What are the symptoms and treatment options for acute tracheobronchitis?

Symptoms and Treatment of Acute Tracheobronchitis

Acute tracheobronchitis is primarily a viral infection characterized by inflammation of the large airways with cough lasting 1-3 weeks, and antibiotics are generally not recommended for treatment unless specific circumstances exist. 1, 2

Symptoms

Acute tracheobronchitis presents with the following clinical features:

• Cough as the predominant symptom, which typically lasts 2-3 weeks 2
• Cough may be productive or non-productive 1
• Possible sputum production ranging from mucoid to purulent 1
• Possible mild constitutional symptoms 1
• Chest discomfort or pain 1
• Wheezing or dyspnea may be present 1
• Sore throat or rhinorrhea may accompany symptoms 1

It's important to note that the presence of purulent (green or yellow) sputum does not necessarily indicate bacterial infection; it simply reflects the presence of inflammatory cells or sloughed mucosal epithelial cells 1.

Etiology

• Most cases (89-95%) are caused by respiratory viruses, including adenovirus, rhinovirus, coronavirus, influenza, parainfluenza, respiratory syncytial virus, and coxsackievirus 1, 3
• Less commonly caused by atypical bacteria such as Mycoplasma pneumoniae and Chlamydophila pneumoniae 1
• Bordetella pertussis should be considered in cases with prolonged cough (>2 weeks) accompanied by paroxysmal cough, whooping, or post-tussive emesis 2

Differential Diagnosis

Acute bronchitis must be distinguished from:

• Pneumonia - suspect if patient has tachycardia (>100 beats/min), tachypnea (>24 breaths/min), fever (>38°C), or abnormal chest examination findings (rales, egophony, tactile fremitus) 1
• Asthma - consider if patient has wheezing, prolonged expiration, history of smoking, or allergic symptoms 1
• Chronic bronchitis exacerbation - defined by cough and sputum production on most days for 3 months over 2 consecutive years 4
• Common cold - primarily upper respiratory symptoms 1

Treatment Approach

Non-Pharmacological Management

• Patient education about the self-limiting nature of the illness (typically 2-3 weeks) 2
• Adequate hydration 4
• Avoidance of respiratory irritants 4

Pharmacological Management

1. Antibiotics:

   • Routine antibiotic treatment is NOT recommended for uncomplicated acute bronchitis 1, 2
   • Antibiotics provide minimal benefit (reducing cough by only about half a day) while risking adverse effects including allergic reactions, nausea, vomiting, and C. difficile infection 2
   • Exceptions where antibiotics may be considered:
     • Suspected pertussis infection (to reduce transmission) 1
     • Patients at high risk for pneumonia (age >75 years, cardiac failure, insulin-dependent diabetes, serious neurological disorders) 1

2. Symptomatic relief:

   • Cough suppressants: Dextromethorphan or codeine for dry, bothersome cough 1
   • Expectorants (guaifenesin), mucolytics, antihistamines, and bronchodilators are generally NOT recommended for acute bronchitis in primary care 1
   • β-agonists (albuterol) have not shown benefit in patients without asthma or chronic obstructive lung disease 1
   • Over-the-counter symptomatic treatments may cause minor adverse effects including nausea, vomiting, headache, and drowsiness 1

Special Considerations

• Chest radiography is warranted if pneumonia is suspected based on vital sign abnormalities or asymmetrical lung sounds 1
• For cough persisting longer than 3 weeks, additional evaluation may be needed to rule out other conditions such as cough-variant asthma 1
• In immunocompromised patients, consider rare but serious causes like invasive aspergillosis, which can present as pseudomembranous necrotizing tracheobronchitis 5

Strategies to Reduce Inappropriate Antibiotic Use

• Delayed prescriptions
• Patient education about the viral nature and expected course of illness
• Referring to the condition as a "chest cold" rather than "bronchitis" 2