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Acute Bronchitis Epidemology, Risk Factors and Management

2585 words (10 pages) Essay in Medical

08/02/20 Medical Reference this

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Abstract

Acute Bronchitis is a common respiratory infection seen in primary care settings and effects millions of patients each year. Although acute bronchitis can be caused by several agents, viruses are the most common cause. The clinical presentation of acute bronchitis is characterized by a cough with or without sputum and signs of a lower respiratory tract infection. Diagnosis is based on clinical manifestations and physical exam findings. With the presentation of cough a clinician needs to properly evaluate symptoms and rule out differential diagnosis’ such as pneumonia. If a clinician does order a chest x-ray the findings in acute bronchitis are normal. Treatment regimens are supportive care and focused on symptom management. Antibiotic use should only be initiated in those cases that a bacterial agent is the suspected cause.

Acute Bronchitis

Introduction

Acute bronchitis is one of the top five reasons patients seek medical care in the United States. Acute bronchitis can be defined as a self-limiting, respiratory disease characterized by a cough lasting greater than 3 weeks (Hart, 2014).  Patients presenting with cough account for 2.7 million outpatient visits, and more than 4 million emergency room visits each year (Kinkade & Long, 2016). The purpose of this paper is to review the literature and guidelines for acute bronchitis in the adult population. This paper will review in detail the epidemiology, etiology, risk factors, pathophysiology, clinical presentation, physical exam findings, management and follow up care. This review will provide education that will help nurse practitioners(NPs) provide comprehensive care and promote healthy outcomes for patients with acute bronchitis.

Epidemiology

Acute bronchitis is a common illness but the exact incidence is not known. It is associated with occurrence primarily in fall and winter months. Acute bronchitis is an acute respiratory infection with cough as the prominent symptom. The symptoms typically last one to two weeks with or without phlegm production. The causative agent is almost always viral, accounting for 90 % of all cases (Hart, 2014). This illness is seen in all age groups, genders, and demographics. Though not associated with any specific race, acute bronchitis is known to occur more frequently in populations with low socioeconomic status and people who live in urban areas (Fayyaz, 2018). Although present in all age groups, children in general, a have six to ten upper respiratory infections (URIs)a year while adults acquire about two to four (Hart, 2014).

Etiology

Respiratory viruses are the most common cause of acute bronchitis. The causative agent is rarely identified in bronchitis, but the typical viruses include influenza, adenovirus, rhinovirus, parainfluenza, and respiratory syncytial virus (Fayyaz, 2018). Bacterial agents are the cause of one to 10 % acute bronchitis cases (Kinkade & Long, 2016). Atypical bacteria such as mycoplasma pneumoniae, chlamydophila pneumoniae, and bordella pertussis are the rare bacteria seen in acute bronchitis (Kinkade & Long, 2016). In coughs lasting longer than two weeks, bordella pertussis should be a considered a causative agent especially in children who are incompletely vaccinated, or in adults whom may be in the need of a booster vaccine.

Risk Factors

The risk factors associated with acute bronchitis are similar to those you would expect to see with any respiratory illness. The risk factors are close contact with someone who has a cold or bronchitis, exposure to tobacco smoke, dust air pollution and those who are not up to date on current immunizations. Patients that are immunocompromised or have co-morbidities such as underlying lung disease, diabetes, and cardiovascular disease are also at risk for developing acute bronchitis.

Pathophysiology

The American College of Chest Physicians (ACCP) define acute bronchitis as an “acute infection of the lower respiratory tree that is manifested predominantly by a cough with or without phlegm production that lasts for up to 3 weeks” (American College of Chest Physicians, 2018) . During an episode of acute bronchitis, the cells of the bronchial lining tissue become irritated, mucous membranes become edematous, and there is hypersecretion of mucus in the bronchial airways.  The collection of  copious amounts of mucous in the airways cause the classic cough seen in acute bronchitis. If the inflammation extends down the bronchial tree, into the bronchioles, and then to the air sacs, the result is bronchopneumonia (Fayyaz, 2018).

One of the difficult aspects of acute bronchitis is the length of illness. A meta analysis in 2013 showed that the average duration of cough in those adults with acute bronchitis was 17.8 days (Ebell, Lundgren, & Youngpairoj, 2013). The presence of purulent sputum is also common in acute bronchitis and does not indicate a bacterial cause (Hart, 2014)

Clinical Presentation

Cough is the primary symptom of acute bronchitis. Cough begins early in the illness and is considered the hallmark symptom. Cough characteristics can vary from dry to productive throughout the progression of the illness. Approximately half of the patients with acute bronchitis report a productive cough with purulent sputum (Blush III, 2013). The presentation of purulent sputum is what can lead clinicians to treat for a bacterial infection with antibiotics, but this is unnecessary. In healthy adults, production of purulent sputum indicates the sloughing of tracheobronchial tissue and inflammatory cells, which is unrelated to alveolar function (Blush III, 2013). Therefore, the presence of purulent sputum alone should never be the only criteria for the decision to prescribe antibiotics for a respiratory illness. 

While cough is the primary symptom of acute bronchitis, patients also present with other constitutional symptoms, such as headache, fatigue, myalgia, sore throat, and  nasal congestion. These symptoms are not specific to acute bronchitis and are present in other respiratory related illnesses. It is also not uncommon for those patients with acute bronchitis to have wheezing or bronchospasms, especially if there is a history of asthma.

Fever is not typical in acute bronchitis. Fever associated with cough is usually associated with pneumonia or influenza. Gastrointestinal symptoms such as nausea, vomiting, and diarrhea are also rare. When patients have severe tracheal involvement, they can experience symptoms such as burning chest pain, associated with coughing and respiration. It is important to understand that respiratory symptoms with bronchitis will be worse and more severe, in the patients with an underlying pulmonary disease or any history of impaired lung function (Fayyaz, 2018).

Physical Exam

On physical examination patients with acute bronchitis may be mildly ill-appearing with low-grade fever present in about one-third of patients (Kinkade & Long, 2016). Assessment findings can vary in severity and are usually not severe. Some patients only have a cough with benign physical assessment findings. Other patients may have localized lymphadenopathy, reddened pharynx, rhinorrhea, and wheezing or rhonchi noted on auscultation. During the physical exam, it is important to rule out pneumonia. Findings that would suggest pneumonia include a high fever, hypoxia, any signs of lung consolidation, crackles and egophony are all concerning and may indicate pneumonia. Pneumonia is not likely in otherwise healthy adults with normal vitals and normal lungs assessments (Kinkade & Long, 2016).

Diagnostic Tests

There is not a gold standard diagnostic test used to diagnose acute bronchitis. Acute bronchitis is a diagnosis based on physical exam and exclusion of other diseases. The approach to testing should be guided by taking a thorough history and physical exam. It is important to take a thorough history that includes the possibility of contact with others that are ill, in particular those who may have influenza or pneumonia. Medical history and social history are also important factors to address and may help determine a diagnosis. Other important factors to address are medications, work exposure, recent travel, and immunization status. All of the data collected through patient history and physical exam, can lead a clinician to determine if diagnostic testing is needed. Additional testing may be needed to confirm or rule out differential diagnoses. As mentioned before, the physical exam in acute bronchitis is typically unremarkable except for the presence of low-grade fever and possibly rhonchi or wheezing. If any signs of dyspnea, high fever, or lung consolidation, then the clinician needs to consider pneumonia in the differential diagnosis. Pneumonia also needs to be considered in older adults because their presentation may be atypical, with the absence of a fever. Patients age seventy-five or older with respiratory rates greater the twenty four breaths a minute, decreased oxygen saturation levels and decreased or changed mental status need to be evaluated for pneumonia (Hart, 2014). If a patient shows any signs of pneumonia or is older than 75 years of age, then a chest x-ray should be ordered. In acute bronchitis the results of chest x-ray are normal, and many patients do not require a chest x-ray to confirm diagnosis unless warranted by physical exam findings. One study showed that 7 % of patients with an initial negative chest x-ray later had positive chest-ray findings for pneumonia (Hart, 2014). Therefore, the absence of clinical findings on a chest x-ray should not override a clinical judgment of an ill-appearing patient, who is suspected to have pneumonia.

Other diagnostic tests that may be ordered would be a complete blood cell count(CBC). This can help rule out bacterial infection by evaluating the presence of an increased white blood cell count (WBC). Leukocytosis is present in 20% of patients, but only half of these patients have significant leukocytosis associated with a bacterial cause (Kinkade & Long, 2016). Procalcitonin levels are currently being evaluated as a potential serum biomarker to differentiate between bacterial or viral infections (Hart, 2014).

 

 

Management

The management of acute bronchitis is primarily supportive care with a focus on cough control. Although cough control is the goal of symptom management, there is no specific treatment used to effectively facilitate this. Most supportive therapy recommendations are over the counter medications (OTC). OTC medications may include antitussives, expectorants, mucolytics, and antihistamine/decongestant combinations. 

Short-term use of antitussives and beta2agonists, have been proven to be beneficial in those patients that experience wheezing (Blush III, 2013). Beta2 agonists are recommended in the patients who have a history of lung disease, but not in those uncomplicated patients who do not exhibit wheezing.

Over the past thirty years, there have been multiple studies that show little to no improvement when antibiotics are prescribed to adults with acute bronchitis (Hart, 2014). Despite the fact that acute bronchitis is almost always caused by viruses for which antibiotics are not effective, 65 to 85 % of patients are prescribed antibiotics (Blush III, 2013). In otherwise healthy patients, even those with a suspected bacterial cause, antibiotics are still not recommended, because they may only modestly reduce the duration and severity (Blush III, 2013)

When treating patients with acute bronchitis, it is very important to establish treatment goals. One qualitative study showed that patient demand was the main reason for antibiotic prescribing in those patients with acute bronchitis (Dempsey, Businger, Whaley, Gagne, & Linder, 2014). NPs need to address patients concerns, treatment expectations, and discuss the clinical course with patients to establish appropriate treatment plans that the patient will be willing to follow. Referring to acute bronchitis as a chest cold and educating patients about the expected duration are also helpful in reducing the number of antibiotic prescriptions (Kinkade & Long, 2016).

Follow-up

Follow up after acute bronchitis is dependent on symptom management and control. If symptoms worsen, such as increased shortness of breath, or presentation of a fever occurs the patient needs to be re-evaluated by the NP. Also, if symptoms are still present after 3 weeks, the patient needs to be seen in the office for re-evaluation with the possible addition of more diagnostic testing. Overall, follow up is very minimal. Patients should be educated on the importance of immunizations, including yearly influenza vaccinations.

NP’s are going to be diagnosing and treating acute bronchitis in the adult population frequently when practicing in primary care. It is essential for NPs to understand the disease cause, clinical course and understanding the current recommendations for evaluation and management. NP’s also need to be able to communicate with patients in a manner that addresses patient-specific issues, and discusses the reasoning for treatment regimens. Patient education should continue to focus on prevention methods, methods of transmission, and treatment regimens with a focus on the ineffectiveness of antibiotics. In otherwise healthy patients, acute bronchitis is almost always caused by a virus and will resolve on its own.

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