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In Practice

Acute Bronchitis

Bjorn Buhagiar

Abstract Introduction
Acute bronchitis is a common respiratory tract infection Acute bronchitis is a self-limited inflammation of the large
usually caused by viruses and encountered often by family airways of the lungs. It affects approximately 5% of adults
doctors. Diagnosis is usually made on clinical symptoms, annually, with a higher incidence observed during winter and
as findings on physical examination are usually limited and autumn rather than in summer and spring.1,2 Acute bronchitis
investigations give non-specific results. Numerous studies represents almost 20% of respiratory tract infections with an
have shown that antimicrobial agents are useless in acute incidence of around 29 episodes per thousand person years.3
bronchitis, and have a negligible effect on symptoms. The In children, 5% of visits to the family doctor are for acute
use of other medications such as β 2-agonists and cough bronchitis, representing around 12% of visits for respiratory
suppressants has also been questioned and these medications tract infections.4,5 On the other hand, in adults, acute bronchitis
are usually reserved for patients suffering from chronic lung comprises 23% of respiratory tract infections encountered by
conditions. Delayed prescription has been considered as a family doctors.6
means of reducing antibiotic overprescribing in respiratory tract
infections, however, the effect of such measures on antibiotic A typical clinical scenario
use and resolution of symptoms is questionable, as are studies A 34 year-old male presented with a three day history of
on the patients’ satisfaction with delayed prescribing. Patients’ increasing cough, progressing from a dry one, to one producing
knowledge on respiratory tract infections and their treatment yellowish sputum. He also complained of night-time low-
must also be considered, as it has been shown that family grade fever which was relieved with paracetamol. The patient
practitioners should be aware of the patients’ expectations when confirmed mild shortness of breath on exertion but denied chest
they attend with a respiratory tract infection. pain. He did not suffer from asthma and had quit smoking ten
years previously. On examination, the patient was afebrile
and auscultation of the chest disclosed faint wheezing on
expiration.

Aetiology
Viruses are the most common cause of acute bronchitis: the
main culprits being influenza A and B viruses, parainfluenza
virus, respiratory syncytial virus, coronavirus, adenovirus
and rhinovirus.7 Bacterial species commonly implicated in
community-acquired pneumonias are also isolated from the
Keywords sputum in a minority of patients suffering from acute bronchitis.1
Acute bronchitis, antimicrobials, delayed prescriptions, These include Streptococcus pneumoniae, Haemophilus
patient expectations influenzae and Moraxella catharralis.8 However, the role of
these species in the disease remains unclear as bronchial biopsies
have not shown bacterial invasion. In some cases, atypical
bacteria such as Bordetella pertussis, Chlamydia pneumoniae
and Mycoplasma pneumoniae may be implicated.1

Clinical presentation
Management of acute bronchitis in the community is very
much dependent on comprehensive history taking and a high
Bjorn Buhagiar MD index of suspicion.
Department of Primary Health Care, Floriana
Email: bjornbuh@maltanet.net

Malta Medical Journal Volume 21 Issue 01 March 2009 45


Signs and symptoms culture for bacteria is infrequently done at community level,
During the first few days of the infection, the symptoms of since the results of such procedure take time, and as previously
acute bronchitis cannot be distinguished from those of a mild highlighted, do not have a particularly relevant role in the
upper respiratory tract infection. However, in the case of acute management of the patient’s condition. Clinical symptoms
bronchitis the cough persists for more than 5 days, usually for 10 that indicate the presence of a bacterial infection would be
to 20 days, although occasionally it may last for 4 or more weeks. production of greenish sputum and the presence of high fever.
This cough is usually dry but some patients may report the If antibiotic treatment is deemed necessary, the medications of
production of sputum. Fever, fatigue and malaise may feature choice are co-amoxiclav, and clarithromycin in patients allergic
together with the cough and more severe symptoms include to penicillin.8
shortness of breath, wheezing and chest pains. Infections by
adenoviridae might also cause gastrointestinal symptoms.9 Other treatment
Examination in patients with acute bronchitis is usually A few randomised controlled trials have studied the effect
normal however in severe cases, there may be a rise in of β2-agonists administered orally or by aerosol for cough
temperature and signs of respiratory distress. Chest examination associated with acute bronchitis. All these trials have involved
can reveal decreased intensity of breath sounds, wheezing, a small number of patients and produced mixed results. Most
rhonchi and prolonged expiration.9 trials involved patients without preexisting lung disease and
showed that daily cough scores and the likelihood of persistent
Investigations cough after seven days did not differ significantly between
Diagnosis of acute bronchitis is usually made from the the active treatment and placebo groups.13-15 However, in one
clinical history and by exclusion of the presence of pneumonia. trial, a subgroup of patients with evidence of airflow limitation
Most family doctors rely on the presence of a persistent dry or had significantly lower scores for symptoms on day two after
productive cough. A chest X-ray can reveal hyperinflation whilst treatment with β2-agonists.13 A recent Cochrane Review of five
a full blood count would feature a raised white blood cell count. A trials involving 418 adults showed that even among patients
sputum sample may disclose increased neutrophils and a culture with airflow obstruction, the potential benefit of β2-agonists is
may grow an organism, when the cause is bacterial. not well supported and should be balanced against the adverse
effects of treatment.16
Treatment Although there are multiple clinical trial data on the use of
Antimicrobial therapy mucolytics and oral steroids in chronic bronchitis, there is no
Antibiotics are not recommended in most cases of acute data that supports the use of these agents in the treatment of
bronchitis. Systematic analyses of clinical trials have suggested acute bronchitis.
that antimicrobial agents may reduce the duration of symptoms
only slightly. A quantitative systemic review showed that Guidelines
resolution of cough was not affected by antibiotic treatment According to the 2001 guidelines of the American College of
and neither was there any significant clinical improvement. The Physicians for the treatment of uncomplicated acute bronchitis,
side-effects of antibiotics were predictably more common in the antibiotic treatment is “not recommended, regardless of the
antibiotic groups than in the placebo groups.9 A meta-analysis of duration of cough.”17 According to the 2006 guidelines of the
eight trials showed that the use of antibiotics in acute bronchitis American College of Chest Physicians (ACCP), routine treatment
reduced the duration of cough and sputum production by with antibiotics for treating acute bronchitis is not justified. They
one and a half days. The results were statistically significant, also suggest that antitussive agents are only occasionally useful
however, one can argue that the risk of side-effects and the and that there is no routine role for inhaled bronchodilators or
societal cost of increasing antibiotic resistance need to be taken mucolytic agents. However, these guidelines note that subgroups
into consideration when interpreting such findings.10 of patients with chronic airflow obstruction at baseline or
Results of a randomised, double-blind trial comparing wheezing at the onset of illness may benefit from beta2-agonists.
patients suffering with acute bronchitis treated with azithromycin These guidelines have been criticised on the grounds that many
with those treated with vitamin C showed no difference between of the recommendations were based more on opinion rather
the groups in the health-related quality of life at seven days or in than on evidence.
the proportion of patients who returned to work, school or usual
activities at home on day three or seven.11 A Cochrane review of Delayed prescriptions
nine randomised, controlled trials of antibiotic agents showed a Delayed prescription is when the family doctor prescribes
significant but minor reduction in the duration of cough. There a medicine and advises the patient to take medication after
was a non-significant reduction in the number of days of feeling a number of days, only if certain signs or symptoms persist
ill and a non-significant increase in adverse events attributed or develop. This can potentially address both the patient’s
to antibiotics.12 expectation of an antibiotic prescription and the practitioner’s
Antibiotics are indicated for acute bronchitis when bacteria clinical uncertainty, while minimising actual antibiotic
are cultivated from sputum cultures. Admittedly, sputum consumption.

46 Malta Medical Journal Volume 21 Issue 01 March 2009


Antibiotic overprescribing patients received it. Half of the patients expected an antibiotic
The use of delayed prescription to reduce antibiotic and more than 70% of these received one. They also reported
overprescribing in acute bronchitis and other respiratory that receiving information or reassurance was more strongly
tract infections has been considered in several studies. The associated with patient satisfaction rather than being prescribed
first evidence of benefit from delayed prescribing using a an antibiotic.29
randomised controlled trial came from a 1997 study involving
patients complaining of a sore throat. This showed that 99% of Conclusion
the immediate prescriptions were consumed whilst only 31% The patient presented in this clinical scenario was not
of delayed prescriptions were consumed without apparent prescribed any antibiotics as there were no clinical features
serious harm.19 Other studies showed that delayed prescriptions suggestive of bacterial aetiology. Instead, the patient’s
resulted in reduced antibiotic prescription also in patients with expectations from the consultation were explored. He stated
otitis media, in those with cough, and in patients with common that he had decided to consult a doctor as he was worried
cold.20-23 Three of these studies reported an increase in signs and that he might be getting a bad infection. It was subsequently
symptoms in patients who received a delayed prescription19,20,22, explained that the bronchitis was probably being caused by a
one study reported a decrease in symptoms23 whilst the other virus and the natural course of the infection was discussed. He
study did not report anything on symptoms.21 was reassured that no antibiotics were required but paracetamol
was prescribed to relieve symptoms. He was also prescribed
Satisfaction with the consultation a short-acting bronchodilator for a brief period to relieve the
and beliefs on delayed prescription shortness of breath. An opportunity was taken to discuss the
Little is known about patients’ response to delayed issue of smoking with the patient. Instead of offering a delayed
prescribing, or the decision-taking processes that they employ prescription, the patient was advised to attend again if symptoms
in choosing whether to take their medication. The satisfaction were to deteriorate or if the cough would persist for more than
of the patient with delayed prescribing was also studied in the three weeks.
studies mentioned above. Two of the randomised trials showed
a significant decrease in satisfaction with the consultation when References
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