Acute Bronchitis

Anumeha Singh; Akshay Avula; Elise Zahn.

Author Information

Last Update: August 15, 2022.

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Continuing Education Activity

Acute bronchitis is the inflammation of the lining of the bronchi. It is a common
presentation in emergency departments, urgent care centers, and primsary care
offices. In the United States, acute bronchitis is among the top ten most common
illnesses among outpatients; about five percent of adults have an episode of acute
bronchitis each year. This activity reviews the evaluation and management of
patients with acute bronchitis and highlights the role of the interprofessional team
in caring for patients with this condition.

Objectives:

 Describe the presentation of a patient with acute bronchitis.

 Explain how to distinguish acute bronchitis from pneumonia.
 Outline the management and treatment options for acute bronchitis.
 Summarize the importance of the interprofessional team in caring for and
counseling patients with acute bronchitis.

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Introduction
Acute bronchitis is an inflammation of the large airways of the lung. It is a
common clinical presentation to emergency departments, urgent care centers, and
primary care offices. About 5% of adults have an episode of acute bronchitis each
year. An estimated 90% of these seek medical advice for the same. In the United
States, acute bronchitis is among the top ten most common illnesses among
outpatients.[1][2][3]

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Etiology
Acute bronchitis is caused by infection of the large airways commonly due to
viruses and is usually self-limiting. Bacterial infection is uncommon.
Approximately 95% of acute bronchitis in healthy adults is secondary to
viruses. It can sometimes be caused by allergens, irritants, and bacteria. Irritants
include smoke inhalation, polluted air inhalation, dust, among others.[4]

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Epidemiology
Acute bronchitis is one of the common presentations in any healthcare setting. It
is estimated that every year, 5% of the general population reports an episode of
acute bronchitis, accounting for more than 10 million office visits yearly.[5] Like
most of the viral diseases of the respiratory tract, acute bronchitis is commonly
seen during the flu season. In the United States, flu season is
common during autumn and winter. It can follow any viral upper respiratory
infection (URI). The common pathogens are respiratory syncytial virus, influenza
virus A and B, parainfluenza, rhinovirus, and other similar viruses.

Factors like a history of smoking, living in a polluted place, crowding, and a

history of asthma, are all risk factors for acute bronchitis. In some people, acute
bronchitis can be triggered by particular allergens like pollens, perfume, and
vapors.

When the infection is bacterial, the isolated pathogens are usually the same as
those responsible for community-acquired pneumonia, for example,
Streptococcus pneumonia and Staphylococcus aureus.[6][7]

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Pathophysiology
Acute bronchitis is the result of acute inflammation of the bronchi secondary to
various triggers, most commonly viral infection, allergens, pollutants, etc.
Inflammation of the bronchial wall leads to mucosal thickening, epithelial-cell
desquamation, and denudation of the basement membrane. At times, a viral upper
respiratory infection can progress to infection of the lower respiratory tract
resulting in acute bronchitis.[8]

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History and Physical

Patients with acute bronchitis present with a productive cough, malaise, difficulty
breathing, and wheezing. Usually, their cough is the predominant complaint and
the sputum is clear or yellowish, although sometimes it can be purulent. Purulent
sputum does not correlate with bacterial infection or antibiotic use.[9] Cough after
acute bronchitis typically persists for 10 to 20 days but occasionally may last for 4
or more weeks. The median duration of cough after acute bronchitis is 18 days.
[10] Paroxysms of cough accompanied by inspiratory whoop or post-tussive
emesis should raise concerns for pertussis. A prodrome of upper respiratory
infection (URI) symptoms like runny nose, sore throat, fever, and malaise are
common. A low-grade fever may be present as well. High-grade fevers in the
setting of acute bronchitis are unusual and further diagnostic workup is required.

On physical exam, lung auscultation may be significant for wheezing; pneumonia

should be suspected when rales, rhonchi, or egophony are appreciated.
Tachycardia can be present reflecting fever as well as dehydration secondary to
the viral illness. The rest of the systems are typically within normal limits.

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Evaluation
Acute bronchitis is a clinical diagnosis based on history, past medical history,
lung exam, and other physical findings. Oxygen saturation plays an important role
in judging the severity of the disease along with the pulse rate, temperature, and
respiratory rate. No further workup is needed if vital signs are normal and there
are no exam findings suggestive of pneumonia. An exception to this rule is elderly
patients >75 years old. Also, further workup is needed when pneumonia is
suspected, the clinical diagnosis is in question, or in cases of high suspicion for
influenza or pertussis. 

Chest x-ray (CXR) findings are not specific and are typically normal.
Occasionally, the chest x-ray demonstrates increased interstitial markings
consistent with the thickening of bronchial walls. A chest x-ray differentiates
pneumonia from acute bronchitis when infiltrates are seen. Evidence-based
guidelines from the American College of Chest Physicians (ACCP) recommend
obtaining a CXR only when heart rate > 100/min, respiratory rate >24
breaths/min, oral body temperature > 38 degrees C, and chest examination
findings of egophony or fremitus.[5]

A complete blood count and chemistry may be ordered as a workup for fever. The
white blood count might be mildly elevated in some cases of acute bronchitis.
Blood chemistry can reflect dehydration changes.

Routine use of rapid microbiological testing is not cost-effective and would not
change management except during influenza season and in cases with high
suspicion of pertussis or other bacterial infection. Gram stain and bacterial sputum
cultures are specifically discouraged as bacteria are rarely the causative agent. 

Spirometry, when performed, demonstrates transient bronchial

hyperresponsiveness in 40% of patients with acute bronchitis. Reversibility of
FEV1 >15% is reported in 17% of patients.[5] Airflow obstruction and bronchial
hyperresponsiveness typically resolve in 6 weeks.

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Treatment / Management
Acute bronchitis is self-limiting and treatment is typically symptomatic and
supportive therapy. For cough relief, nonpharmacological and pharmacological
therapy should be offered. Nonpharmacological therapy includes hot tea, honey,
ginger, throat lozenges, etc. No clinical trials evaluated the efficacy of these
interventions. Antitussive agents like dextromethorphan and codeine are
frequently used in clinical practice to suppress cough based on their effectiveness
in chronic bronchitis and studies on cough in the common cold. No randomized
trials exist to evaluate their effectiveness in acute bronchitis. Codeine should be
avoided due to its addictive potential. Data on the use of a mucolytic agent is
conflicting. 

Beta-agonists are routinely used in acute bronchitis patients with wheezing. Small
randomized control trials on beta-agonists for cough in acute bronchitis had mixed
results. A Cochrane review of five trials demonstrated no significant benefit of
beta-agonists on daily cough except for a small benefit in a subgroup of patients
with wheezing and airflow obstruction at baseline.[11] A more recent Cochrane
review demonstrated similar results.[12] 

Analgesic and antipyretic agents may be used to treat associated malaise, myalgia,
and fever. Prednisone or other steroids can be given to help with the
inflammation as well. Although there is not enough evidence showing their
benefit, they are useful in patients with underlying chronic obstructive pulmonary
disease (COPD) or asthma. Typically the steroid is used as short-term burst
therapy. Sometimes a longer tapering dose of steroids might be warranted,
especially in patients with underlying asthma or COPD.[13][14]

ACCP guidelines recommend against antibiotic use in simple acute bronchitis in

otherwise healthy adults. A Cochrane review of nine randomized, controlled trials
of antibiotic agents showed a minor reduction in the total duration of cough (0.6
days). The decrease in the number of days of illness was not significant per this
review.[15] Hence antibiotic use should be avoided in simple cases considering
the cost of antibiotics, the growing global problem of antibiotic resistance, and the
possible side effects of antibiotic usage. Multiple other international medical
societies recommend against antibiotic use in viral acute bronchitis. Despite thes
recommendations, a large proportion of patients with acute bronchitis are
prescribed antibiotics. No data exist to justify the prospect of cough being less
severe or less prolonged with antibiotic therapy. Antimicrobial therapy is
recommended when a treatable pathogen is identified such as influenza or
pertussis. In patients with influenza infection, oseltamivir or zanamivir should be
promptly started. Macrolides are the treatment of choice for pertussis along with 5
days of isolation. It is interesting to note that whooping cough is only present in a
minority of patients with pertussis. 

Procalcitonin might be useful in deciding on antibiotic use when the diagnosis of

acute bronchitis is uncertain. A meta-analysis demonstrated procalcitonin-guided
antibiotic therapy reduced antibiotic exposure and improved survival.[16]

Lifestyle modification like smoking cessation and the avoidance of allergens and
pollutants play an important role in the avoidance of recurrence and
complications. Flu vaccine and pneumonia vaccine are especially recommended
in special groups including adults older than 65, children younger than two years
(older than six months), pregnant women, and residents of nursing homes and
long-term care facilities. People with asthma, COPD, and other
immunocompromised adults are also at higher risk of developing complications.
Recurrence is seen in up to a third of the cases of acute bronchitis.

In summary, the data for the use of beta-agonists, steroids, and mucolytic agents,
especially in patients with no underlying COPD and asthma, is lacking. Treatment
should be guided by the individual response to them and reported benefit, as well
as, weighing risk and benefit in each case.

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Differential Diagnosis
Other causes of acute cough should be considered especially when a cough
persists for longer than 3 weeks. 

 Asthma: Acute asthma is misdiagnosed as acute bronchitis in

approximately one-third of the patients who present with acute cough.
 Acute/chronic sinusitis
 Bronchiolitis
 COPD
 Gastroesophageal reflux disease (GERD)
 Viral pharyngitis
 Heart failure
 Pulmonary embolism

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Prognosis
Acute bronchitis is self-limiting and resolves with symptomatic treatment in most
instances. Secondary pneumonia is possible. Rare cases of acute respiratory
distress syndrome and respiratory failure have been reported in the literature.[17]
[18]

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Complications
 Secondary pneumonia
 Respiratory distress
 Days missed of school/work

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Deterrence and Patient Education

Patients with acute bronchitis should be made aware of the importance of lifestyle
modifications including smoking cessation and the avoidance of allergens and
pollutants to lower their risk of recurrence and complications. Influenza and
pneumonia immunizations are especially recommended in special groups
including adults older than 65, children younger than two years (older than six
months), pregnant women, and residents of nursing homes and long-term care
facilities. Patients should also be provided education regarding the risks of
prescribing antibiotics when they are not indicated including antibiotic resistance,
cost, and potential side effects.

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Pearls and Other Issues

Sometimes secondary pneumonia can develop. This is usually indicated by
worsening symptoms, productive cough, and fever. In such cases, a chest x-ray is
indicated. This is especially important in immunocompromised adults, the elderly
population, infants and newborns, and smokers. Pulmonary emboli should always
be in differentials in a patient with a cough and shortness of breath. Sometimes
aggressive coughing can lead to spontaneous pneumothorax and or spontaneous
pneumomediastinum. Hence any acute worsening of symptoms usually requires a
chest x-ray.

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Enhancing Healthcare Team Outcomes
Acute bronchitis is a very common disorder that frequently presents to emergency
departments and primary care offices. It is a very common cause of absenteeism
from work and school. The condition is best managed by an interprofessional
team that includes a primary care provider, a nurse, a pharmacist, and a
pulmonologist. The key is coordinating patient education. The nursing staff
should be tasked to work with patients to stop smoking and avoid exposure to
secondhand smoke. The nurses should encourage individuals to get influenza and
pneumococcal vaccines to reduce morbidity. The nurses should monitor patients
for compliance and report back to the clinical team leader patients that are non-
compliant with smoking cessation. In addition, the nurse and pharmacist should
encourage hand washing to limit the spread of micro-organisms.

For those patients whose cough persists, the nurses should monitor for the
possibility of atypical pneumonia or pneumonia that requires antibiotic therapy. In
these cases, the nurse should arrange a follow-up visit with the clinical team for
re-assessment. If an antibiotic is deemed necessary, the pharmacist should
evaluate for drug-drug interaction and allergy prior to filling the prescription. If
there are any concerns, the pharmacist should make the clinical team aware of
potential problems before the drug is dispensed.

The outcomes of patients with acute bronchitis are good; however, it is a common
reason for absenteeism from work. In some patients with underlying COPD and
other lung problems, acute bronchitis can have high morbidity. Patients whose
symptoms persist for more than six weeks need to be re-evaluated to ensure that
the diagnosis is correct. [Level 5][19][20]

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Review Questions
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