Ashley G.

Henderson 21

Bronchitis: Acute
and Chronic

Introduction
Bronchitis, the clinical term for inammation of the bronchi, is divided into acute and chronic forms. It presents
as cough, with or without sputum production, and has the potential for airway infection and no evidence of
pneumonia on physical examination or chest x-ray.
Acute bronchitis (AB) and chronic bronchitis (CB) are distinct entities, although the original presentation of
the patient can appear similar in both cases. The main distinguishing feature clinically is the duration of cough;
however, AB must also be distinguished from acute exacerbations of CB because the underlying pathophysiol-
ogy is dierent. Although both are diseases of the lower airways, CB is clinically dened as a productive cough
for at least 3 months of the year for at least 2 years in a row. It is one component of the spectrum of chronic
obstructive pulmonary disease that is discussed in more detail in Chapter 22. The remainder of this chapter
focuses primarily on AB.

Epidemiology and Pathogenesis release of proinammatory mediators, which lead to

AB affects about 5% of adults annually and is the ninth
most common illness in outpatients in the United States.
Cough is the most common symptom resulting in any
outpatient visit, and AB is the number one cause of cough
in this setting. Although concurrent airway infection is
part of the denition, up to 90% of these infections are
thought to be viral and do not warrant antibiotic treat-
ment. In fact, AB is considered the number one cause of
antibiotic abuse in this country. The usual viral causes
include inuenza A and B, parainuenza, coronavirus, rhi-
novirus, respiratory syncytial virus, and human metapneu-
movirus. There are also some bacterial causes of AB,
including Mycoplasma pneumoniae, Chlamydophila pneu-
moniae, Bordetella pertussis, and Bordetella parapertussis. In
addition, patients with CB can develop acute exacerbations
of their CB with Streptococcus pneumoniae, Moraxella catarrh-
alis, and Haemophilus inuenzae, but these are not com-
monly proved to be a cause of uncomplicated AB. It is
unclear whether these organisms are only colonizers or act
as pathogens.
The cause of the cough is thought to be multifactorial,
but histologically there is epithelial cell damage with
transient bronchial hyperresponsiveness and airow
obstruction. Although some pathologic changes occur, the
symptoms and the physical effects resolve completely in 3
to 6 weeks. Repeated attacks of AB can result in CB.
Clinical Presentation
Patients with AB present with a sudden onset of cough in
the absence of fever, tachycardia, and tachypnea. By deni-
tion, patients should not have asthma, a common cold, or
other upper respiratory tract infection. Uncomplicated AB
is not an exacerbation of CB. Simple upper respiratory
tract infections include rhinitis, laryngitis, pharyngitis, and
sinusitis. They can be caused by both bacteria and viruses
but are distinguished from AB by the lack of inammation
of the lower respiratory tract (trachea, bronchi, and bron-
chioles). The absence of lower tract inammation explains
why cough is rarely present in simple upper respiratory
tract infections.
Some patients with AB may complain of soreness in the
chest or mild shortness of breath, but the primary symptom
is cough, with or without increased sputum production. AB

128

warrants consideration in any patient who presents with
a cough lasting more than 5 days. It is not unusual for a
cough to last 10 to 20 days; however, the mean cough
duration, taking all causes into account, is 18 days, with an
occasional duration of 4 to 5 weeks. Only half of patients
report purulent sputum. The physical exam is usually neg-
ative for a specic nding other than cough; hence, the
presence of crackles or egophony on exam, especially when
associated with fever, warrants further evaluation with
chest x-ray to rule out pneumonia. If a patient presents
with a fever and cough and a negative chest x-ray, inuenza
and pertussis are two potential causes of AB. Otherwise,
other illnesses must be considered because 90% of AB
cases are viral and only one virusinuenzacauses have post-tussive emesis in up to 40% of cases. As previ-
fever.
Inuenza has the potential for high morbidity and mor-
tality, and 93% of these patients present with a cough as
well as weakness (94%), myalgia (94%), and fever (68%).
During inuenza season (primarily winter), the sudden
onset of fever and cough suggests inuenza.
Of the other viral infections that cause AB, coronavirus,
rhinovirus, and adenovirus often present with an upper
respiratory infection with the associated nasal congestion,
rhinorrhea, and pharyngitis, as well as the cough.
Dierential Diagnosis
Because the primary symptom of both acute and CB is
cough, the differential diagnosis is large. The history and
physical exam alone allow the exclusion of many of the
diagnoses.
The differential of AB includes pneumonia or pneumo-
nitis, asthma, upper airway cough syndrome (formerly
postnasal drip syndrome), gastroesophageal reux, CB
with an acute exacerbation, and medication reaction. Many
of these other diagnoses often last more than 3 weeks and
are more likely to present with a chronic cough. There-
fore, the primary differential diagnosis for the acute cough
of AB is pneumonia and an acute exacerbation of CB. The
associated mortality and required treatment for these diag-
noses are different. As previously noted, fever is uncom-
mon in AB unless it is associated with inuenza or pertussis
or unless it is complicated by pneumonia. Another cause
of acute cough is severe acute respiratory syndrome (SARS)
virus, which has a high morbidity and mortality rate and
quickly develops into pneumonia.
Causes of subacute cough (3 to 6 weeks duration)
include upper airway cough syndrome, asthma, gastro-
esophageal reux disease, pertussis, pneumonia, and an
acute exacerbation of CB. Many of these diagnoses can be
distinguished by history and physical examination alone.
Upper airway cough syndrome often presents with upper
airway congestion and the sensation of a drip in the
posterior oropharynx and has often been present for longer
than 6 weeks. Asthma is often intermittent or chronic, with
acute spells of worsening shortness of breath or chest
21  Bronchitis: Acute and Chronic 129
pain, associated with wheezing and exacerbated by change
in season, temperature, or climate. If the patient has a
chronic cough and a smoking history but presents with an
acute change in the baseline cough with increased sputum
production or change in color, the underlying problem is
probably an exacerbation of CB. Gastroesophageal reux
disease most often presents as a chronic cough, with a
history of heartburn or a cough that exacerbates at night-
time or with meals. Pertussis is a cause of cough with fever,
but it is often associated with a more prolonged cough,
lasting as long as 10 to 12 weeks, and coughing paroxysms.
Adults with pertussis often have a milder illness than chil-
dren, do not always have the characteristic whoop, and
ously noted, pneumonia often presents with cough and
fever and typical physical exam ndings of tachycardia,
lung crackles, or egophony. In contrast, only 30% of
elderly patients aged 75 years or older with community-
acquired pneumonia presented with a fever, and only 37%
had tachycardia.
Excluding the specic laboratory diagnosis of inuenza
or pertussis, the specic cause of AB is often not deter-
mined (i.e., type of virus or bacterium), but it can occasion-
ally be elucidated by a careful history. Exposure to ill
contacts, duration of cough, associated symptoms, and vac-
cination history can be helpful. If AB associated with fever
and pneumonia is excluded, then pertussis and inuenza
are the two main causes.
See Chapter 17 on cough for further discussion and
differential diagnoses.
Diagnostic Approach
The routine use of laboratory tests to dene the specic
pathogen in AB is not cost effective; as a result, routine
evaluation with sputum Gram stain and culture and routine
serum tests is not recommended. The exceptions are inu-
enza and pertussis, if clinically suspected. The rapid test
for inuenza is cost effective because it allows for the use
of antiviral agents and improves the understanding of the
epidemiology of outbreaks. Nevertheless, routine screen-
ing for inuenza in AB is not recommended unless the
patient presents with inuenza-like symptoms during the
inuenza season. If pertussis is suspected, a routine com-
plete blood count is helpful to look for the severe leuko-
cytosis associated with this diagnosis. There are complicated
serum and nasal culture recommendations based on the
stage of the infection. Whether these tests are warranted
can be debated because most cases of AB are not pertussis.
Several diagnostic tests can determine other specic patho-
gens but are not cost effective in simple AB and are not
recommended.
Obtaining a chest x-ray (if warranted by history and
physical exam) to rule out pneumonia is usually helpful,
especially given the signicant morbidity and mortality
rates associated with this diagnosis.
130 SECTION III  Disorders of the Respiratory System
Management and Therapy
Optimum Treatment
Most cases of AB are viral or self-limited, and only symp-
tomatic therapy is recommended.
Antimicrobial therapy is not indicated in most cases
because multiple trials have demonstrated only minor
reduction in the duration of cough (0.6 days) and no
difference in the time of return to work, school, or usual
activities at home on day 3 or 7. If a specic treatable
pathogen is identied, antimicrobial therapy is more likely
to be benecial. The use of anti-inuenza agents can
reduce the duration of cough by 1 day if the agent is started
within 48 hours of symptom onset, and treatment of per-
tussis is indicated to limit transmission. Although there are
current recommendations to consider antimicrobial
therapy for M. pneumoniae and C. pneumoniae, there are no
data suggestive of improved outcomes with antimicrobial
treatment.
Other therapies for AB include the use of antitussive
agents, 2 agonists, mucolytic agents, and corticosteroids.
There are limited data and support for the use of 2
agonists, mucolytics, and oral corticosteroids. A recent
Cochrane Database review did not support the use of 2
agonists based on ve trials, including patients with airow
obstruction. There are also no signicant clinical trials to
support the use of antitussive agents, but they are routinely
used for the acute symptomatic benet of the patient.
The current guidelines released by the American
College of Chest Physicians (ACCP) do not recommend
the use of antibiotics. The ACCP recommends 2 agonists
only in the subgroups of patients with chronic airow
obstruction at baseline or wheezing at presentation. There
is no role for mucolytic agents or anticholinergic agents.
For the treatment of pertussis, both the ACCP and the
Centers for Disease Control and Prevention recommend
macrolides as rst-line therapy and, for inuenza, oselta-
mivir or zanamivir. Newer generations of inuenza are
resistant to amantadine and rimantadine.
Avoiding Treatment Errors
As previously stated, the major treatment error is the use
of antimicrobial therapy for AB. Because of rising micro-
bial resistance, physicians are encouraged to use only
symptomatic therapy in patients with simple AB unless
specic microbials are identied or suspected.
Future Directions
AB is highly prevalent in primary care practice. The careful
history and physical examination remain the most helpful
diagnostic tools. Other diagnostic modalities are likely to
become available, including the use of the procalcitonin
test to discriminate between patients with pneumonia and
bronchitis. The chest physical exam remains the most
useful tool to distinguish between these two types of
pulmonary infection. The use of antibiotics is not
recommended for most cases; however, more than 70% of
patients who seek care receive antibiotics. This observation
has led to a campaign to dissuade physicians from this
practice. Limiting the overprescribing of antimicrobials
should decrease the cost of health care and reduce the
emergence of resistant pathogens.
EVIDENCE
1. American College of Chest Physicians: Diagnosis and manage-
ment of cough: ACCP evidence-based clinical practice guidelines.
Chest 129(1 Suppl):1S-23S, 2006.
This paper is a summary of the most up-to-date review of diagnosis
and management of cough as recommended by the American College of
Chest Physicians.
2. Aris R: Cough. In Runge MS, Greganti MA (eds): Netters Internal
Medicine, 2nd ed. Philadelphia, Elsevier, 2009.
3. Braman SS: Chronic cough due to acute bronchitis: ACCP
evidence-based clinical practice guidelines. Chest 129:95S-103S,
2006.
The author summarizes the practice guidelines recommended and
published by the American College of Chest Physicians in the diagnosis
and management of acute bronchitis.
4. The Cochrane Collection. Available at: http://www.cochrane.org.
Accessed April 18, 2007.
This represents a large collection of meta-analyses available on multiple
subjects and accessed on two topics: antibiotics for acute bronchitis and b2
agonists for acute bronchitis. Both are collective meta-analyses and both
were updated in 2006 with good summaries of multiple papers in the
topic of interest.
5. Donohue J: Chronic obstructive pulmonary disease. In Runge MS,
Greganti MA (eds): Netters Internal Medicine, 2nd ed. Philadel-
phia, Elsevier, 2009.
6. Wenzel RP, Fowler AA 3rd: Acute bronchitis. N Engl J Med
355(20):2125-2130, 2006.
This recent review was published with an overview and up-to-date
data on acute bronchitis.