What are the diagnostic criteria and treatment options for bronchitis?

Diagnostic Criteria and Treatment Options for Bronchitis

Bronchitis should be diagnosed clinically based on history and physical examination, without routine laboratory or radiologic studies, and treatment should focus on supportive care rather than medications like bronchodilators, corticosteroids, or antibiotics. 1

Diagnostic Criteria for Bronchitis

Bronchiolitis (in infants)

• Diagnosis is clinical, based on history and physical examination findings 1
• Characterized by acute inflammation, edema and necrosis of epithelial cells lining small airways, increased mucus production, and bronchospasm 1
• Typically presents with viral upper respiratory prodrome followed by increased respiratory distress 1
• Common physical findings include tachypnea, wheezing, crackles, and increased respiratory effort 1
• Pulse oximetry may detect hypoxemia not evident on physical examination 1

Acute Bronchitis (in adults)

• Clinical diagnosis characterized by cough due to acute inflammation of the trachea and large airways 2, 3
• Cough typically lasts about 2-3 weeks 4, 3
• Presence or absence of colored sputum does not reliably differentiate between bacterial and viral infections 4
• Viruses are responsible for more than 90% of acute bronchitis infections 4

Risk Assessment

• For bronchiolitis, assess risk factors for severe disease including: 1

  • Age less than 12 weeks
  • History of prematurity
  • Underlying cardiopulmonary disease
  • Immunodeficiency

• For acute bronchitis, consider differential diagnoses including: 2, 3

  • Pneumonia (suspect with tachypnea, tachycardia, dyspnea, or abnormal lung findings)
  • Exacerbations of asthma or COPD
  • Pertussis (suspect with cough >2 weeks, paroxysmal cough, whooping, post-tussive emesis)
  • COVID-19 or influenza

Diagnostic Testing

When NOT to Order Tests

• Routine laboratory and radiologic studies are not recommended for typical presentations of bronchiolitis 1
• Diagnostic testing is not indicated for acute bronchitis unless there is concern for pneumonia, influenza, COVID-19, or other specific diagnoses 2, 3

When to Consider Testing

• Chest radiography may be useful when: 1

  • The hospitalized child does not improve at the expected rate
  • Severity of disease requires further evaluation
  • Another diagnosis is suspected

• Consider testing for specific pathogens when: 1, 3

  • Pertussis is suspected
  • Specific bacterial infection is suspected
  • Patient cohorting decisions need to be made

Treatment Options

Supportive Care (Primary Treatment)

• Assess hydration and ability to take fluids orally 1, 5
• Consider IV or nasogastric hydration if necessary 5
• Administer supplemental oxygen if SpO₂ falls persistently below 90% 1, 5
• Oxygen may be discontinued when SpO₂ is ≥90%, feeding is adequate, and respiratory distress is minimal 1, 5
• For acute bronchitis, focus on symptom relief and patient education about expected duration of cough (2-3 weeks) 2, 4

Medications NOT Routinely Recommended

• Bronchodilators should not be used routinely in bronchiolitis 1, 5
• Corticosteroids are not recommended for routine use in bronchiolitis or acute bronchitis 1, 2
• Antibiotics are not indicated for bronchiolitis or typical acute bronchitis 1, 2, 4
• Ribavirin should not be used routinely in children with bronchiolitis 1
• Chest physiotherapy is not recommended for routine management of bronchiolitis 1

Special Considerations

• A carefully monitored trial of α-adrenergic or β-adrenergic medication may be an option for bronchiolitis, continuing only if there is a documented positive clinical response 1
• Antibiotics should only be used when there are specific indications of bacterial infection 1, 5
• For acute exacerbations of chronic bronchitis, antibiotics may be considered, particularly in patients with risk factors such as:
  • Age >65 years
  • Severe obstruction (FEV1 <50%)
  • Co-morbid illness
  • Recurrent exacerbations 6

Prevention Strategies

• Hand hygiene is crucial for preventing nosocomial spread of respiratory viruses 5
• Consider palivizumab prophylaxis for high-risk infants 5
• Recommend smoking cessation and avoidance of tobacco smoke exposure 5, 6
• Encourage breastfeeding to decrease risk of lower respiratory tract disease 5

Common Pitfalls to Avoid

• Overuse of antibiotics for viral bronchitis - antibiotics provide minimal benefit (reducing cough by only ~0.5 days) while exposing patients to adverse effects 2, 3
• Overreliance on sputum color to diagnose bacterial infection - colored sputum does not reliably indicate bacterial infection 4
• Unnecessary radiographic studies that may lead to inappropriate antibiotic use 1
• Failure to recognize risk factors for severe disease requiring closer monitoring 1
• Not adequately educating patients about the expected duration of symptoms, leading to unnecessary return visits or antibiotic requests 2, 3