When Should Patients Take Bronchitis Seriously?

Acute bronchitis is one of the most common clinical conditions encountered in ambulatory care, accounting for about 10% of visits in the United States or 100 million visits per year.¹It is characterized by an acute cough for more than 5 days in the absence of chronic obstructive pulmonary disease or pneumonia.². The cough may be associated with either non-purulent or purulent sputum production.

In more than 90% of cases, acute bronchitis has a viral etiology with rhinovirus, enterovirus, influenza A and B, parainfluenza, coronavirus, and respiratory syncytial virus being the most commonly identified pathogens.^3,4It is typically a self-limited disease, resolving within 1 to 4 weeks^1,2,4, with a median duration of 18 days.¹Because of the high likelihood of viral etiology, antibiotics are not recommended for treatment of acute bronchitis.^1,2,5

The diagnoses that have the most overlap with acute bronchitis are upper respiratory infection (URI), acute rhinosinusitis (ARS) and pneumonia. The treatment plans for these differential diagnoses can vary widely. Therefore, an accurate history of present illness and physical exam are critical.²

Acute bronchitis is often preceded by an ARS or URI. The first few days of illness can produce elevated temperature, headache, mild fever of less than 100.9F, nasal/sinus congestion, and pharyngitis.^1,2With involvement of the lower respiratory tract, the cough becomes the dominant symptom. Rhonchi and wheezing may be auscultated upon exam. However, the rhonchi typically clear with a forceful cough. Mild dyspnea may be present, especially with physical activity. Prolonged coughing can also create substernal musculoskeletal pain. Production of sputum, whether it is purulent or not, is common and does not correlate with a bacterial infection.^1,2,5

The cough associated with acute bronchitis can be very bothersome, stripping the patient of days at work or school, as well as sleep. Many patients and providers underestimate the time required to fully recover from acute bronchitis.⁶Ebell and colleagues (2013) conducted a population-based survey to determine patients’ expectations regarding the duration of a cough-related illness. Survey respondents reported a median duration of 5 to 7 days and a mean duration of 7 to 9 days. The mean duration of cough in evidence-based literature is 18 days.⁶It is essential to educate the patient about a realistic expected length of illness. This transparency can prevent inappropriate expectations of antibiotic use and possibly divert additional visits at a higher level of care.

Community acquired pneumonia (CAP) is defined as an acute infection of the pulmonary parenchyma in a patient who acquired the infection within the community versus within a hospital.⁷There are more than 100 microbes (bacteria, fungi, parasites, and viruses) that can cause pneumonia, withS. pneumoniabeing the most commonly identified cause of CAP.⁷Patients with CAP can present with dyspnea, fever, signs of lung consolidation, tachycardia, or tachypnea. Older adults may display mental status changes and are less likely to be febrile upon exam. A respiratory rate above 24 breaths per minute is noted in up to 70% of patients and may be the most sensitive sign in older adult patients.⁷A fever greater than 100.4F and tachycardia are common in most patients. A chest exam can reveal crackles/rales, decreased breath sounds, dullness to percussion, egophony, and tactile fremitus.^2,7It is important to note that while the symptoms listed above support the diagnosis of CAP, none have proven to accurately predict whether the patient actually has pneumonia. Even the sensitivity of the combination of cough, crackles, fever, and tachycardia was less than 50% when a chest radiograph was used as the standard.⁸Therefore, practitioners who suspect pneumonia in a patient, should keep in mind that it is considered the gold standard of care to get a chest radiograph to confirm the presence of an infiltrate (Table).^2,7,8

Table. Indications for a Chest Radiograph in an Adult Patient With Acute Bronchitis

Dyspnea

Difficult or labored Breathing

Tachypnea

>20 breaths per minute

Tachycardia

>100 beats per minute

Low SpO2

<95%

Lung Consolidation:

• Egophony

• Tactile fremitus

• Crackles/rales

• Increased resonance of voice sounds upon auscultation of the lungs (“E” to “A” conversion)
• Vibrations felt with ulnar aspects of bilateral hands on posterior chest wall while patient says “99.” Areas of consolidation will have decreased tactile fremitus.
• Abnormal lung sounds characterized by clicking or rattling sounds

Fever

>100.4 F

^{Adapted from references 2 and 7.}

For most patients with acute bronchitis, symptoms are self-limiting and will resolve in 1-4 weeks. Reassuring the patient with an expected time frame for resolution and recommendations for OTC symptom relief are the mainstays of treatment. Conversely, if a patient presents with abnormal vital signs or signs of lung consolidation, a chest radiograph is indicated. Educating patients with acute bronchitis about what symptoms they should follow up on will engage them in their health care and increase adherence to the treatment plan. They should expect their cough to hang on for 1 to 4 weeks. They may have wheezing. They may produce green phlegm. They may have pain around their ribs, because of the frequent coughing. All these symptoms can present in acute bronchitis and can be appropriately managed with certain OTC and prescription medications, excluding antibiotics). However, patients who develop a fever after the first few days of illness or have more difficulty breathing should seek appropriate follow-up care. Following up with the patient via phone to check on their status is always a good practice and increases both patient and provider satisfaction. Patient education and transparency are truly the best methods of successful management of acute bronchitis.

Bethany Rettberg, NPC, is a family nurse practitioner at a CVS Minute Clinic in Mokena, Illinois.

References

1. File TM. Acute bronchitis in adults.UpToDate.uptodate.com/contents/acute-bronchitis-in-adults?csi=419f3e56-ad814d12-a04e-42d402cb729c&source=contentShare. Updated November 30, 2018. Accessed April 16, 2019.
2. Kinkade S, Long NA. Acute bronchitis.Am Fam Physician.2016;94(7): 560-565.
3. Gencay M, Roth M, Christ-Crain M, Mueller B, Tamm M, Stolz D. Single and multiple viral infections in lower respiratory tract illness in the community.Thorax.2010;80(6):560-567. doi: 10.1159/000321355.
4. Macfarlane J, Holmes W, Gard P, et al. Prospective study of the incidence, aetiology and outcome of adult lower respiratory tract illness in the community.Thorax.2001; 56(2):109-114.
5. 5. Clark TW, Medina MJ, Batham S, Curran MD, Parmar S, Nicholson KG. Adults hospitalized with acute respiratory illness rarely have detectable bacteria in the absence of COPD or pneumonia; viral infection predominates in a large prospective UK sample.J Infect.2014;69(5):507-515. doi: 10.1016/j.jinf.2014.07.023.
6. 6. Ebell MH, Lundgren J, Youngpairoj S. How long does a cough last? Comparing patients’ expectations with data from a systematic review of the literature.Ann Fam Med.2013;11(1):5-13. doi: 10.1370/afm.1430.
7. 7. Bartlett JG. Diagnostic approach to community acquired pneumonia in adults. UpToDate.uptodate.com/contents/diagnostic-approach-to-community-accquired-pneumonia-in-adults?csi=9c830a97-1af1-45de-a3f9-faddeacf9cd&source=contentShare. Updated January 23, 2019. Accessed April 16, 2019.
8. 8. Metlay JP, Kapoor WN, Fine MJ. Does this patient have community acquired pneumonia? Diagnosing pneumonia by history and physical examination.JAMA.1997: 278(17):1440-1445.