What is the initial management for acute chemical irritation of the respiratory tract and acute bronchitis?

Initial Management of Acute Chemical Irritation of the Respiratory Tract and Acute Bronchitis

For acute chemical irritation of the respiratory tract and acute bronchitis, the initial management should focus on removing the irritant, providing supportive care, and treating symptoms without routine antibiotics unless specifically indicated.

Acute Chemical Irritation of the Respiratory Tract

Immediate Management

• Remove the patient from exposure to the chemical irritant immediately - this is the most effective intervention to prevent further damage 1
• Assess for signs of severe respiratory compromise including tachypnea, tachycardia, abnormal chest examination findings, or decreased oxygen saturation 2
• Provide supplemental oxygen if hypoxemia is present, with a target saturation of 88-92% 3
• Monitor for development of non-cardiogenic pulmonary edema or acute respiratory distress syndrome (ARDS), which can occur following chemical inhalation 1, 4

Supportive Care

• For bronchospasm, consider short-acting inhaled β-agonists (such as albuterol) to relieve bronchospasm 5, 4
• Avoid further exposure to the irritant and other respiratory irritants, including tobacco smoke 3
• Consider humidified air or vaporized treatments to help soothe irritated airways 2

Monitoring and Follow-up

• Close monitoring for the first 24-48 hours is essential as respiratory symptoms may worsen, particularly with exposures in small enclosed areas 4
• Poor prognostic factors include advanced age, exposure in small enclosed areas, and prolonged exposure 4

Acute Bronchitis Management

Diagnosis and Assessment

• Acute bronchitis is defined as cough with or without sputum production lasting up to 3 weeks with normal chest radiograph findings 3, 2
• Rule out pneumonia in patients with tachycardia (>100 beats/min), tachypnea (>24 breaths/min), fever (>38°C), or abnormal chest examination findings 2

Antibiotic Management

• Antibiotics should not be routinely prescribed for acute bronchitis as they provide minimal benefit while exposing patients to adverse effects 3, 2
• Purulent sputum or change in sputum color does not indicate bacterial infection and is not an indication for antibiotics 2
• Exception: For confirmed or suspected pertussis (whooping cough), prescribe a macrolide antibiotic and isolate the patient for 5 days from the start of treatment 3, 2

Symptomatic Treatment

• Antitussive agents such as codeine or dextromethorphan may provide modest relief for short-term symptomatic control of coughing 3, 2
• β2-agonist bronchodilators should not be routinely used but may be helpful in select adult patients with wheezing accompanying the cough 3, 2
• Expectorants, postural drainage, chest physiotherapy, and theophylline are not recommended for routine use 3

Patient Education

• Inform patients that cough typically lasts 10-14 days after the office visit 2
• Referring to the condition as a "chest cold" rather than bronchitis may reduce patient expectation for antibiotics 2
• Explain that antibiotics are ineffective for viral infections, which cause 89-95% of acute bronchitis cases 2, 6

When to Consider Escalation of Care

• If acute bronchitis worsens, consider antibiotic therapy only if a complicating bacterial infection is suspected 3
• For chemical inhalation injuries, consider hospitalization if there are signs of respiratory distress, significant oxygen requirement, or development of ARDS 1, 4
• In patients with underlying chronic lung disease, more aggressive management may be needed as they are at higher risk for complications 3, 7

Common Pitfalls to Avoid

• Prescribing antibiotics for uncomplicated acute bronchitis - this contributes to antibiotic resistance without providing significant benefit 3, 2
• Failing to distinguish between acute bronchitis and exacerbation of chronic bronchitis or COPD, which may require different management approaches 3
• Underestimating the severity of chemical inhalation injuries, particularly those occurring in enclosed spaces with concentrated exposures 1, 4
• Not providing clear expectations about the normal duration of symptoms, leading to unnecessary follow-up visits or antibiotic requests 2