Acute Bronchitis/Bronchiolitis

Bronchitis

Acute bronchitis is a common condition characterized by inflammation of the bronchial tubes in the lungs. It usually follows a viral upper respiratory tract infection and presents with cough, which may be productive of sputum.

  1. Diagnosis
    1. The diagnosis of acute bronchitis is typically clinical
  2. Symptoms:
    1. Cough, with or without sputum production
    2. Possible preceding symptoms of an upper respiratory tract infection (URTI), such as sore throat or rhinorrhea
    3. Wheezing
    4. Chest discomfort
    5. Low grade fever
  3. Physical Examination:
    1. Diffuse wheezing
    2. Rhonchi and crackles may be heard on auscultation, although the chest exam can also be normal
    3. Absence of signs that would suggest pneumonia (e.g., localized crackles, dullness to percussion, high fever)
  4. Investigations:
    1. Generally, investigations are not necessary for a straightforward case of acute bronchitis.
    2. Chest X-ray is reserved for cases where pneumonia is suspected, or in patients with chronic respiratory conditions, those who are immunocompromised, or elderly patients.
    3. Sputum culture or rapid viral testing is not routinely done unless influenza is suspected during flu season, or in cases of suspected pertussis.
  5. Differential Diagnosis
    1. Asthma or COPD exacerbation: May present with similar symptoms but usually has a history of chronic symptoms and may respond to bronchodilators.
    2. Pneumonia: Suspected with high fever, localized crackles, hypoxia, or abnormalities on a chest X-ray.
    3. Upper Respiratory Tract Infections (URTI): These often precede bronchitis but can present with similar initial symptoms.
    4. Pertussis: Particularly in unvaccinated populations or those in whom immunity has waned, characterized by the classic ‘whoop’ cough.
    5. Heart Failure: Especially in older patients, presenting with shortness of breath, wheezing, and productive cough.
    6. Lung Cancer: In a smoker or someone with a high risk of lung cancer, any new cough lasting longer than three weeks should be investigated.
  6. Management
    1. Non-pharmacological:
      1. The management of acute bronchitis is mostly supportive.
      2. Rest and hydration.
      3. Humidified air can help soothe irritated bronchial passages.
      4. Smoking cessation advice is crucial for smokers.
    2. Pharmacological:
      1. The majority of cases of acute bronchitis are viral, so antibiotics are generally not indicated.
      2. If the cough is impacting sleep or quality of life, a cough suppressant such as dextromethorphan may be used.
      3. Inhaled bronchodilators may provide relief if there is wheezing or if the patient has underlying reactive airway disease.
      4. Analgesics and antipyretics like paracetamol or ibuprofen can be used for fever and discomfort.
    3. Antibiotics:
      1. Reserved for suspected bacterial infection, which is rare, or for atypical pathogens in cases with a high clinical suspicion.
      2. May also be considered for elderly patients, those with comorbidities, or immunocompromised individuals,particularly if symptoms are severe or worsening after an initial period of improvement.
  7. Education:
    1. Patients should be educated about the self-limiting nature of the condition, typically resolving within a few weeks.
    2. Advice on infection control measures, such as handwashing and covering coughs, to prevent the spread of infection.
  8. Follow-up:
    1. Most cases resolve without complications; however, patients should be advised to seek further medical care if symptoms worsen or if they develop signs of more severe illness, such as high fever, productive cough with discolored sputum, or shortness of breath.
  9. Referral:
    1. Referral to a specialist is rarely needed but may be indicated if there is suspicion of an underlying lung pathology or if the patient does not improve as expected.

In Australia, as in many countries, there is a significant focus on the judicious use of antibiotics to prevent resistance (Antibiotic Stewardship), so they are typically reserved for cases where there is a clear indication. It’s also worth noting that the approach can vary slightly depending on local guidelines and the prevalence of different pathogens at certain times of the year.

Bronchiolitis

Bronchiolitis is a common lower respiratory tract infection that primarily affects infants and young children(<2). It is typically caused by viral infections, with respiratory syncytial virus (RSV) being the most common culprit. Here’s an overview of the diagnosis and management of bronchiolitis:

Diagnosis: The diagnosis of bronchiolitis is primarily based on clinical symptoms and physical examination. Common signs and symptoms include cough, wheezing, fast or labored breathing, nasal congestion, fever, and sometimes, difficulty feeding.

Physical Examination: A physical examination may reveal wheezing, crackles, and signs of respiratory distress, such as nasal flaring, chest retractions, and increased respiratory rate.

Laboratory Tests: In most cases, bronchiolitis doesn’t require specific laboratory tests. However, in severe cases or when the diagnosis is uncertain, tests like a chest X-ray or respiratory viral panel (to identify the causative virus) may be performed.

Management: The management of bronchiolitis typically involves supportive care as it is a viral illness, and antibiotics are not effective against viruses. Here are key aspects of management:

  1. Hydration: Ensure the child receives adequate fluids, as dehydration can be a concern due to increased respiratory effort and decreased feeding. Breastfeeding or formula feeding should be continued if possible.
  2. Humidified Oxygen: In cases of severe respiratory distress or low oxygen levels (<90%), supplemental oxygen via nasal prongs may be required. Oxygen should be humidified to prevent drying of the airways.
  3. Nasal Suctioning: Removing excess mucus from the nose with a bulb syringe or suction device can help alleviate congestion and improve breathing.
  4. Feeding: Encourage the child to feed as tolerated. Smaller, more frequent feeds may be easier for them during times of respiratory distress.
  5. Monitoring: Frequent monitoring of vital signs, respiratory rate, oxygen saturation, and overall clinical status is essential. Hospitalization may be necessary for severe cases or those with significant respiratory distress.
  6. Medications: Medications are not recommended for bronchiolitis. The RCH specifically says do not administer
    1. Beta-2 agonists, including in infants with a personal or family history of atopy
    2. Corticosteroids (nebulised, oral, intramuscular or intravenous)
    3. Adrenaline (nebulised, intramuscular or intravenous) except in peri-arrest or arrest situation
    4. Nebulised hypertonic saline
    5. Antibiotics, including azithromycin
    6. Antivirals
    7. Caffeine

The management of bronchiolitis should be tailored to the individual child’s severity of illness and risk factors. Parents and caregivers should closely follow the guidance of healthcare professionals and seek medical attention if the child’s condition worsens or if there are concerns about their breathing or hydration status. Prevention through good hand hygiene and avoiding close contact with sick individuals is also essential.