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AUTHOR INFORMATION Section 1 of 10 Chronic

Author Information Introduction Clinical Differentials Workup Treatment Medication Follow- Bronchitis
up Miscellaneous Bibliography

Author: Samer Qarah, MD, Fellow, Department of Internal

Medicine, Division of Pulmonary and Critical Care, The Chronic
Brooklyn Hospital Center and Cornell University
Obstructive
Coauthor(s): Ali Hmidi, MD, Staff Physician, Department
of Internal Medicine, Brooklyn Hospital Center, Cornell Pulmonary
University; Klaus-Dieter Lessnau, MD, Assistant Clinical Disease
Professor, Department of Medicine, Weill Medical College
of Cornell University; Medical Director, Department of Pneumonia,
Respiratory Care Services, Div of Pulmonary and Critical Bacterial
Care Medicine, Brooklyn Hospital Center; Roger Olade,
MD, Staff Physician, Department of Internal Medicine,
Brooklyn Hospital Center, Cornell University Weill Medical Pneumonia,
College Community-
Samer Qarah, MD, is a member of the following medical Acquired
societies: American College of Chest Physicians, American
Medical Association, and Medical Society of the State of Pneumonia,
New York Viral
Editor(s): Helen M Hollingsworth, MD, Associate
Professor, Department of Internal Medicine, Division of
Pulmonary and Critical Care, Boston University School of Sinusitis,
Medicine; Francisco Talavera, PharmD, PhD, Senior Acute
Pharmacy Editor, eMedicine; Gregg T Anders, DO,
Medical Director, Great Plains Regional Medical
Command, Brook Army Medical Center; Clinical Associate
Professor, Department of Internal Medicine, Division of Continuing
Pulmonary Disease, University of Texas Health Science Education
Center at San Antonio; Timothy D Rice, MD, Associate
Professor, Departments of Internal Medicine and Pediatrics CME available
and Adolescent Medicine, St Louis University; and Zab for this topic.
Mohsenifar, MD, Director, Division of Pulmonary/Critical Click here to
Care Medicine, Department of Medicine, Cedars-Sinai take this CME.
Medical Center; Professor, Department of Internal
Medicine, University of California at Los Angeles School of
Medicine
INTRODUCTION Section 2 of 10 Get the latest board
and recertification
Author Information Introduction Clinical Differentials Workup Treatment Medication Follow- textbooks from
up Miscellaneous Bibliography
BMPpearls.com

Background: Bronchitis is an inflammation of the bronchial

tubes (bronchi), which are the air passages that extend from (Advertisement)
the trachea into the small airways and the alveoli. Viruses,
bacteria, mycoplasmas, parasites, smoking, or inhalation of
chemical pollutants or dust may cause inflammation. Chronic Get the most
bronchitis is a condition associated with excessive comprehensive online
tracheobronchial mucus production sufficient to cause cough residency
with expectoration for at least 3 months during a period of 2 management system
 available at
consecutive years. Chronic bronchitis is associated with eResidency.net.
hypertrophy of the mucus-producing glands found in the
mucosa of large cartilaginous airways. See Chronic (Advertisement)
Obstructive Pulmonary Disease (COPD) for discussion of
chronic bronchitis.
Patient Education
Although acute bronchitis should not be treated with
antimicrobials, it is frequently difficult to refrain from Click here for
prescribing them. Accurate testing and decision-making patient
protocols as to who would and would not benefit from education.
antimicrobial therapy would be very useful but are not
currently available.

Pathophysiology: During an episode of acute bronchitis, the

cells of the bronchial-lining tissue are irritated and the
mucous membrane is hyperemic and edematous, diminishing
the bronchial mucociliary function. Consequently, the air
passages become clogged by debris, and irritation increases.
In response, a copious secretion of mucus develops, which
causes the characteristic cough of bronchitis. For instance,
with mycoplasmal pneumonia, bronchial irritation results from
the attachment of the organism (Mycoplasma pneumoniae)
to the respiratory mucosa, with eventual sloughing of affected
cells. Acute bronchitis usually lasts about 10 days. If the
inflammation extends downward to the ends of the bronchial
tree, into the small bronchi (bronchioles), and then into the air
sacs, bronchopneumonia results.

Chronic bronchitis is a condition associated with excessive

tracheobronchial mucus production sufficient to cause cough
with expectoration for at least 3 months of the year for more
than 2 consecutive years. The alveolar epithelium is both the
target and the initiator of inflammation in chronic bronchitis.

Predominance of neutrophils and peribronchial distribution of

fibrotic changes result from the action of interleukin 8 (IL-8),
colony-stimulating factors, and other chemotactic and
proinflammatory cytokines. Airway epithelial cells release
these inflammatory mediators in response to toxic, infectious,
and inflammatory stimuli, in addition to decreased release of
regulatory products such as ACE or neutral endopeptidase.

Chronic bronchitis can be categorized as simple chronic

bronchitis, chronic mucopurulent bronchitis, or chronic
bronchitis with obstruction. Mucoid sputum production
characterizes simple chronic bronchitis. Persistent or
recurrent purulent sputum production in the absence of
localized suppurative disease, such as bronchiectasis,
characterizes chronic mucopurulent bronchitis. Chronic
bronchitis with obstruction must be distinguished from
chronic infective asthma. The differentiation is based mainly
on the history of the clinical illness. Patients who have
chronic bronchitis with obstruction present with a long history
of productive cough and late onset of wheezing, whereas
patients who have asthma with chronic obstruction have a
long history of wheezing with late onset of productive cough.

Chronic bronchitis may result from a series of attacks of

acute bronchitis, or it may gradually evolve because of heavy
smoking or inhalation of air contaminated with other
pollutants in the environment. When so-called smoker's
cough is continual rather than occasional, the mucus-
producing layer of the bronchial lining has probably
thickened, narrowing the airways to the point where
breathing becomes increasingly difficult. With immobilization
of the cilia that sweep the air clean of foreign irritants, the
bronchial passages become more vulnerable to further
infection and the spread of tissue damage.

Frequency:

 In the US: Approximately 8 million people have

chronic bronchitis, and 2 million have emphysema.
According to the National Center for Health Statistics,
more than 12 million cases of acute bronchitis
occurred in 1994, a number roughly equal to 5% of the
US population. By way of comparison, 91 million
cases of influenza, 66 million cases of the common
cold, and 31 million cases of other acute upper
respiratory tract infections occurred during that same
year.

 Internationally: Acute bronchitis is common

throughout the world and is one of the top 5 reasons
for physician visits in countries that track such data.

Mortality/Morbidity: Bronchitis is almost always self-limited

in individuals who are otherwise healthy, although it may
result in absenteeism from work and school. Severe cases
occasionally produce deterioration in patients with significant
underlying cardiopulmonary disease or other comorbidities.

Race: No difference in racial distribution exists; however,

bronchitis occurs more frequently in populations with a low
socioeconomic status and in people who live in urban and
highly industrialized areas.

Sex: Bronchitis affects males more than females.

Age:

 In the United States, two thirds of adult males and one

fourth of females have emphysema at death.

 Although found in all age groups, acute bronchitis is

most frequently diagnosed in children younger than 5
years. In 1994, more than 11 of every 100 children
younger than 5 years were diagnosed with bronchitis.
This compared with only 4 of every 100 individuals in
all other age groups.

CLINICAL Section 3 of 10

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History: Obtain a complete history, including information on

exposure to toxic substances and smoking. Patients with
chronic bronchitis are often overweight and cyanotic. Initially,
cough is present in the winter months. Over the years, the
cough progresses from hibernal to perennial, and
mucopurulent relapses increase in frequency, the duration
and severity of which increase to the point of exertional
dyspnea. Symptoms of acute bronchitis include the following:

 Fever

 Cough and sputum production

o Cough begins early in the course of many acute

respiratory infections and tends to become
more prominent as the disease progresses.

o In one prospective study of acute respiratory

disease, 45% of patients were coughing 2
 weeks after presentation, and 25% were
coughing after 3 weeks. Sputum production
was reported in approximately half of the
patients in whom cough occurred.

o An initially dry cough may later induce

production of mucoid sputum, which
characteristically develops a more purulent
character in the later stages of illness.

 Sore throat

 Runny or stuffy nose

 Headache

 Muscle aches

 Extreme fatigue

 Nausea, vomiting, and diarrhea are rare. Severe

cases may cause general malaise and chest pain.
With severe tracheal involvement, burning, substernal
chest pain associated with respiration, and coughing
may occur.

 Dyspnea and cyanosis are not observed in adults

unless the patient has underlying COPD or another
condition that impairs lung function.

Physical: Patients may be afebrile or have a low-grade

fever. The rest of the physical examination findings in acute
bronchitis can vary from normal to pharyngeal erythema,
localized lymphadenopathy, and rhinorrhea to coarse rhonchi
and wheezes that change in location and intensity after a
deep and productive cough. Diffuse wheezes, high-pitched
continuous sounds, and the use of accessory muscles can
be observed in severe cases. Occasionally, diffuse
diminution of air intake or inspiratory stridor occurs; these
findings indicate obstruction of a major bronchi or the
trachea, which requires sequentially vigorous coughing,
suctioning, and, possibly, intubation or even tracheostomy.

 Sustained heave along the left sternal border indicates

right ventricular hypertrophy secondary to chronic
 bronchitis.

 Clubbing on the digits and peripheral cyanosis indicate

cystic fibrosis.

 Bullous myringitis may suggest mycoplasmal

pneumonia.

 Conjunctivitis, adenopathy, and rhinorrhea suggest

adenovirus infection.

Causes: Acute bronchitis is usually caused by infections,

such as those caused by Mycoplasma species, Chlamydia
pneumoniae, Streptococcus pneumoniae, Moraxella
catarrhalis, and Haemophilus influenzae and by viral
infection, such as those caused by influenza, parainfluenza,
adenovirus, rhinovirus, and respiratory syncytial virus.
Exposure to irritants, such as pollution, chemicals, and
cigarette smoke, may also cause acute bronchial irritation.

 Cigarette smoking is indisputably the predominant

cause of chronic bronchitis. Recent studies indicate
that smoking marijuana causes similar damage.

o Smoking impairs ciliary movement, inhibits

function of alveolar macrophages, and leads to
hypertrophy and hyperplasia of mucus-
secreting glands.

o Smoking can also increase airway resistance

via vagally mediated smooth muscle
constriction.

o Unless some other factor can be isolated as the

irritant that produces the symptoms, the first
step in dealing with chronic bronchitis is to stop
smoking.

 Air pollution levels have been associated with

increased respiratory health problems among people
living in affected areas. The Air Pollution and
Respiratory Health Branch of the National Center for
Environmental Health directs the fight of the Centers
for Disease Control and Prevention (CDC) against
respiratory illness associated with air pollution.
 o In 1990, American industry emitted more than
$2.4 billion of toxic pollutants into the
atmosphere.

o In 1991, 98 areas exceeded the Environmental

Protection Agency's recommended levels for
ozone, and an estimated 140 million Americans
lived in those areas. Also in 1991, 76 areas
exceeded recommended levels for carbon
monoxide, 70 exceeded recommended levels
for particulate matter, and 50 exceeded
recommended levels for sulfur dioxide.
o According to the Healthy People 2000 report,
each year in the United States, the following
occur:
 "The health costs of human exposure to
outdoor air pollutants range from $40 to
$50 billion."
 "An estimated 50,000 to 120,000
premature deaths are associated with
exposure to air pollutants."
 "People with asthma experience more
than 100 million days of restricted
activity, costs for asthma exceed $4
billion, and about 4,000 people die of
asthma."

DIFFERENTIALS Section 4 of 10

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Adenoviruses
Allergic and Environmental Asthma
Aspiration Pneumonia
Asthma
Bronchiectasis
Chlamydia Pneumonia
Chronic Bronchitis
Chronic Obstructive Pulmonary Disease
Pneumonia, Bacterial
Pneumonia, Community-Acquired
Pneumonia, Viral
Sinusitis, Acute
Other Problems to be Considered:

 Exercise-induced asthma

 Bacterial tracheitis
 Cough
 Cystic fibrosis
 Influenza
 Hyperreactive airway disease
 Retained foreign body
 Pediatric considerations
o Bronchiolitis
o Croup
o Laryngotracheobronchitis and pertussis

 Streptococcal pharyngitis

o This condition is most commonly caused by

group A streptococcus (45%) and anaerobes
(18%) (often occurring as a co-infection).
Penicillin is the drug of choice, as opposed to
broad-spectrum antimicrobials such as
amoxicillin/clavulanic acid, quinolones, or
macrolides. If the patient is allergic to penicillin,
clindamycin is a good alternative.

o The rapid group A streptococcal antigen tests offer a

quick answer but lack the specificity and sensitivity
of culture. Much of the concern about diagnosing
streptococcal pharyngitis is related to the
complications of infection, particularly acute
rheumatic fever and poststreptococcal
glomerulonephritis as a late complication.
Therefore, maintaining a high level of suspicion for
streptococcus group A in the presence of pharyngitis
is advisable.

WORKUP Section 5 of 10

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Lab Studies:
  Bronchitis may be suspected in patients with an acute respiratory infection
with cough. However, because many more serious diseases of the lower
respiratory tract cause cough, bronchitis must be considered a diagnosis of
exclusion.

 Obtain cultures of respiratory secretions for influenza virus, M pneumoniae,

and Bordetella pertussis when these organisms are suspected. Culture
methods and immunofluorescence tests have been developed for laboratory
diagnosis of C pneumoniae.

 Obtain a throat swab.

 Obtain a CBC count with differential.

 Sputum cytology may be helpful if the cough is persistent.

 Blood culture may sometimes be helpful if bacterial superinfection is

suspected.

Imaging Studies:

 Order chest radiographs.

 Perform bronchoscopy to exclude foreign body aspiration, tuberculosis,

tumors, and other chronic diseases of the tracheobronchial tree and lungs.

Other Tests:

 Influenza tests may be useful. Additional serologic tests, such as for atypical
pneumonia, are not indicated.

Procedures:

 Laryngoscopy can exclude epiglottitis.

Histologic Findings: Goblet cell hyperplasia, mucosal and submucosal

inflammatory cells, edema, peribronchial fibrosis, intraluminal mucus plugs, and
increased smooth muscle are characteristic findings in small airways in chronic
obstructive lung disease.
TREATMENT Section 6 of 10

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Medical Care: Therapy is generally aimed toward alleviation of symptoms.

 To alleviate symptoms, a doctor may prescribe a combination of medications

 that both open up obstructed bronchial airways and thin obstructive mucus
so that it can be coughed up more easily.

 Antitussive medications and antipyretic medications may be used to treat

bronchitis.

 A steam vaporizer near the bed can also be helpful in easing chest
congestion at night.

 Among otherwise healthy individuals, antibiotics have not demonstrated any

consistent benefit in the symptomatology or natural history of acute
bronchitis. Antibiotics are recommended to patients with bronchiectasis or
COPD exacerbation or if purulent sputum production has lasted beyond 7
days without evidence of improvement to other conventional therapy.

 Care for acute bronchitis is primarily supportive and should ensure that the
patient is oxygenating adequately.

Consultations: Primary care physicians can usually treat acute bronchitis unless
severe complications occur or the patient has underlying pulmonary disease or
immunodeficiency.

 Primary care physicians

 Pulmonary medicine specialists

 Infectious disease specialists

Diet:

 The value of a diet of fruits, vegetables, and salads is debatable.

 The value of antioxidants is not proven.

Activity: Bed rest is recommended.

MEDICATION Section 7 of 10

Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Bibliography

Therapy for acute bronchitis is generally aimed toward alleviation of symptoms and
includes the use of analgesics, antipyretics, antitussives, and expectorants.

Among otherwise healthy individuals, antibiotics have not demonstrated any

consistent benefit in the symptomatology or natural history of acute bronchitis.
Nonetheless, surveys from Europe, Australia, and the United States indicate that
80% of patients with acute bronchitis receive antibiotics. Antibiotic overuse
contributes to the emergence of drug-resistant organisms.

Several studies have shown conflicting results on the use of zinc as an adjunct
treatment against influenza A. Most recent studies demonstrated favorable results;
however, participants complained of a bad taste and significant nausea.

Drug Category: Antibiotics -- Studies have focused on healthy individuals

(asthmatic patients excluded) or patients with COPD. A small beneficial effect of
antibiotics in treating patients with COPD appears to exist, and TMP/SMX remains
a good and inexpensive choice. Therefore, it may be reasonable to extend
antibiotic use to asthmatic patients and others with limited cardiopulmonary
reserve. If an antibiotic is to be used, a macrolide is a reasonable first choice
because it is active against mycoplasmal and chlamydial organisms and B
pertussis.

Erythromycin (E.E.S., E-Mycin, Ery-Tab)

-- Inhibits bacterial growth, possibly by
blocking dissociation of peptidyl t-RNA
from ribosomes, causing RNA-
Drug Name
dependent protein synthesis to arrest.
For treatment of staphylococcal,
streptococcal, chlamydial, and
mycoplasmal infections.
Adult Dose 250-500 mg PO qid or 333 mg PO tid
Pediatric Dose 30-50 mg/kg/d PO divided qid
Documented hypersensitivity, hepatic
Contraindications
impairment
Coadministration may increase toxicity
of theophylline, digoxin, carbamazepine,
and cyclosporine; may potentiate
Interactions anticoagulant effects of warfarin;
coadministration with lovastatin and
simvastatin increases risk of
rhabdomyolysis
B - Usually safe but benefits must
Pregnancy
outweigh the risks.
Caution in liver disease; estolate
formulation may cause cholestatic
jaundice; adverse GI effects are
Precautions
common (administer doses pc);
discontinue use if nausea, vomiting,
malaise, abdominal colic, or fever occur
 Clarithromycin (Biaxin) -- Reversibly
binds to the P site of the 50S ribosomal
subunit of susceptible organisms and
Drug Name may inhibit RNA-dependent protein
synthesis by stimulating the dissociation
of peptidyl t-RNA from ribosomes.
Results in bacterial growth inhibition.
Adult Dose 250-500 mg PO bid
Pediatric Dose 7.5 mg/kg PO bid
Documented hypersensitivity,
Contraindications
coadministration of pimozide
Toxicity increases with coadministration
of fluconazole and pimozide; effects
decrease and adverse GI effects may
increase with coadministration of
rifabutin or rifampin; may increase
toxicity of anticoagulants, cyclosporine,
tacrolimus, omeprazole,
carbamazepine, ergot alkaloids,
triazolam, and HMG CoA-reductase
inhibitors; cardiac arrhythmias may
occur with coadministration of cisapride;
Interactions
plasma levels of certain
benzodiazepines may increase,
prolonging CNS depression;
arrhythmias and increase in QTc
intervals occur with disopyramide;
coadministration with omeprazole may
increase plasma levels of both agents;
serum digoxin concentrations may
increase (antibiotic reduces gut flora
that metabolize digoxin in >10% of
patients)
C - Safety for use during pregnancy has
Pregnancy
not been established.
Coadministration with ranitidine or
bismuth citrate is not recommended with
CrCl <25 mL/min; administer half dose
or increase dosing interval if CrCl <30
Precautions mL/min; diarrhea may be a sign of
pseudomembranous colitis;
superinfections may occur with
prolonged or repeated antibiotic
therapies
 Azithromycin (Zithromax) -- Treats mild-
Drug Name
to-moderate microbial infections.
Day 1: 500 mg PO
Adult Dose
Days 2-5: 250 mg PO qd
12 mg/kg PO qd; not to exceed 500
Pediatric Dose
mg/dose
Documented hypersensitivity; hepatic
Contraindications impairment; do not administer with
pimozide
May increase toxicity of theophylline,
warfarin, and digoxin; effects are
reduced with coadministration of
Interactions aluminum and/or magnesium antacids;
nephrotoxicity and neurotoxicity may
occur when coadministered with
cyclosporine
B - Usually safe but benefits must
Pregnancy
outweigh the risks.
Site reactions can occur with IV route;
bacterial or fungal overgrowth may
result with prolonged antibiotic use; may
increase hepatic enzymes and
Precautions
cholestatic jaundice; caution in impaired
hepatic function, prolonged QT intervals,
or pneumonia; caution in patients who
are hospitalized, geriatric, or debilitated
Tetracycline (Sumycin) or Doxycycline
(Bio-Tab, Doryx, Vibramycin) --
Tetracycline: May be an option outside
the United States. Treats gram-positive
and gram-negative organisms as well as
mycoplasmal, chlamydial, and rickettsial
infections. Inhibits bacterial protein
synthesis by binding with 30S and,
Drug Name possibly, 50S ribosomal subunit(s). Less
effective than erythromycin.
Doxycycline: Provides coverage for
mycoplasmal and chlamydial organisms
but not active against B pertussis.
Inhibits protein synthesis and bacterial
growth by binding with 30S and,
possibly, 50S ribosomal subunits of
susceptible bacteria.
 Tetracycline: 250-500 mg PO qid
Adult Dose Doxycycline: 100 mg PO bid on day 1,
then 100 mg PO qd for 7-10 d
Tetracycline:
<8 years: Not recommended
>8 years: 25-50 mg/kg/d (10-20 mg/lb)
PO qid
Pediatric Dose
Doxycycline:
<8 years: Not recommended
>8 years: 2-5 mg/kg/d PO in 1-2 divided
doses; not to exceed 200 mg/d
Documented hypersensitivity, severe
Contraindications
hepatic dysfunction
Bioavailability decreases with antacids
containing aluminum, calcium,
magnesium, iron, or bismuth
subsalicylate; can decrease effects of
Interactions oral contraceptives, causing
breakthrough bleeding and increased
risk of pregnancy; tetracyclines can
increase hypoprothrombinemic effects
of anticoagulants
Pregnancy D - Unsafe in pregnancy
Photosensitivity may occur with
prolonged exposure to sunlight or
tanning equipment; reduce dose in renal
impairment; consider drug serum level
determinations in prolonged therapy;
Precautions tetracycline use during tooth
development (last half of pregnancy
through age 8 y) can cause permanent
discoloration of teeth; Fanconilike
syndrome may occur with outdated
tetracyclines
Drug Name Cefditoren (Spectracef) -- Semisynthetic
cephalosporin administered as prodrug.
Hydrolyzed by esterases during
absorption and distributed in circulating
blood as active cefditoren. Bactericidal
activity results from inhibition of cell wall
synthesis via affinity for penicillin-
binding proteins. No dose adjustment
necessary for mild renal impairment
(CrCl 50-80 mgL/min/1.73 m2) or mild-
 to-moderate hepatic impairment.
Indicated for the treatment of acute
exacerbation of chronic bronchitis
caused by susceptible strains of
Streptococcus pyogenes. The 400-mg
dose is indicated for the treatment of
AECB caused by susceptible strains of
H influenzae, Haemophilus
parainfluenzae, S pneumoniae
(penicillin-susceptible strains only), or M
catarrhalis.
200 mg PO with meals bid for 10 d
Moderate renal impairment (CrCl 30-49
mL/min/1.73 m2: No more than 200 mg
Adult Dose
PO bid
Severe renal impairment (CrCl <30
mL/min/1.73 m2): 200 mg PO qd
<12 years: Not established
Pediatric Dose
>12 years: Administer as in adults
Documented hypersensitivity to drug,
penicillin, related compounds, or milk
protein sodium caseinate; carnitine
Contraindications
deficiency or inborn errors of
metabolism that may result in clinically
significant carnitine deficiency
Absorption reduced with H2 receptor
antagonists and antacids of magnesium
Interactions and aluminum hydroxides may reduce
absorption; probenecid may increase
plasma concentrations of cefditoren
B - Usually safe but benefits must
Pregnancy
outweigh the risks.
May cause diarrhea, nausea, and
vaginal moniliasis (yeast infection);
pseudomembranous colitis may occur;
clinical manifestations of carnitine
Precautions
deficiency may occur with prolonged
use; prolonged use may result in
emergence and overgrowth of resistant
organisms; caution in breastfeeding
Drug Name Trimethoprim and sulfamethoxazole
(Bactrim DS, Septra) -- Inhibits bacterial
synthesis of dihydrofolic acid by
 competing with para-aminobenzoic acid,
resulting in inhibition of bacterial growth.
Antibacterial activity of TMP-SMZ
includes common urinary tract
pathogens, except Pseudomonas
aeruginosa. As with tetracycline, it has
in vitro activity against B pertussis. Not
useful in mycoplasmal infections.
160 mg TMP/800 mg SMZ PO q12h for
Adult Dose
10-14 d
<2 months: Do not administer
Pediatric Dose >2 months: 15-20 mg/kg/d, based on
TMP, PO tid/qid for 14 d
Documented hypersensitivity,
Contraindications megaloblastic anemia due to folate
deficiency, and in late pregnancy
May increase PT when used with
warfarin (perform coagulation tests and
adjust dose accordingly);
coadministration with dapsone may
increase blood levels of both drugs;
coadministration of diuretics increases
incidence of thrombocytopenia purpura
Interactions
in elderly patients; phenytoin levels may
increase with coadministration; may
potentiate effects of methotrexate in
bone marrow depression; hypoglycemic
response to sulfonylureas may increase
with coadministration; may increase
levels of zidovudine
C - Safety for use during pregnancy has
Pregnancy
not been established.
Precautions Avoid in infants because of the
possibility of kernicterus; discontinue at
first appearance of skin rash or sign of
adverse reaction; obtain CBC counts
frequently; discontinue therapy if
significant hematologic changes occur;
goiter, diuresis, and hypoglycemia may
occur with sulfonamides; prolonged IV
infusions or high doses may cause bone
marrow depression (if signs occur,
administer 5-15 mg/d leucovorin);
caution in folate deficiency (eg, patients
 with chronic alcoholism, elderly patients,
patients receiving anticonvulsant
therapy, patients with malabsorption
syndrome); hemolysis may occur in
individuals who are G-6-PD deficient;
patients with AIDS may not tolerate or
respond to TMP-SMZ; caution in renal
or hepatic impairment (perform
urinalyses and renal function tests
during therapy); administer fluids to
prevent crystalluria and stone formation
Amoxicillin (Biomox, Trimox, Amoxil) --
Interferes with synthesis of cell wall
Drug Name mucopeptides during active
multiplication, resulting in bactericidal
activity against susceptible bacteria
250-500 mg PO q8h; not to exceed 3
Adult Dose
g/d
Pediatric Dose 20-50 mg/kg/d PO divided q8h
Contraindications Documented hypersensitivity
Reduces the efficacy of oral
Interactions
contraceptives
B - Usually safe but benefits must
Pregnancy
outweigh the risks.
Adjust dose in renal impairment; may
Precautions
enhance chance of candidiasis.
Ciprofloxacin (Cipro) -- Has a
bacteriocidal property by inhibiting the
Drug Name
DNA gyrase and consequently cell
growth.
Adult Dose 250-500 mg PO bid for 7-14 d
<18 years: Not recommended
Pediatric Dose
> 18 years: Administer as in adults
Contraindications Documented hypersensitivity
Interactions Antacids, iron salts, and zinc salts may
reduce serum levels; administer
antacids 2-4 h before or after taking
fluoroquinolones; cimetidine may
interfere with metabolism of
fluoroquinolones; ciprofloxacin reduces
therapeutic effects of phenytoin;
probenecid may increase ciprofloxacin
 serum concentrations; may increase
toxicity of theophylline, caffeine,
cyclosporine, and digoxin (monitor
digoxin levels); may increase effects of
anticoagulants (monitor PT)
C - Safety for use during pregnancy has
Pregnancy
not been established.
In prolonged therapy, perform periodic
evaluations of organ system functions
(eg, renal, hepatic, hematopoietic);
Precautions adjust dose in renal function
impairment; superinfections may occur
with prolonged or repeated antibiotic
therapy

Drug Category: Antitussives/expectorants -- Sparse data attest to the efficacy of

expectorants outside the test tube.

Guaifenesin with dextromethorphan

(Humibid DM, Robitussin DM) -- Treats
Drug Name
minor cough resulting from bronchial
and throat irritation.
10 mL PO q4h; not to exceed 40
Adult Dose
mL/24h
<2 years: Not recommended
Pediatric Dose 2-6 years: 2.5 mL PO q4h
6-12 years: 5 mL PO q4h
Contraindications Documented hypersensitivity
Interactions None reported
C - Safety for use during pregnancy has
Pregnancy
not been established.
Not to be used to treat productive cough
Precautions or persistent chronic cough resulting
from emphysema
Guaifenesin and codeine (Robitussin
AC) -- The prototype antitussive,
codeine, has been used successfully in
Drug Name
some chronic cough and induced-cough
models, but little clinical data in upper
respiratory tract infections exist.
5-10 mL PO q4-8h; not to exceed 60
Adult Dose
mL/d
 Pediatric Dose 1-1.5 mg/kg of codeine/d PO divided qid
Contraindications Documented hypersensitivity
Interactions Increases toxicity of CNS depressants
C - Safety for use during pregnancy has
Pregnancy
not been established.
Not to be administered for productive
cough or persistent chronic cough from
Precautions
emphysema; caution in renal
impairment

Drug Category: Bronchodilators -- Studies (although limited) have shown an

advantage to using bronchodilators and possible superiority to antibiotics for relieving
bronchitis symptoms.

Albuterol (Proventil, Ventolin) -- Relaxes

bronchial smooth muscle by action on
Drug Name
beta2 receptors with little effect on
cardiac muscle contractility.
2-4 mg/dose PO divided tid/qid; not to
exceed 32 mg/d
Adult Dose
MDI: 2 puffs q4-6h; not to exceed 12
inhalations/d
Pediatric Dose 0.1-2 mg/kg PO tid
Contraindications Documented hypersensitivity
Beta-adrenergic blockers antagonize
effects; inhaled ipratropium may
increase duration of bronchodilatation
Interactions by albuterol; cardiovascular effects may
increase with MAOIs, inhaled
anesthetics, TCAs, and
sympathomimetic agents
C - Safety for use during pregnancy has
Pregnancy
not been established.
Caution in hyperthyroidism, diabetes
Precautions
mellitus, and cardiovascular disorders

Drug Category: Antivirals -- Influenza vaccinations offer greater protection for the
appropriate populations because they offer coverage for influenza A and B. However,
amantadine and rimantadine can be useful during epidemics of influenza A. Zaminivir, the
newest agent, is undergoing clinical trials and may be effective for influenza A and B.
 Rimantadine (Flumadine) -- Inhibits viral
replication of influenza A virus H1N1,
Drug Name H2N2, and H3N2. Prevents viral
penetration into host by inhibiting
uncoating of influenza A.
Adult Dose 200 mg PO qd or 100 mg PO bid
<10 years: 5 mg/kg PO qd, up to 150
Pediatric Dose mg/d
>10 years: Administer as in adults
Contraindications Documented hypersensitivity
Acetaminophen and aspirin reduce
Interactions levels when taken concurrently;
cimetidine increases plasma levels
C - Safety for use during pregnancy has
Pregnancy
not been established.
Precautions Caution in hepatic impairment
Amantadine (Symmetrel) -- Prevents
penetration of virus into host by
inhibiting uncoating of influenza A.
Drug Name
Rimantadine appears to have a better
adverse effect profile and can be taken
qd.
Adult Dose 100 mg PO bid for 5 d
Pediatric Dose 4.4 mg/kg, up to 150 PO mg/d
Contraindications Documented hypersensitivity
Drugs with anticholinergic or CNS
stimulant activity increase toxicity;
concurrent administration of
Interactions
hydrochlorothiazide plus triamterene
may increase plasma concentrations of
amantadine
C - Safety for use during pregnancy has
Pregnancy
not been established.
Caution in liver disease, uncontrolled
psychosis, eczematoid dermatitis,
seizures, and patients receiving CNS
Precautions stimulant drugs; reduce dose in renal
disease when treating Parkinson
disease; do not discontinue this
medication abruptly
Drug Category: Analgesics/antipyretics -- Often helpful in relieving the associated
lethargy, malaise, and fever associated with illness.

Ibuprofen (Ibuprin, Advil, Motrin) --

Usually the DOC for treatment of mild to
Drug Name
moderate pain if no contraindications
exist.
Adult Dose 400-800 mg PO q4-6h
Pediatric Dose 10 mg/kg PO q6-8h
Documented hypersensitivity; peptic
ulcer disease, recent GI bleeding or
Contraindications
perforation, renal insufficiency, or high
risk of bleeding
Coadministration with aspirin increases
risk of inducing serious NSAID-related
adverse effects; probenecid may
increase concentrations and, possibly,
toxicity of NSAIDs; may decrease effect
of hydralazine, captopril, and beta-
Interactions blockers; may decrease diuretic effects
of furosemide and thiazides; monitor PT
closely (instruct patients to watch for
signs of bleeding); may increase risk of
MTX toxicity; phenytoin levels may be
increased when administered
concurrently
B - Usually safe but benefits must
Pregnancy
outweigh the risks.
Category D in third trimester of
pregnancy; caution in congestive heart
failure, hypertension, and decreased
Precautions
renal and hepatic function; caution in
anticoagulation abnormalities or during
anticoagulant therapy
Acetaminophen (Tylenol, Panadol,
Aspirin-Free Anacin) -- DOC for
treatment of pain in patients with
Drug Name
documented hypersensitivity to aspirin
or NSAIDs, with upper GI disease, or
who are taking oral anticoagulants.
325-650 mg PO q4-6h or 1000 mg
Adult Dose
tid/qid; not to exceed 4 g/d
 <12 years: 10-15 mg/kg/dose PO q4-6h
prn; not to exceed 2.6 g/d
Pediatric Dose
>12 years: 325-650 mg PO q4h; not to
exceed 5 doses (2.6 g) in 24 h
Documented hypersensitivity, G-6-PD
Contraindications
deficiency
Rifampin can reduce analgesic effects
of acetaminophen; coadministration with
Interactions barbiturates, carbamazepine,
hydantoins, and isoniazid may increase
hepatotoxicity
B - Usually safe but benefits must
Pregnancy
outweigh the risks.
Hepatotoxicity possible in people with
chronic alcoholism following various
dose levels; severe or recurrent pain or
high or continued fever may indicate a
Precautions serious illness; APAP is contained in
many OTC products, and combined use
with these products may result in
cumulative APAP doses exceeding
recommended maximum dose
FOLLOW-UP Section 8 of 10

Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Bibliography

Further Outpatient Care:

 Routine follow-up care is usually not necessary. If symptoms worsen (eg,

shortness of breath, high fever, vomiting, persistent cough) consider an
alternate diagnosis. If symptoms recur (>3 episodes per y), further
investigation is recommended. If symptoms persist for longer than 1 month,
reassess patient for other causes of cough.

 Flu vaccines are 70-90% effective in preventing flu among healthy adults. In
elderly or chronically ill persons, the flu vaccine may be less effective in
preventing illness than it is in preventing serious complications and death. In
the United States, the flu season usually occurs from approximately
October-April. Influenza vaccination of healthy patients may be beneficial by
reducing absenteeism. Administer influenza vaccine to the following
populations:

o Patients with underlying cardiopulmonary disease should receive

influenza vaccinations annually.
 o Residents of nursing homes and chronic-care facilities and persons
older than 65 years should receive vaccinations annually.

o Adults and children who have chronic disorders of the pulmonary or

cardiovascular systems, including children with asthma, should
receive influenza vaccinations annually.

o Adults and children who have required regular medical follow-up or

hospitalization during the preceding year because of chronic
metabolic diseases (including diabetes), renal dysfunction,
hemoglobinopathies, or immunosuppression (including
immunosuppression caused by medications) should receive influenza
vaccinations annually.

o Children and teenagers (aged 6 mo to 18 y) who are receiving long-

term aspirin therapy and who therefore might be at risk for developing
Reye syndrome after the flu should receive influenza vaccinations
annually.

o Women who will be in the second or third trimester of pregnancy

during the flu season should receive influenza vaccinations.

o In certain situations, such as in nursing homes, also administer

amantadine or rimantadine when an index case is found until the
vaccine has had a chance to take effect.

In/Out Patient Meds:

 Nonsteroidal anti-inflammatory drugs (NSAIDs) are helpful in treating

constitutional symptoms of acute bronchitis, including mild-to-moderate pain.

 Proventil and Robitussin treat cough.

Deterrence/Prevention:

 Influenza vaccine may reduce the incidence of upper respiratory tract

infection and subsequently reduce the incidence of acute bacterial
bronchitis.

Complications:

 Complications occur in about 10% of patients with acute bronchitis.

o Bacterial superinfection

o Lower respiratory tract infection and pneumonia

  Fewer than 5% of patients with bronchitis develop pneumonia.
 Incidence of subsequent pneumonia, however, remains
unaffected by the use of antibiotics.

o Repeated episodes of acute bronchitis may lead to chronic bronchitis.

o Acute bronchitis may lead to reactive airway disease.

o Hemoptysis

Prognosis:

 Patients with acute bronchitis have a good prognosis.

Patient Education:

 Patient education is essential in prevention and treatment of acute

bronchitis. Unfortunately, health care providers usually underemphasize
education. Patients should be counseled to take the following measures:

o Avoid smoking and secondhand smoke.

o Live in a clean environment.

o Receive influenza vaccine yearly between October and December.

o Receive the pneumonia vaccine every 5-10 years if aged 65 years or

more or with chronic disease.

MISCELLANEOUS Section 9 of 10

Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Bibliography

Medical/Legal Pitfalls:

 Carefully explain the course, treatment options, and all possible

complications of acute bronchitis.

Special Concerns:

 Patients may influence the physician's decision regarding treatment (eg, by

insisting on receiving prescribed antibiotics).

 Acute bronchitis continues to be treated with antibiotics, although little

evidence supports the effectiveness of antibiotic treatment in this illness.
 BIBLIOGRAPHY Section 10 of 10

Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Bibliography

 American Academy of Pediatrics, Committee on Drugs: Use of codeine- and

dextromethorphan-containing cough remedies in children. Pediatrics 1997
Jun; 99(6): 918-20[Medline].
 Blinkhorn RJ: Upper respiratory tract infection. In: Textbook of pulmonary
medicine. 5th ed. Boston: Little, Brown, & Co; 1993: 405-407.
 Brickfield FX, Carter WH, Johnson RE: Erythromycin in the treatment of
acute bronchitis in a community practice. J Fam Pract 1986 Aug; 23(2): 119-
22[Medline].
 Denny FW, Clyde WA, Glezen WP: Mycoplasma pneumoniae disease:
clinical spectrum, pathophysiology, epidemiology, and control. J Infect Dis
1971 Jan; 123(1): 74-92[Medline].
 Franks P, Gleiner JA: The treatment of acute bronchitis with trimethoprim
and sulfamethoxazole. J Fam Pract 1984 Aug; 19(2): 185-90[Medline].
 Gonzales R, Steiner JF, Lum A: Decreasing antibiotic use in ambulatory
practice: impact of a multidimensional intervention on the treatment of
uncomplicated acute bronchitis in adults. JAMA 1999 Apr 28; 281(16): 1512-
9[Medline].
 Gonzales R, Sande MA: Uncomplicated acute bronchitis. Ann Intern Med
2000 Dec 19; 133(12): 981-91[Medline].
 Gwaltigy, Jack MJ: Acute bronchitis. In: Douglas & Barnett's Principles of
practice of infectious disease. 4th ed. New York, NY: Churchill Livingston;
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 Huchon GJ, Gialdroni-Grassi G, Leophonte P: Initial antibiotic therapy for
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 Meza RA, Bridges-Webb C, Sayer GP: The management of acute bronchitis
in general practice: results from the Australian Morbidity and Treatment
Survey, 1990-1991. Aust Fam Physician 1994 Aug; 23(8): 1550-3[Medline].
 Nichol KL, Wuorenma J, von Sternberg T: Benefits of influenza vaccination
for low-, intermediate-, and high- risk senior citizens. Arch Intern Med 1998
Sep 14; 158(16): 1769-76[Medline].
 Palmer DA, Bauchner H: Parents' and physicians' views on antibiotics.
Pediatrics 1997 Jun; 99(6): E6[Medline].
 Siegel D, Sande MA: Patterns of antibiotic use in a busy metropolitan
emergency room: analysis of efficacy and cost-appropriateness. West J Med
1983 May; 138(5): 737-41[Medline].
 Smucny J, Fahey T, Becker L: Antibiotics for acute bronchitis (Cochrane
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NOTE:
Medicine is a constantly changing science and not all therapies are clearly established. New research changes drug and
treatment therapies daily. The authors, editors, and publisher of this journal have used their best efforts to provide information that
is up-to-date and accurate and is generally accepted within medical standards at the time of publication. However, as medical
science is constantly changing and human error is always possible, the authors, editors, and publisher or any other party
involved with the publication of this article do not warrant the information in this article is accurate or complete, nor are they
responsible for omissions or errors in the article or for the results of using this information. The reader should confirm the
information in this article from other sources prior to use. In particular, all drug doses, indications, and contraindications should be
confirmed in the package insert. FULL DISCLAIMER

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