly decrease the risk of subsequent pneumo- 25 percent of patients had self-treated an nia. In one large study, the number needed upper respiratory tract illness in the pre- to treat to prevent one case of pneumonia vious year with antibiotics left over from in the month following an episode of acute earlier infections.9 Studies have shown that bronchitis was 119 in patients 16 to 64 years the duration of
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