Bronchitis

Bronchitis

Description

· 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

Etiology

• 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.

Diagnosis

Signs and Symptoms

History

• 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

Tests

Lab

• 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.

Imaging

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.

Treatment

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.

Follow-Up

Disposition

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

References

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.

Miscellaneous

SEE ALSO: Cough; Shortness of Breath

Codes

ICD9-CM

466

490

ICD10

J40