Journal Reading

ACUTE BRONCHITIS
Richard P. Wenzel, M.D., and Alpha A. Flower III, M.D.

Sulistiansyah Hadi Pranata

Case
Mr.X, 40 years old
No underlying lung disease
7-day history of mild shortness of breath with exertion
Productive cough with purulent sputum, no paroxysm

of cough
No contact of ill person in community
Normal vital sign
Rales (-)
Wheezing (+)

Clinical problem
Acute bronchitis is a self-limited inflammation of

large airways of lung

Cough (+) without pneumonia
5% of adults annually
Higher incidence during winter and fall
Virus is the most common cause (influenxa A and B,
parainfluenza, coronavirus, adenovirus, and
rhinovirus)
Bacterial role remains unclear

Pathobiology
Acute bronchitis reflects an inflammation response

to infection of the epithelium of the bronchi

Microscopical examination has shown thickening of
bronchial and tracheal mucosa
In study involving volunteers exposed to rhinovirus
infection: virus was detected in specimens of
induced sputum, in one third of bronchial biopsy
specimens, in quarter of bronchoalveolar lavage
specimens

Natural history
In first few days of infection, the symptoms can not

be distinguished from mild upper respiratory infection

Coughing persist more than 5 days, during these
days pulmonary function test may become abnormal
Cough typically persists for 10 to 20 days but may
last for 4 or more weeks
Purulent sputum (+)

Diagnosis
Should be differentiated from acute inflammation of

smal airways
Should be distinguished from bronchiectasis
Chronic bronchitis diagnosis is reserved for patients
who have cough and sputum production on most
days of the month at least 3 months during 2
consecutive years

diagnosis
Careful history taking, including contact with ill

people
Physical examination
Pertussis common presentation is cough of to 2 to 3
weeks, fever is less common than in viral bronchitis
During an epidemic of influenza, the finding of both
cough and fever was reported to have a predictive
value of 79%

Diagnostic testing
Cough with no fever
Tachycardia
Tachipnea
Normal vital signs
Absence of rales
Special case on pneumonia in elderly patients
Rapid diagnostic tests for several pathogen is used

primarily when the suspected organism is treatable

Treatment
Antimicrobial agents are not recommended in most

cases
More beneficial when a treatable pahogen is identified
2-agonist administered orally or by aerosol have
mixed results
Inhaled or oral orticosteroid may be reasonable for
troublesome cough (i.e. Cough more than 20 days) but
no clinical trial
Data of clinical trial for the use of mucolytic or
antitussive agents are also not available

2001 guidelines of the American college of Physicians

Antibiotic treatment is not recommended
Antitussive agents are only occasionally useful
No routine role for inhaled bronchodilators or
mucolytic agents
Patients with chronic airflow obstruction at baseline
or wheezing do have a benefit from 2-agonists
Inhaled anticholinergic agents are not recommended

ACCP and CDC guidelines recommend macrolide

as first-line therapy for pertussis

For infection with influenza A virus CDC recommend
either oseltamivir or zanamivir

Summary
The patient (Mr.X) most likely has a viral infection

causing uncomplicated acute bronchitis

Chest radiography is not indicated (no signs of
pneumonia)
No rapid test for viral causes should be ordered
(absence of influenza outbreak in community),
neither should antiviral therapy
Influenza unlikely in an unfebrile patient
No history of contact with ill person, the diagnosis of
pertussis is unlikely

summary
2-agonist is used for wheezing and shortness of

breath
codein or inhaled corticosteroid is considerable for
persistent cough

Recognized causes of acute bronchitis and options for therapy