Definition
A.Acute bronchitis is inflammation of the tracheobronchial tree. Bronchitis is nearly always self-limited in the otherwise healthy individual. Generally, the clinical course of acute bronchitis lasts 10 to 14 days. The cause is usually infectious, but allergens and irritants may also produce a similar clinical profile. Asthma can be mistaken as acute bronchitis if the patient has no prior history of asthma.
Incidence
A.Bronchitis is more common in fall and winter in relation to the common cold or other respiratory illness. It occurs in men more frequently than in women. Fewer than 5% of patients with bronchitis develop pneumonia. It is one of the most common conditions seen in outpatients.
Pathogenesis
A.Most attacks are caused by viral agents, such as adenovirus, influenza, parainfluenza viruses, and respiratory syncytial virus (RSV).
B.Bacterial causes (account for only 6% of acute bronchitis cases) include Bordetella pertussis, Mycobacterium tuberculosis, Corynebacterium diphtheriae, and Mycoplasma pneumoniae. B. pertussis should be considered in adults with persistent coughs.
Predisposing Factors
A.Viral infection.
B.Upper respiratory infection (URI).
C.Exposure to cigarette smoke.
D.Exposure to other irritants.
E.Allergens.
F.Chronic aspiration/gastroesophageal reflux disease (GERD).
G.Immunocompromise and frailty.
Common Complaints
A.The most common symptom initially is a dry, hacking, or raspy-sounding cough. The cough then loosens and becomes productive.
Other Signs and Symptoms
A.Sore throat.
B.Rhinorrhea or nasal congestion.
C.Rhonchi during respiration.
D.Low-grade fever.
E.Malaise.
F.Retrosternal pain during deep breathing and coughing.
G.Decreased/lack of appetite.
Subjective Data
A.Ask about onset, duration, and course of symptoms.
B.Is cough productive?
C.Is there substernal discomfort?
D.Is there malaise or fatigue?
E.Has patient had a fever?
F.Does patient smoke? (Smoking aggravates bronchitis.)
G.A review of occupational history may be important in determining whether irritants play a role in symptoms.
H.Assess for symptoms of gastroesophageal reflux.
I.If diabetic, ask about home blood glucose readings.
Physical Examination
A.Check temperature, pulse, and blood pressure (BP). Consider pulse oximetry. Evaluate general appearance.
B.Inspect:
1.Observe overall appearance, including level of consciousness (LOC).
2.Inspect eyes, ears, nose, and throat (pharynx may be injected).
3.Transilluminate sinuses.
C.Palpate: Palpate lymph nodes, maxillary, and frontal sinuses.
D.Auscultate: Auscultate in all lung fields for crackles, wheezing, and rhonchi.
Diagnostic Tests
A.Consider chest x-ray to exclude pneumonia.
Differential Diagnoses
A.Bronchitis.
B.URI.
C.Asthma.
D.Sinusitis.
E.Cystic fibrosis (CF).
F.Aspiration.
G.Respiratory tract anomalies.
H.Foreign-body aspiration.
I.Pneumonia.
J.Chronic obstructive pulmonary disease (COPD) and emphysema.
K.Pertussis.
Plan
A.General interventions—primarily supportive and should ensure the patient is adequately oxygenating:
1.Tell the patient to increase fluid intake.
2.Suggest humidity and mist therapy.
3.Avoid irritants, such as smoke.
B. 
See Section III: Patient Teaching Guide Bronchitis, Acute.
C.Pharmaceutical therapy:
1.Acetaminophen (Tylenol) for fever and malaise.
a.Adults: 625 to 1,000 mg orally every 4 hours; not to exceed 4 g/d.
2.Expectorants such as guaifenesin with dextromethorphan (Robitussin DM, Humibid DM, Mytussin) to treat minor cough from bronchial/throat irritation. Cough suppressants including opiates are rarely appropriate, and include risk of sedation in elderly.
3.Among otherwise healthy individuals, antibiotics have not demonstrated to be beneficial for acute bronchitis and are against current Centers for Disease Control and Prevention (CDC) recommendations. However, oral antibiotics should be considered if symptoms persist for 2 weeks with supportive treatment (long-term persistence indicates bacterial infection):
a.Amoxicillin-clavulanic acid (Augmentin) 250 to 500 mg by mouth every 8 hours.
b.Doxycyline 100 mg by mouth every 12 hours.
c.Trimethoprim-sulfamethoxazole 80 to 160 one tablet by mouth every 12 hours.
d.Sputum cultures prior to antibiotic therapy help isolate causative pathogen.
4.Albuterol (Ventolin) for patients with wheezes or rhonchi, or for patients with a history of bronchoconstriction:
a.Two puffs every 4 to 6 hours or 2 to 4 mg by mouth three to four times a day.
Follow-Up
A.Follow up if patient does not improve in 48 hours.
B.Recommend yearly influenza vaccinations.
C.Ensure older adults have both pneumonia vaccinations recommended by the CDC.
Emergent Issues/Instructions
A.Patients should understand to call the office or go to the ED if shortness of breath (SOB) develops.
Consultation/Referral
A.In uncomplicated cases, mucus production decreases and cough disappears in 7 to 10 days. If symptoms persist, refer the patient to a physician.
B.Refer the patient if you note respiratory distress or worsening condition.
Individual Considerations
A.Geriatrics:
1.Use of hand-held bronchodilator should be demonstrated. Older adults who are cognitively intact or mildly impaired may be unable to use standard inhalers. Spacing chambers may be used to assist in proper delivery of inhaled medications. Nebulized treatments should also be considered for the following issues:
a.Decreased manual dexterity due to arthritis or reduced grip strength.
b.Cognitive impairment: Difficulty coordinating the required activation/inhalation steps to achieve proper penetration of medication into the lungs.
B.Geriatric red flags:
1.Monitor elderly patients for complications such as pneumonia. The elderly have a greater morbidity and mortality rate, and may present with confusion or loss of appetite only.
2.Follow-up may be needed every 24 hours to ensure improvement and to assess for septic changes.
Resource
Pulmonary Disease Aerosol Delivery Devices: A Guide for Physicians, Nurses, Pharmacists, and Other Health Care Professionals is available at www.aarc.org/wp-content/uploads/2018/03/aersol-guides-for-hcp.pdf