Bronchitis - Uncomplicated Acute (1 of 8) 1 Patient presents w/ symptoms of lower resp tract infection (LRTI) 2 EVALUATION Yes ALTERNATIVE Comorbid condition DIAGNOSIS present or is patient >60 years? No 3 DIAGNOSIS No ALTERNATIVE Uncomplicated acute DIAGNOSIS bronchitis Yes Is No pertussis Yes suspected? A Pharmacological therapy A Pharmacological therapy Symptomatic therapy Oral Antibiotic • Analgesics (non-opioid) & Any one of the following: Antipyretics • Co-trimoxazole • Bronchodilator: Beta2-agonist • Macrolide (inhaled) MIMS • Cough & Cold Preparations B Patient education C Follow-up ©• Not usually necessary Not all products are available or approved for above use in all countries. Specifi c prescribing information may be found in the latest MIMS. B26 © MIMS 2019 Bronchitis - Uncomplicated Acute (2 of 8) 1 BRONCHITIS - UNCOMPLICATED ACUTE Signs & Symptoms of Lower Respiratory Tract Infection: • Cough &/or increase in sputum production • Breathlessness/wheeze • Chest pain/aches • Sweats &/or sore throat • BRONCHITIS - ACUTE Increase in temperature Uncomplicated Acute Bronchitis • A self-limiting acute respiratory tract infection characterized by the sudden onset of cough, w/ or without sputum production, in an otherwise healthy individual - Diagnosis is based on clinical fi ndings Pathogenesis • An infl ammatory response to infections of the bronchial epithelium of the large airways of the lungs - Begins w/ mucosal injury, epithelial cell damage & release of proinfl ammatory mediators - Transient airfl ow obstruction & bronchial hyperresponsiveness • Purulence can result from either bacterial or viral infection Etiology Viral • e most common cause (90% of cases) of bronchial infl ammation in otherwise healthy adults presenting w/ acute bronchitis - Infl uenza A & B, parainfl uenza 3 & respiratory syncytial virus (RSV) produce primarily lower respiratory tract disease - Corona virus, adenovirus & rhinoviruses more commonly produce upper respiratory tract symptoms Non-viral • Mycoplasma pneumoniae, Chlamydia pneumoniae, Bordetella pertussis (5-10% of cases) • Environmental cough triggers (eg dust, dander, toxic fume inhalation) Typical Clinical Presentation Signs & Symptoms • Predominant symptom: Cough that is usually productive that persists <3 weeks - e cough generally lasts 7-10 days but occasionally persists for >1 month - Infl uenza (fl u) virus typically causes a nonproductive cough - If cough has been >3 weeks, consider investigation of other diagnoses (eg tuberculosis in endemic areas) • Sputum may be clear, white, yellow, green or even tinged w/ blood - Green/yellow (purulent) sputum production is indicative of an infl ammatory reaction & it can result from either viral or bacterial infection • Cough may be accompanied by clinical features that suggest an acute respiratory tract infection (eg sore throat, rhinorrhea, hoarseness) • Patient may also present w/ retrosternal chest pain on coughing, dyspnea, wheezing, fever, fatigue or night cough 2 EVALUATION Patients w/ Comorbidity • Comorbid conditions: Chronic obstructiveMIMS pulmonary disease (COPD), cardiovascular diseases, neurological diseases, diabetes mellitus (DM), chronic liver or renal failure, recent viral infection, immunodefi ciency, etc • Evaluation & management must be tailored in light of the patient’s comorbid condition - Eg please see Bronchitis - Chronic in Acute Exacerbation disease management chart if patient has underlying COPD Elderly Patients • Require a more careful evaluation & management - Eg chest X-ray, sputum culture, ECG - Appropriate antibiotic therapy should not be withheld since clinical features are less reliable & pneumococcal infection© is common in these patients Not all products are available or approved for above use in all countries. Specifi c prescribing information may be found in the latest MIMS. B27 © MIMS 2019 Bronchitis - Uncomplicated Acute (3 of 8) 3 DIAGNOSIS History • Perform a complete & detailed medical history including tobacco use & exposure to respiratory infections or toxic inhalants Physical Exam • Wheezing, rhonchi, coarse rales, a prolonged expiratory phase or other obstructive signs may be present - Forced expiration may be done to detect wheezing BRONCHITIS - ACUTE Diagnostic Studies • No available test can provide a defi nitive diagnosis of acute bronchitis • In patients presumed to have acute bronchitis, viral cultures, serologic assays & sputum analyses should not be done routinely because the responsible organism is rarely identifi ed in clinical practice • Gram stain or sputum culture in the healthy adult w/ acute bronchitis is not helpful as most cases are caused by a virus • Transient pulmonary function abnormalities (very similar to those of mild asthma) may occur in acute bronchitis; peak expiratory fl ow rate may be measured in these patients • Chest X-ray is typically unnecessary - Purulent sputum is not an indication for a chest X-ray - Consider performing a chest X-ray if vital signs show a heart rate of >100 beats/minute, respiratory rate of >24 breaths/minute, & an oral temperature of >100.4°F (>38°C), & if focal pulmonary consolidation is present on exam Diff erential Diagnoses Pertussis • An uncommon cause of uncomplicated acute bronchitis • May be present in up to 10-20% of adults w/ cough lasting >2-3 weeks - Adults immunized as children but no longer having eff ective immunity may be a reservoir of B pertussis - No classic features of pertussis in adults (as there are in children) but generally presents as severe bronchitis • Pertussis may be considered in children suff ering from severe spasmodic coughing, especially if terminated by vomiting or associated w/ redness of the face & catching of the breath - e incidence of pertussis in children has decreased due to widespread pertussis vaccination • Physicians should limit suspicion & treatment of adult pertussis to patients w/ a high probability of exposure (during outbreak in the community or if there is history of contact w/ a patient who has a known case) • If pertussis is suspected, a diagnostic test should be performed & antimicrobial therapy initiated - Diagnosis may be diffi cult to establish because of delay in suspicion of disease (cultures of nasopharyngeal secretions are usually negative after 2 weeks & reliable serologic tests may not be available) - Polymerase chain reaction (PCR) of nasopharyngeal swabs or aspirates improves detection Asthma • Should be considered in patients w/ repetitive episodes of acute bronchitis - Full spirometric testing w/ bronchodilatation or provocative testing w/ a Methacholine challenge test can be given to help diff erentiate asthma from recurrent bronchitis • Acute bronchitis may cause transient pulmonary abnormalities & the diagnosis of asthma should be considered if abnormalities in pulmonary function persist after the acute phase of the illness • Please see Asthma disease management chart for further information Infl uenza (Flu) • Flu viruses are the most common pathogens found in patients w/ uncomplicated acute bronchitis • During times of outbreak, diagnosis by clinical presentation is as accurate as rapid diagnostic tests - Patient may benefi t from anti-infl uenzaMIMS agents if treated within 48 hours of symptom onset • Please see Infl uenza disease management chart for further information Pneumonia • Potentially the most serious cause of acute cough illness & should be ruled out • In healthy non-elderly adults, the absence of vital sign abnormalities (eg heart rate ≥100 beats/minute, respi- ratory rate >24 breaths/minute, oral temperature ≥38°C & signs of focal consolidation on chest exam) suffi ciently reduces the likelihood of pneumonia to eliminate the need for a chest X-ray • Please see Pneumonia - Community-Acquired disease management chart for further information Upper Respiratory Tract Infection (URTI) • In these settings, cough is not a predominant symptom (eg common cold) Non-pulmonary Causes • Chronic heart© failure (CHF) in elderly patients, gastroesophageal refl ux disease (GERD) & bronchogenic tumor • Please see Heart Failure - Chronic & Gastroesophageal Refl ux Disease disease management charts for further information Not all products are available or approved for above use in all countries. Specifi c prescribing information may be found in the latest MIMS. B28 © MIMS 2019 Bronchitis - Uncomplicated Acute (4 of 8) A PHARMACOLOGICAL THERAPY • Routine use of antibiotics is highly discouraged & should only be considered in patients w/ bacterial infection or pneumonia; consider local resistance patterns when planning use of antibiotics Symptomatic erapy Choice of therapy depends on which symptoms are most bothersome to the patient Analgesics (Non-Opioid) & Antipyretics • Eg Paracetamol, Ibuprofen BRONCHITIS - ACUTE • Benefi cial when infl uenza symptoms eg malaise & fever are prominent • Avoid salicylates in children ≤18 years of age because of the risk of Reye Syndrome Bronchodilators: Beta₂-Agonists • Eg Salbutamol • May be used to reduce the duration & severity of cough in some patients, but routine use for cough palliation is not recommended • Use should be individualized to those who are most likely to benefi t - Justifi ed in patients w/ clinical evidence of airfl ow obstruction or bronchial hyperresponsiveness (eg wheezing or bothersome cough) • Studies have shown that more patients report decrease in cough after 7 days of inhaled bronchodilator as compared to placebo or antibiotic Cough & Cold Preparations • Codeine or Dextromethorphan - May be justifi ed for a nonproductive irritating cough,