Acute bronchitis

Pharmacologc and nonpharmacologic therapeutic choices for acute bronchitis.

1. 5 Acute Bronchitis Anas Bahnassi PhD Pharmacotherapy of Infectious Diseases Anas Bahnassi 2014 A Case-Based Approach

2. Introduction Cough…. One of the most common symptoms in daily practice. When consistent for 3wks or less, with or without sputum, it is consistent with the diagnosis of acute bronchitis. Anas Bahnassi 2014

3. Introduction Acute Bronchitis: Should be differentiated from the common cold, acute exacerbation of chronic bronchitis, asthma, and Anas Bahnassi 2014 community acquired pneumonia. It is self-limiting and symptoms usually resolve within 10-14 days

4. A non-bacterial cause is present in more than 90% of acute bronchitis Anas Bahnassi 2014 Etiologic agent Frequency Comments Viral >90% Most common viral isolates based on age: <1 yr: RSV, parainfluenza , coronavirus . 1-10 yr: Parainfluenza , enterovirus , RSV. >10 yr: Influenza, RSV, parainfluenza . Not infectious Not well studied Chemical and fume exposure. Bacterial 5-10% The only isolates show to cause acute bronchitis are: Chlamydophila pneumoniae , Mycoplasma pneumoniae , Brodetella pertussis , Brodetella parapertussis . There is no evidence that S. pneumoniae , H. Influenzae , M. Catarrhalis cause acute bronchitis in the absence of lung disease. RSV : Respiratory  Syncytial   Virus  

5. Goals of Therapy First “Do No Harm” Rule out serious illness: pneumonia. Minimize symptoms Anas Bahnassi 2014 Limit the unnecessary use of antibiotics

6. Investigations: History: Symptoms: Cough, with or without sputum, can last >3wks in more than 50% of cases of viral infection. Wheezing, tachypnena , respiratory distress, hypoxemia. Green sputum production is a function of peroxidase release from leukocytes, hence it applies only inflammation not necessarily infection. Consider alternative diagnosis when symptoms last >3wks. Obtain vaccination history, travel history, and cigarette smoking. Anas Bahnassi 2014

7. Investigations: Physical Examination: A key to diagnosis: Absence of tachycardia (HR>100 beats/min), tachypnea (>24 breath/min), fever (oral temp. >38 º C) and localized chest findings suggest acute pneumonia. Objective Measurements: No role for routine chest x-ray, viral culture, serological essay, sputum culture, or Gram stain or pulmonary function testing/ spirometry . Anas Bahnassi 2014

8. Management of Acute Bronchitis Anas Bahnassi 2014 Cough ≤ 3 wks ± Sputum Signs of consolidation, airway obstruction, fever, RR, HR During documented outbreak of influenza pertussis ? Acute Bronchitis Consider pneumonia, asthma, or other pulmonary diseases Treat as appropriate Establish expectation of up to 14 days duration of cough. Educate: regarding lack of evidence for antibiotics. Encourage increased fluid intake, humidity. Recommend: antipyretics, analgesics, antitussives , for symptom relief. No No Yes Yes

9. Therapeutic Choices Nonpharmacolgic Nonpharmacologic approach is the mainstay of management: Limit risk of inoculation and transmission by employing strict hand-washing techniques. Increased fluid and humidity may help reduce cough. Anas Bahnassi 2014

10. Analgesic Dose ADR DI Comments Cost APAP 325-500 mg q4-6h PRN (Don’t exceed 4g/24 h) less GI upset than Salicylates Use with caution in hepatic impairment, severe liver damage with overdose Preferred in children $ Ibuprofen 300-400 mg TID-QID (Max 2.4g/d) GI side effects, heartburn ASA/Anticoagulants may bleeding risk Contraindicated in PUD or IBD. Contraindicated in patients with history of risk of ASA/NSAID intolerence (Asthma, anaphylaxis, uricaria , angiedema , rhinitis) $ Therapeutic Choices P harmacolgic Analgesics: APAP, Ibuprofen can be used for symptomatic relief Anas Bahnassi 2014

11. Antitussive Dose ADR DI Comments Cost Codeine Adutls + Children>12yr 10-20mg q4-6h Max 120mg/d Sedation Vomiting Constipa-tion Additive sedation ( CNS depressants ) Use with caution in elderly or debilitated patients $ Dextromethorphan 30mg q6-8h PRN Rare, nausea, drowsiness, dizziness. Caution with CNS depressants Stop MAOI for 2wks prior start. Not recommended for patients with asthma. $ Therapeutic Choices P harmacolgic Antitussives : May provide short symptomatic relief but doesn’t shorten the duration of illness Anas Bahnassi 2014

12. B- aginists Dose ADR DI Comments Cost Salbutamol MDI( 100ug/p) Diskus (200ug/p) Diskus : 1 P TID-QID MDI : 1-2 p QID Max 800ug/d Tremor, restlessness, palpitation, headache, nausea, dizziness. Caution with other sympatho -mimetic agents. Contraindicated in arrythmia , hypertrophic obstructive cardiomyopathy $$$ $$ Terbutaline Turbohaler 1-2 p TID-QID max of 6 p/d Same Same Same $$$ Therapeutic Choices P harmacolgic Bronchodilators: Use is not supported in the absence of airflow obstruction. Adults with cough and wheezing may benefit from the treatment. Anas Bahnassi 2014

13. Therapeutic Choices P harmacolgic Antibiotics: Routine treatment with ABs is not recommended in acute uncomplicated bronchitis. AB treatment doesn’t have a consistent impact on the duration or severity of illness or prevention of complications either in adults or children. “AB treatment may reduce the duration of cough by half a day” Consider ADRs and chance of resistance. Anas Bahnassi 2014

14. Therapeutic Tips Treatment is only supportive in the vast majority of acute bronchitis cases. Patient satisfaction is not related to receiving antibiotics but the quality of pharmacist-patient communication. Educate regarding the lack of evidence of antibiotic use. No evidence supports the use of oral or inhaled corticosteroids. In a documented influenza outbreak consider neuraminidase inhibitors which are active against influenza A and B. Set patient’s expectation to 10-14 days of cough. Most are relieved within 1 wk. Mucolytics and expectorants have failed to show significant benefits. If patient shows no improvement in 2-3 wks consider follow-up. Flu vaccination is recommended. Anas Bahnassi 2014

15. Pharmacotherapy: Infectious Diseases: Anas Bahnassi PhD [email protected] http://www.twitter.com/abpharm http://www.facebook.com/pharmaprof http://www.linkedin.com/in/abahnassi Anas Bahnassi 2014