Doctors Revision

Respiratory System

Acute Bronchitis

Acute inflammation of the large airways (bronchi) without evidence of pneumonia, typically characterized by cough. Usually viral in origin and self-limiting.

Also known as: Chest Cold

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Referral and warning signs

When to refer

Referral usually not necessary. Consider referral if: Pneumonia suspected. Cough persists >3-4 weeks (investigate other causes). Haemoptysis. Recurrent episodes (consider asthma/COPD). Underlying severe comorbidity.

Red flags

  • High fever (>38.5°C)
  • Tachypnea (>24-30/min) or Dyspnoea
  • Hypoxia (low SpO2)
  • Signs of consolidation on chest exam (crackles, bronchial breathing)
  • Haemoptysis
  • Severe underlying cardiopulmonary disease
  • Cough persisting > 3-4 weeks

Signs and symptoms

  • Cough: Often starts dry, then may become productive (sputum usually clear/mucoid, can become purulent later without necessarily indicating bacterial infection). Cough is the predominant symptom and can last 1-3 weeks.
  • May follow symptoms of an upper respiratory tract infection (rhinorrhea, sore throat, malaise).
  • Chest tightness or substernal discomfort, often worse with coughing.
  • Wheezing may occur.
  • Low-grade fever may be present.
  • Absence of high fever, tachypnea, dyspnoea, or signs of consolidation seen in pneumonia.

Risk factors

  • Viral upper respiratory tract infection (precedes most cases)
  • Exposure to irritants (smoke, dust, pollution)
  • Smoking

Diagnosis

Clinical assessment

Diagnosis is primarily clinical, based on acute cough (lasting <3 weeks) in the absence of chronic lung disease (COPD, asthma) and findings suggestive of pneumonia (fever >38.5C, tachypnea, dyspnoea, focal chest signs like crackles/consolidation). Differential diagnosis: Pneumonia, Asthma exacerbation, COPD exacerbation, Pertussis, Common cold (Coryza), Influenza, Acute sinusitis with post-nasal drip, GERD, Heart failure.

Investigations

  • Usually none required for typical presentation.
  • Chest X-ray: Only indicated if pneumonia is suspected (fever, tachypnea, abnormal lung sounds) or if cough persists >3 weeks.
  • Sputum examination: Generally not useful unless TB or Pertussis suspected.
  • Procalcitonin/CRP: May help differentiate viral from bacterial in some settings, but not routine for uncomplicated bronchitis.

Diagnostic criteria

Clinical diagnosis of acute cough, often productive, without signs or symptoms suggestive of pneumonia.

Management

Non-pharmacological management

  • Reassurance: Explain viral etiology and self-limiting nature.
  • Symptomatic Relief:
  • - Rest.
  • - Adequate fluid intake (warm drinks may be soothing).
  • - Humidified air / Steam inhalation (limited evidence).
  • - Honey (for cough, especially in children >1 year).
  • - Avoid irritants (smoke).

Pharmacological treatment

  • Antibiotics: NOT recommended for uncomplicated acute bronchitis as the cause is overwhelmingly viral. Antibiotics do not shorten duration or prevent complications.
  • - Consider antibiotics ONLY if high suspicion of bacterial infection (e.g., persistent high fever, purulent sputum AND underlying comorbidity like severe COPD/immunodeficiency - UCG suggests Amoxicillin or Doxycycline in specific poor-condition patients).
  • Analgesia/Antipyretics: Paracetamol or NSAIDs for fever, headache, malaise.
  • Cough Suppressants (Antitussives): Generally not recommended (cough is protective). Consider dextromethorphan for short-term relief of very bothersome non-productive cough (use with caution). Avoid codeine.
  • Expectorants/Mucolytics (e.g., Guaifenesin): Limited evidence of benefit.
  • Bronchodilators (e.g., Salbutamol inhaler): May provide modest benefit ONLY if wheezing is present.

Monitoring

  • Monitor for resolution of symptoms (cough may persist 2-3 weeks).
  • Advise patient to return if symptoms worsen, high fever develops, dyspnoea occurs, haemoptysis, or cough persists >3-4 weeks.

Complications

  • Rare in healthy individuals.
  • Secondary bacterial pneumonia (uncommon).
  • Prolonged cough.
  • Exacerbation of underlying asthma or COPD.

Prevention

  • Handwashing.
  • Avoid close contact with people with respiratory infections.
  • Smoking cessation.
  • Influenza vaccination.

Patient education

  • Explain that bronchitis is usually viral and self-limiting.
  • Antibiotics are typically not helpful and can cause side effects.
  • Focus on symptomatic relief (fluids, rest, analgesia).
  • Explain that cough can last for several weeks.
  • Advise on when to return if symptoms worsen or persist (red flags).
  • Discuss smoking cessation if applicable.

Uganda-specific notes

Over-prescription of antibiotics for acute bronchitis is common but should be avoided. Differentiate carefully from pneumonia, especially in children and vulnerable adults. Consider TB if cough persists.

References

  • Uganda Clinical Guidelines (UCG) 2023

    Chapter 5, Section 5.2.2

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