Bronchitis medical therapy

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Chetan Lokhande, M.B.B.S [2]

Bronchitis Main page
Patient Information
Overview
Causes
Classification Acute bronchitis Chronic bronchitis
Differential Diagnosis

Overview

Bronchitis is usually caused by a viral agent. The treatment of bronchitis is usually symptomatic with analgesics, decongestants, cough suppressant (codeine or hydrocodone-containing preparations or inhaled corticosteroids). Use of antibiotics should be limited to conditions when a diagnosis with a definitive pathogen is there. Oseltamivir for influenza (during influenza epidemics), and azithromycin for atypical bacterias like mycoplasma, chlamydiae has been shown useful in clinical trials.

Medical Therapy

Acute Bronchitis

Symptomatic

Treatment for acute bronchitis is primarily symptomatic.

• Non-steroidal anti-inflammatory drugs (NSAIDs) may be used to treat fever and sore throat.
• Decongestants can be useful in patients with nasal congestion, and
• Expectorants may be used to loosen mucus and increase expulsion of sputum.
• Cough suppressants may be used if the cough interferes with sleep or is bothersome, although coughing may be useful in expelling sputum from the airways. Even with no treatment, most cases of acute bronchitis resolve quickly.

Antimicrobial Agent

• Only about 5–10% of bronchitis cases are caused by a bacterial infection. Most cases of bronchitis are caused by a viral infection and are "self-limiting" and resolve themselves in a few weeks.
• Antimicrobial agents are not recommended in most cases of acute bronchitis. Various randomized controlled trials and systematic reviews have shown a decrease in symptoms by just a fraction of day with use of antibiotics when compared with placebo. These results though statistically significant are not clinically significant (as improvement by only a fraction of day). Antibiotic therapy did not help in a trial of patients who mainly had bronchitis. About 15% had chronic obstructive lung disease and their results were not reported separately.
• However, treatment with antibiotics can be administered in cases with a definitive treatable pathogen is there. For e.g. treatment of influenza virus with oseltamivir decrease the duration of symptoms by approximately 1 day and result in an earlier return to normal activity Similarly, treatment of patients with pertussis is indicated to limit transmission when the therapy is initiated during the first week of symptoms. However, the symptoms are not less severe even with administration of these antibiotics.
• Thus, in case of definitive diagnosis antibiotics can be used for:
• Influenza
  • Oseltamivir (Tamiflu), 75 mg BD for 5 days
  • Zanamivir 2 puff BD for 5 days
• Atypical bacteria (Bordetella pertusis, mycoplasma pneumonia, chlamydiae pneumonia)
  • Azithromycin (Zithromax) 500mg on day 1 followed by 250mg from day 2-5.

Other Therapy

• Various other treatments like beta 2 agonist, mucolytic agents, anti-tussive agent and corticosteroids have been used in different settings but no proven benefits have been shown in any of the clinical trials.

Chronic Bronchitis Treatment

Chronic bronchitis is treated symptomatically. Inflammation and edema of the respiratory epithelium may be reduced with inhaled corticosteroids. Wheezing and shortness of breath can be treated by reducing bronchospasm (reversible narrowing of smaller bronchi due to constriction of the smooth muscle) with bronchodilators such as inhaled β-Adrenergic agonists (e.g., salbutamol) and inhaled anticholinergics (e.g., ipratropium bromide). Hypoxemia, too little oxygen in the blood, can be treated with supplemental oxygen. However, oxygen supplementation can result in decreased respiratory drive, leading to increased blood levels of carbon dioxide and subsequent respiratory acidosis.

The most effective method of preventing chronic bronchitis and other forms of COPD is to avoid smoking cigarettes and other forms of tobacco.

On pulmonary tests, a bronchitic (bronchitis) may present a decreased FEV1 and FEV1/FVC. However, unlike the other common obstructive disorders, asthma and emphysema, bronchitis rarely causes a high residual volume. This is because the air flow obstruction found in bronchitis is due to increased resistance, which, in general, does not cause the airways to collapse prematurely and trap air in the lungs.

Antibiotics

In most cases, acute bronchitis is caused by viruses, not bacteria and it will go away on its own without antibiotics. To treat acute bronchitis that appears to be caused by a bacterial infection, or as a precaution, antibiotics may be given.

If antibiotics are used, a meta-analysis found that "amoxicillin/clavulanic acid, macrolides, second-generation or third-generation cephalosporins, and quinolones" may be more effective.

Bronchitis, Infants/Children (Age < 5 years)

Antibiotics are not indicated usually except for a few conditions like:

1. Sinusitis
2. Pneumonia
3. Patient doesn't improve even after one week.

Bronchitis, Acute, Age > 5 years

Antibiotics are ineffective most of the times and not recommended except for:

1. Pertussis
2. Start antitussive with inhaled bronchodilator

Bronchitis, Chronic with Acute Exacerbation

For severe exacerbations consider the following management protocol:

1. If patient has low O2 saturation , order a X-ray.
2. Start inhaled anticholinergic bronhodilator
3. Start oral sterids and then taper it over 2 weeks.
4. Non-invasive positive pressure ventilation.
5. For penicillin resistant S.pneumoniae start Levofloxacin and Moxifloxacin.

Antibiotic therapy

Following are the guidelines to treat cystic fibrosis based on the age, condition associated and microbial agent.

Bronchitis   ▸  Chronic with Acute Exacerbation   ▸  Bronchiectasis   ▸  Pertussis

Chronic with Acute Exacerbation Preferred Regimen For mild or moderate disease ▸ Amoxicillin 500 mg po tid OR ▸Doxycycline 100 mg po bid OR ▸TMP-SMX 1 DS tab po bid For severe disease ▸ Amoxicillin clavulanate 875/125 mg po bid OR 500/125 mg po q8h OR 2000/125 mg po bid OR ▸ Azithromycin 500 mg po x 1 dose, then 250 mg q24h x 4 days 500 mg po q24h x 3 days OR ▸Clarithromycin extended release 1000 mg po q24h OR ▸Cefaclor 500 mg po q8h or 500 mg extended release q12h OR ▸ Cefdinir 300 mg po q12h or 600 mg po q24h OR ▸Cefditoren 200 mg tabs—2 tabs bid OR ▸Cefpodoxime proxetil 200 mg po q12h OR ▸Cefprozil 500 mg po q12h OR ▸Ceftibuten 400 mg po q24h OR ▸Cefuroxime axetil 250 or 500 mg q12h OR ▸Levofloxacin 500 mg po q24h OR ▸Moxifloxacin 400 mg po q24h Bronchiectasis Preferred Regimen ▸ Levofloxacin 500 mg po q24h for 14 days OR ▸Moxifloxacin 400 mg po q24h for 14 days Pertussis Preferred Regimen Infant (age < 1 month) ▸ Azithromycin † 10 mg/kg/d for 5 days OR ▸TMP-SMX † (8/40 mg/kg/day) in two divided doses x 14 days Infant 1-5 mo of age ▸ Azithromycin 10 mg/kg/d for 5 days OR ▸TMP-SMX 40 mg/kg/d in 4 divided doses for 14 days Infant (age > 6 months) ▸ Azithromycin children: 10 mg/kg on day 1, then 5 mg/kg/d for days 2-5 (max dose 500 mg OR ▸Erythromycin children: 40 mg/kg/d in 4 divided doses for 14 days (max dose 2000 mg/day) Adult ▸ Azithromycin 500 mg day 1, then 250 mg days 2-5 OR ▸Erythromycin 500 mg 4 times daily x 14 days Alternate Regimen Infant 1-5 mo of age ▸ Clarithromycin 15 mg/kg/d in two divided doses x 7 days OR ▸TMP-SMX CONTRAINDICATED for age < 2 months (8/40 mg/kg/day) in two divided doses x 14 days Infant (age > 6 months) ▸ Clarithromycin 15 mg/kg/d in two divided doses (max dose 1 gm/day) x 7 days OR ▸TMP-SMX 8/40 mg/kg/day in two divided doses x 14 days) Adult ▸ Clarithromycin 500 mg 2 x/day x 7 days OR ▸TMP-SMX 320/1600 mg/day in two divided doses x 14 days † = Recommended agent ; Clarithromycin and TMP-SMX are contraindicated in children below 6 mths and 2 mths respectively

Smoking Cessation

To help the bronchial tree heal faster and not make bronchitis worse, smokers should completely quit smoking.

References

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