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.
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
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