Symptoms

• Cough &/or increase in sputum production
• Breathlessness/wheeze
• Chest pain/aches
• Sweats &/or sore throat
• Increase in temperature

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Evaluation

• 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

• 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

• 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

• 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

• 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

• Mycoplasma pneumoniae, Chlamydia pneumoniae, Bordetella pertussis (5-10% of cases)
• Environmental cough triggers (eg dust, dander, toxic fume inhalation)

• 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

• Perform a complete & detailed medical history including tobacco use

• Wheezing, rhonchi, coarse rales, a prolonged expiratory phase or other obstructive signs may be present
  • Forced expiration may be done to detect wheezing

• 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

• 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

• 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

• 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

• 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

• In these settings, cough is not a predominant symptom (eg common cold)

• Chronic heart failure (CHF) in elderly patients, gastroesophageal reflux disease (GERD) & bronchogenic tumor

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