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Content developed by Clarity Informatics, providers of online solutions to support the nursing community through appraisals and revalidation.

INTRODUCTION

Acute respiratory infections account for 17% of all GP consultations. The annual incidence of acute bronchitis is 44 per 1,000 adult population. It is usually mild and self limiting, but its predominant symptom – cough – is also shared by community-acquired pneumonia (CAP), and it can be difficult to differentiate between the two conditions.

LEARNING OBJECTIVES

On completion of this module, you should be better able to:

  • Distinguish between acute bronchitis and community-acquired pneumonia
  • Outline the management of acute bronchitis and describe when antibiotics should be prescribed
This resource is provided at an intermediate level by Clarity Informatics. Read the article and answer the self-assessment questions, and reflect on what you have learned.
Complete the resource to obtain a certificate to include in your revalidation portfolio. You should record the time spent on this resource in your CPD log.

 

 

Acute bronchitis in adults – Diagnosis and management

DEFINITION

The common chest infections in primary care are:

Acute bronchitis – acute inflammation of the bronchial tree associated with oedema and mucus production.

Community acquired pneumonia (CAP) – acute infection of the lung parenchyma.

Infective exacerbations of chronic obstructive pulmonary disease (COPD).

Common pathogens

Acute bronchitis:

Viral infections account for most cases, but

A significant minority are bacterial, for example

Streptococcus pneumoniae or

Haemophilus influenzae.

PREVALENCE

  • Acute respiratory infections account for 17% of all GP consultations.
  • For acute bronchitis, the annual incidence is 44 per 1,000 adult population.

Prognosis

  • Acute bronchitis is usually mild and self-limiting.
  • Cough usually lasts 7–10 days but can last for up to 3 weeks.

DIAGNOSIS

Cough is the predominant symptom for acute bronchitis and community-acquired pneumonia (CAP).

It can be difficult to differentiate between acute bronchitis and CAP.

Differentiating features

Symptoms, signs and investigations Acute bronchitis CAP
  Cough Cough
History May or may not have sputum, wheeze, or dyspnoea At least one other symptom of sputum, wheeze, dyspnoea, or pleuritic pain
Examination Wheeze often present, but no other focal chest signs Focal chest signs usually present, including dullness to percussion, coarse crepitations, vocal fremitus
  May have systemic features with or without a raised temperature
Features include sweats, fevers, myalgia
At least one systemic feature present with or without a temperature above 38°C
Features include sweats, fevers, myalgia
Investigations (not usually considered necessary in general practice) Chest X-ray – clear Chest X-ray – diagnostic
  • No combination of symptoms or signs is clearly diagnostic of bronchitis.

Elderly people

  • Present more frequently with non-specific symptoms, and
  • Are less likely to have a fever (compared with younger people).

Differential diagnosis

If acute bronchitis and cough persist longer than 3 weeks rule out:

  • Asthma/chronic obstructive pulmonary disease.
  • Post-infectious cough.
  • Whooping cough.
  • Post-nasal drip.
  • Gastro-oesophageal reflux.
  • Tuberculosis.
  • An underlying malignancy in people who smoke.

For people with chest signs, other conditions to rule out include:

  • Pneumonia with underlying malignancy.
  • Heart failure.
  • Pulmonary embolism.
  • Asthma.

MANAGEMENT

  • Adequate analgesia and hydration are all that is usually necessary.
  • Antibiotics are not routinely indicated. If necessary use empirical treatment with:
  • Amoxicillin (first-line), or alternatively
  • Doxycycline.
  • Clarithromycin if amoxicillin or doxycycline is unsuitable.
  • Encourage smoking cessation.

 

Antibiotics for acute bronchitis?

Consider prescribing antibiotics if the person:

Is systemically very unwell.

Is at high risk of serious complications because of a pre-existing comorbid condition such as heart, lung, kidney, liver or neuromuscular disease, or immunosuppression.

Is older than 65 years of age with two or more of the following, or older than 80 years with one or more of the following:

  • Hospital admission in the previous year.
  • Type 1 or type 2 diabetes mellitus.
  • Known congestive heart failure.
  • Concurrent use of oral corticosteroids.

Why are antibiotics not usually prescribed for acute bronchitis?

  • Evidence from a Cochrane review shows that antibiotics have a modest effect in reducing the duration of cough in some people.
  • Some studies estimate that the adverse effects of antibiotics are as frequent as beneficial effects.
  • Most experts agree that antibiotics are not recommended for people with acute bronchitis who do not have any significant pre-existing conditions.

FOLLOW UP FOR ACUTE BRONCHITIS

Follow up is not usually required.

Advise the person to seek advice if:

  • Their condition deteriorates significantly, or
  • Symptoms last longer than 3 weeks.
  • People who have deteriorated should be re-examined to exclude pneumonia.

For people with a pre-existing condition that has deteriorated on treatment, consider:

  • Admission, or
  • A second-line antibiotic (co-amoxiclav or doxycycline).
  • Seeking advice from a microbiologist if either of these are unsuitable.

SUMMARY

  • Difficult to differentiate between acute bronchitis and community acquired pneumonia.
  • Acute bronchitis:
  • Viral infections account for most cases.
  • Antibiotics are not usually required – only needed if the person is immunocompromised or has an existing condition likely to significantly worsen.
  • Ensure smoking cessation advice is given and reinforced (where appropriate).

Resources

Alberta Medical Association. The management of acute bronchitis, 2008 Alberta Medical Association. www.topalbertadoctors.org [Free Full Text]

Braman SS. Chronic cough due to acute bronchitis: ACCP evidence-based clinical practice guidelines. Chest 2006; 129(Suppl. 1): 95S-103S. [Abstract]

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. [Abstract] [Free Full Text]

Morice AH, McGarvey L, Pavord I. (2006) Recommendations for the management of cough in adults. Thorax 2006; 61(Suppl 1):i1-i24. [Free Full Text]

NICE CG69. (2008a) Respiratory tract infections: antibiotic prescribing. Prescribing of antibiotics for self-limiting respiratory tract infections in adults and children in primary care, 2008. [Free Full Text]

Smith SM, Fahey T, Smucny J, Becker LA. Antibiotics for acute bronchitis (Cochrane Review). The Cochrane Library. 2017; 4. www.thecochranelibrary.com [Abstract]  [Free Full Text].