Approach Considerations
Emergency care for acute bronchitis or exacerbation of chronic bronchitis must focus on ensuring that the child has adequate oxygenation and hydration. Outpatient care is appropriate unless bronchitis is complicated by severe underlying disease. General measures include rest, use of antipyretics, adequate oral fluid intake, and avoidance of smoke.
Proper care of any underlying disorder is of paramount importance. Recognition of the role of asthma and institution of appropriate therapies are key to the successful treatment of many patients.
Febrile patients should increase oral fluid intake. Instruct the patient to rest until the fever subsides.
Resolution of symptoms, normal findings on physical examination, and normal pulmonary function test results indicate the end of the need for acute treatment. Patients in whom asthma is diagnosed will likely require ongoing therapy for that disease. Patients with defined hypogammaglobulinemia may need periodic immunoglobulin replacement treatments. These are best coordinated with the assistance of a pediatric allergy, immunology or pulmonary specialist.
Pharmacologic Therapy
Acute bronchitis
In otherwise healthy individuals, the use of antibiotics has not demonstrated any consistent benefit in relieving symptoms or improving the natural history of acute bronchitis. Placebo-controlled studies using doxycycline, erythromycin, and trimethoprim-sulfamethoxazole have failed to show significant benefit in patients with acute bronchitis.
In a study of antibiotic prescribing patterns, a retrospective cohort study of ED patients from 2001-2010, using data from the National Hospital Ambulatory Medical Care Survey (NHAMCS), found lower rates of antibiotic prescriptions among pediatric patients with stable rates than among adult patients. [39] This study highlights growing recognition of the limited role for antibiotics in pediatric patients treated for acute bronchitis and related acute respiratory tract infections.
A study that aimed to determine bacterial prevalence rates for 5 common childhood acute respiratory tract infections found that in the United States, antibiotics are prescribed almost twice as often as expected to outpatients aged 18 years and younger. [40, 41] Another study in the Netherlands by Ivanovska et al reported concerning high antibiotic prescription rates for bronchitis in adolescents compared with children aged 0-4 and 5-11 years. [42]
A research letter reported that physicians are prescribing antibiotics to adults for acute bronchitis at rates between 60% and 80%, despite guidelines and educational efforts that say the rate should be zero. [43, 44]
Medical therapy generally targets symptoms and includes use of analgesics and antipyretics. Antitussives and expectorants are often prescribed but have not been demonstrated to be useful. Few data outside of the research laboratory support the efficacy of expectorants.
The prototype antitussive, codeine, has been successful in some chronic-cough and induced-cough models, but few clinical data address their use in acute bronchitis. The data that are available suggest little benefit. Data show codeine is little or no better than guaifenesin or dextromethorphan in cough suppression.
Preliminary studies suggest a possible role for EPs 7630, an herbal drug preparation derived from Pelargonium sidoides roots, in the treatment of pediatric patients (1-18 y) with acute bronchitis outside the strict indication for antibiotics. Kamin et al demonstrated reduced bronchitis severity symptom scores in patients treated with EPs 7630, with good overall tolerability. [45, 46]
Bronchodilators have failed to demonstrate efficacy in some adult studies of acute bronchitis. Nevertheless, a trial of inhaled albuterol may be worthwhile because it may provide significant relief of symptoms for many pediatric patients.
Chronic bronchitis
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. However, antibiotics may be appropriate in children with chronic wet cough and symptoms persisting beyond 2-4 weeks, most of whom have protracted bacterial bronchitis. [47]
Bronchodilator therapy should be considered and instituted; a beta-adrenergic agonist, such as albuterol or terbutaline may be effective. Several studies have demonstrated that bronchodilators delivered by metered dose inhalers with spacer device are as, or in some cases more effective, in all age groups than nebulized bronchodilators.
In the child who continues to cough despite a trial of bronchodilators and in whom the history and physical examination suggest a wheezy form of bronchitis, corticosteroids should be added. Short courses of dexamethasone (1-2 dose schedules) have been shown to be as effective as longer (5 d) courses of prednisolone; [48] this was preferred by caretakers likely due to the reduced need to administer medication and a lower incidence of vomiting. “Stepped-up” courses of inhaled corticosteroids may also be effective for some patients. [49]
If the response to initial therapies is suboptimal or if a persistent wet cough falls within the definitions of protracted bacterial bronchitis, antibiotic therapy with an agent such as a beta-lactamase–resistant antimicrobial (eg, amoxicillin-clavulanate) or a macrolide may be considered. Certain antibiotics, including the macrolides and fluoroquinolones, have the potential to prolong the QT interval and in studies have been associated with a higher risk for lethal arrhythmias. [50]
Subsequent studies have demonstrated no added risk for adverse cardiovascular events among young and middle-aged adults taking azithromycin who do not have cardiovascular risk factors. Due to potential concerns, the US Food and Drug Administration (FDA) updated its warning for azithromycin with information related to the risk of QT interval prolongation and torsades de pointes, a specific, rare heart rhythm abnormality. Care must be exercised when considering these medications, particularly in patients with congenital or acquired forms of long QT syndrome, forms of congenital or acquired heart disease, patients with bradyarrhythmias, hypokalemia, hypocalcemia, or hypomagnesemia and those taking other medications known to be associated with QTc prolongation. Giudicessi and Ackerman (2013) provide a table of factors to consider when assessing this risk. [51]
Consultations
Referral to a pediatric pulmonologist may be helpful for patients experiencing persistent or recurrent symptoms and whose histories suggest the possibility of tracheobronchial foreign body aspiration, cystic fibrosis, immunodeficiency, or persistent asthma for which appropriate first-line symptom or controller therapies have failed.
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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.
