10/30/23, 11:04 PM Acute Bronchitis - Pulmonary Disorders - MSD Manual Professional Edition

MSD MANUAL
Professional Version

Acute Bronchitis
By Sanjay Sethi , MD, University at Buffalo, Jacobs School of Medicine and Biomedical Sciences
Reviewed/Revised May 2023

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10/30/23, 11:04 PM Acute Bronchitis - Pulmonary Disorders - MSD Manual Professional Edition

Acute bronchitis is inflammation of the tracheobronchial tree, commonly following an upper respiratory infection
in the absence of chronic lung disorders. The cause is almost always a viral infection. The pathogen is rarely
identified. The most common symptom is cough, with or without fever, and possibly sputum production. Diagnosis
is based on clinical findings. Treatment is supportive; antibiotics are usually unnecessary. Prognosis is excellent.

(See also Cough in Children.)

Acute bronchitis is frequently a component of an upper respiratory infection (URI) caused by rhinovirus,
parainfluenza, influenza A or B virus, respiratory syncytial virus, coronavirus, or human metapneumovirus.
Bacteria, such as Mycoplasma pneumoniae, Bordetella pertussis, and Chlamydia pneumoniae, cause less than
5% of cases; these sometimes occur in outbreaks. Acute bronchitis is part of the spectrum of illness that occurs
with SARS-CoV-2 infection, and testing for this virus is appropriate. Fever, myalgias, sore throat, gastrointestinal
symptoms, and loss of smell and taste are more common with the SARS-CoV-2 virus than others.

Acute inflammation of the tracheobronchial tree in patients with underlying chronic bronchial disorders (eg,
asthma, chronic obstructive pulmonary disease [COPD], bronchiectasis, cystic fibrosis) is considered an acute
exacerbation of that disorder rather than acute bronchitis. In these patients, the etiology, treatment, and
outcome differ from those of acute bronchitis.

Symptoms and Signs of Acute Pearls & Pitfalls

Bronchitis Acute cough in patients with
asthma, COPD, bronchiectasis,
Symptoms are a nonproductive or mildly productive cough
or cystic fibrosis should
accompanied or preceded by URI symptoms. Typical symptom
duration before presentation is about 5 days or more. Subjective typically be considered an
dyspnea results from chest pain caused by musculoskeletal exacerbation of that disorder
discomfort due to coughing or chest tightness related to rather than simple acute
bronchospasm, not from hypoxia.
bronchitis.

Signs are often absent but may include scattered rhonchi and
wheezing. Sputum may be clear or purulent. Sputum characteristics do not correspond with a particular
etiology (ie, viral vs bacterial). Mild fever may be present, but high or prolonged fever is unusual and suggests
influenza, pneumonia, or COVID-19.

On resolution, cough is the last symptom to subside and often takes 2 to 3 weeks or even longer to do so.

Diagnosis of Acute Bronchitis

Clinical evaluation

Sometimes chest x-ray to exclude other disorders

Diagnosis is based on clinical presentation. Microbiologic testing is usually unnecessary. However, patients with
signs or symptoms of COVID-19 should be tested for SARS-CoV-2. Diagnostic testing for influenza and pertussis
should also be considered if there is high clinical suspicion based on exposure and/or clinical features.

Patients who complain of dyspnea should have pulse oximetry to rule out hypoxemia.

Chest x-ray is done if findings suggest serious illness or pneumonia (eg, ill appearance, mental status change,
high fever, tachypnea, hypoxemia, crackles, signs of consolidation or pleural effusion). Older patients are the
occasional exception, because they may have pneumonia without fever and auscultatory findings, presenting
instead with altered mental status and tachypnea.

Sputum Gram stain and culture usually have no role. Nasopharyngeal samples can be tested for influenza and
pertussis if these disorders are clinically suspected (eg, for pertussis, persistent and paroxysmal cough after 10
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10/30/23, 11:04 PM Acute Bronchitis - Pulmonary Disorders - MSD Manual Professional Edition
to 14 days of illness, only sometimes with the characteristic whoop and/or retching, exposure to a confirmed
case). Testing for Mycoplasma and Chlamydia infection does not affect treatment so is not recommended. Viral
panel testing is not usually recommended because results do not affect treatment.

Cough resolves within 2 weeks in 75% of patients; in the other 25%, it may take up to 8 weeks to resolve.
Patients with cough that worsens after initial improvement and those with cough that lingers for > 8 weeks
should undergo further evaluation, including a chest x-ray. Evaluation for noninfectious causes of chronic
cough, including asthma, postnasal drip, and gastroesophageal reflux disease, can usually be made on the basis
of the clinical presentation. Differentiation of cough-variant asthma may require pulmonary function testing.

Treatment of Acute Bronchitis

Symptom relief (eg, acetaminophen, hydration, possibly antitussives)

Inhaled beta-agonist for wheezing

Acute bronchitis in otherwise healthy patients is a major cause of antibiotic overuse. Nearly all patients require
only symptomatic treatment, such as acetaminophen and hydration. Evidence supporting efficacy of routine use
of other symptomatic treatments, such as antitussives, mucolytics, and bronchodilators, is weak. Antitussives
should be considered only if the cough is distressing or interfering with sleep. Patients with wheezing may
benefit from an inhaled beta2-agonist (eg, albuterol) for a few days. Broader use of beta2-agonists is not
recommended because adverse effects such as tremor, nervousness, and shaking are common. There are no
clear indications for mucolytics.

Though some studies have shown modest symptomatic benefits with antibiotic use in acute bronchitis, the low
incidence of bacterial causation, self-limiting nature of acute bronchitis, and the risk of adverse effects and
antibiotic resistance argue against widespread antibiotic use. Patient education and delayed prescription (ie, to
be only filled if no improvement after at least a couple of days) help limit unnecessary antibiotic use. Oral
antibiotics are typically not used except in patients with pertussis or during known outbreaks of bacterial
infection (mycoplasma, chlamydia). A macrolide such as azithromycin 500 mg orally once, then 250 mg orally
once a day for 4 days or clarithromycin 500 mg orally twice a day for 7 days is the preferred choice.

Pearls & Pitfalls

Treat most cases of acute
bronchitis in healthy patients
without using antibiotics.

Key Points

Acute bronchitis is viral in > 95% of cases, often part of an upper respiratory infection.

Diagnose acute bronchitis mainly by clinical evaluation; do chest x-ray and/or other tests only in
patients who have manifestations of more serious illness.

Treat most patients only to relieve symptoms.

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