What is the treatment for tracheobronchitis?

Treatment of Tracheobronchitis

Distinguish Between Nosocomial and Community-Acquired Tracheobronchitis

The treatment approach for tracheobronchitis depends critically on whether it is nosocomial (hospital-acquired) or community-acquired, as nosocomial tracheobronchitis in mechanically ventilated patients warrants antibiotic therapy, while community-acquired acute bronchitis does not. 1, 2

Nosocomial Tracheobronchitis (Ventilator-Associated)

For mechanically ventilated patients with nosocomial tracheobronchitis—defined by fever, leukocytosis, purulent tracheal secretions, and positive sputum culture WITHOUT a new lung infiltrate—antibiotic therapy is recommended. 1

Antibiotic Selection for Nosocomial Tracheobronchitis

• Empiric antibiotic coverage should target the most likely pathogens, with Pseudomonas aeruginosa being the most common organism in mechanically ventilated patients 3
• Consider local antibiogram patterns and patient risk factors for multidrug-resistant organisms when selecting antibiotics 1
• Antimicrobial treatment in nosocomial tracheobronchitis patients is associated with lower rates of subsequent ventilator-associated pneumonia and more ventilator-free days 4

Adjunctive Bronchodilator Therapy

• Short-acting β-agonists or anticholinergic bronchodilators should be administered if bronchospasm is present 1, 5
• If the patient does not show prompt response to one bronchodilator, add the other agent 1

Nebulized Antibiotics for Resistant Organisms

• For multidrug-resistant organisms like Acinetobacter baumannii, nebulized antibiotics (colistin 2 million IU every 8-12 hours or aminoglycosides) should be used in combination with intravenous therapy 1
• Nebulized antibiotics should be delivered using ultrasonic or vibrating plate nebulizers 1

Community-Acquired Acute Tracheobronchitis

Antibiotics are NOT indicated for acute community-acquired tracheobronchitis, as viruses cause 89-95% of cases, and antibiotics provide minimal benefit (reducing cough by only half a day) while causing adverse effects. 2, 6

Symptomatic Management

• Central cough suppressants such as codeine or dextromethorphan are recommended for short-term symptomatic relief of bothersome cough 1, 5
• Short-acting β-agonists like albuterol may reduce cough duration and severity in patients with evidence of bronchial hyperresponsiveness 5, 6
• Ipratropium bromide may improve cough in some patients 5

Patient Education

• Emphasize that cough typically lasts 2-3 weeks, which is the natural course of the disease 2
• Educate patients that antibiotics are not beneficial and carry risks including allergic reactions, nausea, vomiting, and Clostridium difficile infection 2

Chemical Tracheobronchitis

The single most critical intervention for chemical tracheobronchitis is immediate cessation of exposure to the chemical irritant, with 90% of patients experiencing resolution of cough after removing the exposure. 7, 8

Pharmacologic Management

• Short-acting β-agonists or anticholinergic bronchodilators should be administered if bronchospasm is present 7
• Antibiotics are NOT indicated unless there is evidence of secondary bacterial infection (fever >38°C persisting more than 3 days or purulent sputum with systemic symptoms) 7
• Inhaled corticosteroids may be considered for patients with severe airflow obstruction or persistent symptoms 7

Chronic Bronchitis with Acute Exacerbation

For patients with chronic bronchitis who develop acute exacerbation (sudden deterioration with increased cough, sputum production, sputum purulence, and/or dyspnea), antibiotics are recommended, particularly for those with severe exacerbations and more severe baseline airflow obstruction. 1, 5

Treatment Algorithm for Acute Exacerbations

• Administer short-acting β-agonists or anticholinergic bronchodilators during the acute exacerbation 1, 5
• Prescribe antibiotics targeting common pathogens (S. pneumoniae, H. influenzae, M. catarrhalis) 1, 9
• Consider a short course (10-15 days) of systemic corticosteroids for severe exacerbations 5

Common Pitfalls to Avoid

• Do not prescribe antibiotics for stable chronic bronchitis or acute community-acquired bronchitis without evidence of bacterial infection, as long-term prophylactic antibiotics have no role and provide no benefit 1, 5
• Do not confuse nosocomial tracheobronchitis with pneumonia—the key distinguishing feature is the absence of a new lung infiltrate on chest radiograph in tracheobronchitis 1
• Do not use postural drainage and chest percussion for either stable chronic bronchitis or acute exacerbations, as clinical benefits have not been proven 1
• Do not use long-term oral corticosteroids for chronic bronchitis, as there is no evidence of benefit and significant risk of harm 1