bronchitis presentation

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StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

StatPearls [Internet].

Acute bronchitis.

Anumeha Singh ; Akshay Avula ; Elise Zahn .

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Last Update: March 9, 2024 .

• Continuing Education Activity

Acute bronchitis, characterized by inflammation in the bronchi lining, is a frequent condition in emergency departments, urgent care centers, and primary care offices. Acute bronchitis ranks among the top 10 most common outpatient illnesses in the United States, affecting approximately 5% of adults annually. This activity discusses the evaluation and management of patients afflicted by acute bronchitis, accentuating the pivotal role played by the interprofessional healthcare team in delivering comprehensive care for these individuals. This activity provides healthcare professionals with the latest insights and evidence-based approaches to enhance their competence in diagnosing and managing acute bronchitis, ultimately improving patient outcomes and healthcare team performance.

• Apply the key clinical features of acute bronchitis for an accurate diagnosis to distinguish it from other respiratory conditions and differentiate between viral and bacterial causes.
• Assess patients presenting with acute bronchitis for underlying risk factors, such as chronic obstructive pulmonary disease (COPD), asthma, or immunosuppression, to develop appropriate management plans.
• Implement evidence-based guidelines and treatment options for acute bronchitis, emphasizing nonpharmacological and pharmacological interventions as needed.
• Collaborate with the interprofessional team to collectively provide evidence-based education on acute bronchitis, treatment expectations, and preventive measures.
• Introduction

Acute bronchitis, a prevalent respiratory infection, is a significant medical concern, particularly among adult patients. This condition involves the lower respiratory tract, specifically targeting the bronchi, the prominent air passages responsible for air transport within the lungs. Acute bronchitis manifests as an inflammation of these bronchi without evidence of pneumonia and typically affects individuals without underlying chronic obstructive pulmonary disease (COPD).

Acute bronchitis is characterized by an acute onset of a persistent cough, with or without sputum production. As a self-limiting condition, it typically follows a benign course, resolving spontaneously over 1 to 3 weeks. The etiology of these symptoms arises from the inflammatory response within the lower respiratory tract, often triggered by viral infections. [1] [2] [3]  

Acute bronchitis presents as a clinical syndrome characterized by a transient and self-limiting inflammation, specifically targeting the larger and mid-sized airways, and devoid of any evidence of pneumonia upon chest radiography examination.

This condition primarily impacts the bronchial tree, leading to irritation, inflammation, and increased mucus production. Viral infections, such as the common cold or influenza viruses, adenovirus, and rhinovirus, are frequent instigators, although exposure to irritants or other respiratory pathogens can also be putative triggers. [4]  These viruses are transmitted through respiratory droplets and induce inflammation and irritation within the bronchial tree, ultimately leading to the characteristic symptoms of acute bronchitis, which encompass coughing, sputum production, and respiratory discomfort. 

Bacterial pathogens play a role in approximately 10% or less of acute bronchitis instances. Among these bacterial pathogens, Mycoplasma pneumoniae , Chlamydia pneumoniae , and Bordetella pertussis are the most commonly identified offenders. [5]  In contrast, the majority, approximately 90% to 95%, of cases in healthy adults are attributed to viral infections. Additional factors, including allergens, irritants, and occasionally bacterial pathogens, can also incite acute bronchitis. [6]

A higher prevalence of influenza viruses A and B are seen in the winter months, escalating transmission and infection rates. These viruses exhibit ease in spreading within crowded indoor settings like schools, workplaces, and public gatherings, where close interpersonal contact facilitates their transmission through respiratory droplets. Influenza viruses' efficiency in infecting and replicating within the respiratory tract allows for rapid viral multiplication, culminating in significant damage to the bronchiolar epithelial cells. This damage, coupled with the body's immune response, contributes to the distinctive symptoms of acute bronchitis. [7] [8]  

While viral infections are more prevalent during the winter season, acute bronchitis can arise at any time of the year, often linked to strains of adenovirus, rhinovirus, and coronavirus. [9] [10]  Furthermore, understanding the dynamics of viral infections causing acute bronchitis throughout the year is essential for healthcare providers and public health officials in implementing effective prevention and control strategies, especially in the context of evolving respiratory viruses and changing environmental factors. Examples of this are as follows:

• Influenza, RSV, and human coronaviruses typically exhibit peak incidence during winter. As stated previously, this seasonal pattern arises as people tend to spend more time indoors and engage in close interpersonal contact, creating an environment conducive to the rapid transmission of these viruses.
• Rhinoviruses typically experience peaks in incidence during the spring and fall seasons, coinciding with shifts in weather patterns. Seasonal allergies may also contribute to these peaks by potentially facilitating the transmission of the virus during these times.
• Enteroviruses, a group encompassing several viruses responsible for respiratory and gastrointestinal illnesses, peak in summer. This case surge aligns with increased outdoor activities, providing more significant opportunities for viral transmission. 

Vaccination status, particularly against viruses like influenza, can influence the etiology of acute bronchitis. A study conducted in France revealed that among 164 cases of acute bronchitis in adults who have received influenza vaccination, 37% were found to have a viral origin. Within the identified viral causes, 21% of cases were attributed to rhinovirus. This underscores that despite being vaccinated against influenza, individuals may remain susceptible to rhinovirus infections, which can manifest as bronchitis symptoms. [11]  

Exposure to irritants such as smoke, contaminated air, dust, and other environmental pollutants can also cause acute bronchitis or exacerbate preexisting respiratory conditions. Furthermore, allergens can trigger an allergic response within the airways, ultimately culminating in inflammation and the onset of bronchitis symptoms, particularly in individuals who are susceptible to such triggers. [12]

• Epidemiology

Acute bronchitis represents a common clinical presentation across various healthcare settings. In the United States, approximately 5% of individuals annually report physician-diagnosed cases of acute bronchitis. The numbers tend to peak during winter, aligning with the seasonal prevalence of respiratory viral infections like influenza and RSV, which often coincide with flu season. [13] [14]  

Similarly, a study conducted in the United Kingdom reported similar rates of acute bronchitis, with an incidence of 54 cases per 1000 persons. Notably, these rates exhibit variability among different age groups, with lower rates among younger men (36 per 1000) and higher rates in individuals older than 85 (225 per 1000). [8]  These discrepancies in incidence may be attributed to variations in healthcare-seeking behavior, age-related immune responses, and exposure to viral pathogens in different settings.

In addition, several risk factors contribute to the development of acute bronchitis, including a history of smoking, residence in polluted areas, crowded living conditions, and a prior history of asthma. Specific allergens such as pollen, perfume, and vapors can potentially trigger acute bronchitis in susceptible individuals.

In instances where the infection is of bacterial origin, the isolated pathogens tend to overlap with those commonly associated with community-acquired pneumonia. Examples of such pathogens are  Streptococcus pneumonia and Staphylococcus aureus . [15] [16]

• Pathophysiology

Acute bronchitis is inflammation affecting the large and mid-sized airways (bronchi), frequently precipitated by viral infections. The wide array of anatomical sites within the respiratory tract where these pathogens can take hold underscores the diverse impact of these microorganisms on the respiratory tract. A study involving volunteers exposed to rhinovirus infections demonstrated the various locations within the respiratory system where the virus could be detected. [9]  

The inflammatory process triggers increased blood flow and cellular activity within the affected bronchi, resulting in heightened 18F-fluorodeoxyglucose (FDG) uptake when observed via positron-emission tomography (PET) scan. [17]  Additionally, bronchial inflammation can stem from various triggers, with viral infections, allergens, and pollutants among the most common culprits. The inflammation of the bronchial wall leads to mucosal thickening, epithelial cell desquamation, and denudation of the basement membrane. In some instances, a viral upper respiratory infection can progress to a lower respiratory tract infection, resulting in acute bronchitis. [18]

• History and Physical

Patients affected with acute bronchitis typically exhibit a range of symptoms, including a productive cough, feelings of malaise, breathing difficulties, and wheezing. Often, the most prominent complaint is the persistent cough, with an accompanying clear or yellowish sputum production. However, on occasion, the sputum can take on a purulent appearance. Purulent sputum does not necessarily correlate with a bacterial infection or necessitate antibiotic treatment. [19]  

Following an episode of acute bronchitis, the cough typically persists for 10 to 20 days, with a median duration of 18 days. [20]  Occasionally, bronchitis cough may extend beyond 4 weeks. Paroxysms of cough accompanied by an inspiratory whoop or posttussive emesis should raise concerns for pertussis infection. 

In the early stages of infection, the symptoms of mild upper respiratory infections and acute bronchitis can often overlap, creating a challenge in distinguishing between both based solely on symptoms. Both conditions may present with common respiratory symptoms such as:

• Cough: Initially, the cough may start as dry and irritating, but as acute bronchitis advances, it can transition to producing sputum. In acute bronchitis, this cough tends to persist for longer, often extending beyond 5 days. Approximately 50% of patients with acute bronchitis report the production of purulent sputum. [21]  Prolonged or forceful coughing may lead to chest wall or substernal musculoskeletal pain, usually self-limiting. 
• Mild fever: A low-grade fever may be present in both conditions, although it is more frequently associated with upper respiratory infections. The presence of high-grade fevers in the setting of acute bronchitis is unusual and warrants further diagnostic evaluation. 
• Fatigue and body aches: Mild upper respiratory infections and acute bronchitis can cause fatigue and general bodily discomfort.

The differentiation between these 2 conditions becomes more apparent as the infection develops. If the symptoms predominantly affect the upper respiratory tract and resolve within a few days, it is more likely to be a mild upper respiratory infection. Conversely, if the symptoms persist for a week or longer and are accompanied by lower respiratory tract symptoms, this presentation indicates acute bronchitis.

During a physical examination, lung auscultation may reveal the presence of wheezing. In some instances, the detection of rhonchi may improve or clear with coughing, suggesting that the airway secretions or obstruction causing the sound can be alleviated through coughing efforts.

Pneumonia should be considered a potential diagnosis when detecting rales or egophony. Mild tachycardia may accompany these findings, indicating fever and dehydration secondary to the viral illness. It is important to note that similar signs of tachycardia can also be observed in bacterial infections. In general, the evaluation of the rest of the body systems typically falls within normal limits.

Acute bronchitis is typically diagnosed clinically, relying on a comprehensive assessment encompassing a medical history, pulmonary examination, and other pertinent physical findings. The evaluation of oxygen saturation, along with the assessment of pulse rate, temperature, and respiratory rate, serves as a pivotal indicator for gauging the severity of the condition. In cases where vital signs fall within normal ranges and no physical examination findings suggest pneumonia, further diagnostic investigations are generally unnecessary. However, an exception to this rule applies to older patients (>75 years) or individuals with neurocognitive impairment. In such instances, a more extensive workup should be considered part of the evaluation process.

Chest x-ray (CXR) findings in cases of acute bronchitis are generally nonspecific and often appear normal. The CXR findings may occasionally reveal increased interstitial markings indicative of bronchial wall thickening. A CXR proves particularly valuable in distinguishing pneumonia from acute bronchitis when infiltrates are present. Evidence-based guidelines established by the American College of Chest Physicians (ACCP) recommend obtaining a CXR where specific criteria are met, including the following: [14]

• Heart rate exceeding 100 bpm
• Respiratory rate greater than 24 breaths/min
• Oral body temperature surpassing 38 °C
• Chest examination findings of egophony or fremitus 

Laboratory testing, including a complete blood count and chemistry panel, may be conducted as part of the diagnostic workup for fever. The white blood count might show a mild elevation in some cases of acute bronchitis.

Rapid microbiological testing for respiratory infections may not always be cost-effective or essential in every situation. Nevertheless, specific scenarios exist in which testing can be beneficial and potentially result in alterations to the treatment approach. Some of these circumstances include:

• Influenza season: During the influenza season, rapid testing for influenza may be recommended in specific patient populations. This population includes individuals at a heightened risk of complications, such as older individuals, young children, pregnant women, and individuals with chronic medical conditions. Healthcare workers who develop respiratory symptoms may also benefit from rapid testing to determine the presence of influenza and assess the appropriateness of the antiviral treatment.
• Viral pandemics: In the context of viral pandemics, such as the COVID-19 pandemic, rapid testing becomes essential for diagnosing and managing the infection. Swift identification of cases is imperative for promptly implementing appropriate infection control measures, timely administration of treatment, and prevention of further viral transmission.
• High suspicion of pertussis or bacterial infections: When a strong clinical suspicion of pertussis (whooping cough) or other bacterial respiratory infections arises, rapid testing proves valuable in confirming the diagnosis. Such testing can serve as a guide for initiating antibiotic treatment, thereby aiding in the containment of further transmission.

Multiplex polymerase-chain-reaction (PCR) testing of nasopharyngeal swabs or aspirates is a diagnostic tool that allows for the simultaneous detection of multiple pathogens in a single test. This method helps diagnose infections attributed to specific bacteria, such as B  pertussis (the causative agent of whooping cough), M  pneumoniae , or C  pneumonia . [22]  

The advantage of multiplex PCR testing lies in its ability to rapidly and accurately identify the presence of these bacterial pathogens in respiratory samples, facilitating the differentiation of various causes of respiratory infections. By detecting the target bacteria's genetic material (DNA or RNA), PCR testing provides a sensitive and specific diagnosis, especially when compared to traditional culture methods, which may have sensitivity and turnaround time limitations. However, it remains essential to ensure this testing approach is adequately validated and employed within a comprehensive clinical assessment context. This approach provides an accurate interpretation of results and supports sound decision-making regarding patient management. Gram stain and bacterial sputum cultures are typically discouraged in acute bronchitis cases, as bacteria seldom serve as the causative agent. 

Assessing procalcitonin levels can be a valuable tool in determining whether antibiotics should be prescribed when the diagnosis of acute bronchitis is uncertain. A meta-analysis has shown that procalcitonin-guided antibiotic therapy reduced antibiotic exposure and improved overall survival. [23]

Spirometry, when performed, reveals transient bronchial hyperresponsiveness in approximately 40% of patients with diagnosed acute bronchitis. A reported 17% of these patients exhibit reversibility of FEV1 (forced expiratory volume in 1 second) greater than 15%. [14]  Airflow obstruction and bronchial hyperresponsiveness typically resolve within 6 weeks. [24]

• Treatment / Management

Acute bronchitis is typically a self-limiting condition, and its treatment primarily revolves around providing symptomatic and supportive therapy. For alleviating cough, both nonpharmacological and pharmacological approaches can be considered. Nonpharmacological strategies include remedies such as hot tea, honey, ginger, and throat lozenges. Notably, the efficacy of these interventions has not been evaluated through clinical trials. 

In clinical practice, antitussive agents like dextromethorphan (with or without codeine) are often used to suppress cough based on their effectiveness in managing chronic bronchitis symptoms and data from studies on cough associated with the common cold. No randomized trials specifically assess the efficacy in antitussive agents in acute bronchitis. Codeine usage should be avoided due to its addictive potential.

The available data regarding the use of mucolytic agents in acute bronchitis treatment are conflicting and lack a clear consensus on efficacy. Therefore, these agents' role in managing acute bronchitis remains a subject of ongoing investigation and debate.

Beta-agonists are commonly administered to patients with acute bronchitis who exhibit wheezing. However, the findings from small randomized control trials investigating the use of beta-agonists for cough in acute bronchitis have yielded mixed results. In a Cochrane review encompassing 5 trials, no substantial benefit of beta-agonists on daily cough was observed, except for a minor advantage in a subgroup of patients with wheezing and airflow obstruction at baseline. [25]  A more recent Cochrane review reported similar outcomes. [26]  

Analgesic and antipyretic agents may manage associated symptoms like malaise, myalgia, and fever. Additionally, prednisone or other steroids may be administered to address inflammation. While the evidence supporting their benefit in acute bronchitis is limited, they can be useful in patients with underlying chronic obstructive pulmonary disease (COPD) or asthma. Typically, steroids are utilized as a short-term burst therapy. In certain cases, an extended tapering course of steroids may be warranted, especially for patients with underlying asthma or COPD. [27] [28]

ACCP guidelines recommend against antibiotic use in cases of uncomplicated acute bronchitis among otherwise healthy adults. A comprehensive Cochrane review of 9 randomized, controlled trials of antibiotic agents found only a minor reduction in the total duration of cough (0.6 days) with no significant decrease in the overall duration of illness. [29]

Consequently, antibiotic use should be avoided in uncomplicated cases of acute bronchitis, considering factors such as the cost of antibiotics, the increasing global concern of antibiotic resistance, and the potential side effects associated with antibiotic usage. Numerous other international medical societies also advise against antibiotic use in cases of viral acute bronchitis. Despite these recommendations, many patients diagnosed with acute bronchitis are prescribed antibiotics.

It is important to emphasize that no empirical data justify the belief that antibiotic therapy leads to less severe or shorter duration of cough in acute bronchitis. Antimicrobial therapy is recommended only when a treatable pathogen is identified, as with pertussis (see  Table.  Pathogens and Treatments Related to Acute Bronchitis). Antiviral treatment should be considered for influenza infection. 

Table. Pathogens and Treatments Related to Acute Bronchitis.

* The use of oseltamivir and zanamivir has been shown to offer minor benefits in reducing the duration of influenza symptoms by an average of half a day in adults. These medications are also effective in reducing the risk of symptomatic influenza when used as a prophylactic measure. However, limited evidence supports the claim that these drugs can reduce the risk of hospital admission or pneumonia. Furthermore, a Cochrane review suggests that there is insufficient evidence to support the use of neuraminidase inhibitors in preventing the person-to-person spread of influenza. The complications associated with influenza, such as pneumonia, cannot be reduced by treatment trials due to the lack of clear diagnostic definitions. The use of oseltamivir has been found to increase the risk of adverse effects such as nausea, vomiting, psychiatric effects, and renal events in adults. Therefore, the balance between the benefits and harms of using neuraminidase inhibitors for prophylaxis or treatment should be carefully considered when making decisions. [40]

In summary, robust data are lacking supporting the use of beta-agonists, steroids, neuraminidase inhibitors, and mucolytic agents, particularly in patients without underlying COPD and asthma. Treatment decisions should be based on the individual's response to these interventions and the reported benefits while carefully considering the balance between potential risks and benefits in each case.

• Differential Diagnosis

Other potential causes of acute cough should be considered, especially when the cough persists for a duration exceeding 3 weeks. Other conditions to consider are as follows:

• Asthma: Acute asthma exacerbation can be frequently misdiagnosed as acute bronchitis, with around one-third of patients presenting with acute cough.
• Acute or chronic sinusitis
• Bronchiolitis
• Gastroesophageal reflux disease (GERD)
• Viral pharyngitis
• Heart failure
• Pulmonary embolism

Acute bronchitis typically follows a self-limiting course and frequently improves with symptomatic interventions. However, clinicians should remain aware of potential secondary complications, such as pneumonia. Cases of acute respiratory distress syndrome and respiratory failure associated with acute bronchitis have been documented in the literature. Consequently, while acute bronchitis is often manageable with symptomatic care, the healthcare team should be mindful of potential complications and ready to administer appropriate interventions if necessary. [41] [42]

• Complications

Complications associated with acute bronchitis include:

• Secondary pneumonia
• Acute respiratory distress syndrome
• Prolonged symptoms
• Spontaneous pneumothorax
• Spontaneous pneumomediastinum
• Deterrence and Patient Education

Lifestyle modifications like smoking cessation and minimizing exposure to allergens and pollutants are essential in preventing the recurrence of acute bronchitis and reducing the risk of complications. The flu and pneumonia vaccines are particularly advised in specific groups, including adults 65 and older, children younger than 2 years (but older than 6 months), pregnant women, and individuals residing in nursing homes and long-term care facilities. People with conditions like asthma, COPD, and other individuals who are immunocompromised also risk developing complications. Recurrence occurs in up to one-third of acute bronchitis cases.

Additionally, patients should receive education regarding the risks associated with unnecessary antibiotic prescriptions, including the development of antibiotic resistance, cost implications, and potential adverse effects. Patients should be encouraged to engage in open and informed discussions with their healthcare practitioners to ensure that treatment decisions align with their clinical needs, promoting effective and responsible healthcare practices.

• Pearls and Other Issues

Acute bronchitis is a very common respiratory symptom that affects the bronchial tree. The majority (90%) of cases are caused by viruses, resulting in inflammation and increased mucus production. Occasionally, secondary pneumonia can develop, typically characterized by worsening symptoms, a productive cough, and fever. In such cases, a CXR is advisable, particularly for adults in an immunocompromised state, older individuals, infants, newborns, and individuals who smoke.

Identifying the pathogen responsible for acute bronchitis is helpful, although not always necessary. In recent years, new technological developments have made this possible, such as multiplex polymerase-chain reaction (PCR) testing of nasopharyngeal swabs that can identify more than one organism at once.

Acute bronchitis is usually a self-limiting condition and rarely requires treatment. Acute bronchitis caused by specific types of pathogens can be treated with antiviral therapies in addition to symptomatic and supportive therapies. 

Ensuring pulmonary emboli are on the list of differentials for patients with cough and shortness of breath is prudent. Aggressive coughing can result in spontaneous pneumothorax or spontaneous pneumomediastinum, underscoring the importance of a CXR when acute symptom deterioration occurs.

• Enhancing Healthcare Team Outcomes

In managing acute bronchitis, an interprofessional healthcare team comprising physicians, advanced practitioners, nurses, pharmacists, and other health professionals is critical in delivering patient-centered care, improving outcomes, ensuring patient safety, and optimizing team performance. To achieve these goals, the team must employ various skills and strategies, uphold ethical standards, embrace shared responsibilities, foster open interprofessional communication, and coordinate care effectively. Here are key components for enhancing healthcare team outcomes in acute bronchitis management:

• Skills and Expertise : Each team member should possess the clinical skills and expertise relevant to their role in acute bronchitis care. Physicians should be proficient in diagnosis and treatment options, nurses should excel in patient monitoring and education, and pharmacists should be well-versed in medication management and potential drug interactions.
• Evidence-Based Practice : The team should consistently apply evidence-based guidelines and current best practices in diagnosing and managing acute bronchitis. Staying current with the latest research and recommendations is crucial for delivering high-quality care.
• Responsibilities and Roles : Clearly defined roles and responsibilities within the team are essential. Physicians diagnose and prescribe treatment, nurses provide patient education and monitor progress, pharmacists ensure safe medication use, and other professionals contribute their specialized knowledge.
• Care Coordination : Coordinating care is central to optimizing patient outcomes. This involves scheduling follow-up appointments, ensuring adherence to treatment plans, and actively involving patients in their care decisions.
• Patient Education : Nurses are vital in educating patients about their condition, treatment options, and preventive measures. Empowering patients with knowledge encourages active participation in their care and contributes to improved outcomes.
• Medication Management : Pharmacists should review medication regimens to identify potential interactions and allergies, which can help minimize adverse drug events and improve patient safety.
• Timely Follow-Up : Patients with persistent symptoms should have timely follow-up appointments scheduled to assess progress and consider alternative treatments if necessary. This underscores the importance of continuity of care. Acute bronchitis can lead to high morbidity in patients with underlying COPD and other preexisting pulmonary conditions. It is crucial to recognize that when symptoms persist for more than 6 weeks, a reevaluation is essential to confirm the accuracy of the initial diagnosis and assess the potential presence of complicating factors. [43] [44]
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Disclosure: Anumeha Singh declares no relevant financial relationships with ineligible companies.

Disclosure: Akshay Avula declares no relevant financial relationships with ineligible companies.

Disclosure: Elise Zahn declares no relevant financial relationships with ineligible companies.

This book is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) ( http://creativecommons.org/licenses/by-nc-nd/4.0/ ), which permits others to distribute the work, provided that the article is not altered or used commercially. You are not required to obtain permission to distribute this article, provided that you credit the author and journal.

• Cite this Page Singh A, Avula A, Zahn E. Acute Bronchitis. [Updated 2024 Mar 9]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

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INTRODUCTION

Acute bronchitis is a common clinical condition characterized by an acute onset but persistent cough, with or without sputum production. It is typically self-limited, resolving within one to three weeks. Symptoms result from inflammation of the lower respiratory tract and are most frequently due to viral infection.

Treatment is focused on patient education and supportive care. Antibiotics are not needed for the great majority of patients with acute bronchitis but are greatly overused for this condition. Reducing antibiotic use for acute bronchitis is a national and international health care priority. (See 'Avoiding antibiotic overuse' below.)

The clinical features, diagnosis, and management of acute bronchitis are addressed here. Chronic bronchitis, a subtype of chronic obstructive pulmonary disease, is discussed separately. (See "Management of infection in exacerbations of chronic obstructive pulmonary disease" and "Chronic obstructive pulmonary disease: Diagnosis and staging" .)

DEFINITIONS

● Acute bronchitis is a lower respiratory tract infection involving the large airways (bronchi), without evidence of pneumonia, that occurs in the absence of chronic obstructive pulmonary disease.

● Chronic bronchitis is commonly seen in current and former smokers and is defined as a cough that lasts for at least three months in each of two successive years. (See "Chronic obstructive pulmonary disease: Diagnosis and staging", section on 'Definitions' .)

SCOTT KINKADE, MD, MSPH, AND NATALIE A. LONG, MD

Am Fam Physician. 2016;94(7):560-565

Patient information : See related handout on acute bronchitis , written by the authors of this article.

Author disclosure: No relevant financial affiliations.

Cough is the most common illness-related reason for ambulatory care visits in the United States. Acute bronchitis is a clinical diagnosis characterized by cough due to acute inflammation of the trachea and large airways without evidence of pneumonia. Pneumonia should be suspected in patients with tachypnea, tachycardia, dyspnea, or lung findings suggestive of pneumonia, and radiography is warranted. Pertussis should be suspected in patients with cough persisting for more than two weeks that is accompanied by symptoms such as paroxysmal cough, whooping cough, and post-tussive emesis, or recent pertussis exposure. The cough associated with acute bronchitis typically lasts about two to three weeks, and this should be emphasized with patients. Acute bronchitis is usually caused by viruses, and antibiotics are not indicated in patients without chronic lung disease. Antibiotics have been shown to provide only minimal benefit, reducing the cough or illness by about half a day, and have adverse effects, including allergic reactions, nausea and vomiting, and Clostridium difficile infection. Evaluation and treatment of bronchitis include ruling out secondary causes for cough, such as pneumonia; educating patients about the natural course of the disease; and recommending symptomatic treatment and avoidance of unnecessary antibiotic use. Strategies to reduce inappropriate antibiotic use include delayed prescriptions, patient education, and calling the infection a chest cold.

Cough is the most common illness-related reason for ambulatory care visits, accounting for 2.7 million outpatient visits and more than 4 million emergency department visits annually. 1 Acute bronchitis is a clinical diagnosis characterized by acute cough, with or without sputum production, and signs of lower respiratory tract infection in the absence of chronic lung disease, such as chronic obstructive pulmonary disease, or an identifiable cause, such as pneumonia or sinusitis. 2

Acute bronchitis is most often caused by a viral infection. 3 , 4 The most commonly identified viruses are rhinovirus, enterovirus, influenza A and B, parainfluenza, coronavirus, human metapneumovirus, and respiratory syncytial virus. 3 Bacteria are detected in 1% to 10% of cases of acute bronchitis. 3 – 5 Atypical bacteria, such as Mycoplasma pneumoniae , Chlamydophila pneumoniae , and Bordetella pertussis , are rare causes of acute bronchitis. In a study of sputum samples of adults with acute cough for more than five days, M. pneumoniae was isolated in less than 1% of cases and C. pneumoniae was not identified. 6

Approximately 10% of patients presenting with a cough lasting at least two weeks have evidence of B. pertussis infection. 7 , 8 During outbreaks, pertussis detection is more likely in children and those with prolonged coughs. 6 , 9 Antibiotics can eradicate B. pertussis from the nasopharynx. They do not seem to shorten the course of illness unless given in the first one to two weeks. 10 Isolated outbreaks of pertussis occur throughout the United States, and increased testing of adults and children should be considered during these periods.

MEDICAL HISTORY

Cough is the predominant and defining symptom of acute bronchitis. The primary diagnostic consideration in patients with suspected acute bronchitis is ruling out more serious causes of cough, such as asthma, exacerbation of chronic obstructive pulmonary disease, heart failure, or pneumonia. The diagnoses that have the most overlap with acute bronchitis are upper respiratory tract infections and pneumonia. Whereas acute bronchitis and the common cold are self-limited illnesses that do not require antibiotic treatment, the standard therapy for pneumonia is antibiotics.

Besides cough, other signs and symptoms of acute bronchitis include sputum production, dyspnea, nasal congestion, headache, and fever. 4 , 11 , 12 The first few days of an acute bronchitis infection may be indistinguishable from the common cold. Patients may have substernal or chest wall pain when coughing. Fever is not a typical finding after the first few days, and presence of a fever greater than 100°F (37.8°C) should prompt consideration of influenza or pneumonia. Production of sputum, even purulent, is common and does not correlate with bacterial infection. 13 , 14

Because the cough associated with bronchitis is so bothersome and slow to resolve, patients often seek treatment. Patients and clinicians may underestimate the time required to fully recover from acute bronchitis. 15 The duration of acute bronchitis–related cough is typically two to three weeks, with a pooled estimate of 18 days in one systematic review. 15 This corresponds to results of a prospective trial, which found that patients who had a cough for at least five days had a median of 18 days of coughing. 16

PHYSICAL EXAMINATION

On physical examination, patients with acute bronchitis may be mildly ill-appearing, and fever is present in about one-third of patients. 4 , 11 Lung auscultation may reveal wheezes, as well as rhonchi that typically improve with coughing. It is important to rule out pneumonia. High fever; moderate to severe ill-appearance; hypoxia; and signs of lung consolidation, such as decreased breath sounds, bronchial breath sounds, crackles, egophony, and increased tactile fremitus, are concerning for pneumonia. Pneumonia is unlikely in nonfrail older adults who have normal vital signs and normal lung examination findings. 17 – 20

DIAGNOSTIC TESTING

Laboratory testing is usually not indicated in the evaluation of acute bronchitis. Leukocytosis is present in about 20% of patients; significant leukocytosis is more likely with a bacterial infection than with bronchitis. 21 Although rapid testing is available for some respiratory pathogens, it is usually not necessary in the typical ambulatory care patient. 22 Testing for influenza and pertussis may be considered when the suspicion is high and treatment would impact the course of the illness.

Biomarkers may assist in identifying patients who might benefit from antibiotics. Studies using C-reactive protein levels to guide antibiotic use in patients with respiratory tract infections are inconclusive, 23 although an elevated C-reactive protein level was associated with an increased likelihood of pneumonia in a large primary care trial. 24 A clinical decision rule for pneumonia was developed and prospectively validated by Swiss researchers, who found that pneumonia could be ruled out in patients with a C-reactive protein level of less than 50 mcg per mL and no dyspnea or daily fever. 25 Procalcitonin testing may be useful in the differentiation of pneumonia and acute bronchitis, but it is not widely available in clinical settings. 26 A large primary care trial of patients with lower respiratory tract infections found that procalcitonin testing added no benefit to a model that included signs, symptoms, and C-reactive protein levels. 24

INDICATIONS FOR CHEST RADIOGRAPHY

In patients with symptoms of acute bronchitis, imaging is primarily used to rule out pneumonia. Evidence-based guidelines from the American College of Chest Physicians state that imaging is not needed in patients with acute bronchitis symptoms who have normal vital signs and normal lung examination findings. 22 Patients with pneumonia typically have tachypnea, tachycardia, or dyspnea. 12 An exception to this rule is patients older than 75 years, who may present with more subtle signs of pneumonia and are less likely to have fever or tachycardia. 19

Table 1 includes indications for chest radiography in patients with symptoms of acute bronchitis. 22

Supportive care and symptom management are the mainstay of treatment for acute bronchitis. The role of antibiotics is limited. Since 2005, the National Committee for Quality Assurance has recommended avoidance of antibiotic prescribing for acute bronchitis as a Healthcare Effectiveness Data and Information Set Measure. 27 All major guidelines on bronchitis, including those from the American College of Chest Physicians, recommend against using antibiotics for acute bronchitis unless the patient has a known pertussis infection. 2 , 22 The American Academy of Pediatrics recommends that antibiotics not be used for apparent viral respiratory illnesses, including sinusitis, pharyngitis, and bronchitis. 28 Despite these recommendations, antibiotics are often prescribed for acute bronchitis. 29

OVER-THE-COUNTER MEDICATIONS

Over-the-counter medications are often recommended as first-line treatment for acute cough. However, a Cochrane review on over-the-counter medications for acute cough in the community setting showed a paucity of good data; existing trials are of low quality and report conflicting results. 30

A randomized controlled trial showed that compared with placebo, there was no benefit from ibuprofen in decreasing severity or duration of cough in patients with acute bronchitis. 31 Another randomized controlled trial comparing ibuprofen, acetaminophen, and steam inhalation found that those with a lower respiratory tract infection or age younger than 16 years had a modest reduction in symptom severity when taking ibuprofen over acetaminophen, although the ibuprofen group was more likely to seek care again for new or nonresolving symptoms. 32

Antihistamines are often used in combination with decongestants in the treatment of acute cough. Two trials of antihistamines alone showed no benefit compared with placebo in relieving cough symptoms. Combination decongestant/antihistamines are more likely to have adverse effects with no to modest improvement in cough symptom scores. 30 In 2008, The U.S. Food and Drug Administration warned against the use of over-the-counter cough medications containing antihistamines and antitussives in young children because of the high risk for harm, and these medications are no longer labeled for use in children younger than four years. They are continuing to investigate the safety of these medications in children up to 11 years of age. 30 , 33

ANTITUSSIVES

Antitussives work by reducing the cough reflex and can be divided into central opioids and peripherally acting agents. Codeine is a centrally acting, weak opioid that suppresses cough. Two studies show no benefit from codeine in decreasing cough symptoms, 30 and the American College of Chest Physicians does not recommend its use in the treatment of upper respiratory tract infections. 22

Dextromethorphan is a nonopioid, synthetic derivative of morphine that works centrally to decrease cough. Three placebo-controlled trials show that dextromethorphan, 30 mg, decreased the cough count by 19% to 36% ( P < .05) compared with placebo, which is equivalent to eight to 10 fewer coughing bouts per 30 minutes. 30

Benzonatate is a peripherally acting antitussive that is thought to suppress cough via anesthesia of the respiratory stretch receptors. One small study comparing benzonatate, guaifenesin, and placebo showed significant improvement with the combination of benzonatate and guaifenesin, but not with either agent alone. 34

EXPECTORANTS

Guaifenesin is a commonly used expectorant. It is thought to stimulate respiratory tract secretions, thereby increasing respiratory fluid volumes and decreasing mucus viscosity, and it may also have antitussive properties.

A Cochrane review including three trials of guaifenesin vs. placebo showed some benefit. 30 In one trial, patients reported that guaifenesin decreased cough frequency and intensity by 75% at 72 hours compared with 31% in the placebo group (number needed to treat = 2). A second trial showed decreased cough frequency (100% of the guaifenesin group vs. 94% of the placebo group; P = .5) and improved cough severity (100% of the guaifenesin group vs. 91% of the placebo group; P = .2) at 36 hours, and reduced sputum thickness (96% of the guaifenesin group vs. 54% of the placebo group; P = .001). A third trial using an extended-release formulation of guaifenesin showed improved symptom severity at day 4 but no difference at day 7. 30

BETA2 AGONISTS

Many patients with acute bronchitis have bronchial hyperreactivity, leading to impaired airflow in a mechanism similar to asthma. A 2015 Cochrane review does not support the routine use of beta 2 agonists for acute cough. 35 Two trials included children and found no benefit from albuterol in decreasing daily cough scores, daily proportion of cough, or median duration of cough, although both studies excluded children who were wheezing at the time of evaluation or had signs of bronchial obstruction. The studies of adults had mixed results, but the findings suggest that beta 2 agonists should be avoided if there is no underlying history of lung disease or evidence of wheeze or airway obstruction. However, beta 2 agonists may have some benefit in certain adults, especially those with wheezing at the time of evaluation who do not have a previous diagnosis of asthma or chronic obstructive pulmonary disease. Because there is limited supportive evidence, the use of such medications should be weighed against the risk of adverse effects, including tremor, shakiness, and nervousness. 35

HERBAL AND OTHER PREPARATIONS

Alternative medications are commonly used in the treatment of acute bronchitis. Pelargonium sidoides has some reported modest effectiveness in the treatment of acute bronchitis, but the quality of evidence is considered low, and the studies were all done by the manufacturer in Ukraine and Russia. 36 There are insufficient data to recommend for or against the use of Chinese medicinal herbs for the treatment of acute bronchitis, and there are safety concerns. 37

A Cochrane review of honey for acute cough in children included two small trials comparing honey with dextromethorphan, diphenhydramine (Benadryl), and no treatment. 38 Honey was found to be better than no treatment in decreasing the frequency and severity of cough, decreasing bothersome cough, and improving quality of sleep. Given the warnings against the use of antitussives in young children, honey is a reasonable alternative for the relief of acute cough in children older than one year. 38

ANTIBIOTICS

At least 90% of acute bronchitis episodes are viral, yet antibiotics are commonly prescribed. Unnecessary antibiotic prescriptions result in adverse effects and contribute to rising health care costs and antimicrobial resistance. A recent study of antibiotic prescribing trends from 1996 to 2010 found that antibiotics were prescribed in 71% of visits for acute bronchitis and that the rate of prescribing increased during the study period. 29 Although clinicians are more likely to prescribe antibiotics in patients with purulent sputum, a prospective observational study showed no difference in outcomes when antibiotics were prescribed to patients with green or yellow sputum, indicating that this is not a useful indicator of bacterial infection. 39 Smokers are also more likely to receive antibiotic prescriptions, with some populations of smokers being prescribed antibiotics more than 90% of the time despite no difference in outcomes. 40

A Cochrane review suggests there is no net benefit to using antibiotics for acute bronchitis in otherwise healthy individuals. 41 Although antibiotics decreased cough duration by 0.46 days, decreased ill days by 0.64 days, and decreased limited activity by 0.49 days, there was no difference in clinical improvement at follow-up. The most common adverse effects reported were nausea, diarrhea, headache, skin rash, and vaginitis with a number needed to harm of 5. Given minimal symptom improvement in an otherwise self-limited condition, increased rate of adverse effects, and potential for antibiotic resistance, it is wise to limit the use of antibiotics in the general population; further study in frail older persons and individuals with multiple comorbidities is needed. 41 If pertussis is confirmed or suspected because of a persistent cough accompanied by symptoms of paroxysmal cough, whooping cough, and post-tussive emesis, or recent pertussis exposure, treatment with a macrolide is recommended. 10

STRATEGIES TO REDUCE INAPPROPRIATE ANTIBIOTIC USE

Delayed prescribing, in which the patient is given an antibiotic prescription at the visit but told not to fill it unless symptoms continue beyond a predetermined time, significantly decreases antibiotic use. 42 A Cochrane review showed no difference in clinical outcomes between patients with acute bronchitis who were treated immediately with antibiotics and those with delayed or no antibiotic treatment. In addition, patients reported comparable satisfaction when given immediate vs. delayed antibiotics (92% vs. 87%). 43

Patients who present with the expectation that they will receive an antibiotic are more likely to receive one, even if the clinician thinks the prescription is unnecessary. 44 In fact, the strongest predictor for an antibiotic prescription is the clinician's perception of patient desire for antibiotics. 45 However, patients want symptom relief and will often accept leaving without an antibiotic prescription if the clinician addresses their concerns, shows personal interest, discusses the expected course of the illness, and explains the treatment plan. 45 Calling the infection a chest cold 44 and educating the patient about the expected duration of illness (two to three weeks) 15 are also helpful. Table 2 includes strategies for reducing antibiotic prescriptions for acute bronchitis. 29 , 42 , 43

Data Sources : The PubMed database was searched in Clinical Queries using the term acute bronchitis. Systematic reviews were searched and narrowed by etiology, diagnosis, therapy, prognosis, and clinical prediction guidelines. The Agency for Healthcare Research and Quality, National Guideline Clearinghouse, National Quality Measures Clearinghouse, and Essential Evidence Plus were also searched. Search date: January 2015.

note: This review updates a previous article on this topic by Albert , 46 Knutson and Braun , 47 and Hueston and Mainous . 48

National Hospital Ambulatory Medical Care Survey: 2011 outpatient department summary tables. http://www.cdc.gov/nchs/data/ahcd/nhamcs_outpatient/2011_opd_web_tables.pdf . Accessed March 28, 2015.

Woodhead M, Blasi F, Ewig S, et al.; Joint Taskforce of the European Respiratory Society and European Society for Clinical Microbiology and Infectious Diseases. Guidelines for the management of adult lower respiratory tract infections—full version. Clin Microbiol Infect. 2011;17(suppl 6):E1-E59.

Clark TW, Medina MJ, Batham S, Curran MD, Parmar S, Nicholson KG. Adults hospitalised 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.

Gencay M, Roth M, Christ-Crain M, Mueller B, Tamm M, Stolz D. Single and multiple viral infections in lower respiratory tract infection. Respiration. 2010;80(6):560-567.

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.

Wadowsky RM, Castilla EA, Laus S, et al. Evaluation of Chlamydia pneumoniae and Mycoplasma pneumoniae as etiologic agents of persistent cough in adolescents and adults. J Clin Microbiol. 2002;40(2):637-640.

Philipson K, Goodyear-Smith F, Grant CC, Chong A, Turner N, Stewart J. When is acute persistent cough in school-age children and adults whooping cough?. Br J Gen Pract. 2013;63(613):e573-e579.

Riffelmann M, Littmann M, Hülsse C, O'Brien J, Wirsing von König CH. Pertussis [in German]. Dtsch Med Wochenschr. 2006;131(50):2829-2834.

Cornia PB, Hersh AL, Lipsky null, et al. Does this coughing adolescent or adult patient have pertussis?. JAMA. 2010;304(8):890-896.

Altunaiji S, Kukuruzovic R, Curtis N, Massie J. Antibiotics for whooping cough (pertussis). Cochrane Database Syst Rev. 2007;3:CD004404.

Verheij T, Hermans J, Kaptein A, Mulder J. Acute bronchitis: course of symptoms and restrictions in patients' daily activities. Scand J Prim Health Care. 1995;13(1):8-12.

van Vugt SF, Verheij TJ, de Jong PA, et al.; GRACE Project Group. Diagnosing pneumonia in patients with acute cough: clinical judgment compared to chest radiography. Eur Respir J. 2013;42(4):1076-1082.

Altiner A, Wilm S, Däubener W, et al. Sputum colour for diagnosis of a bacterial infection in patients with acute cough. Scand J Prim Health Care. 2009;27(2):70-73.

Steurer J, Held U, Spaar A, et al. A decision aid to rule out pneumonia and reduce unnecessary prescriptions of antibiotics in primary care patients with cough and fever. BMC Med. 2011;9:56.

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.

Ward JI, Cherry JD, Chang SJ, et al.; APERT Study Group. Efficacy of an acellular pertussis vaccine among adolescents and adults. N Engl J Med. 2005;353(15):1555-1563.

Ebell MH. Predicting pneumonia in adults with respiratory illness. Am Fam Physician. 2007;76(4):560-562.

Wootton DG, Feldman C. The diagnosis of pneumonia requires a chest radiograph (x-ray) – yes, no or sometimes?. Pneumonia. 2014;5:1-7.

Metlay JP, Schulz R, Li YH, et al. Influence of age on symptoms at presentation in patients with community-acquired pneumonia. Arch Intern Med. 1997;157(13):1453-1459.

Evertsen J, Baumgardner DJ, Regnery A, Banerjee I. Diagnosis and management of pneumonia and bronchitis in outpatient primary care practices. Prim Care Respir J. 2010;19(3):237-241.

Holm A, Nexoe J, Bistrup LA, et al. Aetiology and prediction of pneumonia in lower respiratory tract infection in primary care. Br J Gen Pract. 2007;57(540):547-554.

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

Aabenhus R, Jensen JU, Jørgensen KJ, Hróbjartsson A, Bjerrum L. Biomarkers as point-of-care tests to guide prescription of antibiotics in patients with acute respiratory infections in primary care. Cochrane Database Syst Rev. 2014;11:CD010130.

van Vugt SF, Broekhuizen BD, Lammens C, et al.; GRACE Consortium. Use of serum C reactive protein and procalcitonin concentrations in addition to symptoms and signs to predict pneumonia in patients presenting to primary care with acute cough: diagnostic study. BMJ. 2013;346:f2450.

Held U, Steurer-Stey C, Huber F, Dallafior S, Steurer J. Diagnostic aid to rule out pneumonia in adults with cough and feeling of fever. A validation study in the primary care setting. BMC Infect Dis. 2012;12:355.

Albrich WC, Dusemund F, Bucher B, et al.; ProREAL Study Team. Effectiveness and safety of procalcitonin-guided antibiotic therapy in lower respiratory tract infections in “real life”: an international, multicenter poststudy survey (ProREAL) [published correction appears in Arch Intern Med . 2014;174(6):1011]. Arch Intern Med. 2012;172(9):715-722.

National Committee for Quality Assurance. 2015 Healthcare Effectiveness Data and Information Set Measures. http://www.ncqa.org/Portals/0/HEDISQM/Hedis2015/List_of_HEDIS_2015_Measures.pdf . Accessed March 10, 2015.

American Academy of Pediatrics. Five things physicians and patients should question. http://www.choosingwisely.org/wp-content/uploads/2015/02/AAP-Choosing-Wisely-List.pdf . Accessed September 15, 2015.

Barnett ML, Linder JA. Antibiotic prescribing for adults with acute bronchitis in the United States, 1996–2010. JAMA. 2014;311(19):2020-2022.

Smith SM, Schroeder K, Fahey T. Over-the-counter (OTC) medications for acute cough in children and adults in community settings. Cochrane Database Syst Rev. 2014;11:CD001831.

Llor C, Moragas A, Bayona C, et al. Efficacy of anti-inflammatory or antibiotic treatment in patients with non-complicated acute bronchitis and discoloured sputum: randomised placebo controlled trial. BMJ. 2013;347:f5762.

Little P, Moore M, Kelly J, et al.; PIPS Investigators. Ibuprofen, paracetamol, and steam for patients with respiratory tract infections in primary care. BMJ. 2013;347:f6041.

Briars LA. The latest update on over-the-counter cough and cold product use in children. J Pediatr Pharmacol Ther. 2009;14(3):127-131.

Dicpinigaitis PV, Gayle YE, Solomon G, Gilbert RD. Inhibition of cough-reflex sensitivity by benzonatate and guaifenesin in acute viral cough. Respir Med. 2009;103(6):902-906.

Becker LA, Hom J, Villasis-Keever M, van der Wouden JC. Beta2agonists for acute cough or a clinical diagnosis of acute bronchitis. Cochrane Database Syst Rev. 2015;9:CD001726.

Timmer A, Günther J, Motschall E, Rücker G, Antes G, Kern WV. Pelargonium sidoides extract for treating acute respiratory tract infections. Cochrane Database Syst Rev. 2013;10:CD006323.

Jiang L, Li K, Wu T. Chinese medicinal herbs for acute bronchitis. Cochrane Database Syst Rev. 2012;2:CD004560.

Oduwole O, Meremikwu MM, Oyo-Ita A, Udoh EE. Honey for acute cough in children. Cochrane Database Syst Rev. 2014;12:CD007094.

Butler CC, Kelly MJ, Hood K, et al. Antibiotic prescribing for discoloured sputum in acute cough/lower respiratory tract infection. Eur Respir J. 2011;38(1):119-125.

Oeffinger KC, Snell LM, Foster BM, Panico KG, Archer RK. Treatment of acute bronchitis in adults. J Fam Pract. 1998;46(6):469-475.

Smith SM, Fahey T, Smucny J, Becker LA. Antibiotics for acute bronchitis. Cochrane Database Syst Rev. 2014;3:CD000245.

Little P, Moore M, Kelly J, et al. Delayed antibiotic prescribing strategies for respiratory tract infections in primary care. BMJ. 2014;348:g1606.

Spurling GK, Del Mar CB, Dooley L, et al. Delayed antibiotics for respiratory infections. Cochrane Database Syst Rev. 2013;4:CD004417.

Phillips TG, Hickner J. Calling acute bronchitis a chest cold may improve patient satisfaction with appropriate antibiotic use. J Am Board Fam Pract. 2005;18(6):459-463.

Hirschmann JV. Antibiotics for common respiratory tract infections in adults. Arch Intern Med. 2002;162(3):256-264.

Albert RH. Diagnosis and treatment of acute bronchitis. Am Fam Physician. 2010;82(11):1345-1350.

Knutson D, Braun C. Diagnosis and management of acute bronchitis. Am Fam Physician. 2002;65(10):2039-2044.

Hueston WJ, Mainous AG. Acute bronchitis. Am Fam Physician. 1998;57(6):1270-1276.

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• Patient Care & Health Information
• Diseases & Conditions

A spirometer is a diagnostic device that measures the amount of air you're able to breathe in and out and the time it takes you to exhale completely after you take a deep breath.

During the first few days of illness, it can be difficult to distinguish the signs and symptoms of acute bronchitis from those of a common cold. During the physical exam, your doctor will use a stethoscope to listen closely to your lungs as you breathe.

In some cases, your doctor may suggest the following tests:

• Chest X-ray. A chest X-ray can help determine if you have pneumonia or another condition that may explain your cough. This is especially important if you smoke or have ever smoked.
• Sputum tests. Sputum is the mucus that you cough up from your lungs. It can be tested to see if you have illnesses that could be helped by antibiotics. Sputum can also be tested for signs of allergies.
• Pulmonary function test. During a pulmonary function test, you blow into a device called a spirometer, which measures how much air your lungs can hold and how quickly you can get air out of your lungs. This test checks for signs of asthma, chronic bronchitis or emphysema.

More Information

• Chest X-rays

Most cases of acute bronchitis get better without treatment, usually within a couple of weeks.

Medications

In some circumstances, your doctor may recommend other medications, including:

• Cough medicine. If your cough keeps you from sleeping, you might try cough suppressants at bedtime.
• Other medications. If you have allergies, asthma or chronic obstructive pulmonary disease (COPD), your doctor may recommend an inhaler and other medications to reduce inflammation and open narrowed passages in your lungs.
• Antibiotics. Because most cases of acute bronchitis are caused by viral infections, antibiotics aren't effective. However, if your doctor suspects that you have a bacterial infection, he or she may prescribe an antibiotic.

If you have chronic bronchitis, you may benefit from:

• Pulmonary rehabilitation. This is a breathing exercise program in which a respiratory therapist teaches you how to breathe more easily and increase your ability to be physically active.
• Oxygen therapy. This delivers extra oxygen to help you breathe.

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Clinical trials

Explore Mayo Clinic studies testing new treatments, interventions and tests as a means to prevent, detect, treat or manage this condition.

Lifestyle and home remedies

If you have bronchitis, to help you feel better, you may want to try the following self-care measures:

• Get enough rest. Rest and sleep help your body heal.
• Drink plenty of fluids. Staying hydrated can help to thin mucus.
• Avoid lung irritants. Don't smoke. Wear a mask when the air is polluted or if you're exposed to irritants, such as paint or household cleaners with strong fumes.
• Use a humidifier. Warm, moist air helps relieve coughs and loosens mucus in your airways. Be sure to clean the humidifier according to the manufacturer's recommendations to avoid the growth of bacteria and fungi in the water container.
• Consider a face covering in cold air. If cold air makes your cough worse and causes shortness of breath, put on a face mask or cover your mouth and nose with a scarf before you go outside.

Preparing for your appointment

You're likely to start by seeing your family doctor. If you have chronic bronchitis, you may be referred to a doctor who specializes in lung diseases (pulmonologist).

What you can do

Before your appointment, make a list of answers to the following questions:

• Have you recently had a cold or the flu?
• Have you ever had pneumonia?
• Do you have any other medical conditions?
• What medications, vitamins and supplements do you take regularly?
• Are you exposed to lung irritants at your job?
• Do you smoke or are you around tobacco smoke?

If possible, bring a family member or friend to your appointment. Sometimes it can be difficult to remember all the information provided. Someone who accompanies you may remember something that you missed or forgot.

If you've ever seen another physician for your cough, tell your present doctor what tests were done. If possible, bring the reports with you, including results of a chest X-ray, sputum culture and pulmonary function test.

What to expect from your doctor

Your healthcare professional is likely to ask you several questions, such as:

• When did your symptoms begin?
• Have your symptoms been continuous or occasional?
• Do your symptoms affect your sleep or work?
• Does anything improve or worsen your symptoms?
• Does cold air bother you?
• Do you notice that you wheeze sometimes?
• Have you had bronchitis before? Has it ever lasted more than three weeks?
• In between bouts of bronchitis, have you noticed that you're more short of breath than you were a year earlier?
• Do you exercise? Can you climb one flight of stairs without difficulty? Can you walk as fast as you used to?
• Do you smoke? If so, how much and for how long?
• Have you inhaled recreational drugs?
• Have you received the annual flu shot?
• Have you ever been vaccinated against pneumonia? If so, when?
• Chest cold (acute bronchitis). Centers for Disease Control and Prevention. https://www.cdc.gov/antibiotic-use/community/for-patients/common-illnesses/bronchitis.html. Accessed Jan. 4, 2021.
• Bronchitis. National Heart, Lung, and Blood Institute. https://www.nhlbi.nih.gov/health-topics/bronchitis. Accessed Jan. 4, 2021.
• Acute bronchitis. Merck Manual Professional Version. https://www.merckmanuals.com/professional/pulmonary-disorders/acute-bronchitis/acute-bronchitis. Accessed Jan. 5, 2021.
• Chronic obstructive pulmonary disease (COPD). Merck Manual Professional Version. https://www.merckmanuals.com/professional/pulmonary-disorders/chronic-obstructive-pulmonary-disease-and-related-disorders/chronic-obstructive-pulmonary-disease-copd. Accessed Jan. 5, 2021.
• Ferri FF. Acute bronchitis. In: Ferri's Clinical Advisor 2021. Elsevier; 2021. https://www.clinicalkey.com. Accessed Jan. 5, 2021.
• Ferri FF. Chronic obstructive pulmonary disease. In: Ferri's Clinical Advisor 2021. Elsevier; 2021. https://www.clinicalkey.com. Accessed Jan. 5, 2021.
• Goldman L, et al., eds. Acute bronchitis and tracheitis. Goldman-Cecil Medicine. 26th ed. Elsevier; 2020. https://www.clinicalkey.com. Accessed Jan. 5, 2021.
• AskMayoExpert. Upper respiratory tract infection. Mayo Clinic; 2023.
• Be antibiotics aware: Smart use, best care. Centers for Disease Control and Prevention. https://www.cdc.gov/patientsafety/features/be-antibiotics-aware.html. Accessed Jan. 5, 2021.
• Indoor air facts No. 8: Use and care of home humidifiers. U.S. Environmental Protection Agency. https://www.epa.gov/indoor-air-quality-iaq/indoor-air-facts-no-8-use-and-care-home-humidifiers. Accessed Jan. 5, 2021.
• Ambrosino N, et al. Lifestyle interventions in prevention and comprehensive management of COPD. Breathe. 2018; doi:10.1183/20734735.018618.
• How to prevent the spread of respiratory illnesses in disaster evacuation centers. Centers for Disease Control and Prevention. https://www.cdc.gov/disasters/disease/respiratoryic.html. Accessed Jan. 7, 2021.
• Baqir M (expert opinion). Mayo Clinic. Jan. 18, 2021.
• Acute bronchitis: Is it contagious?

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