Bronchitis

Background: Bronchitis is an inflammation of the bronchial tubes (bronchi), which are the air passages that extend from the trachea into the small airways and the alveoli. Viruses, bacteria, mycoplasmas, parasites, smoking, or inhalation of chemical pollutants or dust may cause inflammation. Chronic bronchitis is a condition associated with excessive tracheobronchial mucus production sufficient to cause cough with expectoration for at least 3 months during a period of 2 consecutive years. Chronic bronchitis is associated with hypertrophy of the mucus-producing glands found in the mucosa of large cartilaginous airways. 

Although acute bronchitis should not be treated with antimicrobials, it is frequently difficult to refrain from prescribing them. Accurate testing and decision-making protocols as to who would and would not benefit from antimicrobial therapy would be very useful but are not currently available.

Pathophysiology: During an episode of acute bronchitis, the cells of the bronchial-lining tissue are irritated and the mucous membrane is hyperemic and edematous, diminishing the bronchial mucociliary function. Consequently, the air passages become clogged by debris, and irritation increases. In response, a copious secretion of mucus develops, which causes the characteristic cough of bronchitis. For instance, with mycoplasmal pneumonia, bronchial irritation results from the attachment of the organism (Mycoplasma pneumoniae) to the respiratory mucosa, with eventual sloughing of affected cells. Acute bronchitis usually lasts about 10 days. If the inflammation extends downward to the ends of the bronchial tree, into the small bronchi (bronchioles), and then into the air sacs, bronchopneumonia results.

Chronic bronchitis is a condition associated with excessive tracheobronchial mucus production sufficient to cause cough with expectoration for at least 3 months of the year for more than 2 consecutive years. The alveolar epithelium is both the target and the initiator of inflammation in chronic bronchitis.

Predominance of neutrophils and peribronchial distribution of fibrotic changes result from the action of interleukin 8 (IL-8), colony-stimulating factors, and other chemotactic and proinflammatory cytokines. Airway epithelial cells release these inflammatory mediators in response to toxic, infectious, and inflammatory stimuli, in addition to decreased release of regulatory products such as ACE or neutral endopeptidase.

Chronic bronchitis can be categorized as simple chronic bronchitis, chronic mucopurulent bronchitis, or chronic bronchitis with obstruction. Mucoid sputum production characterizes simple chronic bronchitis. Persistent or recurrent purulent sputum production in the absence of localized suppurative disease, such as bronchiectasis, characterizes chronic mucopurulent bronchitis. Chronic bronchitis with obstruction must be distinguished from chronic infective asthma. The differentiation is based mainly on the history of the clinical illness. Patients who have chronic bronchitis with obstruction present with a long history of productive cough and late onset of wheezing, whereas patients who have asthma with chronic obstruction have a long history of wheezing with late onset of productive cough.

Chronic bronchitis may result from a series of attacks of acute bronchitis, or it may gradually evolve because of heavy smoking or inhalation of air contaminated with other pollutants in the environment. When so-called smoker's cough is continual rather than occasional, the mucus-producing layer of the bronchial lining has probably thickened, narrowing the airways to the point where breathing becomes increasingly difficult. With immobilization of the cilia that sweep the air clean of foreign irritants, the bronchial passages become more vulnerable to further infection and the spread of tissue damage.

Frequency:

• In the US: Approximately 8 million people have chronic bronchitis, and 2 million have emphysema. According to the National Center for Health Statistics, more than 12 million cases of acute bronchitis occurred in 1994, a number roughly equal to 5% of the US population. By way of comparison, 91 million cases of influenza, 66 million cases of the common cold, and 31 million cases of other acute upper respiratory tract infections occurred during that same year.

• Internationally: Acute bronchitis is common throughout the world and is one of the top 5 reasons for physician visits in countries that track such data.

Mortality/Morbidity: Bronchitis is almost always self-limited in individuals who are otherwise healthy, although it may result in absenteeism from work and school. Severe cases occasionally produce deterioration in patients with significant underlying cardiopulmonary disease or other comorbidities.

Race: No difference in racial distribution exists; however, bronchitis occurs more frequently in populations with a low socioeconomic status and in people who live in urban and highly industrialized areas.

Sex: Bronchitis affects males more than females.

Age:

• In the United States, two thirds of adult males and one fourth of females have emphysema at death.

• Although found in all age groups, acute bronchitis is most frequently diagnosed in children younger than 5 years. In 1994, more than 11 of every 100 children younger than 5 years were diagnosed with bronchitis. This compared with only 4 of every 100 individuals in all other age groups.

CLINICAL

History: Obtain a complete history, including information on exposure to toxic substances and smoking. Patients with chronic bronchitis are often overweight and cyanotic. Initially, cough is present in the winter months. Over the years, the cough progresses from hibernal to perennial, and mucopurulent relapses increase in frequency, the duration and severity of which increase to the point of exertional dyspnea. Symptoms of acute bronchitis include the following:

• Fever

• Cough and sputum production

• Cough begins early in the course of many acute respiratory infections and tends to become more prominent as the disease progresses.

• In one prospective study of acute respiratory disease, 45% of patients were coughing 2 weeks after presentation, and 25% were coughing after 3 weeks. Sputum production was reported in approximately half of the patients in whom cough occurred.

• An initially dry cough may later induce production of mucoid sputum, which characteristically develops a more purulent character in the later stages of illness.

• Sore throat

• Runny or stuffy nose

• Headache

• Muscle aches

• Extreme fatigue

• Nausea, vomiting, and diarrhea are rare. Severe cases may cause general malaise and chest pain. With severe tracheal involvement, burning, substernal chest pain associated with respiration, and coughing may occur.

• Dyspnea and cyanosis are not observed in adults unless the patient has underlying COPD or another condition that impairs lung function.

Physical: Patients may be afebrile or have a low-grade fever. The rest of the physical examination findings in acute bronchitis can vary from normal to pharyngeal erythema, localized lymphadenopathy, and rhinorrhea to coarse rhonchi and wheezes that change in location and intensity after a deep and productive cough. Diffuse wheezes, high-pitched continuous sounds, and the use of accessory muscles can be observed in severe cases. Occasionally, diffuse diminution of air intake or inspiratory stridor occurs; these findings indicate obstruction of a major bronchi or the trachea, which requires sequentially vigorous coughing, suctioning, and, possibly, intubation or even tracheostomy.

• Sustained heave along the left sternal border indicates right ventricular hypertrophy secondary to chronic bronchitis.

• Clubbing on the digits and peripheral cyanosis indicate cystic fibrosis.

• Bullous myringitis may suggest mycoplasmal pneumonia.

• Conjunctivitis, adenopathy, and rhinorrhea suggest adenovirus infection.

Causes: Acute bronchitis is usually caused by infections, such as those caused by Mycoplasma species, Chlamydia pneumoniae, Streptococcus pneumoniae, Moraxella catarrhalis, and Haemophilus influenzae and by viral infection, such as those caused by influenza, parainfluenza, adenovirus, rhinovirus, and respiratory syncytial virus. Exposure to irritants, such as pollution, chemicals, and cigarette smoke, may also cause acute bronchial irritation.

• Cigarette smoking is indisputably the predominant cause of chronic bronchitis. Recent studies indicate that smoking marijuana causes similar damage.

• Smoking impairs ciliary movement, inhibits function of alveolar macrophages, and leads to hypertrophy and hyperplasia of mucus-secreting glands.

• Smoking can also increase airway resistance via vagally mediated smooth muscle constriction.

• Unless some other factor can be isolated as the irritant that produces the symptoms, the first step in dealing with chronic bronchitis is to stop smoking.

• Air pollution levels have been associated with increased respiratory health problems among people living in affected areas. The Air Pollution and Respiratory Health Branch of the National Center for Environmental Health directs the fight of the Centers for Disease Control and Prevention (CDC) against respiratory illness associated with air pollution.

• In 1990, American industry emitted more than $2.4 billion of toxic pollutants into the atmosphere.

• In 1991, 98 areas exceeded the Environmental Protection Agency's recommended levels for ozone, and an estimated 140 million Americans lived in those areas. Also in 1991, 76 areas exceeded recommended levels for carbon monoxide, 70 exceeded recommended levels for particulate matter, and 50 exceeded recommended levels for sulfur dioxide.

• According to the Healthy People 2000 report, each year in the United States, the following occur:
  • "The health costs of human exposure to outdoor air pollutants range from $40 to $50 billion."

  • "An estimated 50,000 to 120,000 premature deaths are associated with exposure to air pollutants."

  • "People with asthma experience more than 100 million days of restricted activity, costs for asthma exceed $4 billion, and about 4,000 people die of asthma."

DIFFERENTIALS

Adenoviruses
Allergic and Environmental Asthma
Aspiration Pneumonia
Asthma
Bronchiectasis
Chlamydia Pneumonia
Chronic Bronchitis
Chronic Obstructive Pulmonary Disease
Pneumonia, Bacterial
Pneumonia, Community-Acquired
Pneumonia, Viral
Sinusitis, Acute
Other Problems to be Considered:

• Exercise-induced asthma
  
  
• Bacterial tracheitis
  
  
• Cough
  
  
• Cystic fibrosis
  
  
• Influenza
  
  
• Hyperreactive airway disease
  
  
• Retained foreign body
  
  
• Pediatric considerations
  
  
  • Bronchiolitis
    
    
  • Croup
    
    
  • Laryngotracheobronchitis and pertussis
  
  
• Streptococcal pharyngitis
  
  
  • This condition is most commonly caused by group A streptococcus (45%) and anaerobes (18%) (often occurring as a co-infection). Penicillin is the drug of choice, as opposed to broad-spectrum antimicrobials such as amoxicillin/clavulanic acid, quinolones, or macrolides. If the patient is allergic to penicillin, clindamycin is a good alternative.
    
    
  • The rapid group A streptococcal antigen tests offer a quick answer but lack the specificity and sensitivity of culture. Much of the concern about diagnosing streptococcal pharyngitis is related to the complications of infection, particularly acute rheumatic fever and poststreptococcal glomerulonephritis as a late complication. Therefore, maintaining a high level of suspicion for streptococcus group A in the presence of pharyngitis is advisable.

WORKUP

Lab Studies:

• Bronchitis may be suspected in patients with an acute respiratory infection with cough. However, because many more serious diseases of the lower respiratory tract cause cough, bronchitis must be considered a diagnosis of exclusion.

• Obtain cultures of respiratory secretions for influenza virus, M pneumoniae, and Bordetella pertussis when these organisms are suspected. Culture methods and immunofluorescence tests have been developed for laboratory diagnosis of C pneumoniae.

• Obtain a throat swab.

• Obtain a CBC count with differential.

• Sputum cytology may be helpful if the cough is persistent.

• Blood culture may sometimes be helpful if bacterial superinfection is suspected.

Imaging Studies:

• Order chest radiographs.

• Perform bronchoscopy to exclude foreign body aspiration, tuberculosis, tumors, and other chronic diseases of the tracheobronchial tree and lungs.

Other Tests:

• Influenza tests may be useful. Additional serologic tests, such as for atypical pneumonia, are not indicated.

Procedures:

• Laryngoscopy can exclude epiglottitis.

TREATMENT

Medical Care: Therapy is generally aimed toward alleviation of symptoms.

• To alleviate symptoms, a doctor may prescribe a combination of medications that both open up obstructed bronchial airways and thin obstructive mucus so that it can be coughed up more easily.

• Antitussive medications and antipyretic medications may be used to treat bronchitis.

• A steam vaporizer near the bed can also be helpful in easing chest congestion at night.

• Among otherwise healthy individuals, antibiotics have not demonstrated any consistent benefit in the symptomatology or natural history of acute bronchitis. Antibiotics are recommended to patients with bronchiectasis or COPD exacerbation or if purulent sputum production has lasted beyond 7 days without evidence of improvement to other conventional therapy.

• Care for acute bronchitis is primarily supportive and should ensure that the patient is oxygenating adequately.

Consultations: Primary care physicians can usually treat acute bronchitis unless severe complications occur or the patient has underlying pulmonary disease or immunodeficiency.

• Primary care physicians

• Pulmonary medicine specialists

• Infectious disease specialists

Diet:

• The value of a diet of fruits, vegetables, and salads is debatable.

• The value of antioxidants is not proven.

Activity: Bed rest is recommended.

MEDICATION

Therapy for acute bronchitis is generally aimed toward alleviation of symptoms and includes the use of analgesics, antipyretics, antitussives, and expectorants.

Among otherwise healthy individuals, antibiotics have not demonstrated any consistent benefit in the symptomatology or natural history of acute bronchitis. Nonetheless, surveys from Europe, Australia, and the United States indicate that 80% of patients with acute bronchitis receive antibiotics. Antibiotic overuse contributes to the emergence of drug-resistant organisms.

Several studies have shown conflicting results on the use of zinc as an adjunct treatment against influenza A. Most recent studies demonstrated favorable results; however, participants complained of a bad taste and significant nausea.

Drug Category: Antibiotics -- Studies have focused on healthy individuals (asthmatic patients excluded) or patients with COPD. A small beneficial effect of antibiotics in treating patients with COPD appears to exist, and TMP/SMX remains a good and inexpensive choice. Therefore, it may be reasonable to extend antibiotic use to asthmatic patients and others with limited cardiopulmonary reserve. If an antibiotic is to be used, a macrolide is a reasonable first choice because it is active against mycoplasmal and chlamydial organisms and B pertussis.

Drug Name	Erythromycin (E.E.S., E-Mycin, Ery-Tab) -- Inhibits bacterial growth, possibly by blocking dissociation of peptidyl t-RNA from ribosomes, causing RNA-dependent protein synthesis to arrest. For treatment of staphylococcal, streptococcal, chlamydial, and mycoplasmal infections.
Adult Dose	250-500 mg PO qid or 333 mg PO tid
Pediatric Dose	30-50 mg/kg/d PO divided qid
Contraindications	Documented hypersensitivity, hepatic impairment
Interactions	Coadministration may increase toxicity of theophylline, digoxin, carbamazepine, and cyclosporine; may potentiate anticoagulant effects of warfarin; coadministration with lovastatin and simvastatin increases risk of rhabdomyolysis
Pregnancy	B - Usually safe but benefits must outweigh the risks.
Precautions	Caution in liver disease; estolate formulation may cause cholestatic jaundice; adverse GI effects are common (administer doses pc); discontinue use if nausea, vomiting, malaise, abdominal colic, or fever occur

Drug Name	Clarithromycin (Biaxin) -- Reversibly binds to the P site of the 50S ribosomal subunit of susceptible organisms and may inhibit RNA-dependent protein synthesis by stimulating the dissociation of peptidyl t-RNA from ribosomes. Results in bacterial growth inhibition.
Adult Dose	250-500 mg PO bid
Pediatric Dose	7.5 mg/kg PO bid
Contraindications	Documented hypersensitivity, coadministration of pimozide
Interactions	Toxicity increases with coadministration of fluconazole and pimozide; effects decrease and adverse GI effects may increase with coadministration of rifabutin or rifampin; may increase toxicity of anticoagulants, cyclosporine, tacrolimus, omeprazole, carbamazepine, ergot alkaloids, triazolam, and HMG CoA-reductase inhibitors; cardiac arrhythmias may occur with coadministration of cisapride; plasma levels of certain benzodiazepines may increase, prolonging CNS depression; arrhythmias and increase in QTc intervals occur with disopyramide; coadministration with omeprazole may increase plasma levels of both agents; serum digoxin concentrations may increase (antibiotic reduces gut flora that metabolize digoxin in >10% of patients)
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	Coadministration with ranitidine or bismuth citrate is not recommended with CrCl <25 mL/min; administer half dose or increase dosing interval if CrCl <30 mL/min; diarrhea may be a sign of pseudomembranous colitis; superinfections may occur with prolonged or repeated antibiotic therapies

Drug Name	Azithromycin (Zithromax) -- Treats mild-to-moderate microbial infections.
Adult Dose	Day 1: 500 mg PO Days 2-5: 250 mg PO qd
Pediatric Dose	12 mg/kg PO qd; not to exceed 500 mg/dose
Contraindications	Documented hypersensitivity; hepatic impairment; do not administer with pimozide
Interactions	May increase toxicity of theophylline, warfarin, and digoxin; effects are reduced with coadministration of aluminum and/or magnesium antacids; nephrotoxicity and neurotoxicity may occur when coadministered with cyclosporine
Pregnancy	B - Usually safe but benefits must outweigh the risks.
Precautions	Site reactions can occur with IV route; bacterial or fungal overgrowth may result with prolonged antibiotic use; may increase hepatic enzymes and cholestatic jaundice; caution in impaired hepatic function, prolonged QT intervals, or pneumonia; caution in patients who are hospitalized, geriatric, or debilitated

Drug Name	Tetracycline (Sumycin) or Doxycycline (Bio-Tab, Doryx, Vibramycin) -- Tetracycline: May be an option outside the United States. Treats gram-positive and gram-negative organisms as well as mycoplasmal, chlamydial, and rickettsial infections. Inhibits bacterial protein synthesis by binding with 30S and, possibly, 50S ribosomal subunit(s). Less effective than erythromycin. Doxycycline: Provides coverage for mycoplasmal and chlamydial organisms but not active against B pertussis. Inhibits protein synthesis and bacterial growth by binding with 30S and, possibly, 50S ribosomal subunits of susceptible bacteria.
Adult Dose	Tetracycline: 250-500 mg PO qid Doxycycline: 100 mg PO bid on day 1, then 100 mg PO qd for 7-10 d
Pediatric Dose	Tetracycline: <8 years: Not recommended >8 years: 25-50 mg/kg/d (10-20 mg/lb) PO qid Doxycycline: <8 years: Not recommended >8 years: 2-5 mg/kg/d PO in 1-2 divided doses; not to exceed 200 mg/d
Contraindications	Documented hypersensitivity, severe hepatic dysfunction
Interactions	Bioavailability decreases with antacids containing aluminum, calcium, magnesium, iron, or bismuth subsalicylate; can decrease effects of oral contraceptives, causing breakthrough bleeding and increased risk of pregnancy; tetracyclines can increase hypoprothrombinemic effects of anticoagulants
Pregnancy	D - Unsafe in pregnancy
Precautions	Photosensitivity may occur with prolonged exposure to sunlight or tanning equipment; reduce dose in renal impairment; consider drug serum level determinations in prolonged therapy; tetracycline use during tooth development (last half of pregnancy through age 8 y) can cause permanent discoloration of teeth; Fanconilike syndrome may occur with outdated tetracyclines

Drug Name	Cefditoren (Spectracef) -- Semisynthetic cephalosporin administered as prodrug. Hydrolyzed by esterases during absorption and distributed in circulating blood as active cefditoren. Bactericidal activity results from inhibition of cell wall synthesis via affinity for penicillin-binding proteins. No dose adjustment necessary for mild renal impairment (CrCl 50-80 mgL/min/1.73 m2) or mild-to-moderate hepatic impairment. Indicated for the treatment of acute exacerbation of chronic bronchitis caused by susceptible strains of Streptococcus pyogenes. The 400-mg dose is indicated for the treatment of AECB caused by susceptible strains of H influenzae, Haemophilus parainfluenzae, S pneumoniae (penicillin-susceptible strains only), or M catarrhalis.
Adult Dose	200 mg PO with meals bid for 10 d Moderate renal impairment (CrCl 30-49 mL/min/1.73 m2: No more than 200 mg PO bid Severe renal impairment (CrCl <30 mL/min/1.73 m2): 200 mg PO qd
Pediatric Dose	<12 years: Not established >12 years: Administer as in adults
Contraindications	Documented hypersensitivity to drug, penicillin, related compounds, or milk protein sodium caseinate; carnitine deficiency or inborn errors of metabolism that may result in clinically significant carnitine deficiency
Interactions	Absorption reduced with H2 receptor antagonists and antacids of magnesium and aluminum hydroxides may reduce absorption; probenecid may increase plasma concentrations of cefditoren
Pregnancy	B - Usually safe but benefits must outweigh the risks.
Precautions	May cause diarrhea, nausea, and vaginal moniliasis (yeast infection); pseudomembranous colitis may occur; clinical manifestations of carnitine deficiency may occur with prolonged use; prolonged use may result in emergence and overgrowth of resistant organisms; caution in breastfeeding

Drug Name	Trimethoprim and sulfamethoxazole (Bactrim DS, Septra) -- Inhibits bacterial synthesis of dihydrofolic acid by competing with para-aminobenzoic acid, resulting in inhibition of bacterial growth. Antibacterial activity of TMP-SMZ includes common urinary tract pathogens, except Pseudomonas aeruginosa. As with tetracycline, it has in vitro activity against B pertussis. Not useful in mycoplasmal infections.
Adult Dose	160 mg TMP/800 mg SMZ PO q12h for 10-14 d
Pediatric Dose	<2 months: Do not administer >2 months: 15-20 mg/kg/d, based on TMP, PO tid/qid for 14 d
Contraindications	Documented hypersensitivity, megaloblastic anemia due to folate deficiency, and in late pregnancy
Interactions	May increase PT when used with warfarin (perform coagulation tests and adjust dose accordingly); coadministration with dapsone may increase blood levels of both drugs; coadministration of diuretics increases incidence of thrombocytopenia purpura in elderly patients; phenytoin levels may increase with coadministration; may potentiate effects of methotrexate in bone marrow depression; hypoglycemic response to sulfonylureas may increase with coadministration; may increase levels of zidovudine
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	Avoid in infants because of the possibility of kernicterus; discontinue at first appearance of skin rash or sign of adverse reaction; obtain CBC counts frequently; discontinue therapy if significant hematologic changes occur; goiter, diuresis, and hypoglycemia may occur with sulfonamides; prolonged IV infusions or high doses may cause bone marrow depression (if signs occur, administer 5-15 mg/d leucovorin); caution in folate deficiency (eg, patients with chronic alcoholism, elderly patients, patients receiving anticonvulsant therapy, patients with malabsorption syndrome); hemolysis may occur in individuals who are G-6-PD deficient; patients with AIDS may not tolerate or respond to TMP-SMZ; caution in renal or hepatic impairment (perform urinalyses and renal function tests during therapy); administer fluids to prevent crystalluria and stone formation

Drug Name	Amoxicillin (Biomox, Trimox, Amoxil) -- Interferes with synthesis of cell wall mucopeptides during active multiplication, resulting in bactericidal activity against susceptible bacteria
Adult Dose	250-500 mg PO q8h; not to exceed 3 g/d
Pediatric Dose	20-50 mg/kg/d PO divided q8h
Contraindications	Documented hypersensitivity
Interactions	Reduces the efficacy of oral contraceptives
Pregnancy	B - Usually safe but benefits must outweigh the risks.
Precautions	Adjust dose in renal impairment; may enhance chance of candidiasis.

Drug Name	Ciprofloxacin (Cipro) -- Has a bacteriocidal property by inhibiting the DNA gyrase and consequently cell growth.
Adult Dose	250-500 mg PO bid for 7-14 d
Pediatric Dose	<18 years: Not recommended > 18 years: Administer as in adults
Contraindications	Documented hypersensitivity
Interactions	Antacids, iron salts, and zinc salts may reduce serum levels; administer antacids 2-4 h before or after taking fluoroquinolones; cimetidine may interfere with metabolism of fluoroquinolones; ciprofloxacin reduces therapeutic effects of phenytoin; probenecid may increase ciprofloxacin serum concentrations; may increase toxicity of theophylline, caffeine, cyclosporine, and digoxin (monitor digoxin levels); may increase effects of anticoagulants (monitor PT)
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	In prolonged therapy, perform periodic evaluations of organ system functions (eg, renal, hepatic, hematopoietic); adjust dose in renal function impairment; superinfections may occur with prolonged or repeated antibiotic therapy

Drug Category: Antitussives/expectorants -- Sparse data attest to the efficacy of expectorants outside the test tube.

Drug Name	Guaifenesin with dextromethorphan (Humibid DM, Robitussin DM) -- Treats minor cough resulting from bronchial and throat irritation.
Adult Dose	10 mL PO q4h; not to exceed 40 mL/24h
Pediatric Dose	<2 years: Not recommended 2-6 years: 2.5 mL PO q4h 6-12 years: 5 mL PO q4h
Contraindications	Documented hypersensitivity
Interactions	None reported
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	Not to be used to treat productive cough or persistent chronic cough resulting from emphysema

Drug Name	Guaifenesin and codeine (Robitussin AC) -- The prototype antitussive, codeine, has been used successfully in some chronic cough and induced-cough models, but little clinical data in upper respiratory tract infections exist.
Adult Dose	5-10 mL PO q4-8h; not to exceed 60 mL/d
Pediatric Dose	1-1.5 mg/kg of codeine/d PO divided qid
Contraindications	Documented hypersensitivity
Interactions	Increases toxicity of CNS depressants
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	Not to be administered for productive cough or persistent chronic cough from emphysema; caution in renal impairment

Drug Category: Bronchodilators -- Studies (although limited) have shown an advantage to using bronchodilators and possible superiority to antibiotics for relieving bronchitis symptoms.

Drug Name	Albuterol (Proventil, Ventolin) -- Relaxes bronchial smooth muscle by action on beta2 receptors with little effect on cardiac muscle contractility.
Adult Dose	2-4 mg/dose PO divided tid/qid; not to exceed 32 mg/d MDI: 2 puffs q4-6h; not to exceed 12 inhalations/d
Pediatric Dose	0.1-2 mg/kg PO tid
Contraindications	Documented hypersensitivity
Interactions	Beta-adrenergic blockers antagonize effects; inhaled ipratropium may increase duration of bronchodilatation by albuterol; cardiovascular effects may increase with MAOIs, inhaled anesthetics, TCAs, and sympathomimetic agents
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	Caution in hyperthyroidism, diabetes mellitus, and cardiovascular disorders

Drug Category: Antivirals -- Influenza vaccinations offer greater protection for the appropriate populations because they offer coverage for influenza A and B. However, amantadine and rimantadine can be useful during epidemics of influenza A. Zaminivir, the newest agent, is undergoing clinical trials and may be effective for influenza A and B.

Drug Name	Rimantadine (Flumadine) -- Inhibits viral replication of influenza A virus H1N1, H2N2, and H3N2. Prevents viral penetration into host by inhibiting uncoating of influenza A.
Adult Dose	200 mg PO qd or 100 mg PO bid
Pediatric Dose	<10 years: 5 mg/kg PO qd, up to 150 mg/d >10 years: Administer as in adults
Contraindications	Documented hypersensitivity
Interactions	Acetaminophen and aspirin reduce levels when taken concurrently; cimetidine increases plasma levels
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	Caution in hepatic impairment

Drug Name	Amantadine (Symmetrel) -- Prevents penetration of virus into host by inhibiting uncoating of influenza A. Rimantadine appears to have a better adverse effect profile and can be taken qd.
Adult Dose	100 mg PO bid for 5 d
Pediatric Dose	4.4 mg/kg, up to 150 PO mg/d
Contraindications	Documented hypersensitivity
Interactions	Drugs with anticholinergic or CNS stimulant activity increase toxicity; concurrent administration of hydrochlorothiazide plus triamterene may increase plasma concentrations of amantadine
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	Caution in liver disease, uncontrolled psychosis, eczematoid dermatitis, seizures, and patients receiving CNS stimulant drugs; reduce dose in renal disease when treating Parkinson disease; do not discontinue this medication abruptly

Drug Category: Analgesics/antipyretics -- Often helpful in relieving the associated lethargy, malaise, and fever associated with illness.

Drug Name	Ibuprofen (Ibuprin, Advil, Motrin) -- Usually the DOC for treatment of mild to moderate pain if no contraindications exist.
Adult Dose	400-800 mg PO q4-6h
Pediatric Dose	10 mg/kg PO q6-8h
Contraindications	Documented hypersensitivity; peptic ulcer disease, recent GI bleeding or perforation, renal insufficiency, or high risk of bleeding
Interactions	Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; monitor PT closely (instruct patients to watch for signs of bleeding); may increase risk of MTX toxicity; phenytoin levels may be increased when administered concurrently
Pregnancy	B - Usually safe but benefits must outweigh the risks.
Precautions	Category D in third trimester of pregnancy; caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in anticoagulation abnormalities or during anticoagulant therapy

Drug Name	Acetaminophen (Tylenol, Panadol, Aspirin-Free Anacin) -- DOC for treatment of pain in patients with documented hypersensitivity to aspirin or NSAIDs, with upper GI disease, or who are taking oral anticoagulants.
Adult Dose	325-650 mg PO q4-6h or 1000 mg tid/qid; not to exceed 4 g/d
Pediatric Dose	<12 years: 10-15 mg/kg/dose PO q4-6h prn; not to exceed 2.6 g/d >12 years: 325-650 mg PO q4h; not to exceed 5 doses (2.6 g) in 24 h
Contraindications	Documented hypersensitivity, G-6-PD deficiency
Interactions	Rifampin can reduce analgesic effects of acetaminophen; coadministration with barbiturates, carbamazepine, hydantoins, and isoniazid may increase hepatotoxicity
Pregnancy	B - Usually safe but benefits must outweigh the risks.
Precautions	Hepatotoxicity possible in people with chronic alcoholism following various dose levels; severe or recurrent pain or high or continued fever may indicate a serious illness; APAP is contained in many OTC products, and combined use with these products may result in cumulative APAP doses exceeding recommended maximum dose

FOLLOW-UP

Further Outpatient Care:

• Routine follow-up care is usually not necessary. If symptoms worsen (eg, shortness of breath, high fever, vomiting, persistent cough) consider an alternate diagnosis. If symptoms recur (>3 episodes per y), further investigation is recommended. If symptoms persist for longer than 1 month, reassess patient for other causes of cough.

• Flu vaccines are 70-90% effective in preventing flu among healthy adults. In elderly or chronically ill persons, the flu vaccine may be less effective in preventing illness than it is in preventing serious complications and death. In the United States, the flu season usually occurs from approximately October-April. Influenza vaccination of healthy patients may be beneficial by reducing absenteeism. Administer influenza vaccine to the following populations:

• Patients with underlying cardiopulmonary disease should receive influenza vaccinations annually.

• Residents of nursing homes and chronic-care facilities and persons older than 65 years should receive vaccinations annually.

• Adults and children who have chronic disorders of the pulmonary or cardiovascular systems, including children with asthma, should receive influenza vaccinations annually.

• Adults and children who have required regular medical follow-up or hospitalization during the preceding year because of chronic metabolic diseases (including diabetes), renal dysfunction, hemoglobinopathies, or immunosuppression (including immunosuppression caused by medications) should receive influenza vaccinations annually.

• Children and teenagers (aged 6 mo to 18 y) who are receiving long-term aspirin therapy and who therefore might be at risk for developing Reye syndrome after the flu should receive influenza vaccinations annually.

• Women who will be in the second or third trimester of pregnancy during the flu season should receive influenza vaccinations.

• In certain situations, such as in nursing homes, also administer amantadine or rimantadine when an index case is found until the vaccine has had a chance to take effect.

In/Out Patient Meds:

• Nonsteroidal anti-inflammatory drugs (NSAIDs) are helpful in treating constitutional symptoms of acute bronchitis, including mild-to-moderate pain.

• Proventil and Robitussin treat cough.

Deterrence/Prevention:

• Influenza vaccine may reduce the incidence of upper respiratory tract infection and subsequently reduce the incidence of acute bacterial bronchitis.

Complications:

• Complications occur in about 10% of patients with acute bronchitis.

• Bacterial superinfection

• Lower respiratory tract infection and pneumonia
  • Fewer than 5% of patients with bronchitis develop pneumonia.

  • Incidence of subsequent pneumonia, however, remains unaffected by the use of antibiotics.

• Repeated episodes of acute bronchitis may lead to chronic bronchitis.

• Acute bronchitis may lead to reactive airway disease.

• Hemoptysis

Prognosis:

• Patients with acute bronchitis have a good prognosis.

Patient Education:

• Patient education is essential in prevention and treatment of acute bronchitis. Unfortunately, health care providers usually underemphasize education. Patients should be counseled to take the following measures:

• Avoid smoking and secondhand smoke.

• Live in a clean environment.

• Receive influenza vaccine yearly between October and December.

• Receive the pneumonia vaccine every 5-10 years if aged 65 years or more or with chronic disease.

Medical/Legal Pitfalls:

• Carefully explain the course, treatment options, and all possible complications of acute bronchitis.

Special Concerns:

• Patients may influence the physician's decision regarding treatment (eg, by insisting on receiving prescribed antibiotics).

• Acute bronchitis continues to be treated with antibiotics, although little evidence supports the effectiveness of antibiotic treatment in this illness.

REFERENCES

• American Academy of Pediatrics, Committee on Drugs: Use of codeine- and dextromethorphan-containing cough remedies in children. Pediatrics 1997 Jun; 99(6): 918-20
• Blinkhorn RJ: Upper respiratory tract infection. In: Textbook of pulmonary medicine. 5th ed. Boston: Little, Brown, & Co; 1993: 405-407.
• Brickfield FX, Carter WH, Johnson RE: Erythromycin in the treatment of acute bronchitis in a community practice. J Fam Pract 1986 Aug; 23(2): 119-22
• Denny FW, Clyde WA, Glezen WP: Mycoplasma pneumoniae disease: clinical spectrum, pathophysiology, epidemiology, and control. J Infect Dis 1971 Jan; 123(1): 74-92
• Franks P, Gleiner JA: The treatment of acute bronchitis with trimethoprim and sulfamethoxazole. J Fam Pract 1984 Aug; 19(2): 185-90
• Gonzales R, Steiner JF, Lum A: Decreasing antibiotic use in ambulatory practice: impact of a multidimensional intervention on the treatment of uncomplicated acute bronchitis in adults. JAMA 1999 Apr 28; 281(16): 1512-9
• Gonzales R, Sande MA: Uncomplicated acute bronchitis. Ann Intern Med 2000 Dec 19; 133(12): 981-91
• Gwaltigy, Jack MJ: Acute bronchitis. In: Douglas & Barnett's Principles of practice of infectious disease. 4th ed. New York, NY: Churchill Livingston; 1995: 606-608.
• Huchon GJ, Gialdroni-Grassi G, Leophonte P: Initial antibiotic therapy for lower respiratory tract infection in the community: a European survey. Eur Respir J 1996 Aug; 9(8): 1590-5
• Meza RA, Bridges-Webb C, Sayer GP: The management of acute bronchitis in general practice: results from the Australian Morbidity and Treatment Survey, 1990-1991. Aust Fam Physician 1994 Aug; 23(8): 1550-3
• Nichol KL, Wuorenma J, von Sternberg T: Benefits of influenza vaccination for low-, intermediate-, and high- risk senior citizens. Arch Intern Med 1998 Sep 14; 158(16): 1769-76
• Palmer DA, Bauchner H: Parents' and physicians' views on antibiotics. Pediatrics 1997 Jun; 99(6): E6
• Siegel D, Sande MA: Patterns of antibiotic use in a busy metropolitan emergency room: analysis of efficacy and cost-appropriateness. West J Med 1983 May; 138(5): 737-41
• Smucny J, Fahey T, Becker L: Antibiotics for acute bronchitis (Cochrane Review). Cochrane Database Syst Rev 2000; 4: CD000245

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