Pharmacologc and nonpharmacologic therapeutic choices for acute bronchitis.

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

2. Pharmacotherapy of Infectious Diseases A Case-Based Approach
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. Pharmacotherapy of Infectious Diseases A Case-Based Approach
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. Pharmacotherapy of Infectious Diseases A Case-Based Approach
A non-bacterial cause is present in
more than 90% of acute bronchitis
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.
Anas Bahnassi 2014
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. Pharmacotherapy of Infectious Diseases A Case-Based Approach
Goals of Therapy
• First “Do No Harm”
• Rule out serious illness: pneumonia.
• Minimize symptoms
• Limit the unnecessary use of
antibiotics
Anas Bahnassi 2014

6. Pharmacotherapy of Infectious Diseases A Case-Based Approach
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. Pharmacotherapy of Infectious Diseases A Case-Based Approach
Investigations:
• Physical Examination:
– A key to diagnosis:
• Absence of tachycardia (HR>100 beats/min), tachypnea
(>24 breath/min), fever (oral temp. >38ºC) 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. Pharmacotherapy of Infectious Diseases A Case-Based Approach
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

9. Pharmacotherapy of Infectious Diseases A Case-Based Approach
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. Pharmacotherapy of Infectious Diseases A Case-Based Approach
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/Antic
oagulants
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
Pharmacolgic
• Analgesics: APAP, Ibuprofen can be used for
symptomatic relief
Anas Bahnassi 2014

11. Pharmacotherapy of Infectious Diseases A Case-Based Approach
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
$
Dextrome
thorphan
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
Pharmacolgic
• Antitussives: May provide short symptomatic
relief but doesn’t shorten the duration of illness
Anas Bahnassi 2014

12. Pharmacotherapy of Infectious Diseases A Case-Based Approach
Therapeutic Choices
Pharmacolgic
• Bronchodilators: Use is not supported in the absence of airflow
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 $$$
obstruction.
• Adults with cough and wheezing may benefit from the treatment.
Anas Bahnassi 2014

13. Pharmacotherapy of Infectious Diseases A Case-Based Approach
Therapeutic Choices
Pharmacolgic
• 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. Pharmacotherapy of Infectious Diseases A Case-Based Approach
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 of Infectious Diseases A Case-Based Approach
Pharmacotherapy:
Infectious Diseases:
Anas Bahnassi PhD
abahnassi@gmail.com
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Anas Bahnassi 2014