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Abstract: Acute bronchitis affects millions of individuals, significantly impacting patient health and the healthcare industry. Understanding evaluation and treatment guidelines for acute bronchitis allows the nurse practitioner to practice comprehensive care for patients. This article reviews evidence-based practices when caring for the patient with acute bronchitis, promoting optimization of healthy outcomes.
The purpose of this article is to review the evaluation and management of acute bronchitis in the adult population. Essential pathophysiology will be reviewed, and current evidence-based practices in evaluation and treatment will be identified. Best evidence guidelines will be examined, and implications for practice and essential patient education will be addressed. This will provide an understanding for nurse practitioners (NPs) regarding methods to promote healthy outcomes in patients affected with acute bronchitis.
Acute bronchitis is a common diagnosis seen in various healthcare settings. By definition, it is a clinical condition that involves an acute respiratory tract infection where cough is the hallmark feature. Symptoms typically last 1 to 2 weeks, and while phlegm may be present, there is no evidence of bronchial consolidation as with pneumonia.1 Typically viral in origin, it is considered in the spectrum of acute upper respiratory infections (URIs), or the "common cold," which also includes acute otitis media, pharyngitis and tonsillitis, and acute sinusitis.2 It is seen across the full spectrum of ages, gender, and demographics. As part of the diagnosis of URI, it accounts for greater than 36 million office visits annually.3 On average, adults acquire two to four URIs annually, and children may have as many as six to 10.4 As one of the three most commonly diagnosed illnesses in the ambulatory care setting along with essential hypertension and diabetes, URI is not only a significant clinical concern but an economic burden as well. Indirect costs for URIs are related to work days lost in adults who are ill in addition to those that are required to care for their sick children. Losses are estimated at $22.5 billion annually.5 The National Center for Health Statistics estimates that URIs lead to almost 20 million lost work days in adults and 21 million lost school days in children per year. Direct costs include the large number of office visits and diagnostic testing, which is frequent and of limited clinical value. These direct costs are $17 billion annually. Accounting for both direct and indirect costs, the toll approaches $40 billion per year.5 While data that specifically address acute bronchitis and its economic impact are limited, as part of the spectrum of URIs, it clearly has a significant burden on the population as well as healthcare providers.
Acute bronchitis is a diagnosis that implies self-limiting, large airway inflammation, the hallmark symptom of which is a cough that may or may not produce phlegm. The lack of small airway involvement or evidence of consolidation and infiltrate on chest X-ray is important to this diagnosis. While in rare circumstances, bacteria that commonly cause community-acquired pneumonia are isolated in the sputum of patients with acute bronchitis, the primary cause is attributed to several viral species.2 Although the benefit of isolating viral species is limited in evaluation and management in patients with acute bronchitis, there are several typical organisms that have been identified. Both influenza A and B species, parainfluenza virus, respiratory syncytial virus, coronavirus, adenovirus, and rhinovirus have all been recognized in isolates of those with acute bronchitis. It is occasionally discovered that bacterial species are found in sputum samples of patients with acute bronchitis; however, the role of these species is unclear, since resultant bronchial biopsies do not show invasion of the bacteria into large airways.6 Although fewer than 10% of cases have a bacterial cause, other considerations include atypical bacteria, such as Bordetella pertussis, Chlamydophila pneumoniae, and Mycoplasma pneumoniae. These are important to consider clinically because unlike their viral counterparts, they may be responsive to antibiotic treatment.7 Further complicating the identification of causative agents, common upper respiratory flora such as Haemophilus influenzae and Streptococcus pneumoniae are often found; however, it is unclear if their presence has any impact on the development of disease. Overall, sputum cultures of patients with acute bronchitis are challenging to assess because it is difficult to determine if they are accurate samples or contaminated by pathogens from the upper airway. Therefore, sputum cultures are often unreliable in guiding treatment strategies.8
Regardless of the causative pathogen, their impact can vary based on several factors, including comorbid conditions like underlying lung disease, presence of a local epidemic, vaccination status of the patient and population, and the season. Particularly in the fall and early spring, vehicles such as influenza are more likely to contribute to acute bronchitis.1 Given its likelihood for increased severity of illness, influenza should be considered and specifically evaluated for in the proper clinical context.
The American College of Chest Physicians (ACCP) describes acute bronchitis as "an acute infection of the lower respiratory tree that is manifested predominantly by cough with or without phlegm production that lasts for up to 3 weeks."9 Although acute bronchitis is commonly considered part of the URI diagnosis, by definition, bronchitis is inflammatory involvement of the lower respiratory tract. While there is often overlap between these two clinical conditions, they are mutually exclusive. In fact, the presence of cough due to the common cold is as high as 83% in the first 2 days of illness onset, and considering that acute bronchitis and the common cold share many of the same characteristics, it is often impossible to distinguish between the two.9 Furthermore, conditions specifically associated with URIs such as postnasal drip often result in the need for throat clearing and coughing; this can be confusing for the diagnosis of acute bronchitis.9 Clearly, these conditions tend to have overlapping clinical characteristics, and while ideally could be considered independently, they are often in tandem.
In addition to the multiple causative organisms that can lead to the development of acute bronchitis, there are wide variations in the distribution of effects in the lower respiratory tree (see Anatomy of the lung). Acute bronchitis may also be complemented by involvement of smaller airways as well. What is important to the distinction, however, is the absence of smaller airway consolidation and infiltrate as is seen in pneumonia. Regardless, acute bronchitis is an inflammatory reaction of the epithelium of the bronchi in response to infection by the causative organism(s). This reaction is in response to mucosal injury and epithelial cell damage and leads to the resultant release of proinflammatory mediators. This leads to epithelial cell desquamation and shedding, which causes bronchial hyperresponsiveness and the need for airway clearance, manifested by the characteristic cough. Depending on the extent, location of involvement, and possibly the organism itself, the cough may or may not result in significant phlegm production.6,7
While beyond the scope of this article, the pathophysiology of disease in at-risk populations is another point of distinction. This includes patients with underlying lung disease (COPD and bronchiectasis), immunocompromised patients (HIV, chemotherapy), or patients with other significant comorbid diseases (such as heart failure). An acute exacerbation of chronic bronchitis in a patient with COPD, for example, is a different disease than acute bronchitis in an otherwise healthy individual, varying in likely cause and pathology. These distinctions should be considered and managed accordingly.
Cough that begins early in the course of the illness is the hallmark symptom of acute bronchitis. Characteristics of the cough can vary. While often described as dry and nonproductive, it is not uncommon for the cough to progress from clear to discolored productive consistency as the illness evolves. About half of all patients with acute bronchitis report the presence of a cough that produces purulent sputum.10 A common but usually inaccurate notion is that a productive cough indicates the existence of bacterial infection and is an indication for antibiotic therapy. In fact, in otherwise healthy individuals, the production of purulent sputum is usually a manifestation of sloughing of the tracheobronchial epithelium and inflammatory cells, unrelated to alveolar infection. Sputum production has been shown to be a poor predictor for the presence of alveolar disease, such as pneumonia, and should not serve alone as a basis for the decision to administer antibiotics.10 The duration of the cough varies greatly, lasting anywhere from 5 to 20 days, with one study finding that the median time to patients feeling recovered was 11 days with complete symptom resolution to 15 days.11 While duration of cough itself is not a predictor of the presence of either acute bronchitis or other diagnoses, with a prolonged course, other alternate causes should be considered.
In addition to the presence of cough, patients with acute bronchitis often have other constitutional symptoms suggestive of infection, including fever, malaise, myalgia, and fatigue. These are not specific to this disease process, and given the fact that there is significant overlap in the symptoms of acute bronchitis and a URI, distinction between the two is almost impossible.9 Acute bronchitis is essentially a diagnosis of exclusion, where other symptoms and findings are not suggestive of an alternate cause. As an example, the presence of high fever, the previously mentioned constitutional symptoms, and marked dyspnea should suggest to the clinician the possibility of pneumonia. In this situation, further evaluation with a chest X-ray to evaluate for infiltrates and alveolar consolidation would be warranted. The only true diagnostic tool for evaluation of acute bronchitis is time and ongoing evaluation of the patient to see if another disease process reveals itself. In an otherwise healthy patient, the disease course is generally self-limited and responsive only to symptom control. Asthma, allergic bronchospasm, reflux esophagitis, chronic aspiration, lung tumors, heart failure, and ACE inhibitor use are other possible diagnoses in a patient with cough that may be appropriate to consider. Some of these may be considered along with acute bronchitis in the differential diagnosis of acute cough, and in the correct clinical scenario, specific evaluation may be necessary.
When acute bronchitis is considered, the approach to testing is generally guided by the taking of a thorough history and the evaluation of physical exam features that suggest an alternate diagnosis. There is no reasonable testing available that specifically confirms the diagnosis of acute bronchitis, and as mentioned, it is often a diagnosis of exclusion. Although there is no evidence that routine pulmonary function testing has significant impact on the disease course of acute bronchitis in otherwise healthy patients, it has been found that temporary limitations in airflow occur in about 40% of those with acute bronchitis, and 17% have reversibility of forced expiratory volume in one second greater than 15%.9 It is important to take a careful history that includes consideration of contact with others that are ill, in particular with infectious illness, such as pneumonia and influenza. It is also important to consider the patient's previous health and social history, especially focusing on previous cardiovascular and pulmonary status. Medications, tobacco, alcohol and illicit drug use, current or previous work exposures, recent travel, and immunization status are other considerations that are important to evaluate. While none of these specifically confirm acute bronchitis, they may suggest alternate diagnoses that could benefit from diagnostic testing. Cough in the absence of fever, tachypnea, tachycardia, and negative physical exam findings for pulmonary consolidation (crackles and egophony) reduce the likelihood of pneumonia, and a chest X-ray is likely not necessary. Patients with at-risk characteristics or findings suggestive of other pathology should be evaluated by clinically appropriate measures. The diagnosis of acute bronchitis can then be reasonably made in a patient with an acute respiratory infection; the chief characteristic symptom of which is cough with or without sputum production, if it has lasted no longer than 3 weeks, and there is no radiographic or clinical evidence of pneumonia and URI, acute asthma, or acute COPD exacerbation.9
The approach to management of patients with acute bronchitis should include an understanding of the disease course as well as a review of the evidence of beneficial treatment options. The ACCP has published guidelines that detail the management of acute bronchitis, which are summarized here.12 Despite the fact that the vast majority of cases of acute bronchitis are caused by viruses for which antibiotics are ineffective, between 65% and 80% of patients receive them.9 This is contrary to the fact that except in the few cases where the cause is bacterial, they have no impact on improvement in clinical outcomes.10,13 In otherwise healthy patients-even when bacterial cause is considered-the use of antibiotics is still not recommended, since they only modestly reduce the severity and duration of symptoms. One review found that the period of symptoms was decreased by only a fraction of a day with the use of the three most common antibiotics: erythromycin, doxycycline, and trimethoprim-sulfamethoxazole.7 If pertussis is suspected in the proper clinical scenario, then there is evidence that supports the use of empiric antibiotic administration while confirmation of the diagnosis is obtained, although the impact of antibiotic use is a decrease in transmission rather than resolution of symptoms.14 The CDC also recommends that if influenza is suspected, proper antiviral therapy should be initiated within 48 hours of the onset of symptoms, which has been shown to decrease the duration by approximately 1 day.15
Short-term therapy with antitussives and beta2-agonists in situations where wheezing is associated with coughing episodes has been found to be beneficial in treatment of acute bronchitis. Antitussives, such as codeine preparations and dextromethorphan, offer reduction in symptoms with patients who have chronic bronchitis, and their use may be beneficial in acute bronchitis. An empiric trial may be useful, although routine use of antitussives is not routinely suggested.12 In uncomplicated cases of acute bronchitis where wheezing is not an associated symptom, the use of beta2-agonists is not supported; however, when patients have previous underlying lung conditions, such as asthma, airflow obstruction, or wheezing, the addition of such medications may be helpful.9,16
Mucokinetic/expectorant agents and inhaled or parenteral corticosteroid treatments have not been shown to be helpful in the treatment of acute bronchitis; the ACCP does not endorse their use.12 In addition, while there are no specific recommendations that address primary health considerations, such as vaccination status and substance use cessation, particularly tobacco, it seems reasonable that a discussion about these would be beneficial. It is always important for the NP to routinely address this with patients, since it has an overall impact on health concerns in addition to acute bronchitis. Education that speaks specifically to ensuring vaccinations such as influenza, pertussis, and pneumonia would also be helpful.12 While the direct impact on acute bronchitis may be limited, the benefit of ensuring patient vaccination to both the patient and the community is valuable in reducing the prevalence of other, possibly more significant diseases that manifest with cough.
Acute bronchitis is one of the most common diagnoses encountered in healthcare today. It is essential that the NP has an understanding of the cause, evaluation, and management strategies for this illness as well as methods to communicate with patients in a manner that promotes awareness and healthy outcomes.
In understanding the pathophysiology of acute bronchitis, it is imperative to recognize that in the otherwise healthy adult patient, the vast majority of cases are caused by viruses. It is crucial to communicate this to patients so they understand the benefit of antibiotic use is limited. The CDC recommends that practitioners refer to acute bronchitis as a "chest cold" to reduce the expectation that antibiotics are necessary for treatment (see Acute cough illness). Clinical evaluation is often directed at ruling out other, more serious clinical conditions, such as pneumonia. The use of diagnostic testing, such as chest X-rays and pulmonary or lab data, has limited benefit in the evaluation of acute bronchitis and is not recommended other than to rule out other disease processes (if clinically indicated). Other symptom control that may offer benefit in the proper clinical setting includes a short course of antitussives and possibly beta2-agonists. There is no evidence that mucolytics and inhaled or parenteral corticosteroids offer any benefit to treatment.12
NPs are ideally situated to deliver care to patients for whom acute bronchitis is a clinical consideration. Having an understanding of the disease's cause and course, understanding the current recommendations for evaluation and management, and having the ability to communicate with patients in a manner that identifies these issues, are essential characteristics of an NP. Patient education should focus on understanding the methods of transmission and approaches to limit spread, appreciation of the therapies of symptom control, and understanding that in general, antibiotics do not change the course or severity of illness. In this manner, the NP as part of the multidisciplinary care delivery team can offer comprehensive care that maximizes patient understanding and healthy outcomes.
The CDC recommends that healthcare providers refer to acute bronchitis (also known as acute cough illness) as a chest cold to help reduce the expectation by patients that antibiotics are needed for treatment. It is important to explain to patients that the majority of cases (over 90%) are caused by viruses, and the benefit of antibiotic use is limited.
The following are tips to reduce antibiotic use
* Tell patients that antibiotic use increases the risk of an antibiotic resistant infection, and provide education materials on antibiotic resistance.
* Identify and validate patient concerns.
* Recommend specific symptomatic therapy.
* Spend time answering patient questions and offer an alternative plan if symptoms worsen.
* Remember: Effective communication is more important than an antibiotic for patient satisfaction.
* See http://www.cdc.gov/getsmart or contact the local health department for more information and patient education materials.
Source: Centers for Disease Control and Prevention. Acute Cough Illness (Acute Bronchitis). 2011. http://www.cdc.gov/getsmart/campaign-materials/info-sheets/adult-acute-cough-ill.
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