Acute bronchitis

Evaluation and management

Abstract: Acute bronchitis affects millions of individuals, significantly impacting patient
health and the healthcare industry. Understanding evaluation and treatment guidelines
for acute bronchitis allows the nurse practitioner to practice comprehensive care for
patients. This article reviews evidence-based practices when caring for the patient with
acute bronchitis, promoting optimization of healthy outcomes.

By Raymond R. Blush III, MSN, ACNP-BC

he purpose of this article is to review the evalua- office visits annually.3 On average, adults acquire two to four

T tion and management of acute bronchitis in the

adult population. Essential pathophysiology will
be reviewed, and current evidence-based practices in evalu-
ation and treatment will be identified. Best evidence guide-
lines will be examined, and implications for practice and
essential patient education will be addressed. This will pro-
vide an understanding for nurse practitioners (NPs) regard-
ing methods to promote healthy outcomes in patients
affected with acute bronchitis.
■ Epidemiology
URIs annually, and children may have as many as six to 10.4
As one of the three most commonly diagnosed illnesses in
the ambulatory care setting along with essential hyperten-
sion and diabetes, URI is not only a significant clinical con-
cern but an economic burden as well. Indirect costs for URIs
are related to work days lost in adults who are ill in addition
to those that are required to care for their sick children.
Losses are estimated at $22.5 billion annually.5 The Na-
tional Center for Health Statistics estimates that URIs lead
to almost 20 million lost work days in adults and 21 million
lost school days in children per year. Direct costs include
Illustration by John Bavosi / Science Photo Library ©

Acute bronchitis is a common diagnosis seen in various
healthcare settings. By definition, it is a clinical condition
that involves an acute respiratory tract infection where
cough is the hallmark feature. Symptoms typically last 1 to
2 weeks, and while phlegm may be present, there is no evi-
dence of bronchial consolidation as with pneumonia.1
Typically viral in origin, it is considered in the spectrum of
acute upper respiratory infections (URIs), or the “common
cold,” which also includes acute otitis media, pharyngitis
and tonsillitis, and acute sinusitis.2 It is seen across the full
spectrum of ages, gender, and demographics. As part of the
diagnosis of URI, it accounts for greater than 36 million
Key words: acute bronchitis, cough, upper respiratory tract infection, URI
the large number of office visits and diagnostic testing,
which is frequent and of limited clinical value. These direct
costs are $17 billion annually. Accounting for both direct
and indirect costs, the toll approaches $40 billion per year.5
While data that specifically address acute bronchitis and its
economic impact are limited, as part of the spectrum of
URIs, it clearly has a significant burden on the population
as well as healthcare providers.
■ Etiology
Acute bronchitis is a diagnosis that implies self-limiting,
large airway inflammation, the hallmark symptom of which

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www.tnpj.com October 2013 15
The Nurse Practitioner • January

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 Acute bronchitis: Evaluation and management
is a cough that may or may not produce phlegm. The lack
of small airway involvement or evidence of consolidation
and infiltrate on chest X-ray is important to this diagnosis.
While in rare circumstances, bacteria that commonly cause
community-acquired pneumonia are isolated in the spu-
tum of patients with acute bronchitis, the primary cause
is attributed to several viral species.2 Although the benefit
of isolating viral species is limited in evaluation and man-
agement in patients with acute bronchitis, there are several
typical organisms that have been identified. Both influ-
enza A and B species, parainfluenza virus, respiratory
Acute bronchitis is an inflammatory
reaction of the epithelium of the bronchi
in response to infection.
syncytial virus, coronavirus, adenovirus, and rhinovirus
have all been recognized in isolates of those with acute
bronchitis. It is occasionally discovered that bacterial spe-
cies are found in sputum samples of patients with acute
bronchitis; however, the role of these species is unclear,
since resultant bronchial biopsies do not show invasion of
6
the bacteria into large airways. Although fewer than 10%
of cases have a bacterial cause, other considerations include
atypical bacteria, such as Bordetella pertussis, Chlamydophi-
la pneumoniae, and Mycoplasma pneumoniae. These are
important to consider clinically because unlike their viral
counterparts, they may be responsive to antibiotic treat-
7
ment. Further complicating the identification of causative
agents, common upper respiratory flora such as Haemoph-
ilus influenzae and Streptococcus pneumoniae are often
found; however, it is unclear if their presence has any im-
pact on the development of disease. Overall, sputum cul-
tures of patients with acute bronchitis are challenging to
assess because it is difficult to determine if they are accurate thelial cell desquamation and shedding, which causes
samples or contaminated by pathogens from the upper
airway. Therefore, sputum cultures are often unreliable in
guiding treatment strategies.8
Regardless of the causative pathogen, their impact can
vary based on several factors, including comorbid condi-
tions like underlying lung disease, presence of a local
epidemic, vaccination status of the patient and popula-
tion, and the season. Particularly in the fall and early
spring, vehicles such as influenza are more likely to
contribute to acute bronchitis.1 Given its likelihood for
increased severity of illness, influenza should be consid-
ered and specifically evaluated for in the proper clinical
context.
16 The Nurse Practitioner • Vol. 38, No. 10
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■ Pathophysiology
The American College of Chest Physicians (ACCP) de-
scribes acute bronchitis as “an acute infection of the
lower respiratory tree that is manifested predominantly
by cough with or without phlegm production that lasts
for up to 3 weeks.”9 Although acute bronchitis is com-
monly considered part of the URI diagnosis, by definition,
bronchitis is inflammatory involvement of the lower re-
spiratory tract. While there is often overlap between these
two clinical conditions, they are mutually exclusive. In
fact, the presence of cough due to the common cold is as
high as 83% in the first 2 days of ill-
ness onset, and considering that acute
bronchitis and the common cold
share many of the same characteris-
tics, it is often impossible to distin-
guish between the two.9 Furthermore,
conditions specifically associated with
URIs such as postnasal drip often re-
sult in the need for throat clearing and coughing; this can
be confusing for the diagnosis of acute bronchitis.9 Clear-
ly, these conditions tend to have overlapping clinical
characteristics, and while ideally could be considered
independently, they are often in tandem.
In addition to the multiple causative organisms that
can lead to the development of acute bronchitis, there are
wide variations in the distribution of effects in the lower
respiratory tree (see Anatomy of the lung). Acute bronchi-
tis may also be complemented by involvement of smaller
airways as well. What is important to the distinction,
however, is the absence of smaller airway consolidation
and infiltrate as is seen in pneumonia. Regardless, acute
bronchitis is an inflammatory reaction of the epithelium
of the bronchi in response to infection by the causative
organism(s). This reaction is in response to mucosal in-
jury and epithelial cell damage and leads to the resultant
release of proinflammatory mediators. This leads to epi-
bronchial hyperresponsiveness and the need for airway
clearance, manifested by the characteristic cough. De-
pending on the extent, location of involvement, and pos-
sibly the organism itself, the cough may or may not result
in significant phlegm production.6,7
While beyond the scope of this article, the pathophysi-
ology of disease in at-risk populations is another point of
distinction. This includes patients with underlying lung
disease (COPD and bronchiectasis), immunocompromised
patients (HIV, chemotherapy), or patients with other sig-
nificant comorbid diseases (such as heart failure). An acute
exacerbation of chronic bronchitis in a patient with COPD,
for example, is a different disease than acute bronchitis in
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 Acute bronchitis: Evaluation and management

an otherwise healthy individual, varying in likely cause and

pathology. These distinctions should be considered and
managed accordingly.

■ Clinical presentation
Cough that begins early in the course of the illness is the
hallmark symptom of acute bronchitis. Characteristics of
the cough can vary. While often described as dry and
nonproductive, it is not uncommon for the cough to prog-
ress from clear to discolored productive consistency as the
illness evolves. About half of all patients with acute bron-
chitis report the presence of a cough that produces purulent
sputum.10 A common but usually inaccurate notion is that
a productive cough indicates the existence of bacterial infec-
tion and is an indication for antibiotic therapy. In fact, in
otherwise healthy individuals, the production of purulent
sputum is usually a manifestation of sloughing of the tra-
cheobronchial epithelium and inflammatory cells, unre-
lated to alveolar infection. Sputum production has been
shown to be a poor predictor for the presence of alveolar
disease, such as pneumonia, and should not serve alone as
a basis for the decision to administer antibiotics.10 The du-
ration of the cough varies greatly, lasting anywhere from 5
to 20 days, with one study finding that the median time to
patients feeling recovered was 11 days with complete symp-
tom resolution to 15 days.11 While duration of cough itself
is not a predictor of the presence of either acute bronchitis
or other diagnoses, with a prolonged course, other alternate
causes should be considered.
In addition to the presence of cough, patients with
acute bronchitis often have other constitutional symptoms
suggestive of infection, including fever, malaise, myalgia,
and fatigue. These are not specific to this disease process,
and given the fact that there is significant overlap in the
symptoms of acute bronchitis and a URI, distinction be-
tween the two is almost impossible.9 Acute bronchitis is
essentially a diagnosis of exclusion, where other symptoms
and findings are not suggestive of an alternate cause. As
an example, the presence of high fever, the previously
mentioned constitutional symptoms, and marked dyspnea
should suggest to the clinician the possibility of pneumo-
nia. In this situation, further evaluation with a chest X-ray
to evaluate for infiltrates and alveolar consolidation would
be warranted. The only true diagnostic tool for evaluation
of acute bronchitis is time and ongoing evaluation of the
patient to see if another disease process reveals itself. In
an otherwise healthy patient, the disease course is gener-
ally self-limited and responsive only to symptom control.
Asthma, allergic bronchospasm, reflux esophagitis, chron-
ic aspiration, lung tumors, heart failure, and ACE inhibi-
tor use are other possible diagnoses in a patient with cough

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 Acute bronchitis: Evaluation and management

that may be appropriate to consider. Some of these may ■ Diagnostic testing

be considered along with acute bronchitis in the differen- When acute bronchitis is considered, the approach to
tial diagnosis of acute cough, and in the correct clinical testing is generally guided by the taking of a thorough
scenario, specific evaluation may be necessary. history and the evaluation of physical exam features that

Anatomy of the lung

Mucous Submucosa
Mucosa gland

Cartilage

Serosa Smooth muscle

Lungs

Terminal
bronchiole Mucosa

Arteriole Smooth
muscle
Venule
Cartilage

Alveolar sacs

Capillaries

Type II
pneumocyte

Type I
pneumocyte

Alveolar
ducts
Capillary

Source: Rubin R, Strayer DS, eds. Rubin’s Pathology: Clinicopathologic Foundations of Medicine. 6th ed. Philadelphia, PA: Wolters Kluwer/Lippincott Williams &
Wilkins; 2012:539.

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suggest an alternate diagnosis. There is no reasonable
testing available that specifically confirms the diagnosis
of acute bronchitis, and as mentioned, it is often a diag-
nosis of exclusion. Although there is no evidence that
routine pulmonary function testing has significant im-
pact on the disease course of acute bronchitis in otherwise
healthy patients, it has been found that temporary limi-
tations in airflow occur in about 40% of those with acute
bronchitis, and 17% have reversibility of forced expira-
tory volume in one second greater than 15%. 9 It is
important to take a careful history that includes consid-
eration of contact with others that are ill, in particular
with infectious illness, such as pneumonia and influenza.
It is also important to consider the patient’s previous
health and social history, especially focusing on previous
cardiovascular and pulmonary status. Medications, to-
bacco, alcohol and illicit drug use, current or previous
work exposures, recent travel, and immunization status
are other considerations that are important to evaluate.
While none of these specifically confirm acute bronchitis,
they may suggest alternate diagnoses that could benefit
from diagnostic testing. Cough in the absence of fever,
tachypnea, tachycardia, and negative physical exam find-
ings for pulmonary consolidation (crackles and egoph-
ony) reduce the likelihood of pneumonia, and a chest
X-ray is likely not necessary. Patients with at-risk char-
acteristics or findings suggestive of other pathology
should be evaluated by clinically appropriate measures.
The diagnosis of acute bronchitis can then be reasonably
made in a patient with an acute respiratory infection; the
chief characteristic symptom of which is cough with or
without sputum production, if it has lasted no longer
than 3 weeks, and there is no radiographic or clinical
evidence of pneumonia and URI, acute asthma, or acute
COPD exacerbation.9
■ Treatment
The approach to management of patients with acute bron-
chitis should include an understanding of the disease
course as well as a review of the evidence of beneficial
treatment options. The ACCP has published guidelines that
detail the management of acute bronchitis, which are sum-
marized here.12 Despite the fact that the vast majority of
cases of acute bronchitis are caused by viruses for which
antibiotics are ineffective, between 65% and 80% of pa-
tients receive them.9 This is contrary to the fact that except
in the few cases where the cause is bacterial, they have no
impact on improvement in clinical outcomes.10,13 In other-
wise healthy patients—even when bacterial cause is
considered—the use of antibiotics is still not recommended,
since they only modestly reduce the severity and duration
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Acute bronchitis: Evaluation and management
Acute cough illness
The CDC recommends that healthcare providers refer to
acute bronchitis (also known as acute cough illness) as a
chest cold to help reduce the expectation by patients
that antibiotics are needed for treatment. It is important
to explain to patients that the majority of cases (over
90%) are caused by viruses, and the benefit of antibiotic
use is limited.
The following are tips to reduce antibiotic use
• Tell patients that antibiotic use increases the risk of an
antibiotic resistant infection, and provide education
materials on antibiotic resistance.
• Identify and validate patient concerns.
• Recommend specific symptomatic therapy.
• Spend time answering patient questions and offer an
alternative plan if symptoms worsen.
• Remember: Effective communication is more impor-
tant than an antibiotic for patient satisfaction.
• See www.cdc.gov/getsmart or contact the local health
department for more information and patient educa-
tion materials.
Source: Centers for Disease Control and Prevention. Acute Cough Illness
(Acute Bronchitis). 2011. http://www.cdc.gov/getsmart/campaign-materials/
info-sheets/adult-acute-cough-illness.pdf.
of symptoms. One review found that the period of symp-
toms was decreased by only a fraction of a day with the use
of the three most common antibiotics: erythromycin,
doxycycline, and trimethoprim-sulfamethoxazole.7 If per-
tussis is suspected in the proper clinical scenario, then there
is evidence that supports the use of empiric antibiotic
administration while confirmation of the diagnosis is ob-
tained, although the impact of antibiotic use is a decrease
in transmission rather than resolution of symptoms.14 The
CDC also recommends that if influenza is suspected, prop-
er antiviral therapy should be initiated within 48 hours of
the onset of symptoms, which has been shown to decrease
the duration by approximately 1 day.15
Short-term therapy with antitussives and beta 2 -
agonists in situations where wheezing is associated with
coughing episodes has been found to be beneficial in
treatment of acute bronchitis. Antitussives, such as
codeine preparations and dextromethorphan, offer reduc-
tion in symptoms with patients who have chronic bron-
chitis, and their use may be beneficial in acute bronchitis.
An empiric trial may be useful, although routine use of
antitussives is not routinely suggested. 12 In uncompli-
cated cases of acute bronchitis where wheezing is not an
associated symptom, the use of beta 2-agonists is not
supported; however, when patients have previous under-
lying lung conditions, such as asthma, airflow obstruction,
or wheezing, the addition of such medications may be
helpful.9,16
The Nurse Practitioner • October 2013 19
 Acute bronchitis: Evaluation and management
Mucokinetic/expectorant agents and inhaled or par-
enteral corticosteroid treatments have not been shown to
be helpful in the treatment of acute bronchitis; the ACCP
does not endorse their use.12 In addition, while there are
no specific recommendations that address primary health
considerations, such as vaccination status and substance
use cessation, particularly tobacco, it seems reasonable
that a discussion about these would be benefi cial. It is
always important for the NP to routinely address this with
patients, since it has an overall impact on health concerns
in addition to acute bronchitis. Education that speaks
specifically to ensuring vaccinations such as influenza,
pertussis, and pneumonia would also be helpful.12 While
the direct impact on acute bronchitis may be limited, the
benefit of ensuring patient vaccination to both the patient
and the community is valuable in reducing the prevalence
of other, possibly more significant diseases that manifest
with cough.
■ Implications for practice
Acute bronchitis is one of the most common diagnoses
encountered in healthcare today. It is essential that the NP
has an understanding of the cause, evaluation, and manage-
ment strategies for this illness as well as methods to com-
municate with patients in a manner that promotes awareness
and healthy outcomes.
In understanding the pathophysiology of acute bron-
chitis, it is imperative to recognize that in the otherwise
healthy adult patient, the vast majority of cases are caused
by viruses. It is crucial to communicate this to patients so
they understand the benefit of antibiotic use is limited.
The CDC recommends that practitioners refer to acute
bronchitis as a “chest cold” to reduce the expectation that
antibiotics are necessary for treatment (see Acute cough
illness). Clinical evaluation is often directed at ruling out
other, more serious clinical conditions, such as pneumo-
nia. The use of diagnostic testing, such as chest X-rays and
pulmonary or lab data, has limited benefit in the evalua-
tion of acute bronchitis and is not recommended other
than to rule out other disease processes (if clinically in-
dicated). Other symptom control that may offer benefit
in the proper clinical setting includes a short course of
antitussives and possibly beta2-agonists. There is no evi-
dence that mucolytics and inhaled or parenteral cortico-
steroids offer any benefit to treatment.12
NPs are ideally situated to deliver care to patients for
whom acute bronchitis is a clinical consideration. Having
an understanding of the disease’s cause and course, un-
derstanding the current recommendations for evaluation
and management, and having the ability to communicate
with patients in a manner that identifies these issues, are
20 The Nurse Practitioner • Vol. 38, No. 10
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
essential characteristics of an NP. Patient education
should focus on understanding the methods of transmis-
sion and approaches to limit spread, appreciation of the
therapies of symptom control, and understanding that
in general, antibiotics do not change the course or sever-
ity of illness. In this manner, the NP as part of the mul-
tidisciplinary care delivery team can offer comprehensive
care that maximizes patient understanding and healthy
outcomes.
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Raymond R. Blush is Clinical Faculty at University of Michigan School of
Nursing, Ann Arbor, Mich.
The author has disclosed that he has no financial relationships related to this
article.
DOI-10.1097/01.NPR.0000434092.41971.ad
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