Diagnosis and Treatment Options in Acute Bronchitis

Release Date: July 1, 2011

Expiration Date: July 31, 2013

FACULTY:

Kimberly L. Tackett, PharmD, BCPS, CDE
Associate Professor
South University School of Pharmacy
Savannah, Georgia

C. Scott Lancaster, PharmD
Associate Professor
South University School of Pharmacy
Savannah, Georgia

FACULTY DISCLOSURE STATEMENTS:

Drs. Tackett and Lancaster have no actual or potential conflicts of interest in relation to this activity.

Postgraduate Healthcare Education, LLC does not view the existence of relationships as an implication of bias or that the value of the material is decreased. The content of the activity was planned to be balanced, objective, and scientifically rigorous. Occasionally, authors express opinions that represent their own viewpoint. Conclusions drawn by participants should be derived from objective analysis of scientific data.

ACCREDITATION STATEMENT:

Pharmacy
acpePostgraduate Healthcare Education, LLC is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education.
UAN: 0430-0000-11-019-H01-P
Credits: 2.0 hours (0.20 ceu)
Type of Activity: Knowledge

TARGET AUDIENCE:

This accredited activity is targeted to pharmacists. Estimated time to complete this activity is 120 minutes.

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DISCLAIMER:

Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of their patients’ conditions and possible contraindications or dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities.

GOAL:

To review the diagnosis of acute bronchitis, and present nonpharmacologic and pharmacologic treatment options for the patient with acute bronchitis.

OBJECTIVES:

After completing this activity, the participant should be able to:

  1. Identify symptoms of acute bronchitis.
  2. Differentiate between presentation of acute bronchitis and other respiratory illnesses.
  3. Explain the role of antibiotic treatment in acute bronchitis.
  4. Evaluate nonpharmacologic and pharmacologic treatment strategies for the patient with acute bronchitis.

Acute bronchitis is the fifth most common diagnosis for patients presenting with a primary symptom of cough, with or without phlegm, lasting from 1 to 3 weeks.1,2 The disease is a self-limiting inflammation of the large airways within the lung that is characterized by a cough, without the presence of pneumonia, as confirmed by the absence of an infiltrate on chest radiograph.3 The cough may last for up to 3 weeks in about 50% of patients as a result of either an infectious or noninfectious etiology.4 The triggering factor leads to an inflammatory response with airway hyperresponsiveness and mucus production.

There are an estimated 5% of adults who seek medical attention for acute bronchitis resulting in greater than 10 million office visits per year.1 A large part of the treatment costs are due to patients receiving an average of two prescriptions per visit, and the disease resulting in 2 to 3 days of missed work.5 Office visits for acute bronchitis result in a prescription for antimicrobial therapy in 70% to 90% of the cases, though most cases are due to a virus.2 The reported incidence of acute bronchitis has been found to be higher during the winter and fall as compared to the summer and spring.3

PATHOGENESIS

The diagnosis of respiratory illnesses is based upon the area of inflammation within the respiratory system.2 Acute bronchitis is an inflammation of the epithelium in the bronchi, usually due to an upper-airway infection that clinically presents as a cough. An estimated 85% to 95% of acute bronchitis cases are a result of viral infections, and bacterial causes are more common in patients with chronic health problems.3 The most commonly isolated viruses include influenza A and B, parainfluenza, and respiratory syncytial virus (RSV); less common causes are coronavirus, adenovirus, and rhinovirus.2 Bacterial pathogens most commonly involved are those that cause community-acquired pneumonia, such as Mycoplasma pneumoniae, Strepto coccus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, and Bordetella pertussis.2,4 The specific pathogen, if isolated, is often related to either the season of the year or the influenza vaccination status of the patient.

DIAGNOSIS

The diagnosis of acute bronchitis is primarily clinical since there are no specific diagnostic criteria. Many patients who are misdiagnosed with acute bronchitis actually present with acute cough due to asthma exacerbation, the common cold, or acute exacerbation of chronic obstructive pulmonary disease (COPD).1 A thorough assessment of the patient should be performed to rule out other causes of the cough. This includes a physical examination, medication, and social history, as well as history of tobacco use. Distinguishing acute bronchitis from a simple upper-respiratory infection within the first few days of illness is difficult, with a cough lasting greater than 5 days suggesting acute bronchitis. In patients with acute bronchitis, the cough usually lasts for 2 to 3 weeks, and airway hyperresponsiveness may last for 5 to 6 weeks. A different diagnosis should be considered for cough lasting greater than 3 weeks. Cough in the absence of fever, respiratory rate less than 24 breaths per minute, and heart rate of less than 100 beats per minute are suggestive of the diagnosis.3 If these criteria are present, a chest x-ray is not indicated, with the exception of cough in the elderly patient or signs of consolidation present on chest examination. Community-acquired pneumonia in patients of age greater than 75 may present without distinctive signs and symptoms. Symptoms in this patient population that may suggest pneumonia include tachypnea, change in mental status or behavioral change, and decreased oxygen saturation.3

Healthy adults diagnosed with acute bronchitis are typically uncomplicated cases; however, patients with underlying lung disease (i.e., COPD or bronchiectasis), congestive heart failure, or immune compromise are at high risk for complications.1 The color of the sputum is not an accurate predictor in the differentiation between viral or bacterial etiologies, and in greater than 30% of patients the causative pathogen remains unidentified. Viral and bacterial cultures and serologic assays are not routinely performed for identification purposes. Patients with severe spastic cough should be evaluated for pertussis. The diagnosis of pertussis is established by culturing the nasopharynx by swab or aspirate.6 Common pathogenic etiologies for acute bronchitis are listed in TABLE 1.

It is important to rule out other causes of cough with or without phlegm production, such as the common cold, reflux esophagitis, acute asthma, or chronic obstructive pulmonary disease.1,4 Differentiating acute bronchitis from the common cold and acute exacerbation of chronic bronchitis (AECB) or asthma is difficult based upon symptoms. The mild upper-respiratory symptoms of the common cold, such as nasal stuffiness and discharge, sneezing, sore throat, and cough, are shared by those of acute and chronic bronchitis.3 Patients with acute bronchitis typically present with symptoms of bronchial obstruction, wheezing, and dyspnea on exertion, as seen in asthma exacerbation; however, with acute bronchitis, cough persists beyond the acute period of 5 to 7 days. Differential diagnoses for acute cough with or without phlegm are listed in TABLE 2.

TREATMENT OPTIONS

Symptomatic treatment for cough is the primary need in patients presenting with acute bronchitis since the infection is likely viral in nature. Evidence does not consistently support the effectiveness of treatment due to acute bronchitis being a self-limiting condition in which patients will improve without treatment.7 Many patients will present with symptoms of the common cold and may benefit from treatment with acetaminophen, a nonsteroidal anti-inflammatory medication, or a nasal decongestant. Caution should be exercised in administering nonsteroidal anti-inflammatory medications to patients younger than 3 months, elderly patients, and those patients with compromised kidney function.

The primary goal of treatment is reduction of symptom severity, but improving patient function and quality of life is also important. Successfully assessing these goals may be done by examining how often patients return for treatment of the same episode. Studies have shown that despite aggressive treatment of acute bronchitis, many patients seen in the emergency department will have recurrent symptoms requiring hospitalization. Acute bronchitis therapy consists of beta 2-agonists, antitussive agents, protussive agents, and antibiotics or antivirals if the infection is thought to be due to an infection.

Nonpharmacologic

Reasonable nonpharmacologic treatment options include reduction of environmental cough triggers and vaporized treatments, especially in environments with low humidity.2 Patients should be counseled to rest, to increase their fluid intake (especially if a fever is present), and to stop smoking.

Smoking Cessation

Smoking cessation should be encouraged when any patient who is actively smoking presents with a respiratory condition. A pharmacist is the most resourceful health care practitioner for information about smoking cessation products since the majority of these are OTC products. Pharmacists and practitioners should assess the smoking status of an individual as well as their interest in cessation. Further, attempts should be made to determine the type of tobacco product being consumed, as well as how much and how often. If a patient is initially unwilling to stop smoking, each subsequent visit should assess readiness to quit as well as further education on the benefits of smoking cessation, reinforcing goals of complete and long-term abstinence from using any tobacco product. Other important factors to discuss with patients, who may or may not be actively using tobacco products, are the health consequences associated with second-hand and third-hand smoke. In a clinical setting, patients are able to express how troublesome second-hand smoke is for their respiratory illness; however, many times a connection with exacerbations from residual smoke on clothing, furniture, and bedding is not made.

It has been established that within the first 9 months after smoking cessation, coughing, sinus congestion, and shortness of breath decrease and the lungs become better able to clear mucus, thereby reducing infection.8 Effective smoking cessation strategies include nonpharmacologic cognitive behavioral therapy as well as pharmacologic products (see TABLE 3). As previously mentioned, most pharmacologic products for smoking cessation are available OTC as nicotine-replacement therapy (NRT) products: nicotine patches available in different strengths and both 16- and 24-hour formulations, nicotine gum, and nicotine lozenge. Selection of an NRT product depends on patient preference, medical history, and contraindications and precautions to therapy.9

Nicotine patches are widely used as NRT products, due in part to the OTC availability of these products, their ease of use, and overall effectiveness.10 Historically, nicotine patches have been used alone as replacement therapy. More recent evidence suggests use of multiple NRTs, thereby providing higher serum nicotine concentrations leading to less bothersome withdrawal symptoms and improved treatment efficacy.9

Precautions to take when recommending an NRT patch would be evidence of any skin disorders such as psoriasis or eczema; use of the patch should be avoided in these patients due to possible worsening of the skin disorder. A counseling point that should be extended to patients purchasing a nicotine patch is to remove the 24-hour patch prior to bedtime should abnormal dreams or disruptions in sleep pattern occur.

Other available OTC nicotine-replacement products include the nicotine gum and nicotine lozenge. The nicotine gum is available in 2-mg and 4-mg strengths, as well as various flavors, and is dosed based on the number of cigarettes that a patient smokes. The nicotine lozenge is available in the same strengths as the gum, but is recommended for use based on the time of the first cigarette of the day. Patients with extensive dental work or dental appliances should be cautioned on use of the gum or lozenge. Also, pharmacists should advise those that may select the gum or lozenge of the possibility of dyspepsia; however, this is generally worsened by swallowing excessively while using these products. Generally, all NRT products should be avoided or used with caution in women who are pregnant, patients with cardiovascular disease, and adolescents.9

Two prescription products widely used as smoking cessation therapies include sustained-release bupropion and varenicline (see TABLE 3). Bupropion, initially marketed as a dopamine and norepinephrine reuptake inhibitor, has been associated with decreases in cravings for cigarettes and lessening of nicotine withdrawal. Bupropion is dosed at 150 mg a day for 3 days, followed by 150 mg two times daily up to 12 weeks.30 Bupropion can be used in combination with NRT products and can be advantageous in those with concomitant depression. Bupropion should be avoided in those patients with seizure disorders.

Varenicline, the newest prescription product available, mechanistically aids in smoking cessation through combined agonist activity at the nicotinic acetylcholine receptor and inhibition of nicotine binding.11 Varenicline is dosed initially at 0.5 mg daily for 3 days, followed by 0.5 mg twice daily for 4 days, then 1 mg twice daily as a maintenance dose for 12 total weeks of therapy. Important counseling points with varenicline include picking a quit date within the first week of therapy and warning of nausea and abnormal dreams as the most common side effects. Also, caution should be undertaken in those with depressed mood and behavior changes, agitation, or suicidal ideation, as postmarketing studies have indicated possible worsening with varenicline therapy.11

Antibiotics

Upper respiratory infections and bronchitis are conditions associated with excessive antibiotic prescription use.1 On average, 70% to 90% of office visits for acute bronchitis result in the patient receiving a prescription for either an antiviral or antimicrobial medication.2 A study of Medicaid claims data found that 75% of patients presenting with acute bronchitis were prescribed an antibiotic.12 Additionally, the investigators concluded that emergency room physicians were likely to prescribe some type of medication, and rural physicians were more likely to prescribe combination antibiotic and bronchodilator therapy than urban physicians. High-risk patients presenting with symptoms of influenza infection during influenza season should receive antiviral therapy within 36 hours of symptom onset.4

A majority of systematic reviews have found no benefit from using antibiotics with the exception of a modest reduction in duration of symptoms.3 Routine antibiotic treatment has not been shown to have a consistent impact on the duration or severity of the illness or on the development of complications such as pneumonia.13 A meta-analysis of randomized trials found a statistically significant reduction in cough duration with antibiotic treatment, but concluded that the risk for potential adverse effects offset the small benefit seen with antibiotic therapy.14 A Cochrane review concluded that patients receiving antibiotics (erythromycin, azithromycin, amoxicillin/clavulanate, doxycycline, trimethoprim/sulfamethoxazole, cefuroxime) did have better outcomes than those receiving placebo.15 Those receiving antibiotics had a reduction in days feeling ill and a reduction in days with limited activity, though there was no significant difference in presence of productive cough at follow-up or mean duration of cough. Arguments against using antibiotics in acute bronchitis include cost, adverse effects, and changes in bacterial susceptibilities with only modest improvement in symptoms. Identifying the subgroup that will likely benefit from antibiotic use is difficult, and ruling out the presence of pneumonia when considering treatment is of utmost importance.12

Patients with symptoms of upperrespiratory illness and those who have been sick for less than a week may be the least likely to benefit from therapy with an antibiotic.15

Clinical trials have examined the use of procalcitonin levels, which is typically elevated in bacterial infections, in guiding antibiotic therapy in patients presenting to the emergency room with respiratory infections.16,17 Utilizing an algorithm with predefined procalcitonin levels for initiating or stopping antibiotics, investigators were able to decrease antibiotic use without adversely affecting clinical outcomes. Schuetz et al compared guidelinedirected care with the use of procalcitonin levels for initiation and continuation of antibiotic therapy in patients with lower respiratory symptoms presenting to the emergency room.18 Patients had moderately severe illness, presenting with cough plus fever, elevated white cell count, and chills. Using procalcitonin levels to guide therapy in those patients presenting with acute bronchitis decreased the use of antibiotics by 50% (50% of patients receiving usual vs. 23.2% for procalcitonin-guided therapy) with no difference found in outcomes.

C-reactive protein is another biomarker that has shown promise in directing antibiotic therapy in patients with lower respiratory tract infections.19 A randomized clinical trial by Cals et al examined the use of C-reactive protein point-of-care testing in guiding initiation of antibiotic therapy.19 The investigators concluded that this practice, in combination with enhanced patient communication skills, significantly reduced antibiotic prescribing without compromising the patient’s satisfaction with care or recovery.

Selection of antibiotics is based on activity against the common pathogens (Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis) implicated in acute bronchitis and the ability to penetrate into the sputum and bronchial mucosa.20 Rarely is the causative pathogen isolated, occurring in only about 30% of cases.4 The choice of antibiotic prescribed for the treatment of acute bronchitis has changed over time. Prior to 1990, approximately 20% of antibiotics prescribed were classified as broad-spectrum. Recently, it has been estimated that up to 60% of prescribed antibiotics were classified as broad spectrum.21,22 Amoxicillin, doxycycline, erythromycin, and trimethoprim/sulfamethoxazole are commonly used for treatment of acute bronchitis, but due to increasing resistance practitioners may prefer to use second-generation and third-generation cephalosporins or macrolides. If the infection is thought to be due to pertussis, the patient should be treated with a macrolide and started as soon as possible to reduce transmission. Symptoms that are strongly suggestive of pertussis infection include recent exposure to a case of pertussis, whooping sound, or posttussive vomiting.1 Treatment regimens for pertussis include erythromycin 500 mg four times daily for 14 days, clarithromycin 500 mg twice daily for 14 days, or azithromycin 500 mg on Day 1 followed by 250 mg daily for 4 days. Antibiotics show the greatest clinical benefit when started early within the first week.

Patients with AECB may require therapy with a broad-spectrum antibiotic, such as a fluoroquinolone, if significant impairment of the lung is present or the patients are considered high risk. High-risk patients are those of age greater than 65, having a forced expiratory volume in 1 second of less than 50% predicted at baseline, or those patients with comorbid diseases.20 A meta-analysis performed by Dimopoulos et al found that first-line antibiotics (i.e., amoxicillin, ampicillin, doxycycline, and trimethoprim/sulfamethoxazole) were less effective than second-line antibiotics (i.e., amoxicillin/clavulanate, respiratory fluoroquinolones, and macrolides) in the treatment of AECB.20 However, the authors found no difference between the regimens in mortality, microbiologic outcomes, and reported adverse events. A subgroup analysis of trials comparing penicillins to macrolides showed that penicillins were less effective, but there were no differences in adverse events between the two treatments. Dosages for antibiotics commonly used in the treatment of acute bronchitis are listed in TABLE 4.

The optimal duration of antimicrobial therapy has not been well determined in patients with acute bronchitis. The European guidelines for patients with lower respiratory tract infection recommend maintaining treatment to an average of 7 to 10 days.20 Shortening the length of therapy has been advocated as a way to prevent resistance. A meta-analysis performed by Falagas et al found that short-duration (5 days) antimicrobial treatment was not associated with lower treatment success as compared to long-duration treatment, and that patients receiving 5 days of therapy experienced fewer adverse effects.23

Bronchodilators

Effective treatments for cough of acute bronchitis are not well supported in the literature, but include beta 2-agonists due to many practitioners assuming patients have reversible airflow restriction contributing to their symptoms.24 Benefits from the use of short-acting inhaled beta 2-agonists (i.e., albuterol) include improving shortness of breath and cough.3 Patients with acute bronchitis may present with bronchospasm, and treatment with a bronchodilator would be effective. Studies have shown a decrease in cough, and patients return to work earlier when treated with bronchodilators as compared to those treated with antibiotic therapy.7 There is consistent data to support the use of beta 2-agonist therapy in decreasing the duration of cough in those patients with troublesome cough and airway hyperresponsiveness.1,2 Also, patients with airflow obstruction at baseline and wheezing may benefit from beta 2-agonist therapy.1,24 A Cochrane review of beta 2-agonists in acute bronchitis concluded that the potential benefit is not well supported and should be weighed against the potential for adverse effects.24 Common adverse effects include tremor, nervousness, and shakiness.

There is insufficient evidence to support the routine use of inhaled anticholinergic and corticosteroid therapy. A Cochrane review of inhaled corticosteroids suggests a possible benefit to high-dose, episodic inhaled corticosteroids, but failed to find benefit in low-dose, preventative therapy.25 Despite the lack of clinical data, many clinicians will initiate a brief trial (i.e., about 5 to 7 days) of oral or inhaled corticosteroids for patients with persistent and troublesome cough.

Clinical studies have shown the benefit of using an aerochamber for maximizing delivery of inhaled therapy via metered-dose inhalers (MDIs).7 Bronchodilators may be administered as either a nebulized solution or in the form of a MDI. Though studies have failed to show superiority between using either a nebulizer or an MDI with a spacer, many patients with acute bronchitis will be prescribed a nebulized solution.7

Antitussive and Protussive Therapy

Therapy for the cough associated with acute bronchitis may target controlling the cough (antitussive) or increasing secretions (protussive).1 The American College of Chest Physicians recommends a short course of antitussive therapy to reduce severe coughing during acute illness (such as hydrocodone, codeine, or dextromethorphan), though there is a lack of consistent evidence showing the benefit. There have been no double-blind, placebo-controlled studies examining the use of codeine on cough with acute bronchitis, and results of clinical trials with dextromethorphan are conflicting. Antitussive therapy is recommended for those patients in whom cough is causing discomfort and inhibiting clearance of airway secretions.26 Patients presenting with a persistent mild cough may benefit from dextromethorphan; severe cough may require therapy with codeine or codeine derivative. The efficacy of antitussive therapy depends on the cause of the cough. Cough due to viral respiratory tract infections has not been shown to respond to antitussive therapy, but chronic cough has been shown to improve with antitussive therapy.2 The tendency of these agents to dry bronchial secretions may aggravate the cough and prolong recovery. Antitussive agents and their dosages are listed in TABLE 5.

Protussive therapy would be indicated in patients requiring clearance of airway secretions. The clinical effectiveness of this type of therapy is questionable, and therapeutic trials have failed to show favorable effects on the cough associated with acute bronchitis.1 Physicians commonly prescribe guaifenesin in dosages of 600 mg to 1,200 mg as protussive therapy for cough, and it is a component in many OTC antitussive therapies.

Complementary and Alternative Therapies

Patient use of nonprescription medications for relief of symptoms is increasing due to ease of access. A meta-analysis performed by Agbabiaka et al concluded that there is evidence that Pelargonium sidoides is effective in treating acute bronchitis as compared to placebo.27 Patients taking P sidoides experienced a reduction in bronchitis symptom scores without experiencing any serious adverse events. A clinical trial by Evans et al assessed improvement in health-related quality of life at 7 days in patients presenting with a clinical diagnosis of acute bronchitis randomized to treatment with azithromycin or vitamin C 500 mg on Day 1 and 250 mg daily on Days 2 through 5.28 The investigators concluded that azithromycin was no more effective than vitamin C in reduction of symptoms or improvement in quality of life.

PHARMACIST’S ROLE

The pharmacist, as a part of the health care team, can assist in improving outcomes by optimizing the treatment in patients diagnosed with acute bronchitis. Appropriate selection and dosing of antibiotic therapy may be guided by the pharmacist, as well as selection of supportive therapies for cough. Pharmacists may also play a role in reducing the unnecessary use of antibiotic agents in treating acute bronchitis and identifying those populations that may benefit from therapy. Patients either seen in the emergency room or admitted to the hospital require counseling for appropriate use of nebulizer or MDI prior to discharge to ensure optimal therapy.

Pharmacists can counsel on appropriate use, adverse effects, and anticipated outcomes with pharmacotherapy. Also, for those patients who are admitted to the hospital, the pharmacist is able to recommend transition from intravenous to oral therapies.

In the community setting, pharmacists play a significant role in recommending therapy for cough and nonpharmacologic therapies in patients with acute bronchitis. Recommendations for cough products should be based upon patient description of the cough as either productive or nonproductive in nature. Patients should be advised that their cough might persist for an average of 10 to 21 days.

Pharmacists are able to counsel those patients inquiring about smoking cessation on the availability of OTC products and appropriate dosing. Pharmacists should evaluate the patient for tobacco use, assess their willingness to quit, and assist with selection of the appropriate product. The patient should be advised on the long-term cardiovascular and cancer-related benefits of smoking cessation, as well as other reasons to quit such as effects of secondary smoke on family members, tooth loss, and wrinkles. Patients need assistance to optimally select and use smoking cessation medications based on their personal preferences, financial situation (i.e., prescription insurance, deductible, coverage), and the potential for adverse effects.

REFERENCES

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