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Saturday, March 7, 2009




· Hyperemia and edema of the mucous membranes

· Production of mucopurulent exudates

· Impairment of the productive function of the cilia, lymphatics, and phagocytes

· Airway obstruction from:

o Edema

o Secretions

o Bronchial muscle spasm


  • Viral infections are the primary cause of bronchitis:
    • Parainfluenza
    • Influenza A and B
    • Respiratory syncytial virus
    • Human meta pneumovirus
    • Echovirus
    • Coronavirus
    • Adenovirus
    • Coxsackievirus
    • Rhinovirus
    • Measles and herpes viruses (can cause severe viral bronchitis)
  • Particularly severe or long-lasting bronchitis:
    • Mycoplasma pneumoniae
    • Chlamydia pneumoniae
    • Bordetella pertussis:
      • Rates of pertussis are increasing, even in the fully immunized population (little protection remains after 10 years).
  • Other bacteria have not been conclusively proven to cause bronchitis except in those with chronic lung disease.


Signs and Symptoms


  • Complaints that may precede upper respiratory tract infection (URTI) symptoms:
    • Malaise
    • Chills
    • Myalgias
    • Coryza
    • Sore throat
  • Onset of URTI symptoms:
    • Mile dyspnea
    • Cough, initially dry and nonproductive
    • Cough, later becomes mucoid or mucopurulent
    • Chest pain or burning related to cough
    • Initial symptoms improve after 3-5 days, with 1-3 weeks of residual cough and malaise

Physical Exam

  • Fever, not usually above 102°F (38.5°C)
  • Tachypnea
  • Mild hemoptysis
  • Wheezing
  • Rales
  • Scattered rhonchi
  • Pulmonary function tests are frequently abnormal

Essential Workup

  • The diagnosis is clinical
  • Pulse oximetry
  • Influenza A and B testing if identification of these organisms is required for treatment or reporting
  • Evaluate for pertussis:
    • Acute cough illness lasting 14 days or more in a person with paroxysmal cough, posttussive vomiting, or inspiratory whoop
    • 14 days or more of cough within an outbreak setting



  • Influenza A and B testing may help immediately confirm clinical suspicion.
  • In most cases, no specific test will help make the diagnosis immediately.
  • Viral or bacterial cultures are rarely helpful.
  • CBC may show leukocytosis, but this is a nonspecific finding.
  • Pertussis may be confirmed using polymerase chain reaction (PCR) testing, but diagnosis will be delayed.


Chest radiograph:

  • No evidence of consolidation
  • Indications:
    • Shortness of breath
    • Hypoxia
    • Chest pain
    • Heart rate >100 beats/minute
    • Respiratory rate 24 breaths/minute
    • Temperature 38 °C
    • Focal findings on chest examination
    • Elderly patient with multiple comorbid conditions
    • Hypoxia
    • 14 days or more of cough

Diagnostic Procedures/Surgery

None specific

Differential Diagnosis

  • Acute and subacute <8>
    • Pneumonia
    • Reactive airway disease
    • Aspiration
    • Acute sinusitis
    • Bacterial tracheitis
    • Occupational exposure
  • Chronic >8 weeks:
    • Asthma
    • Gastroesophageal reflux disease
    • Chronic bronchitis
    • Bronchiectasis
    • ACE inhibitor use
    • Bronchogenic carcinoma
    • Carcinomatosis
    • Sarcoidosis
    • Left ventricular failure
    • Aspiration syndrome
    • Psychogenic/habit

Pediatric Considerations

  • Aggressive initial management of these patients is seldom required.
  • Administer oxygen if the patient is hypoxic.
  • Fluids may be administered if the patient is dehydrated.


Pre Hospital

  • Maintain adequate oxygenation
  • Bronchodilators if wheezing is present

Initial Stabilization

  • Aggressive initial management of these patients is seldom required.
  • Administer oxygen if the patient is hypoxic.
  • Fluids may be administered if the patient is dehydrated.

ED Treatment

  • Bronchitis is usually a viral process; treatment is symptomatic.
  • Cough suppressants may be considered.
  • β-adrenergic inhaler for patients with severe cough or wheezing
  • Amantadine may be used in known outbreaks of influenza A.
  • Oseltamivir (Tamiflu) and zanamivir (Relenza) may be considered in patients with recent onset of influenza.
  • Antibiotics:
    • Generally, antibiotics are not indicated (even when secretions are purulent).
    • Antibiotics do not improve overall illness duration, activity limitation, or work loss in healthy patients with no underlying lung disease.
    • Consider use in those patients who have recurrence of fever after initial improvement.
  • Symptomatic control with antipyretics and analgesics
  • Although patients should be encouraged to stop smoking, the use of tobacco is not an indication for antibiotics unless the patient has a known history of emphysema.

Medication (Drugs)

  • Albuterol: 0.5 mL in a 0.5% solution nebulized q6h
  • Amantadine: 100 mg PO per day, must be given within 48 hours of symptom onset
  • Oseltamivir (Tamiflu) and zanamivir (Relenza) within 48 hours of symptom onset for influenza-related bronchitis:
    • Zanamivir: 10 mg inhalation q12h — 5 days (no pediatric dosing)
    • Oseltamivir: 75 mg PO b.i.d. (peds: 2 mg/kg) — 5 days
  • Erythromycin should be given to proven cases of pertussis and to household contacts of those with proven pertussis.
  • Yearly influenza vaccinations should be encouraged in health care providers and in the high-risk population (elderly, immunocompromised, chronic lung disease).

Pediatric Considerations

  • Use of acetaminophen rather than aspirin for analgesia.
  • Repeated bouts in children should lead to referral for complete evaluation of the respiratory tract.



Admission Criteria

  • Underlying significant cardiopulmonary compromise
  • Significant hypoxia
  • Ill patient with unclear diagnosis

Discharge Criteria

  • No pulmonary compromise should be present.
  • Instruct patients, particularly high-risk patients, to return if no improvement or worsening of symptoms occurs.
  • Bed rest
  • Fluids
  • Aspirin or acetaminophen


1. Aagaard E, Gonzales R. Management of acute bronchitis. Infect Dis Clinic N Am. 2004; 18:919-937.

2. Gonzoles R, Sande MA: Uncomplicated acte bronchitis. Ann Intern Med. 2000;133:981-991.

3. Hirschmann JV: Antibiotics for common respiratory tract infections in adults. Arch Intern Med. 2002; 162:256-264.

4. Linder JA, Sims I: Antibiotic treatment of acute bronchitis in smokers. A systemic review. J Gen Inern Med. 2002;17:230-234.

5. Stephens MM, Nashelsky J: Do inhaled beta-agonists control cough in URIs or acute bronchitis? J Fam Prac. 2004;53:662-663.

6. Ward MA: Emergency department management of acute respiratory tract infections in adults. Sem Resp Infec. 2002:17:65-71.


SEE ALSO: Cough; Shortness of Breath







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