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Source: Gonzales R, et al. Ann Intern Med 2001; 134:521-529.
The term "acute bronchitis" usually designates an acute respiratory tract infection in which cough, with or without phlegm, is a predominant feature. In the United States, about 5% of adults self-report an episode of acute bronchitis each year, and up to 90% of these persons seek medical attention. In 1997, adults in the United States made more than 10 million office visits for bronchitis. As a result, acute bronchitis consistently ranks among the 10 most common conditions leading to outpatient visits.
• Evaluation of acute cough.
A wide variety of infections and inflammatory disorders can lead to an acute cough illness. The American College of Chest Physicians defines acute cough illness as lasting fewer than three weeks.1 Acute upper respiratory tract infections account for approximately 70% of primary diagnoses, with asthma (6%) and pneumonia (5%) being the next most common. Previously undiagnosed asthma is a consideration in patients presenting with an acute cough. The diagnosis of asthma is difficult to establish because many patients with acute bronchitis will have transient bronchial hyper-responsiveness. The primary objective when assessing a healthy adult with uncomplicated acute cough is to exclude the presence of pneumonia. An evidence-based review concluded that absence of abnormalities in vital signs (heart rate >100 beats/min, respiratory rate > 24 breaths/min, or oral temperature >38°) and chest examination (rales, egophony, or fremitus) sufficiently reduces the likelihood of pneumonia to the point where further diagnostic testing usually is not necessary.2
• Microbiology of acute uncomplicated bronchitis.
As in community-acquired pneumonia, microbiological studies of uncomplicated acute bronchitis identify a pathogen in the minority of cases, ranging from 16%-40%.
Specific viruses most frequently associated with acute bronchitis are:
• influenza B;
• influenza A;
• respiratory syncytial virus;
• corona virus;
To date, only B. pertussis, M. pneumoniae, and C pneumoniae (TWAR) have been established as nonviral causes of uncomplicated acute bronchitis in adults.
• Nursing considerations.
Routine antibiotic treatment of uncomplicated acute bronchitis is not recommended, regardless of the duration of cough. The one uncommon circumstance for which evidence supports antibiotic treatment of patients with uncomplicated acute bronchitis is suspicion of pertussis.
Influenza is the most common pathogen isolated in patients with uncomplicated acute bronchitis. The neuraminidase inhibitors zanamivir and oseltamivir have demonstrated some efficacy in reducing illness duration in adults with naturally acquired influenza A and B if treatment begins within 48 hours of symptom onset.3
In most cases, cough is the major symptom for which patients seek relief. Randomized, controlled trials have demonstrated a consistent benefit of therapy with albuterol vs. placebo in reducing the duration and severity of cough.4 Preparations containing dextromethorphan or codeine probably have a modest effect on severity and duration of cough. Cough of more than three weeks duration, cough associated with underlying lung disease, or experimentally induced cough have been shown to respond to dextromethorphan or codeine. Elimina-tion of environmental cough triggers such as dust and dander, as well as the use of vaporized air treatments in low-humidity environments, such as high altitude, also are reasonable options.
Consider discussing the lack of benefit of antibiotic treatment for treatment for uncomplicated acute bronchitis and the need for clinicians to stop prescribing antibiotics for this condition as a standard of practice. Mounting evidence indicates that patient satisfaction with the office encounter does not depend on receipt of antibiotic therapy but instead is related to the patient-centered quality of the encounter.5
Comment on Patient Education
By David Ost, MD, FACP
Assistant Professor of Medicine
NYU School of Medicine
Director of Interventional Pulmonology
Division of Pulmonary and Critical Care Medicine
North Shore University Hospital
Most cases of acute bronchitis occur in otherwise healthy adults, in whom this acute cough illness can be called "uncomplicated acute bronchitis." The principles in this guideline are intended to apply to such patients, and do not necessarily apply to patients with chronic lung diseases such as chronic obstructive pulmonary disease.
Recommendations for discussing the management of acute bronchitis with patients include:
• Provide realistic expectations of the duration of the patient’s cough, which typically will last for 10-14 days after the office visit.
• Refer to the cough illness as a "chest cold" rather than bronchitis.6
• Personalize the risk of unnecessary antibiotic use.
• Explain to patients why we need to be more selective in treating only those conditions for which a major clinical benefit of antibiotics has been proven.
• Alert patients to the current epidemic in antibiotic resistance among community bacterial pathogens, and explain the public health concern.
(Editor’s note: Najma Usmani, MD, an internal medicine fellow at North Shore University Hospital, also contributed to this article.)
1. Irwin RS, et al. Chest 1998; 114:133S-181S.
2. Metlay JP, et al. JAMA 1997; 278:1,440-1,445.
3. Hayden FG, et al. N Engl J Med 1997; 337:874-880.
4. Melbye H, et al. Fam Pract 1991; 8:216-222.
5. Hamm RM, et al. J Fam Pract 1996; 43:56-62.
6. Gonzales R, et al. Am J Med 2000; 108:83-85.