Bronchitis: Breathing Easier Through Treatment and Management

Common causes of bronchitis include viruses that cause the common cold and the flu.

Bronchitis, a common respiratory condition caused by infection or exposure to irritants, is one of the most common illnesses for which patients seek medical care.^1,2 It is characterized by inflammation of the mucous membranes in the bronchial tubes ^1-3 and is classified as either acute or chronic (Table 1^1-3). According to the Centers for Disease Control and Prevention (CDC) and the American Lung Association, an estimated 10.1 million individuals in 42 the United States were diagnosed with chronic bronchitis in 2011.^4,5 Although chronic bronchitis can affect individuals of any age, the highest number of reported cases is among those 65 years and older, and the condition affects twice as many women as men.^4,5

Causes of Bronchitis

A variety of factors have been recognized as triggers for bronchitis, including exposure to irritants (chemical and pollution), but the most common causes of acute bronchitis include the same viruses that cause the common cold and the flu.^1-3 Bacterial infection may also cause acute bronchitis.^1-3 The most frequent cause of chronic bronchitis is tobacco use, representing an estimated 80% to 90% of chronic bronchitis cases.^1-3 According to the American Lung Association, chronic bronchitis is one of the 2 main types of chronic obstructive pulmonary disease (COPD).^1,3,5 Most individuals with COPD have both emphysema and chronic bronchitis.^1,3,5,6

Airway obstruction in chronic bronchitis occurs because swelling and excessive mucus production cause the bronchioles to become narrower than usual.⁷ Chronic bronchitis may be a manifestation of a history of several acute bronchitis attacks, or it may have a gradual onset due to a history of heavy tobacco use or inhalation of irritants such as secondhand smoke or other pollutants.^1,2,6,7 The most common sign of bronchitis is cough, followed by possible sputum production; the condition appears to occur most frequently during the winter months.^7,8 Other common signs and symptoms of bronchitis are outlined in Online Table 2.^7,8

TABLE 2: SIGNS AND SYMPTOMS OF BRONCHITIS

Acute Bronchitis

Chronic Bronchitis

• Hacking cough that is productive or minimally productive and persists for 10 to 20 days
• If mucus is colored, an infection may be present
• Possible low-grade fever
• Tenderness or soreness in the chest with coughing
• Sore throat from constant coughing

• Possible wheezing

• Chronic cough and sputum that last for at least 3 months
• Increased mucus production
• Sputum may be clear or yellowish or greenish depending on the presence of a bacterial infection
• Dyspnea, wheezing
• Frequent clearing of the throat
• Fatigue

Adapted from references 7 and 8.

Managing and Treating Bronchitis

The main goals in treating both acute and chronic bronchitis are relieving symptoms, enabling the patient to breathe more comfortably, and improving overall quality of life.

Acute Bronchitis

Whereas acute bronchitis generally resolves quickly in healthy patients, cardiopulmonary or other comorbid conditions may exacerbate the condition.¹ Typically, treatment for acute bronchitis is symptomatic and may entail the use of analgesics, antipyretics, antitussives, and/or expectorants.

The majority of acute bronchitis cases are caused by viruses; therefore, the use of antibiotics is typically not recommended.^1,2,6 Due to the overuse of antibiotics and ongoing concerns about drug-resistant organisms, the CDC and other health organizations oppose the routine use of antibiotics in uncomplicated bronchitis unless the patient has a bacterial infection.^1,8,9 Results from a recent study show that overuse of antibiotics in acute bronchitis rose by 70% between 1996 and 2010 despite CDC guidelines.¹⁰

Patients with acute bronchitis should be advised to quit smoking, avoid exposure to secondhand smoke, implement good hand washing techniques into daily routine, and maintain recommended immunizations, especially the yearly influenza vaccine.⁹

Chronic Bronchitis

The goals of treating chronic bronchitis are to alleviate symptoms, prevent further complications, and slow progression of the disease.^1,3,9,11-13 Chronic bronchitis may require a combination of therapies, including the use of bronchodilator medications, inhaled steroids, antibiotics, vaccines, oxygen therapy, and pulmonary rehabilitation.^1,3,9,11-13 The two major drug classes used to treat chronic bronchitis include bronchodilators and steroids.^1,9,11-13 Short-acting beta-agonists such as ipratropium bromide are often used for controlling bronchospasms, dyspnea, and chronic cough in stable patients with chronic bronchitis.^1,9,11-13 In some cases, a long-acting beta-agonist in conjunction with an inhaled corticosteroid may be employed to control chronic cough.^1,9,11-13 Results from some studies suggest that treatment with mucolytics has been associated with a small decrease in acute exacerbations in patients with chronic bronchitis.^1,14 The use of antibiotics may be needed for chronic bronchitis exacerbations caused by bacterial infections; the mostly commonly used antibiotics include macrolides, quinolones, and amoxicillin/clavulanate.^1,15,16

Some studies have concluded that the most effective measures for managing chronic bronchitis are smoking cessation and avoidance of irritants,especially tobacco fumes.^1,9,11,13 Some patients with chronic bronchitis may require pulmonary rehabilitation (in which the patient is taught exercises and other ways to ease breathing), supplemental oxygen therapy, and lifestyle modifications such as quitting smoking, getting plenty of rest, and avoiding irritants such as aerosol sprays, dust, and chemicals.¹² Because chronic bronchitis can increase a patient’s risk for pulmonary infection, patients should be encouraged to obtain a yearly influenza vaccination; to protect against pneumonia, patients should also consider the pneumococcal vaccination.^1,17,18

Newly Approved Medications

In August 2014, the FDA approved olodaterol (Striverdi Respimat, Boehringer Ingelheim) inhalation spray, a long-acting beta₂-agonist bronchodilator indicated for the treatment of airflow obstruction in patients with COPD, including chronic bronchitis and/or emphysema¹⁹ (Online Table 3). This long-term maintenance medication is administered once daily. The most commonly reported adverse reactions include nasopharyngitis, upper respiratory tract infection, urinary tract infection, cough, dizziness rash, diarrhea, back pain, and arthralgia.¹⁹

TABLE 3: PHARMACOLOGIC THERAPIES FOR BRONCHITIS

Drug Class

Indication

Examples

Antitussives/expectorants

These agents are used to treat minor cough resulting from bronchial and throat irritation. For patients with chronic bronchitis, central cough suppressants such as codeine and dextromethorphan

are recommended only for short-term symptomatic relief of cough.

· Dextromethorphan, codeine (antitussives)

· Guaifenesin (expectorant)

Bronchodilators

Bronchodilators aid in relieving the symptoms of chronic bronchitis by relaxing and opening the air passages in the lungs.

Beta₂-adrenergic agonists, short-acting bronchodilators:

· Albuterol (Proventil HFA, Ventolin HFA, ProAir HFA)

· Levalbuterol (Xopenex, Xopenex HFA)

· Metaproterenol

Beta₂-adrenergic agonists, long-acting bronchodilators

· Indacterol (Arcapta Neohaler)

· Salmeterol (Serevent Diskus)

· Formoterol (Performist, Foradil)

· Arformoterol (Brovana)

· Olodaterol (Striverdi Respimat)

Anticholinergics

· Tiotropium (Spiriva)

· Ipratropium (Atrovent HFA)

· Aclidinium (Tudorza Pressair)

· Umeclidinium (Incruse Ellipta)

Xanthine derivatives

· Theophylline (Elixophyllin, Theo-24, Theochron)

Long-acting bronchodilator/corticosteroid combinations

Combination therapy is suggested when a patient’s symptoms remain uncontrolled with bronchodilator monotherapy.

· Budesonide/formoterol (Symbicort)

· Fluticasone/salmeterol (Advair Diskus)

· Fluticasone/vilanterol (Breo Ellipta)

Beta-adrenergic agonist/anticholinergic agent combinations

These agents offer the quick onset of a beta-adrenergic agonist with the prolonged action of an anticholinergic agent.

· Umeclidinium/vilanterol (Anoro Ellipta)

· Ipratropium/albuterol (DuoNeb, Combivent Respimat)

Systemic corticosteroids

For patients with an acute exacerbation of chronic bronchitis, a short course of systemic corticosteroid therapy is sometimes administered; studies report positive results.

· Methylprednisolone

· Prednisone

Inhaled corticosteroids

An inhaled corticosteroid may provide symptom relief in some patients.

· Budesonide (Pulmicort, Pulmicort Flexhaler)

Phosphodiesterase-4 inhibitors

These anti-inflammatory drugs are used for acute exacerbations of chronic bronchitis and chronic obstructive pulmonary disease. They have been shown to decrease exacerbations, relieve dyspnea, and improve lung function.

· Roflumilast (Daliresp)

Analgesics/antipyretics

These agents are beneficial in providing symptomatic relief of fatigue, malaise, and fever associated with illness.

· Ibuprofen

· Acetaminophen

· Naproxen

Antibiotics

Occasionally, antibiotics are used to treat chronic bronchitis exacerbations caused by bacterial infections. Broad-spectrum antibiotics are often the choice.

· Penicillin

· Cephalosporins

· Fluoroquinolones

· Macrolides

· Sulfonamides

· Tetracyclines

Adapted from references 1, 3, 9, 10, 12-18, 21.

In April 2014, the FDA also approved umeclidinium inhalation powder (Incruse Ellipta, GlaxoSmithKline), a long-acting muscarinic antagonist monotherapy, a type of bronchodilator also known as a long-acting anticholinergic.²⁰ It is indicated for the long-term, once-daily maintenance treatment of airflow obstruction in patients with COPD, including chronic bronchitis and/or emphysema.²⁰ It is available as a powder for inhalation via a plastic inhaler.²⁰ The most commonly reported adverse effects include cough, arthralgia, upper respiratory tract infection, and nasopharyngitis.²⁰

The Pharmacist’s Role

Pharmacists can be an instrumental resource for patients with bronchitis via medication counseling, keeping them abreast of new developments in the treatment and management of bronchitis, and encouraging them to adhere to their recommended therapy. During couseling, patients should be educated on the proper use of inhalation devices to ensure appropriate dose delivery. If a patient is still smoking, pharmacists should stress the importance of smoking cessation and encourage the patient to discuss possible smoking cessation therapies with his or her primary health care provider. Studies show that 50% of patients with chronic bronchitis who have a history of smoking will no longer cough after 1 month of smoking cessation, and 80% will no longer cough after 2 months. ¹² Patients should also be reminded to eat a balanced diet and get plenty of rest when needed. For more information, see Online Table 4 and visit ClinicalTrials.gov at http://clinicaltrials.gov/search/open/condition=%22Bronchitis,+Chronic%22.

TABLE 4: EDUCATIONAL RESOURCES REGARDING BRONCHITIS

· American Thoracic Society: http://patients.thoracic.org/?page_id=43

· COPD Foundation: www.copdfoundation.org/What-is-COPD/COPD-Facts/Glossary.aspx

· National Heart, Lung, and Blood Institute: www.nhlbi.nih.gov/health/health-topics/topics/copd/

· American Lung Association: www.lung.org/lung-disease/copd/about-copd/

Ms. Terrie is a clinical pharmacist and medical writer based in Haymarket, Virginia.

References

1. Fayyaz J, Olade RB, Lessnau K-D. Bronchitis. Medscape website. http://emedicine.medscape.com/article/297108-overview#a0101?cc=aHR0cDovL2VtZWRpY2luZS5tZWRzY2FwZS5jb20vYXJ0aWNsZS8yOTcxMDgtb3ZlcnZpZXcjYTAxMDE=&cookieCheck=1. Updated March 28, 2014. Accessed October 6, 2014.

2. American Lung Association. Trends in COPD (chronic bronchitis and emphysema): Morbidity and mortality. American Lung Association website. www.lung.org/finding-cures/our-research/trend-reports/copd-trend-report.pdf. Updated March 2013. Accessed October 6, 2014.

3. Chronic bronchitis. PDRhealth.com website. www.pdrhealth.com/diseases/chronic-bronchitis. Accessed October 6, 2014.

4. Freid VM, Bernstein AB, Bush A. Multiple chronic conditions among adults aged 45 and over: trends over the past 10 years. Centers for Disease Control and Prevention website. www.cdc.gov/nchs/data/databriefs/db100.htm. Updated July 31, 2012. Accessed October 6, 2014.

5. Chronic obstructive pulmonary disease (COPD) fact sheet. American Lung Association website. www.lung.org/lung-disease/copd/resources/facts-figures/COPD-Fact-Sheet.html. Updated May 2014. Accessed October 6, 2014.

6. What is COPD? National Heart, Lung, and Blood Institute website. www.nhlbi.nih.gov/health/health-topics/topics/copd/. Updated July 31, 2013. Accessed October 6, 2014.

7. What is chronic obstructive pulmonary disease (COPD)? American Thoracic Society website. www.thoracic.org/clinical/copd-guidelines/for-patients/what-is-chronic-obstructive-pulmonary-disease-copd.php. Accessed October 6, 2014.

8. What are the signs and symptoms of bronchitis? National Heart, Lung, and Blood Institute website. www.nhlbi.nih.gov/health/health-topics/topics/brnchi/signs.html. Updated May 1, 2009. Accessed October 6, 2014.

9. Bronchitis (chest cold). Centers for Disease Control and Prevention website. www.cdc.gov/getsmart/antibiotic-use/uri/bronchitis.html. Updated September 30, 2013. Accessed October 6, 2014.Barnett ML, Linder JA. Antibiotic prescribing for adults with acute bronchitis in the United States, 1996-2010. JAMA. 2014;311(19):2020-2022.

10. Braman SS. Chronic cough due to chronic bronchitis: ACCP evidence-based clinical practice guidelines. Chest. 2006;129(1 Suppl):104S-115S.

11. Davis CP. Chronic bronchitis. MedicineNet.com website. www.medicinenet.com/chronic_bronchitis/page6.htm#what_is_the_treatment_for_chronic_bronchitis. Updated November 26, 2013. Accessed October 6, 2014.

12. Braman SS. Chronic cough due to acute bronchitis: ACCP evidence-based clinical practice guidelines. Chest. Jan 2006;129(1 Suppl):95S-103S.

13. Poole PJ, Black PN. Mucolytic agents for chronic bronchitis or chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2010;2:CD001287.

14. Budey MM, Weidemann HP. Acute bacterial exacerbation of chronic bronchitis. Cleveland Clinic website. www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/pulmonary/acute-bacterial-exacerbation-chronic-bronchitis/. Accessed October 6, 2014.

15. Siempos II, Dimopoulos G, Korbila IP, Manta K, Falagas ME. Macrolides, quinolones and amoxicillin/clavulanate for chronic bronchitis: a meta-analysis. Eur Respir J. 2007;29(6):1127-1137.

16. Chronic obstructive pulmonary disease (COPD). Merck Manuals website. www.merckmanuals.com/professional/pulmonary_disorders/chronic_obstructive_pulmonary_disease_and_related_disorders/chronic_obstructive_pulmonary_disease_copd.html. Updated June 2014. Accessed October 6, 2014.

17. Living with chronic bronchitis. National Heart, Lung, and Blood Institute website. www.nhlbi.nih.gov/health/health-topics/topics/brnchi/livingwith.html. Updated May 1, 2009. Accessed October 6, 2014.

18. FDA approves Boehringer Ingelheim’s Striverdi® Respimat® (olodaterol) inhalation spray for maintenance treatment of COPD. Boehringer Ingelheim website. http://us.boehringer-ingelheim.com/news_events/press_releases/press_release_archive/2014/08-01-14-fda-approves-boehringer-ingelheims-striverdi-respimat-olodaterol-inhalation-spray-maintenance-treatment-copd.html. Updated August 1, 2014. Accessed October 6, 2014.

19. GSK receives approval for Incruse™ Ellipta® (umeclidinium) in the US for the treatment of COPD. GlaxoSmithKline website. http://us.gsk.com/en-us/media/press-releases/2014/gsk-receives-approval-for-incruse-ellipta-umeclidinium-in-the-us-for-the-treatment-of-copdandnbsp/. Updated April 30, 2014. Accessed October 6, 2014.

20. Mosenifar Z, Harrington A, Nikhanj NS, et al. Chronic obstructive pulmonary disease treatment & management. Medscape website. http://emedicine.medscape.com/article/297664-treatment. Updated September 25, 2014. Accessed October 6, 2014.