Acute Bronchitis

Symptoms are a nonproductive or mildly productive cough accompanied or preceded by URI symptoms. Typical symptom duration before presentation is usually 5 days or more (1). Subjective dyspnea results from chest pain caused by musculoskeletal discomfort due to coughing or chest tightness related to bronchospasm, not from hypoxia.

Signs are often absent but may include scattered rhonchi and wheezing. Sputum may be clear or purulent. Sputum characteristics do not correspond with a particular etiology (ie, viral vs bacterial) or response to antibiotic therapy. Mild fever may be present, but high or prolonged fever is unusual and suggests influenza, pneumonia, or COVID-19.

On resolution, cough is the last symptom to subside and often takes 2 to 3 weeks but rarely can take even longer to do so.

• Clinical evaluation

• Sometimes chest radiographs to exclude other disorders

Diagnosis is primarily based on clinical presentation.

Patients who complain of dyspnea should have pulse oximetry to exclude hypoxemia.

Chest radiographs are done if clinical findings (eg, ill appearance, mental status change, high fever, tachypnea, hypoxemia, abnormal auscultatory findings such as altered breath sounds or crackles) suggest pneumonia or other serious illness. Older patients are the occasional exception in whom a lower threshold for radiography is required, because they may have pneumonia without fever and auscultatory findings, presenting instead with altered mental status and tachypnea.

Microbiologic testing (eg, sputum Gram stain and culture) is usually unnecessary. However, patients with signs or symptoms suggestive of COVID-19 should be tested for SARS-CoV-2. Diagnostic testing for influenza and pertussis in nasopharyngeal swab specimens should also be considered if there is high clinical suspicion based on exposure and/or clinical features. Patients with 10 to 14 days of ongoing symptoms should be evaluated for pertussis, particularly if they are unvaccinated, have a persistent paroxysmal cough or intermittent characteristic whoop and/or retching, or exposure to a confirmed case. Testing for Mycoplasma and Chlamydia infection is not necessary unless part of an outbreak. Viral panel testing is not usually recommended because results do not affect treatment.

Cough resolves within 2 weeks in 80% of patients; in the other 20%, it may take up to 8 weeks to resolve (1). Patients with cough that worsens after initial improvement and those with cough that lingers for > 8 weeks should undergo further evaluation, including a chest x-radiograph. Evaluation for noninfectious causes of chronic cough, such as asthma (including cough-variant asthma), postnasal drip, and gastroesophageal reflux disease, can usually be made on the basis of the clinical presentation. Differentiation of cough-variant asthma may require pulmonary function testing.

• Symptom relief (eg, acetaminophen, hydration, possibly antitussives)Symptom relief (eg, acetaminophen, hydration, possibly antitussives)

• Inhaled beta-agonist for wheezing

Nearly all patients require only symptomatic treatment, such as acetaminophen and hydration. Evidence supporting efficacy of Nearly all patients require only symptomatic treatment, such as acetaminophen and hydration. Evidence supporting efficacy ofroutine use of other symptomatic treatments, such as antitussives, mucolytics, and bronchodilators, is weak. Ibuprofen is generally not recommended as it has not been found to be helpful in aiding symptom resolution (use of other symptomatic treatments, such as antitussives, mucolytics, and bronchodilators, is weak. Ibuprofen is generally not recommended as it has not been found to be helpful in aiding symptom resolution (1). Antitussives (dextromethorphan) with or without mucolytics (guaifenesin) should be considered only if the cough is distressing or interfering with sleep. Patients with wheezing may benefit from an inhaled beta2-agonist (eg, albuterol) for a few days. Broader use of beta2-agonists is not recommended because adverse effects such as tremor, nervousness, and shaking are common ((dextromethorphan) with or without mucolytics (guaifenesin) should be considered only if the cough is distressing or interfering with sleep. Patients with wheezing may benefit from an inhaled beta2-agonist (eg, albuterol) for a few days. Broader use of beta2-agonists is not recommended because adverse effects such as tremor, nervousness, and shaking are common (2).

Acute bronchitis in otherwise healthy patients is a major cause of antibiotic overuse. The low incidence of bacterial causation, self-limiting nature of acute bronchitis, and the risk of adverse effects argue against widespread antibiotic use (3). Limiting inappropriate antibiotic use, which may be as high as 45% worldwide, is key in preventing antibiotic resistance (4). Patient education and delayed prescription (ie, to be only filled if no improvement after at least a couple of days) help limit unnecessary antibiotic use. Oral antibiotics are typically not used except in patients with pertussis or during known outbreaks of bacterial infection (mycoplasma, chlamydia). A macrolide such as azithromycin or clarithromycin is the preferred choice.or during known outbreaks of bacterial infection (mycoplasma, chlamydia). A macrolide such as azithromycin or clarithromycin is the preferred choice.