key: cord-022451-8qtjr0a9
authors: Barrett, Bruce
title: Productive Cough (Acute Bronchitis)
date: 2009-05-15
journal: Essential Family Medicine
DOI: 10.1016/b978-1-4160-2377-7.50034-3
sha: 
doc_id: 22451
cord_uid: 8qtjr0a9

nan

C h a p t e r Productive Cough (Acute Bronchitis) 1. Acute bronchitis is a very common diagnosis and is usually caused by viral infection. 2. Other causes of acute cough, such as pneumonia, gastroesophageal reflux disease, and allergy, should be considered. 3. The best available evidence suggests that antibiotics may reduce symptoms and illness duration slightly. Costs and side effects make the benefit-harm trade off tenuous at best. 4. Neither age nor smoking status has been linked to antibiotic effectiveness. 5. Only doxycycline, erythromycin, and trimethoprim/sulfamethoxazole have been tested in positively reported randomized, controlled trials (RCTs); hence, these are the only antibiotics that should be considered.

6. There is very little RCT-based evidence for or against the effectiveness of antitussive treatments. However, limited use may be supported, especially when the cough is interfering with sleep. 7. Nonsteroidal anti-inflammatory drugs are effective for pain, but significant toxicity risks raise the need for caution. 8. Over-the-counter cold formulas containing decongestants and/or antihistamines are not appropriate treatments for acute bronchitis but may be helpful if nasal congestion or drainage is present. 9. Mucolytics and expectorants have not been adequately assessed for acute bronchitis, but evidence from common cold and chronic bronchitis suggests possible effectiveness.

Jane Doe is a 58-year-old woman who presents at your clinic with productive cough of 10 days' duration. Jane first felt ill 2 weeks ago on the first of October. She remembers feeling a scratchy throat, which progressed to sore throat, general malaise, and cough. The cough has been bothersome both during the day and at night. It has kept her awake and has awakened her out of sleep. During the past week, she has coughed up phlegm. At first, it was clear to white. Now it is green or brown. There has been no blood. She felt alternately "slightly feverish" and "chilly" during the first few days of this illness but denies high temperatures and has not felt feverish for the past several days. She denies nasal symptoms, chest pain, shortness of breath, and vomiting. She may have had some increased dyspnea on exertion, especially in the beginning of the illness. She denies sensations of maxillary pain or postnasal drip. Her sore throat has resolved. This acute illness has caused her to reduce smoking to "a few cigarettes a day." She notes that "I really should quit that stuff." She has been using an over-the-counter combination cold formula, which she believes has helped manage the cough, although it does make her "a bit groggy."

You have known Jane since she first came to you about 4 years ago with chest pain. Previously, she had neglected her health care for many years. That original chest pain was burning in quality, bothered her most when she felt stressed, and was diagnosed empirically as reflux esophagitis when it responded to antacids. Her heartburn is now well controlled with lifestyle modifications and ranitidine (Zantac), 150 mg once or twice daily. Routine health screenings revealed tobacco use (one pack per day for 30 years) and hyperlipidemia, which is now well controlled on a statin. She also takes a daily aspirin for heart attack and stroke prevention. Her blood pressure has ranged from normal to borderline. Random blood glucose screening was normal. She has had two urinary tract infections since coming to you, both of which resolved with fluids and short courses of antibiotics. With motivational counseling, she reduced her cigarette consumption to less than half a pack per day, has improved her diet, and walks a brisk mile several days per week. Mammograms, Pap smears, and a screening sigmoidoscopy have all been negative. Jane received all recommended childhood immunizations but has declined influenza vaccination. She remembers receiving antibiotics for acute coughing illnesses several years before meeting you.

Jane's father died of a heart attack at age 64. He was a smoker. Jane's mother is alive and well at 77 but was diagnosed with type 2 diabetes and hypertension in her 60s. Jane's grandparents died in their 70s and 80s of unknown causes. She has a brother and two sisters but is unaware of any major health issues.

Jane is married with three adult children. She works as an office manager. She attributes daily work stress and relationship stress as the primary obstacles to smoking cessation. Her husband nags her to quit smoking. She denies physical or sexual abuse.

In addition to the acute symptoms mentioned, Jane has occasional mild heartburn, generally well controlled with antacids or ranitidine. She denies any chest pain or pressure with exercise. She also denies weight loss and feels that her general health, energy, and quality of life have improved slightly over the past 3 years. She is not aware of any significant occupational or environmental exposures but does live in a city that has occasional ozone alerts.

Jane is 5 feet 10 inches and 180 pounds (body mass index = 25.8). Her blood pressure today is 128/86 mm Hg, her heart rate is 68 beats per minute, and her temperature is 37˚C (98.6˚F) by ear thermometer. Her respiratory rate is about 20 breaths per minute. Her mucous membranes (ocular, nasal, and oral) are moist, without any abnormal signs. Tympanic membranes are clear, with normal light reflex and no signs of middle ear fluid. Posterior pharynx is somewhat erythematous but is without exudates, swelling, or signs of postnasal drainage. There is no tenderness to maxillary percussion.

There are two small, smooth, mobile, and nontender lymph nodes palpable in the anterior chain on the left side of her neck. Posterior auscultation of the lungs reveals neither rales nor rhonchi. Inspiratory effort is good, with full and symmetrical chest wall expansion. Heart sounds are normal.

You consider a chest radiograph, peak flow, complete blood count, C-reactive protein, and/or testing for streptococcal pharyngitis or pertussis but decide to order no tests.

Although you have not seen Jane before with this specific constellation of symptoms, you presumptively diagnose acute bronchitis, most likely caused by recent and perhaps ongoing upper airway viral infection with mid-airway inflammatory sequelae. Chronic exposure to tobacco smoke and possibly to other airborne pollutants is likely an underlying contributory factor.

The list of possible causes of acute coughing illness includes asthma, bronchiectasis, cancer, chemical bronchitis, chronic obstructive pulmonary disease, drugs (e.g., angiotensin-converting enzyme inhibitor), eosinophilic bronchitis, gastroesophageal reflux disease, interstitial lung disease, pneumonia, and sinusitis. Infectious viral respiratory pathogens include adenovirus, coronavirus, enterovirus, influenza, parainfluenza, respiratory syncytial virus, and rhinovirus. Each of these classes of virus has many subtypes; hence, there are several hundred specific viral strains that can lead to upper respiratory infection with cough. You know that influenza and respiratory syncytial virus are confined to the months November through April in your locale and thus are not in today's differential diagnosis. Last year, your state experienced an epidemic of pertussis, which was eventually controlled with an aggressive test-and-treat strategy. This year, your state public health department has reported only rare cases. Sinusitis is excluded by lack of fever, face pain, maxillary tenderness, or purulent discharge in nasal passageways or posterior pharynx.

There is no history of occupational or environmental exposure. The history of esophageal reflux suggests a possible contribution, but the symptoms are much more specific for acute infectious bronchitis, presumed viral.

Chapter 31 Productive Cough (Acute Bronchitis)

Acute bronchitis, presumed viral, is a very common clinical diagnosis . There are no sensitive or specific supporting tests. The main diagnostic job of the clinician is to rule out other causes. Jane has neither paroxysmal nor whooping cough and has no known exposure risk factors. Therefore, you decide not to do the uncomfortable nasopharyngeal swab required for pertussis polymerase chain reaction testing. With normal vital signs and lung sounds and with the lack of chest pain or pressure, persistent fever, and shortness of breath, you decide the pretest probability of pneumonia is too low to order a chest radiograph. You are aware of recent research showing that C-reactive protein might be useful in the absence of a chest radiograph (Almirall et al., 2004• B ; Flanders et al., 2004• B ; Garcia et al., 2003• B ) but also know it to be too nonspecific to be helpful in this case. You do note the history of heartburn responsive to H 2 blockers and discuss the possibility that esophageal reflux disease may have contributed to Jane's symptoms. Together you decide to schedule an upper endoscopy sometime in the next month or two.

After careful consideration and a detailed discussion of risks and benefits, you suggest conservative treatment: drinking lots of fluids, rest, and cough medicine. Jane will try an over-the-counter dextromethorphan-guaifenesin combination cough syrup. If that is unsuccessful, and especially if the cough keeps her awake at night, she will fill your prescription for a codeine-guaifenesin cough syrup. She will avoid cold formulas with antihistamines or decongestants, as she has neither allergic symptoms nor nasal congestion and these agents have side effect risks as well as being an expense.

You specifically ask Jane whether she wants or expects an antibiotic prescription. She says she would take any medicine that you think would be helpful and asks your opinion. You discuss the fact that antibiotics may be slightly better than placebo in relieving the symptom severity and duration of acute bronchitis. However, you also note the risk of side effects and touch on the societal problem of antibiotic resistance. You offer a "delayed fill" antibiotic prescription, but Jane declines. You also provide reassurance that the symptoms will go away and give her a few specific signs that would require a return visit (hemoptysis, shortness of breath or difficulty breathing, chest pain or pressure, persistent fever, cough lasting more than 6 weeks). You gently discuss the association between smoking and bronchitis and mention that more than a million Americans have kicked the habit and that you believe that she can too.

You see Jane again for smoking cessation counseling and follow-up after an upper endoscopy performed by a gastroenterologist colleague, which showed a small hiatal hernia but no specific lesions or signs of esophageal inflammation. Although smoking cessation is initially unsuccessful, after several attempts over a few years, Jane eventually kicks the habit. In the meantime, she has two other occurrences of acute bronchitis, both of which she treats at home with fluids, rest, and over-the-counter cough suppressants.

Acute bronchitis is a very common result of upper respiratory infection. Although bacterial and chemical causes are known, the vast majority of cases of acute bronchitis stem from viral agents. There are no known effective treatments for acute bronchitis. Whether a cough is productive and the color of the phlegm are not predictive of etiologic agent (virus vs. bacteria) or response to therapy. Systematic reviews of RCTs of antibiotics suggest small but statistically significant benefits of antibiotics over placebo in terms of persistence and severity of cough (Anonymous, 1998 (Smucny et al., 2004a • A ). Of the nine published RCTs, three are "positive" in that they report statistically significant benefits of doxycycline (Verheij et al., 1994 • A ) and erythromycin (Dunlay et al., 1987 (Franks and Gleiner, 1984 • A ) failed to find substantial benefit, most primary outcomes trended toward benefit, and a few secondary outcomes reached statistical significance. It should be noted that the number of unpublished RCTs is unknown. However, it is suspected that several negative trials conducted by drug companies remain unpublished. Because positive trials are more likely to be published than negative trials and because internal biases tend to favor treatment over placebo, actual benefits may be less.

There are no RCTs that specifically address the question of whether antibiotics are useful for tobacco smokers with acute bronchitis. However, Linder and Sim (2002• A ) reviewed the nine trials Chapter 31 Productive Cough (Acute Bronchitis) noted above (774 participants), looking specifically at the 276 smokers included. There were no statistically significant differences between smokers and nonsmokers. However, trends actually suggested that antibiotics were less effective for smokers than nonsmokers. This is a secondary analysis ("data dredging"); hence, conclusions are tentative but certainly do not support the widespread practice of justifying antibiotic prescriptions with smoking status.

Although it may be reasonable to prescribe antibiotics for some patients with acute bronchitis (e.g., if early pneumonia is suspected or if there is underlying chronic lung disease), most experts recommend against this practice (Anonymous, 1997• A ; Gonzales et al., 2001a,b• C) because societal harms (antibiotic resistance) and individual adverse effects may outweigh potential benefits. Side effects of antibiotics, such as nausea, diarrhea, vaginal candidiasis, and allergic reaction, occur frequently with most antibiotics. When using antibiotics for acute bronchitis, the number needed to treat (Walter, 2001) and the number needed to harm are similar and in the range of 10 to 20 (Anonymous, 1998 (Cantrell et al., 2002• B ; Walter, 2001; Stone et al., 2000 • B ) . This unfortunate situation is due both to patient demand and to physicians' beliefs and prescribing habits. Education, in the form of a pamphlet or physician advice, significantly reduces the desire for antibiotics (Macfarlane et al., 2002 • A ) . Some evidence suggests that writing a delayed prescription may reduce antibiotic use (Arroll et al., 2004 • A ) .

Unfortunately, there is very little reliable evidence regarding the effectiveness of cough treatments. Systematic reviews of RCTs have concluded that there is neither good evidence for nor good evidence against the effectiveness of antitussives (Anonymous, 2002 a • A ; Schroeder and Fahey, 2004• A ; Smith and Feldman, 1993 • A ). However, with the definite possibility of specific effectiveness (Parvez, 1998 • A ) and with evidence suggesting that the placebo effect for cough treatments is substantial (Eccles, 2002; Lee et al., 1992 • B ), the use of over-the-counter dextromethorphan-containing formulations and/or limited use of prescription codeine or hydrocodone may be reasonable. Although benzonatate (Tessalon) has been approved as a prescription cough medicine, there is virtually no evidence for or against its effectiveness. Furthermore, the number and quality of RCTs on beta agonist (e.g., albuterol inhaler) used in the setting of acute bronchitis are limited.

Although some evidence supports use (Hueston, 1994 • A ), the weight of evidence currently suggests that beta agonists are not very helpful in this setting (Anonymous, 2002b • A ; Smucny et al., 2004b • A ).

Expectorants and mucolytics have not been adequately assessed in the setting of acute bronchitis. However, evidence from trials for common cold and in the setting of chronic lung disease suggests possible benefits and little harm (Anonymous, 2002a • A ; Schroeder and Fahey, 2004• A ; Smith and Feldman, 1993 • A ). Neither antihistamines nor decongestants have been shown to be helpful for bronchitis, and both carry risks. Antihistamines can cause drowsiness, which may lead to a motor vehicle accident. Decongestants are contraindicated in the settings of hypertension and heart disease. For children, there is no evidence of any benefit of any over-the-counter medicine for colds or bronchitis and reasonable evidence of potential harm (Anonymous, 2002a• A ; Gunn et al., 2001; Schroeder and Fahey, 2004 • A ). Nonsteroidal anti-inflammatory drugs may help if pain is present. However, the widespread use of nonsteroidal antiinflammatory drugs is associated with major morbidity and mortality, with more than 10,000 Americans dying each year, mostly from gastrointestinal bleeding, but also from congestive heart failure and renal failure (Fries, 1991• B ; Heerdink et al., 1998• B ; Page and Henry, 2000; Wolfe et al., 1999 • B ) . Although the effectiveness of nonsteroidal anti-inflammatory drugs appears similar, risks vary, with ibuprofen being among the safest. Acetaminophen, not a nonsteroidal anti-inflammatory drug, is even safer.

There is a broad body of robust evidence that tobacco smoking cessation can be facilitated through a variety of physician-assisted modalities . Although no specific evidence links acute illness with readiness to quit, it makes good sense that the occasion of an episode of acute bronchitis might provide opportunity and incentive to support active attempts at tobacco cessation or at least to "plant the seed." The fact that Jane's father smoked and died of a heart attack at age 64 might also be diplomatically used as a motivational tool.

Acute bronchitis is the most common diagnosis when a patient presents with prolonged acute cough. There are no specific methods for diagnosing bron-Chapter 31 Productive Cough (Acute Bronchitis) chitis or for distinguishing bronchitis from upper respiratory infection with cough. The first job of the clinician is to rule out other causes, such as pneumonia, asthma, bacterial sinusitis, and gastroesophageal reflux disease. Once the diagnosis of acute infectious bronchitis is reached, the clinician's task turns to supporting the patient, in terms of both reassurance and selection of therapy. In most cases, antibiotics should be avoided. Until and unless better evidence emerges, the use of over-the-counter and prescription antitussives can be cautiously supported in adults. Decongestants should be avoided, especially if hypertension or heart disease is present. Beta-agonist inhalers may help those with wheezing or a history of asthma. Supportive home treatments, such as fluids, rest, and avoidance of stressors, make good sense but are largely unsupported by evidence. Unless symptoms dramatically worsen, most patients with acute bronchitis do not need a return visit. 

Contribution of C-reactive protein to the diagnosis and assessment of severity of community-acquired pneumonia

:106.• A Anonymous. Beta 2 -agonists are ineffective but increase adverse effects in acute bronchitis without underlying pulmonary disease

Delayed prescriptions for reducing antibiotic use in acute respiratory infections. Cochrane Database Syst Rev

Erythromycin in the treatment of acute bronchitis in a community practice

Antibiotic prescribing in ambulatory care settings for adults with colds, upper respiratory tract infections, and bronchitis

A placebo-controlled, double-blind trial of erythromycin in adults with acute bronchitis

Quantitative systematic review of randomized controlled trials comparing antibiotic with placebo for acute cough in adults

Performance of a bedside C-reactive protein test in the diagnosis of community-acquired pneumonia in adults with acute cough

• A Fries JF. NSAID gastropathy: The second most deadly rheumatic disease? Epidemiology and risk appraisal

C-reactive protein levels in community-acquired pneumonia

Principles of appropriate antibiotic use for treatment of uncomplicated acute bronchitis: Background

NSAIDs associated with increased risk of congestive heart failure in elderly patients taking diuretics

Albuterol delivered by metered-dose inhaler to treat acute bronchitis

Effectiveness of erythromycin in the treatment of acute bronchitis

Training health professionals in smoking cessation. Cochrane Database Syst Rev

Antibiotic treatment of acute bronchitis in smokers: A systematic review

• A NHS Centre for Reviews and Dissemination. Quantitative systematic review of randomised controlled trials comparing antibiotic with placebo for acute cough in adults

Objective evaluation of the pharmacodynamic response of 30 and 60 mg of dextromethorphan in acute cough

Doxycycline in acutse bronchitis: A randomized double-blind trial

Over-the-counter medications for acute cough in children and adults in ambulatory settings

Nicotine replacement therapy for smoking cessation

Over-the-counter cold medications: A critical review of clinical trials between 1950 and 1991

Telephone counselling for smoking cessation

Antibiotic prescribing for patients with colds, upper respiratory tract infections, and bronchitis: A national study of hospital-based emergency departments

Randomised controlled trial of antibiotics in patients with cough and purulent sputum

Effects of doxycycline in patients with acute cough and purulent sputum: A double blind placebo controlled trial

Number needed to treat (NNT): Estimation of a measure of clinical benefit

A randomized, controlled trial of doxycycline in the treatment of acute bronchitis

Gastrointestinal toxicity of nonsteroidal antiinflammatory drugs