Bronchitis

Diagnosis/Condition: Discipline: ICD-9 Codes: ICD-10 Codes: Origination Date: Review/Revised Date: Next Review Date: Bronchitis, Acute Bronchitis, Chronic Bronchitis, w/ exacerbation Bronchitis, chronic, w/o exacerbation ND 466.0, 491.9, 491.21, 491.2 02/2000 11/2005, 01/2008, 04/2010, 05/2012 05/2014

Acute bronchitis is a clinical syndrome produced by inflammation of the airway (trachea, bronchi, and bronchioles) of the lung that is characterized by cough, without pneumonia. Ninety percent of cases occur in association with a viral upper respiratory infection (URI), including the influenza virus and are rarely a primary bacterial infection in healthy individuals (10%) and nonsmokers. For this reason, antibiotics are almost never needed.i Other causes include; inhalation and irritation from gas, smoke, dust particles, perfumes, or pollution. The disorder affects approximately 5% of adults annually, with a higher incidence observed during the winter and fall than in the summer and spring. In the United States, acute bronchitis is the ninth most common illness among outpatients. Generally, acute bronchitis is self-limiting, with complete healing and full return to normal function typically seen within 10-14 days following symptom onset. Chronic bronchitis is recurring inflammation and degeneration/hypertrophy of the bronchial tubes that may be associated with an active infection. It is often part of an underlying disease process, such as asthma, recurrent aspiration, cystic fibrosis, or exposure to an airway irritant (allergies). There tends to be more mucous present in chronic bronchitis due to increased production or decreased clearance. The diagnosis of chronic bronchitis is reserved for patients who have cough and sputum production on most days of the month for at least 3 months (90 days) of the year during 2 consecutive years or a productive cough that lasts more than 2 weeks despite medical therapy.ii,iii When chronic bronchitis occurs with decreased expiratory airflow, it is considered a defining characteristic of chronic obstructive pulmonary disease (COPD).

Subjective Findings and History

Acute: Recent or concurrent URI (fatigue, rhinorrhea, pharyngitis) Myalgias Cough typically persists for more than five days, occasionally up to 3 or more weeks iv Wheezing

Chronic: History of dry/productive coughs, asthma, COPD; with exacerbations Shortness of breath (SOB). Exposure to cigarette smoke or industrial pollution Can often be confused with an asthma diagnosis Cough and sputum production on most days
The CHP Group Bronchitis Clinical Pathway 1

Objective Findings:
Acute: Dry cough becoming productive (phlegm/mucous) Retrosternal pain during deep breathing or coughing Mild or no fever (unless bacterial or due to influenza when fevers may be higher) Signs of URI Pharyngitis May have audible breath sounds, with scattered and bilateral crackles and wheezes No consolidation Chronic: Chronic cough, maybe intermittently productive Usually no fever May hear wheezing or crackles, scattered and bilateral No consolidation unless infection present Assessment: Full pulmonary evaluation and vital signs Perform diagnostic tests in step-wise fashion for outpatient AP and lateral chest films indicated with the following indications: abnormal vital signs (pulse >100/min, respiratory rate >24 breaths/minute, or temperature >38 C), or rales or signs of consolidation on chest examination or age over 75 y.o.. CXR is usually generally normal in uncomplicated bronchitis.v,vi Evaluate children for pertussis regardless of immunization history Testing for inhalant/food allergies if indicated Culture/gram stain of sputum if fever present or pronounced abnormal lung sounds. Bacterial cultures of expectorated sputum in patients with a negative chest radiograph are not recommended. Labs: CBC, sputum sample (culture and sensitivity) (difficult to obtain), procalcitonin to distinguish between bacterial and nonbacterial infection Pulmonary function tests may show airflow obstruction that is reversible using bronchodilators Acute bronchitis should be differentiated from acute inflammation of the small airways asthma or bronchiolitis, bronchiectasis and acute exacerbation of chronic bronchitis. The differential diagnosis should also include reactions to inhalants, pneumonia, and pleurisy,. The differential diagnosis for chronic bronchitis includes asthma, retained foreign body, COPD, malignancy, and pneumonia.
Plan

Treatment goals: Ensure patient is adequately oxygenating Reassurance and symptomatic treatment are key Management to prevent development of pneumonia or other secondary infection Identification and avoidance of known triggers (e.g. tobacco smoke, pollen) Proper management of any underlying disease process (asthma, COPD) Support immune function
The CHP Group Bronchitis Clinical Pathway 2

Acute: Nutritional support and adequate hydration (to thin mucous) Cough syrups for symptomatic relief (especially when it interrupts sleep) (limited positive data) Expectorant medicines: botanicals (Mentha piperita, Thymus vulgaris) or OTC: Guanfenisen Avoidance of allergens (smoke), simple sugars, and mucus inducing foods Immune supporting supplements (vitamins A, B, C, D, zinc, quercetin Cool-mist humidifiers or steam vaporizers Glutathione and N-acetyl cysteine (NAC)vii Botanicals for lung tonification, expectoration or cough, anti-infective, analgesia, antipyretic, or anti-inflammatory effects Specific Botanicals o EPs 7630 (derived from Pelargonium sidoides roots), in patients outside the strict indication for antibiotics demonstrated reduced bronchitis severity symptom scores in patients treated with EPs 7630, with good overall tolerability.
viii,ix,x,xi,xii,xiii,xiv,xv

o Menthol and other aromatics xvi,xvii,xviii Corticosteroids in persistent coughs. In otherwise healthy individuals, the use of antibiotics has not demonstrated any consistent benefit in relieving symptoms or improving the natural history of acute bronchitis.xix,xx,xxi,i Chronic: Identification and treatment of underlying conditions: emphysema, assess for malignancy, COPD Treatment of acute exacerbations as above, with diagnostic evaluation as indicated Additional therapies dependent on underlying causative condition Consider instituting bronchodilator therapy (e.g. a beta-adrenergic agonist such as albuterol) or inhaled corticosteroids for persistent cough and airway hyperreactivity Antibiotics should not be the primary therapy unless a secondary bacterial infection is present Consider influenza and pneumococcal vaccinations in patients with chronic bronchitis and underlying conditions Acetylcysteine (Fabrol) xxii,xxiii,xxiv,xxv Esberitox N (Schaper & Brummer, Saltzgitter, Germany)- a proprietary extract of
echinacea, baptisia, and thuja
xxvi

Acute and Chronic Herbs: Ginseng (shown to improve forced vital capacity, maximum inspiratory pressure, and maximum oxygen consumption during exercise, consistent with increased strength and endurance of respiratory muscles.xxvii Dark honeyxxviii

Physical Therapy
Diathermy Postural drainage
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The CHP Group Bronchitis Clinical Pathway

Mustard plaster or other poultices Hydrotherapy Breathing exercises Rest Appropriate homeopathic prescription Antibiotics if appropriate: with development of secondary bacterial infection

Length of Treatment
Resolution of acute bronchitis should begin within 48-72 hours, but symptoms can last for several weeks Dependent upon cause

Referrals
Criteria for referral or re-evaluation: high fever, acute episode unresponsiveness to therapy; unable to determine inciting cause; acute respiratory failure or unrelenting pneumonia; chronic infection due to immune deficiency. Patients with chronic bronchitis and established diagnoses of asthma, structural airway disease, or immunodeficiency need careful periodic monitoring to minimize further lung damage and progression to chronic irreversible lung disease.

Practitioner Resources
National Insittute for Health and Clinical Excellence. Prescribing of antibiotics for self limiting respiratory tract infections in adults and children in primary care. 2008. (Clinical guideline 69). www.nice.org.uk/guidance/index.jsp?action=download&o=41323 (Accessed February 10, 2012) Oregon Health Authority. Judicious Use of Antibitics. Bronchitis Treatment Guidelines.
http://public.health.oregon.gov/PREVENTIONWELLNESS/SAFELIVING/ANTIBIOTICRESISTANCE/Page s/provider.aspx (Accessed February 10th, 2012)

Braman SS. Chronic cough due to acute bronchitis: ACCP evidence-based clinical practice guidelines. Chest 2006 Jan;129(1 Suppl):95S-103S. ROSS HA. Diagnosis and Treatment of Acute Bronchitis. Am Fam Physician. 2010 Dec 1;82(11):1345-1350.
Chronic obstructive pulmonary disease. Institute for Clinical Systems Improvement - Private

Nonprofit Organization. 2001 Dec (revised 2011 Mar). Braman SS. Chronic cough due to acute bronchitis: ACCP evidence-based clinical practice guidelines. Chest 2006; 129:95S.

Patient Resources:
Comprehensive overview from MayoClinic.com covers symptoms, causes, and treatment of this potentially serious lung infection.
http://www.mayoclinic.com/health/bronchitis/DS00031

The CHP Group Bronchitis Clinical Pathway

Clinical Pathway Feedback

CHP desires to keep our clinical pathways customarily updated. If you wish to provide additional input, please use the e-mail address listed below and identify which clinical pathway you are referencing. Thank you for taking the time to give us your comments. Chuck Simpson, DC, CHP Medical Director: csimpson@chpgroup.com
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Smucny J, Fahey T, Becker L, Glazier R. Antibiotics for acute bronchitis. Cochrane Database Syst Rev 2004; :CD000245. ii Brunton S, Carmichael BP, Colgan R, et al. Acute exacerbation of chronic bronchitis: a primary care consensus guideline. Am J Manag Care. Oct 2004; 10(10): 689-96. iii Chronic bronchitis, asthma and pulmonary emphysema. A statement by the Committee on Diagnostic Standards for Nontuberculous Respiratory Diseases. Am Rev Respir Dis 1962; 85:762. iv Wenzel, RP, Fowler AA, 3rd. Clinical practice. Acute bronchitis. N Engl J Med 2006; 355:2125. v Snow, V, Mottur-Pilson, C, Gonzales, R. Principles of appropriate antibiotic use for treatment of acute bronchitis in adults. Ann Intern Med 2001; 134:518. vi Gonzales R, et al. Principles of appropriate antibiotic use for treatment of uncomplicated acute bronchitis: background. Ann Intern Med 2001 Mar 20;134(6):521-9. vii Allen, J. inhaled glutathione for the prevention of air pollution-related health effects: a brief review. Altern Ther Health Med. 14(3):42-4, 2008 May-Jun. viii Kamin W, Maydannik VG, Malek FA, Kieser M. Efficacy and tolerability of EPs 7630 in patients (aged 6-18 years old) with acute bronchitis. Acta Paediatr. Apr 2010;99(4):537-43. ix Kamin W, Maydannik V, Malek FA, Kieser M. Efficacy and tolerability of EPs 7630 in children and adolescents with acute bronchitis - a randomized, double-blind, placebo-controlled multicenter trial with a herbal drug preparation from Pelargonium sidoides roots. Int J Clin Pharmacol Ther. Mar 2010;48(3):184-91. x Henry D, et al. Effectiveness of short-course therapy (5 days) with cefuroxime axetil in treatment of secondary bacterial infections of acute bronchitis. Antimicrob Agents Chemother 1995 Nov;39(11):2528-34. xi Linder JA; Sim I. Antibiotic treatment of acute bronchitis in smokers: a systematic review. J Gen Intern Med 2002 Mar;17(3):230-4. xii Little P, et al. Information leaflet and antibiotic prescribing strategies for acute lower respiratory tract infection: a randomized controlled trial. JAMA 2005 Jun 22;293(24):3029-35. xiii Matthys H, Heger M. Treatment of acute bronchitis with a liquid herbal drug preparation from Pelargonium sidoides (EPs 7630): a randomised, double-blind, placebo-controlled, multicentre study. Curr Med Res Opin. 2007 Feb;23(2):323-31. xiv Timmer A, et al. Pelargonium sidoides extract for acute respiratory tract infections. Cochrane Database Syst Rev. 2008;CD006323. xv Agbabiaka, TB, R Guo, Ernst, E. Pelargonium Sidoides for Acute Bronchitis: a Systematic Review and Meta-Analysis. Phytomedicine. 2008; 15 (5): 378-385. xvi Berger H, Jarosch E, Madreiter H. Effect of [sic] VapoRub and petrolatum on frequency and amplitude of breathing in children with acute bronchitis. J Int Med Res 1978a;6:483486. xvii Berger H, Madreiter H, Jarosch E. Effect of vaporub on the restlessness of children with acute bronchitis. J Int Med Res 1978b;6:491493. xviii Amir Hasani, Demetri Pavia, Nathan Toms, Paul Dilworth, and John E. Agnew. The Journal of Alternative and Complementary Medicine. April 2003, 9(2): 243-249. xix Gonzales, R, Sande, M. What will it take to stop physicians from prescribing antibiotics in acute bronchitis? Lancet 1995; 345:665. xx Orr PH; Scherer K; Macdonald A; Moffatt ME. Randomized placebo-controlled trials of antibiotics for acute bronchitis: a critical review of the literature. J Fam Pract 1993 May;36(5):507-12. Journal of Alternative & Complementary Medicine. 9(2):243-9, 2003 Apr. xxi Hasani A. Pavia D. Toms N. Dilworth P. Agnew JE. Effect of aromatics on lung mucociliary clearance in patients with chronic airways obstruction. J Altern Complement Med. 2003 Apr;9(2):243-9. The CHP Group Bronchitis Clinical Pathway 5

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Tattersall AB, Bridgman KM, Huitson A. Acetylcysteine (Fabrol) in chronic bronchitisa study in general practice. J Int Med Res 1983;11:27984. xxiii Multicenter Study Group. Long-term oral acetylcysteine in chronic bronchitis. A double-blind controlled study. Eur J Respir Dis 1980;61:111:93108. xxiv Boman G, Bcker U, Larsson S, et al. Oral acetylcysteine reduces exacerbation rate in chronic bronchitis: a report of a trial organized by the Swedish Society for Pulmonary Diseases. Eur J Respir Dis 1983;64:40515. xxv Grandjean EM, Berthet P, Ruffmann R, Leuenberger P. Efficacy of oral long-term N-Acetylcysteine in chronic bronchopulmonary disease: A meta-analysis of published double-blind, placebo-controlled clinical trials. Clin Ther 2000;22:20921. xxvi Nakajima S, Tohda Y, Ohkawa K, Chihara J, Nagasaka Y. Effect of saiboku to (TJ 96) on bronchial asthma. Induction of glucocorticoid receptor, beta adrenaline receptor, IgE Fc epsilon receptor expression and its effect on experimental immediate and late asthmatic reaction. Ann N Y Acad Sci. 1993;685:549 560. xxvii Gross D, et al. Ginseng improves pulmonary functions and exercise capacity in patients with COPD. Monaldi Arch Chest Dis. 2002;57:242 246. xxviii Paul IM, et al. Effect of honey, dextromethorphan, and no treatment on nocturnal cough and sleep quality for coughing children and their parents. Arch Pediatr Adolesc Med. 2007;161(12):11401146.

The CHP Group Bronchitis Clinical Pathway