eMedicine Specialties > Emergency Medicine > Pulmonary
Bronchitis: Treatment & Medication
Updated: Jan 14, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Emergency Department Care
Care for acute bronchitis is primarily supportive and should ensure that the patient is adequately oxygenating.
Medication
Therapy is generally symptomatic and includes use of analgesics, antipyretics, antitussives, and expectorants. Among otherwise healthy individuals, antibiotics have not demonstrated consistent benefit in the symptomatology or natural history of acute bronchitis.3,4 Nonetheless, surveys from Europe, Australia, and the United States show that 80% of patients with acute bronchitis receive antibiotics. Antibiotic overuse contributes to the emergence of drug-resistant organisms. Cognizant of this, the Centers for Disease Control and Prevention (CDC) recently collaborated with numerous medical societies to publish a series of articles on the judicious use of antibiotics for several common conditions, including bronchitis, and have recommended against routine antibiotic use in uncomplicated bronchitis.
Patients are up to 4 times more likely to expect antibiotics for the diagnosis of bronchitis than for a chest cold. Therefore, limiting use of the diagnosis bronchitis may make reduction of antibiotic use more acceptable to patients.
Reviews have also noted that antibiotic use in smokers without chronic obstructive pulmonary disease is no more effective than in nonsmokers.5
Several studies have shown conflicting results on the use of zinc as an adjunct treatment against influenza A.6 Some recent studies have shown favorable results; however, participants complained of a bad taste and significant nausea. Broader use of zinc cannot be recommended at this time.
Antibiotics
Studies have focused on healthy individuals (excluding people with asthma) or patients with chronic obstructive pulmonary disease. Antibiotics may offer a small beneficial effect in patients with chronic obstructive pulmonary disease. Therefore, extending antibiotic therapy to people with asthma and other patients with limited cardiopulmonary reserve may be reasonable. If an antibiotic is to be used, a macrolide is a reasonable first choice because the macrolides are active against mycoplasmal and chlamydial organisms and B pertussis.
Erythromycin (EES, E-Mycin, Ery-Tab)
Used for prophylaxis in patients with penicillin allergy who are undergoing dental, PO, or respiratory tract procedures. Inhibits RNA-dependent protein synthesis, possibly by stimulating dissociation of peptidyl tRNA from ribosomes, resulting in arrest of bacterial replication.
Adult
250-500 mg PO qid or 333 mg PO tid
Pediatric
30-50 mg/kg/d PO divided qid
Coadministration may increase toxicity of theophylline, digoxin, carbamazepine, and cyclosporine; may potentiate anticoagulant effects of warfarin; coadministration with lovastatin or simvastatin increases risk of rhabdomyolysis
Documented hypersensitivity; hepatic impairment
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in liver disease; estolate formulation may cause cholestatic jaundice; adverse GI effects are common (administer doses pc); discontinue use if nausea, vomiting, malaise, abdominal colic, or fever occur
Clarithromycin (Biaxin)
Reversibly binds to P site of 50S ribosomal subunit of susceptible organisms and may inhibit RNA-dependent protein synthesis by stimulating dissociation of peptidyl tRNA from ribosomes, inhibiting bacterial growth.
Adult
250-500 mg PO bid
Pediatric
7.5 mg/kg PO bid
Toxicity increases with coadministration of fluconazole or pimozide; effects decrease and GI adverse effects may increase with coadministration of rifabutin or rifampin; may increase toxicity of anticoagulants, cyclosporine, tacrolimus, digoxin, omeprazole, carbamazepine, ergot alkaloids, triazolam, and HMG CoA–reductase inhibitors
Plasma levels of certain benzodiazepines may increase, prolonging CNS depression; arrhythmias and increase in QTc intervals occur with disopyramide; coadministration with omeprazole may increase plasma levels of both agents
Documented hypersensitivity; concurrent pimozide
Pregnancy
C - Safety for use during pregnancy has not been established.
Precautions
Coadministration with ranitidine or bismuth citrate not recommended if CrCl <25 mL/min; administer half dose or increase dosing interval if CrCl <30 mL/min; diarrhea may be sign of pseudomembranous colitis; superinfections may occur with prolonged or repeated antibiotic therapies
Azithromycin (Zithromax)
Used to treat mild-to-moderate infections caused by susceptible strains of microorganisms; indicated for chlamydial and gonorrheal infections of genital tract.
Adult
Day 1: 500 mg PO
Days 2-5: 250 mg PO
Pediatric
12 mg/kg PO qd; not to exceed 500 mg/dose
May increase toxicity of theophylline, warfarin, and digoxin; effects reduced with coadministration of aluminum and/or magnesium antacids; nephrotoxicity and neurotoxicity may occur when coadministered with cyclosporine
Documented hypersensitivity; hepatic impairment; concurrent pimozide
Pregnancy
C - Safety for use during pregnancy has not been established.
Precautions
Site reactions can occur with IV route; bacterial or fungal overgrowth may result with prolonged antibiotic use; may increase hepatic enzymes and cholestatic jaundice; caution in patients with impaired hepatic function, prolonged QT intervals, or pneumonia; caution in hospitalized, geriatric, or debilitated patients
Cefditoren pivoxil (Spectracef)
Semisynthetic cephalosporin administered as prodrug. Hydrolyzed by esterases during absorption and distributed in circulating blood as active cefditoren.
Bactericidal activity results from inhibition of cell wall synthesis via affinity for penicillin-binding proteins.
No dose adjustment necessary for mild renal impairment (CrCl 50-80 mgL/min/1.73 m2) or mild-to-moderate hepatic impairment.
Indicated for the treatment of acute exacerbation of chronic bronchitis caused by susceptible strains of Streptococcus pyogenes.
Adult
400 mg PO with meals bid for 10 d
Moderate renal impairment (CrCl 30-49 mL/min/1.73 m2): Not to exceed 200 mg PO bid
Severe renal impairment (CrCl <30 mL/min/1.73 m2): 200 mg PO qd
Pediatric
<12 years: Not established
>12 years: Administer as in adults
Absorption reduced with H2 receptor antagonists and antacids of magnesium and aluminum hydroxides; probenecid may increase plasma concentrations of cefditoren
Documented hypersensitivity to drug, penicillin, related compounds, or milk protein sodium caseinate; carnitine deficiency or inborn errors of metabolism that may result in clinically significant carnitine deficiency
Pregnancy
B - Usually safe but benefits must outweigh the risks.
Precautions
May cause diarrhea, nausea, and vaginal moniliasis (yeast infection); pseudomembranous colitis may occur; clinical manifestations of carnitine deficiency may occur with prolonged use; prolonged use may result in emergence and overgrowth of resistant organisms; caution in breastfeeding
Tetracycline (Sumycin)
For susceptible bacterial infections of both gram-positive and gram-negative organisms as well as infections caused by mycoplasmal, chlamydial, or rickettsial organisms. Inhibits bacterial protein synthesis by binding with 30S and, possibly, 50S ribosomal subunit(s). Provides coverage for mycoplasmal, chlamydial, and B pertussis organisms, but less effective than erythromycin.
Adult
50-500 mg PO qid
Pediatric
<8 years: Not recommended
>8 years: 10-20 mg/lb (25-50 mg/kg) PO divided qid
Bioavailability decreases with antacids containing aluminum, calcium, magnesium, iron, or bismuth subsalicylate; can decrease effects of PO contraceptives, causing breakthrough bleeding and increased risk of pregnancy; can increase hypoprothrombinemic effects of anticoagulants
Documented hypersensitivity; severe hepatic dysfunction
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Photosensitivity may occur with prolonged exposure to sunlight or tanning equipment; reduce dose in renal impairment; consider drug serum level determinations in prolonged therapy; use during tooth development (ie, last half of pregnancy through age 8 y) can cause permanent discoloration of teeth; Fanconilike syndrome may occur with outdated tetracyclines
Doxycycline (Bio-Tab, Doryx, Vibramycin)
Provides coverage for mycoplasmal and chlamydial organisms but not active against B pertussis; inhibits protein synthesis and bacterial growth by binding with 30S and, possibly, 50S ribosomal subunits of susceptible bacteria.
Adult
100 mg PO bid
Pediatric
<8 years: Not recommended
>8 years: 2-5 mg/kg/d PO qd or divided q12h; not to exceed 200 mg/d
Bioavailability decreases with antacids containing aluminum, calcium, magnesium, iron, or bismuth subsalicylate; can increase hypoprothrombinemic effects of anticoagulants; can decrease effects of PO contraceptives, causing breakthrough bleeding and increased risk of pregnancy
Documented hypersensitivity; severe hepatic dysfunction
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Photosensitivity may occur with prolonged exposure to sunlight or tanning equipment; reduce dose in renal impairment; consider drug serum level determinations in prolonged therapy; use during tooth development (ie, last half of pregnancy through age 8 y) can cause permanent discoloration of teeth; Fanconilike syndrome may occur with outdated tetracyclines
Trimethoprim-sulfamethoxazole (Bactrim)
Inhibits bacterial synthesis of dihydrofolic acid by competing with para-aminobenzoic acid, inhibiting bacterial growth. Antibacterial activity of TMP-SMZ includes common urinary tract pathogens except Pseudomonas aeruginosa. Like tetracycline, has in vitro activity against B pertussis; not useful in mycoplasmal infections.
Adult
160 mg TMP/800 mg SMZ PO q12h for 10-14 d
Pediatric
<2 months: Contraindicated
>2 months: 15-20 mg/kg/d (TMP) PO divided tid/qid for 14 d
May increase PT when used with warfarin (perform coagulation tests and adjust dose accordingly); coadministration with dapsone may increase blood levels of both drugs; coadministration of diuretics increases incidence of thrombocytopenic purpura in elderly people; may increase phenytoin levels; may potentiate effects of methotrexate in bone marrow depression; may increase hypoglycemic response to sulfonylureas; may increase levels of zidovudine
Documented hypersensitivity; megaloblastic anemia due to folate deficiency; age <2 mo
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Discontinue at first appearance of rash or sign of adverse reaction; obtain CBC counts frequently; discontinue therapy if significant hematologic changes occur; goiter, diuresis, and hypoglycemia may occur with sulfonamides; prolonged IV infusions or high doses may cause bone marrow depression (if signs occur, administer 5-15 mg/d leucovorin); caution in folate deficiency (eg, chronic alcoholism, elderly persons, those receiving anticonvulsant therapy, those with malabsorption syndrome); hemolysis may occur in G-6-PD deficiency; patients with AIDS may not tolerate or respond to TMP-SMZ; caution in renal or hepatic impairment (perform urinalyses and renal function tests during therapy); administer fluids to prevent crystalluria and stone formation
Analgesics/antipyretics
These agents are used to control fever as well as myalgias and arthralgias.
Ibuprofen (Ibuprin, Advil, Motrin)
Usually DOC for treatment of mild to moderate pain if no contraindications are recognized. Inhibits inflammatory reactions and pain, probably by decreasing activity of enzyme cyclooxygenase, which results in inhibition of prostaglandin synthesis.
Adult
400-800 mg PO q4-6h
Pediatric
10 mg/kg PO q6-8h
Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity; may decrease effects of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase risk of methotrexate toxicity; may increase phenytoin levels
Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency; high risk of bleeding
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in CHF, hypertension, and decreased renal or hepatic function; caution in anticoagulation abnormalities or during anticoagulant therapy, monitor PT closely and instruct patients to watch for signs of bleeding
Acetaminophen (Tylenol, Panadol, Aspirin-free Anacin)
DOC for treatment of pain in those with documented hypersensitivity to aspirin or NSAIDs, with upper GI disease, or taking PO anticoagulants
Adult
625-1000 mg PO q4h; not to exceed 4 g/d
Pediatric
<12 years: 10-15 mg/kg/dose PO q4-6h prn; not to exceed 2.6 g/d
>12 years: 325-650 mg PO q4h; not to exceed 5 doses in 24 h
Rifampin can reduce analgesic effects; coadministration with barbiturates, carbamazepine, hydantoins, or isoniazid may increase hepatotoxicity
Documented hypersensitivity; G-6-PD deficiency
Pregnancy
B - Usually safe but benefits must outweigh the risks.
Precautions
Hepatotoxicity possible in chronic alcoholism following various dose levels; severe or recurrent pain or high or continued fever may indicate serious illness; acetaminophen is contained in many OTC products and combined use with these products may result in cumulative acetaminophen doses exceeding recommended maximum dose
Antitussives and expectorants
Little data on the efficacy of expectorants outside the test tube are available. The prototype antitussive, codeine, has been used successfully in some chronic cough and induced cough models;7 however, little clinical data on upper respiratory infections are available. Existing data indicate that codeine is slightly better or equal in efficacy to guaifenesin, dextromethorphan, or even placebo.
Guaifenesin and codeine (Robitussin A-C, Guiatuss AC, Mytussin AC)
Treats minor cough resulting from bronchial and throat irritation.
Adult
5-10 mL PO q4-8h; not to exceed 60 mL/d
Pediatric
1-1.5 mg/kg/d codeine PO divided qid
Increases toxicity of CNS depressant drugs
Documented hypersensitivity
Pregnancy
C - Safety for use during pregnancy has not been established.
Precautions
Do not administer for productive cough or persistent chronic cough from emphysema; caution in renal impairment
Guaifenesin with dextromethorphan (Humibid DM, Mytussin, Robitussin DM)
Treats minor cough resulting from bronchial and throat irritation.
Adult
10 mL PO q4h
Pediatric
<2 years: Not recommended
2-6 years: 2.5 mL PO q4h
6-12 years: 5 mL PO q4h
>12 years: Administer as in adults
None reported
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Do not use to treat productive cough or persistent chronic cough resulting from emphysema
Bronchodilators
Studies have shown that bronchodilators are advantageous and may even be superior to antibiotics for bronchitis symptoms. However, patient numbers in trials are disappointingly few given how commonly acute bronchitis is diagnosed.
Albuterol sulfate (Proventil, Ventolin)
Beta-agonist used in treatment of bronchospasm refractory to epinephrine. Relaxes bronchial smooth muscle by action on beta2-receptors and shows little effect on cardiac muscle contractility.
Adult
2 puffs q4-6h or 2-4 mg PO tid/qid
Pediatric
0.1-2 mg/kg PO tid
Beta-adrenergic blockers antagonize effects; inhaled ipratropium may increase duration of bronchodilatation by albuterol; cardiovascular effects may increase with MAOIs, inhaled anesthetics, tricyclic antidepressants, or sympathomimetic agents
Documented hypersensitivity
Pregnancy
C - Safety for use during pregnancy has not been established.
Precautions
Caution in hyperthyroidism, diabetes mellitus, and cardiovascular disorders
Antiviral agents
Influenza vaccinations offer greater protection for the appropriate populations because they offer coverage for influenza A and B. Amantadine and rimantadine have been demonstrated to be useful during epidemics of influenza A, but are no longer recommended because of resistance. Zanamivir and oseltamivir are the neuraminidase inhibitors that are now preferred for chemoprophylaxis during outbreaks of influenza A and B, although data from institutional outbreaks are limited.
Oseltamivir (Tamiflu)
Inhibits neuraminidase, which is a glycoprotein on the surface of influenza virus that destroys an infected cell's receptor for viral hemagglutinin. By inhibiting viral neuraminidase, decreases release of viruses from infected cells and thus viral spread. Effective to treat influenza A or B. Start within 40 h of symptom onset. Available as cap and PO susp. Oseltamivir (Tamiflu) resistance has emerged in the US during the 2008-2009 influenza season. The US Centers for Disease Control and Prevention (CDC) has issued revised interim recommendations for antiviral treatment and prophylaxis of influenza. Preliminary data from a limited number of states indicate the prevalence of influenza A (H1N1) virus strains resistant to oseltamivir (Tamiflu) is high. Because of this, zanamivir (Relenza) is recommended as the initial choice for antiviral prophylaxis or treatment when influenza A infection or exposure is suspected. A second-line alternative is a combination of oseltamivir plus rimantadine may be used, rather than oseltamivir alone. Local influenza surveillance data and laboratory testing can assist the physician regarding antiviral agent choice.
Adult
Acute illness: 75 mg PO bid for 5 d
Prophylaxis: 75 mg PO qd for 10 d
Pediatric
Acute illness:
<1 year: Not indicated
>1 year:
<15 kg: 30 mg PO bid for 5 d
>15-23 kg: 45 mg PO bid for 5 d
>23-40 kg: 60 mg PO bid for 5 d
>40 kg: Administer as in adults
Prophylaxis:
<1 year: Not established
>1 year:
<15 kg: 30 mg PO qd for 10 d
>15-23 kg: 45 mg PO qd for 10 d
24-40 kg: 60 mg PO qd for 10 d
>40 kg: Administer as in adults
None reported
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in renal impairment, chronic cardiac or respiratory disease, and breastfeeding; do not use in children <1 y (preclinical trials have demonstrated death in young animals, possibly related to immature blood-brain barriers)
Zanamivir (Relenza)
Inhibitor of neuraminidase, which is a glycoprotein on the surface of the influenza virus that destroys the infected cell's receptor for viral hemagglutinin. By inhibiting viral neuraminidase, release of viruses from infected cells and viral spread are decreased. Effective against both influenza A and B. To be inhaled through Diskhaler PO inhalation device. Circular foil discs containing 5-mg blisters of drug are inserted into supplied inhalation device.
Adult
Treatment: 10 mg (2 inhalations, 5 mg/inhalation) inhaled PO q12h for 5 d; initiate within 2 d of symptom onset
Prophylaxis: 10 mg (2 inhalations, 5 mg/inhalation) inhaled PO qd for 10 d; initiate within 36 h of exposure
Pediatric
Treatment:
<7 years: Not established
>7 years: Administer as in adults
Prophylaxis:
<5 years: Not established
>5 years: Administer as in adults
None reported
Documented hypersensitivity; obstructive airway disease
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Monitor respiratory status; may cause bronchospasm; caution in breastfeeding
More on Bronchitis |
| Overview: Bronchitis |
| Differential Diagnoses & Workup: Bronchitis |
 Treatment & Medication: Bronchitis |
| Follow-up: Bronchitis |
| References |
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References
National Center for Health Statistics. Current estimates from the national health interview survey: United States, 1994. Vital health statistics. 1995;10. [Medline].
Black S. Epidemiology of pertussis. Pediatr Infect Dis J. Apr 1997;16(4 Suppl):S85-9. [Medline].
Braman SS. Chronic cough due to acute bronchitis: ACCP evidence-based clinical practice guidelines. Chest. Jan 2006;129(1 Suppl):95S-103S. [Medline].
Gonzales R, Steiner JF, Sande MA. Antibiotic prescribing for adults with colds, upper respiratory tract infections, and bronchitis by ambulatory care physicians. JAMA. Sep 17 1997;278(11):901-4. [Medline].
Franks P, Gleiner JA. The treatment of acute bronchitis with trimethoprim and sulfamethoxazole. J Fam Pract. Aug 1984;19(2):185-90. [Medline].
Mossad SB, Macknin ML, Medendorp SV, Mason P. Zinc gluconate lozenges for treating the common cold. A randomized, double-blind, placebo-controlled study. Ann Intern Med. Jul 15 1996;125(2):81-8. [Medline].
American Academy of Pediatrics. Committee on Drugs. Use of codeine- and dextromethorphan-containing cough remedies in children. American Academy of Pediatrics. Committee on Drugs. Pediatrics. Jun 1997;99(6):918-20. [Medline].
Brickfield FX, Carter WH, Johnson RE. Erythromycin in the treatment of acute bronchitis in a community practice. J Fam Pract. Aug 1986;23(2):119-22. [Medline].
Croughan-Minihane MS, Petitti DB, Rodnick JE. Clinical trial examining effectiveness of three cough syrups. J Am Board Fam Pract. Mar-Apr 1993;6(2):109-15. [Medline].
Dunlay J, Reinhardt R, Roi LD. A placebo-controlled, double-blind trial of erythromycin in adults with acute bronchitis. J Fam Pract. Aug 1987;25(2):137-41. [Medline].
Gonzales R, Bartlett JG, Besser RE. Principles of appropriate antibiotic use for treatment of uncomplicated acute bronchitis: background. Ann Emerg Med. Jun 2001;37(6):720-7. [Medline].
Gonzales R, Wilson A, Crane LA, Barrett PH. What's in a name? Public knowledge, attitudes, and experiences with antibiotic use for acute bronchitis. Am J Med. Jan 2000;108(1):83-5. [Medline].
Huchon GJ, Gialdroni-Grassi G, Leophonte P, et al. Initial antibiotic therapy for lower respiratory tract infection in the community: a European survey. Eur Respir J. Aug 1996;9(8):1590-5. [Medline].
Hueston WJ. A comparison of albuterol and erythromycin for the treatment of acute bronchitis. J Fam Pract. Nov 1991;33(5):476-80. [Medline].
Hueston WJ. Albuterol delivered by metered-dose inhaler to treat acute bronchitis. J Fam Pract. Nov 1994;39(5):437-40. [Medline].
King DE, Williams WC, Bishop L. Effectiveness of erythromycin in the treatment of acute bronchitis. J Fam Pract. Jun 1996;42(6):601-5. [Medline].
Meza RA, Bridges-Webb C, Sayer GP, et al. The management of acute bronchitis in general practice: results from the Australian Morbidity and Treatment Survey, 1990-1991. Aust Fam Physician. Aug 1994;23(8):1550-3. [Medline].
Molfino NA. Genetics of COPD. Chest. May 2004;125(5):1929-40. [Medline].
Palmer DA, Bauchner H. Parents' and physicians' views on antibiotics. Pediatrics. Jun 1997;99(6):E6. [Medline].
Siegel D, Sande MA. Patterns of antibiotic use in a busy metropolitan emergency room: analysis of efficacy and cost-appropriateness. West J Med. May 1983;138(5):737-41. [Medline].
Smith NM, Bresee JS, Shay DK. Prevention and Control of Influenza: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. Jul 28 2006;55(RR-10):1-42. [Medline].
Smucny J, Fahey T, Becker L, Glazier R. Antibiotics for acute bronchitis. Cochrane Database Syst Rev. 2004;CD000245. [Medline].
Snyder LD, Eisner MD. Obstructive lung disease among the urban homeless. Chest. May 2004;125(5):1719-25. [Medline].
Stott NC, West RR. Randomised controlled trial of antibiotics in patients with cough and purulent sputum. Br Med J. Sep 4 1976;2(6035):556-9. [Medline].
Taylor JA, Novack AH, Almquist JR. Efficacy of cough suppressants in children. J Pediatr. May 1993;122(5 Pt 1):799-802. [Medline].
Williamson HA. A randomized, controlled trial of doxycycline in the treatment of acute bronchitis. J Fam Pract. Oct 1984;19(4):481-6. [Medline].
Further Reading
Keywords
tracheobronchitis, chronic obstructive lung disease, COLD, obstructive airway disease, OAD, chronic obstructive pulmonary disease, COPD, respiratory tract infection, asthma, viralrespiratory tract infection, bacterial respiratory tract infection, chronic bronchitis, CB, acute bronchitis, cough, viral infection
adenovirus, influenza, parainfluenza, respiratory syncytial virus, RSV, rhinovirus, coxsackievirus, herpes simplex virus, HSV, Streptococcus pneumoniae, Moraxella catarrhalis, Haemophilus influenzae, Chlamydia pneumoniae, Mycoplasma species
airpollution, air pollutants, smoking, second-hand smoke, allergies, chronic aspiration, gastroesophagealreflux, GER, fungal infection
