Medication Summary
In acute bronchitis, medical therapy generally targets symptoms and includes use of analgesics and antipyretics.
In chronic bronchitis, bronchodilator therapy should be considered and instituted (a beta-adrenergic agonist, such as albuterol or terbutaline). Beta-adrenergic agents are less toxic and have a more rapid onset of action. Stepped-up use of inhaled corticosteroids may also be an effective initial intervention.
In the child who continues to cough despite a trial of bronchodilators and in whom the history and physical examination findings suggest a wheezy form of bronchitis, oral corticosteroids should be added. If the response is suboptimal or if fever persists, antibiotic therapy with an agent such as a macrolide or beta-lactamase–resistant antimicrobial may be considered.
Antibiotics should not be the primary therapy. They usually do not result in a cure and may delay the start of more appropriate asthma therapies.
Analgesic and antipyretic agents
Class Summary
These agents are used to control fever, myalgias, and arthralgias.
Acetaminophen (Tylenol, Aspirin-Free Anacin, Feverall)
This is the treatment of choice for pain in patients who are unable to take aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs).
Ibuprofen (Ibuprin, Advil, Motrin)
This NSAID is the usual treatment of choice for mild-to-moderate pain if no contraindications exist. Ibuprofen reduces inflammatory reactions and pain, probably by decreasing activity of cyclooxygenase, which inhibits prostaglandin synthesis.
Corticosteroids, systemic
Class Summary
These agents are used for short courses (3-10 d) to gain prompt control of inadequately controlled acute asthmatic episodes. Systemic corticosteroids also are used for long-term prevention of symptoms in severe persistent asthma, as well as for suppression, control, and reversal of inflammation. Frequent and repetitive use of beta2-agonists has been associated with beta2-receptor subsensitivity and down-regulation; these processes are reversed with corticosteroids.
Higher-dose corticosteroids have no advantage in severe exacerbations of asthma, and intravenous administration has no advantage over oral therapy, provided that GI tract transit time or absorption is not impaired. The usual regimen is to continue frequent multiple daily dosing until the forced expiratory volume in 1 second (FEV1) or peak expiratory flow (PEF) is 50% of the predicted or personal best values; then, the dose is changed to twice daily. This usually occurs within 48 hours.
Prednisolone (Pediapred, Orapred)
Prednisolone works by decreasing inflammation by suppressing migration of polymorphonuclear leukocytes and reducing capillary permeability.
Prednisone (Sterapred)
Prednisone may decrease inflammation by reversing increased capillary permeability and suppressing polymorphonuclear leukocyte activity. Prednisone stabilizes lysosomal membranes and suppresses lymphocytes and antibody production.
Bronchodilators
Class Summary
Studies have found that bronchodilators relieve symptoms of bronchitis, and they have been found to be superior to antibiotics in this setting. However, patient numbers in these trials were disappointingly small, given how commonly acute bronchitis is diagnosed.
Albuterol sulfate (Proventil, Ventolin, ProAir)
Terbutaline ( Brethine, Bricanyl, Brethaire, or Terbulin)
A beta-adrenergic agonist useful in the treatment of epinephrine-refractory bronchospasm, albuterol relaxes bronchial smooth muscle by acting on beta2-adrenergic receptors. It has little effect on cardiac muscle contractility. A ready-to-use solution for nebulization is available as 0.083% (2.5 mg/3 mL).).
Antibiotics
Class Summary
Antibiotics should not be the primary therapy for patients with acute bronchitis. They usually do not result in a cure and may delay the start of more appropriate asthma therapies. Studies of antibiotic effectiveness have focused on healthy individuals or patients with chronic obstructive lung disease. Patients with chronic obstructive pulmonary disease (COPD) or limited cardiopulmonary reserve, such as patients with asthma, may experience a very limited beneficial effect.
Amoxicillin-clavulanic acid (Augmentin)
Amoxicillin is a semisynthetic bactericidal beta-lactam antibiotic that inhibits cell wall synthesis. This agent contains amoxicillin combined with clavulanate, a beta-lactamase inhibitor.
Azithromycin (Zithromax)
Azithromycin is used to treat mild to moderately severe infections caused by susceptible strains of microorganisms. It is indicated for chlamydial and gonorrheal infections of the genital tract.
Antivirals
Class Summary
Vaccination is the most important preventive measure for influenza; vaccinations offer coverage for influenza A and B and, thereby, provide greater protection from bronchitis in the appropriate populations. Antiviral drugs represent a second line of defense.
Antiviral agents with activity against influenza virus include amantadine, rimantadine, oseltamivir, and zanamivir. Amantadine and rimantadine are not currently recommended by the Centers for Disease Control and Prevention (CDC) for influenza because of widespread resistance among influenza A strains. Oseltamivir (Tamiflu) resistance emerged in the United States during the 2008-2009 influenza season and was found in some strains of H1N1 influenza virus during the 2009-2010 epidemic.
For current recommendations on the use of antiviral drugs for influenza, see the CDC information for health care professionals on antiviral drugs for influenza.
Oseltamivir (Tamiflu)
Oseltamivir 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, oseltamivir decreases release of viruses from infected cells and thus viral spread.
This agent is effective against influenza A and B, although resistance against influenza A emerged in the United States during the 2008-2009 influenza season. Start within 40 hours of symptom onset. Available in capsules and oral suspension.
Zanamivir (Relenza)
Zanamivir is an 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. Zanamivir is effective against both influenza A and B. It is inhaled through the Diskhaler oral inhalation device. Circular foil discs that contain 5-mg blisters of drug are inserted into the supplied inhalation device.
Corticosteroids, inhaled
Class Summary
Corticosteroids are the most potent anti-inflammatory agents. Inhaled forms are topically active, poorly absorbed, and least likely to cause adverse effects. No study has shown significant toxicity with inhaled steroid use in children at doses less than the equivalent of 400 mcg/d of beclomethasone. They are used for long-term control of symptoms and for the suppression, control, and reversal of inflammation.
Inhaled forms reduce the need for systemic corticosteroids. They block late asthmatic responses to allergens; reduce airway hyperresponsiveness; inhibit cytokine production, adhesion protein activation, and inflammatory cell migration and activation; and reverse beta2-receptor down-regulation and subsensitivity (in acute asthmatic episodes with long-term beta2-agonist use).
Beclomethasone (Qvar)
Beclomethasone inhibits bronchoconstriction mechanisms, causes direct smooth muscle relaxation, and may decrease the number and activity of inflammatory cells, which, in turn, decrease airway hyperresponsiveness. It is available in a metered-dose inhaler (MDI) that delivers 40 or 80 mcg/actuation.
Fluticasone (Flovent HFA, Flovent Diskus)
Fluticasone has extremely potent vasoconstrictive and anti-inflammatory activity. It is available in an MDI (44-mcg, 110-mcg, or 220-mcg per actuation) and Diskus powder for inhalation (50-mcg, 100-mcg, or 250-mcg per actuation).
Budesonide inhaled (Pulmicort Flexhaler, Pulmicort Respules)
Budesonide reduces inflammation in airways by inhibiting multiple types of inflammatory cells and decreasing production of cytokines and other mediators involved in the asthmatic response. It is available as Flexhaler powder for inhalation (90 mcg/actuation [delivers approximately 80 mcg/actuation]) and Respules suspension for inhalation.
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Normal airway color and architecture (in a child with mild tracheomalacia).
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Airway of a child with chronic bronchitis shows erythema, loss of normal architecture, and swelling.
