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5Acute BronchitisAnas Bahnassi PhD

Pharmacotherapy of Infectious DiseasesA Case-Based Approach

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Introduction

• Cough….– One of the most common

symptoms in daily practice.– When consistent for 3wks or less,

with or without sputum, it is consistent with the diagnosis of acute bronchitis.

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Introduction

• Acute Bronchitis:Should be differentiated from the common cold, acute exacerbation of chronic bronchitis, asthma, andcommunity acquired pneumonia. It is self-limiting and symptoms usually resolve within 10-14 days

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A non-bacterial cause is present in more than 90% of acute bronchitisEtiologic agent Frequency Comments

Viral >90% Most common viral isolates based on age:<1 yr: RSV, parainfluenza, coronavirus.1-10 yr: Parainfluenza, enterovirus, RSV.>10 yr: Influenza, RSV, parainfluenza.

Not infectious Not well studied

Chemical and fume exposure.

Bacterial 5-10% The only isolates show to cause acute bronchitis are:Chlamydophila pneumoniae, Mycoplasma pneumoniae, Brodetella pertussis, Brodetella parapertussis.

There is no evidence that S. pneumoniae, H. Influenzae, M. Catarrhalis cause acute bronchitis in the absence of lung disease.

RSV: Respiratory Syncytial Virus

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Goals of Therapy

• First “Do No Harm”• Rule out serious illness: pneumonia.• Minimize symptoms

• Limit the unnecessary use of antibiotics

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Investigations:

• History:– Symptoms:

• Cough, with or without sputum, can last >3wks in more than 50% of cases of viral infection.

• Wheezing, tachypnena, respiratory distress, hypoxemia.• Green sputum production is a function of peroxidase

release from leukocytes, hence it applies only inflammation not necessarily infection.

• Consider alternative diagnosis when symptoms last >3wks.

– Obtain vaccination history, travel history, and cigarette smoking.

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Investigations:

• Physical Examination:– A key to diagnosis:• Absence of tachycardia (HR>100 beats/min), tachypnea

(>24 breath/min), fever (oral temp. >38ºC) and localized chest findings suggest acute pneumonia.

• Objective Measurements:• No role for routine chest x-ray, viral culture, serological

essay, sputum culture, or Gram stain or pulmonary function testing/spirometry.

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Management of Acute Bronchitis

Cough ≤ 3 wks± Sputum

Signs of consolidation, airway

obstruction, fever, RR, HR

During documented outbreak of influenza

pertussis?

Acute Bronchitis

Consider pneumonia, asthma, or other

pulmonary diseases

Treat as appropriate

• Establish expectation of up to 14 days duration of cough.

• Educate: regarding lack of evidence for antibiotics.

• Encourage increased fluid intake, humidity.

• Recommend: antipyretics, analgesics, antitussives, for symptom relief.

No

No

Yes

Yes

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Therapeutic ChoicesNonpharmacolgic

• Nonpharmacologic approach is the mainstay of management:– Limit risk of inoculation and transmission by

employing strict hand-washing techniques.– Increased fluid and humidity may help reduce

cough.

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Analgesic Dose ADR DI Comments Cost

APAP 325-500 mg q4-6h PRN (Don’t exceed 4g/24 h)

less GI upset than Salicylates

Use with caution in hepatic impairment, severe liver damage with overdosePreferred in children

$

Ibuprofen 300-400 mg TID-QID (Max 2.4g/d)

GI side effects, heartburn

ASA/Anticoagulants may bleeding risk

Contraindicated in PUD or IBD.Contraindicated in patients with history of risk of ASA/NSAID intolerence (Asthma, anaphylaxis, uricaria, angiedema, rhinitis)

$

Therapeutic ChoicesPharmacolgic

• Analgesics: APAP, Ibuprofen can be used for symptomatic relief

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Antitussive Dose ADR DI Comments Cost

Codeine Adutls + Children>12yr10-20mg q4-6hMax 120mg/d

SedationVomitingConstipa-tion

Additive sedation (CNS depressants)

Use with caution in elderly or debilitated patients

$

Dextromethorphan

30mg q6-8h PRN

Rare, nausea, drowsiness, dizziness.

Caution with CNS depressantsStop MAOI for 2wks prior start.

Not recommended for patients with asthma.

$

Therapeutic ChoicesPharmacolgic

• Antitussives: May provide short symptomatic relief but doesn’t shorten the duration of illness

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B-aginists Dose ADR DI Comments Cost

SalbutamolMDI(100ug/p)Diskus (200ug/p)

Diskus: 1 P TID-QIDMDI: 1-2 p QID Max 800ug/d

Tremor, restlessness, palpitation, headache, nausea, dizziness.

Caution with other sympatho-mimetic agents.

Contraindicated in arrythmia, hypertrophic obstructive cardiomyopathy

$$$$$

TerbutalineTurbohaler

1-2 p TID-QID max of 6 p/d

Same Same Same $$$

Therapeutic ChoicesPharmacolgic• Bronchodilators: Use is not supported in the absence of airflow

obstruction.• Adults with cough and wheezing may benefit from the treatment.

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Therapeutic ChoicesPharmacolgic

• Antibiotics:– Routine treatment with ABs is not recommended

in acute uncomplicated bronchitis.– AB treatment doesn’t have a consistent impact on

the duration or severity of illness or prevention of complications either in adults or children.

– “AB treatment may reduce the duration of cough by half a day”

– Consider ADRs and chance of resistance.

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Therapeutic Tips• Treatment is only supportive in the vast majority of acute bronchitis

cases.• Patient satisfaction is not related to receiving antibiotics but the quality

of pharmacist-patient communication.• Educate regarding the lack of evidence of antibiotic use.• No evidence supports the use of oral or inhaled corticosteroids.• In a documented influenza outbreak consider neuraminidase inhibitors

which are active against influenza A and B.• Set patient’s expectation to 10-14 days of cough. Most are relieved

within 1 wk.• Mucolytics and expectorants have failed to show significant benefits.• If patient shows no improvement in 2-3 wks consider follow-up.• Flu vaccination is recommended.

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Anas Bahnassi 2014

Pharmacotherapy:Infectious Diseases:

Anas Bahnassi PhD

abahnassi@gmail.com

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