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Bronchitis - Uncomplicated Acute Overview
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Symptoms
Signs & Symptoms
Cough &/or increase in sputum production
Breathlessness/wheeze
Chest pain/aches
Sweats &/or sore throat
Increase in temperature
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Evaluation
Patients w/ Comorbidity
Comorbid conditions: Chronic obstructive pulmonary disease (COPD), CV diseases, neurological diseases, diabetes mellitus (DM), chronic liver or renal failure, recent viral infection, immunodeficiency, etc
Evaluation & management must be tailored in light of the patient’s comorbid condition
Eg 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
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Diagnosis
Uncomplicated Acute Bronchitis
A self-limiting acute respiratory tract infection (RTI) characterized by the sudden onset of cough, w/ or w/o sputum production, in an otherwise healthy individual
Diagnosis is based on clinical findings
Pathogenesis
An inflammatory response to infections of the bronchial epithelium of the large airways of the lungs
Begins w/ mucosal injury, epithelial cell damage & release of proinflammatory mediators
Transient airflow obstruction & bronchial hyperresponsiveness
Purulence can result from either bacterial or viral infection
Etiology
Viral
The most common cause (90% of cases) of bronchial inflammation in otherwise healthy adults presenting w/ acute bronchitis
Influenza A & B, parainfluenza 3 & resp syncytial virus produce primarily lower resp tract disease
Corona virus, adenovirus & rhinoviruses more commonly produce upper resp 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 wk
The cough generally lasts 7-10 days but occasionally persists for >1 mth
Influenza (flu) virus typically causes a nonproductive cough
If cough has been >3 wk, 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 inflammatory reaction & it can result from either viral or bacterial infection
Cough may be accompanied by clinical features that suggest an acute RTI (eg sore throat, rhinorrhea, hoarseness)
Patient may also present w/ retrosternal chest pain on coughing, dyspnea, wheezing, fever, fatigue or night cough
History
Perform a complete & detailed medical history including tobacco use
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
Diagnostic Studies
No available test can provide a definitive 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 identified 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 but diagnostic pulmonary function testing need not be performed in previously healthy 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/min, respiratory rate of >24 breaths/min, & an oral temperature of >100.4°F (>38°C), & if focal pulmonary consolidation is present on exam
Differential Diagnoses
Pertussis
An uncommon cause of uncomplicated acute bronchitis
May be present in up to 10-20% of adults w/ cough lasting >2-3 wk
Adults immunized as children but no longer having effective 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 suffering from severe spasmodic coughing, esp if terminated by vomiting or associated w/ redness of the face & catching of the breath
The 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 difficult to establish because of delay in suspicion of disease (cultures of nasopharyngeal secretions are usually negative after 2 wk & 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 differentiate 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
Influenza (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 benefit from anti-influenza agents if treated w/in 48 hr of symptom onset
For more detailed diagnosis & treatment of influenza, see Influenza Disease Management Chart
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 HR ≥100 beats/min, resp rate >24 breaths/min, oral body temp ≥38°C & signs of focal consolidation on chest exam) sufficiently reduces the likelihood of pneumonia to eliminate the need for a chest x-ray
For more detailed diagnosis of pneumonia, see Pneumonia - Community Acquired Disease Management Chart
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 reflux disease (GERD) & bronchogenic tumor
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â—€Bronchitis - Uncomplicated Acute Overview
Bronchitis - Uncomplicated Acute Treatmentâ–¶