Bronchitis Dr. M. A. Sofi

Acute bronchitis Most common conditions encountered in clinical practice. Self-limited inflammation of the bronchi due to upper airway infection. Present with a cough lasting more than five days (typically 1 – 3 weeks), which may be associated with sputum production. Should be distinguished from chronic bronchitis, a condition in patients with COPD distinguished by a cough for at least three months in each of two successive years.

Causes of Bronchitis Acute bronchitis is most often caused by viruses that infect the epithelium of the bronchi, resulting in inflammation and increased secretion of mucus. In addition to viruses: Bacteria Exposure to tobacco smoke Exposure to pollutants or solvents GERD can also cause acute bronchitis. The usual causes of acute bronchitis are viral infections of URT including: Influenza A and B Parainfluenza Coronavirus (types 1-3) Rhinovirus Respiratory syncytial virus Human metapneumovirus.

Causes of Bronchitis Bacterial pathogens that cause pneumonia (e.g.,) Streptococcus pneumoniae Haemophilus influenzae, Staphylococcus aureus, Moraxella catarrhalis, or even gram-negative bacilli) can also cause acute bronchitis No convincing evidence to support the concept of "acute bacterial bronchitis" caused by these pathogens in adults. Other pathogens — that can cause acute bronchitis, although less commonly than viruses, include: Mycoplasma pneumoniae Chlamydophila (formerly Chlamydia) pneumoniae Bordetella pertussis

Signs and symptoms Nausea, vomiting, and diarrhea (rare) A complete history of exposure to toxic substances and smoking. Symptoms of bronchitis include: Cough (the most commonly observed symptom) Sputum production (clear, yellow, green, or even blood-tinged) Purulent sputum is reported in 50% of persons Changes in sputum color are due to peroxidase released by leukocytes in sputum. Fever (relatively unusual; in conjunction with cough, suggestive of influenza or pneumonia) Nausea, vomiting, and diarrhea (rare) General malaise and chest pain (in severe cases) Dyspnea and cyanosis (only seen with underlying COPD or another condition that impairs lung function) Sore throat Runny or stuffy nose Headache Muscle aches Extreme fatigue

Physical examination findings: The physical examination findings in acute bronchitis can vary from normal to Pharyngeal erythema Localized lymphadenopathy Rhinorrhea Coarse rhonchi Wheezes that change in location and intensity after a deep and productive cough. Occasionally, diffuse diminution of air intake Occasionally inspiratory stridor (findings indicate obstruction of a major bronchi or the trachea) Requiring sequentially vigorous coughing, suctioning Possibly, intubation or even tracheostomy.

Physical examination of the chest may reveal: DIAGNOSIS Self-limited inflammation of the bronchi due to upper airway infection, which is most often viral. Present with a cough lasting more than five days (typically one to three weeks), which may be associated with sputum production. For most patients with acute bronchitis, the diagnosis is based upon the history and physical examination, and further testing is not needed. Physical examination of the chest may reveal: Wheezing or rhonchi, but signs of consolidation or rales should not be present. Patients are generally afebrile There may be a low-grade temperature There should be no evidence of chronic pulmonary disease.

Investigations Chest x-ray — To exclude pneumonia Abnormal vital signs (pulse >100/minute, Respiratory rate >24 breaths/minute, Temperature >38ºC) Rales or signs of consolidation on chest examination The role of procalcitonin (PCT) in distinguishing patients who would benefit from antibiotic therapy is emerging. PCT is a more specific marker of bacterial infection than white blood count or C-reactive protein Microbiology — Bacterial cultures of expectorated sputum in patients with a negative chest radiograph are not recommended. Influenza should be considered in patients who present with symptoms of acute bronchitis and fever during influenza season

DIFFERENTIAL DIAGNOSIS Chronic bronchitis — Chronic bronchitis, by definition, is diagnosed in patients who have cough and sputum production on most days of the month for at least three months of the year during two consecutive years Pneumonia — Abnormal vital signs (fever, tachypnea, or tachycardia) and signs of consolidation or rales on physical examination suggest the possibility of pneumonia Gastroesophageal reflux — (GERD) is a common cause of intermittent or persistent cough. Cough may be present in the absence of complaints of symptoms of reflux, such as heartburn or sour taste in the mouth.

DIFFERENTIAL DIAGNOSIS Postnasal drip syndrome — The diagnosis of postnasal drip is suggested in patients who describe the sensation of postnasal drainage or the need to frequently clear their throat. Caused by the common cold, allergic rhinitis, vasomotor rhinitis, postinfectious rhinitis, rhinosinusitis, and/or environmental irritants. Asthma — Patients with acute bronchitis often have airway hyperreactivity with changes in pulmonary function testing. In contrast to patients with asthma, airway obstruction is transient in patients with acute bronchitis and usually resolves in five to six weeks.

DIFFERENTIAL DIAGNOSIS Mycoplasma pneumoniae — Mycoplasma pneumoniae is a relatively common cause of URT infection in young adults. Characterized by pharyngitis, constitutional symptoms, and cough that may be persistent for up to four to six weeks However, studies of adults with acute cough lasting for more than five days implicate M. pneumoniae in fewer than 1 percent of cases Data from seroepidemiologic studies suggest that M. pneumoniae is more likely to cause mild upper respiratory symptoms, such as sore throat and head congestion, than pneumonia. For most patients, M. pneumoniae infection usually manifests as a "nasty cold"

low-grade fever, although uncommon, are suggestive findings DIFFERENTIAL DIAGNOSIS Chlamydophila pneumoniae — In a study of 63 college students with acute bronchitis, C. pneumoniae was the responsible pathogen in 5 percent of cases. Clinical features include: pharyngitis laryngitis bronchitis hoarseness low-grade fever, although uncommon, are suggestive findings Pertussis — Bordetella pertussis the etiologic agents of whooping cough, was responsible for substantial morbidity and mortality before a vaccine was introduced in the mid-1940s. However, the incidence of pertussis has increased worldwide over the past 15 to 20 years Even with this increase, B pertussis only accounts for about 1 percent of cases of acute bronchitis in the US

Diagnostic Considerations Streptococcal pharyngitis is caused by group A streptococci (45%) and anaerobes (18%), which often occur as a co-infection. Much of the concern about diagnosing streptococcal pharyngitis is related to the complications of infection, particularly ARF and PSGN as a late complication. Maintaining a high level of suspicion for streptococci group A in the presence of pharyngitis is advisable. Other medical issues/problems to consider include the following: Exercise-induced asthma Bacterial tracheitis Cough Cystic fibrosis Influenza Hyperreactive airway disease Retained foreign body Tonsillitis Occupational exposures

TREATMENT Limit the use of cough suppressants The major therapeutic issue in most cases of acute bronchitis is the decision to use or forgo antibacterial agents. Multiple studies indicate that patients with acute bronchitis do not experience significant benefit from antibiotic therapy Most patients with acute bronchitis require only reassurance and symptomatic treatment. Symptomatic — Many patients with acute bronchitis may benefit from symptomatic treatment using a nonsteroidal antiinflammatory drug, aspirin, acetaminophen, and/or ipratropium

Bronchitis : Preventions These measures help prevent bronchitis and protect your lungs in general: Avoid tobacco smoke – Whether it includes your own smoke or second hand smoke from others, try to avoid it. Get an annual flu shot – Most cases of acute bronchitis result from influenza. So, getting your yearly flu shot can help protect you from both bronchitis and the flu.

Limit the use of cough suppressants since mucus should be coughed up to help unblock bronchi. Reduce intake of foods such as sugar, white flour, dairy and others that may be mucus- producing.

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