AUTHOR AND EDITOR INFORMATION

Section 1 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Acknowledgments
• Multimedia
• References

INTRODUCTION

Section 2 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Acknowledgments
• Multimedia
• References

Background

Acute bronchitis is a clinical syndrome produced by inflammation of the trachea, bronchi, and bronchioles. In children, acute bronchitis usually occurs in association with viral respiratory tract infection. Acute bronchitis is rarely a primary bacterial infection in otherwise healthy children. Symptoms of acute bronchitis usually include cough that produces phlegm and may be associated with retrosternal pain during deep breathing or coughing. Generally, the clinical course of acute bronchitis is self-limited, with complete healing and full return to function typically seen within 10-14 days following symptom onset.

Chronic bronchitis is recurring inflammation and degeneration of the bronchial tubes that may be associated with active infection. Chronic bronchitis is often part of an underlying disease process, such as asthma, cystic fibrosis, dyskinetic cilia syndrome, foreign body aspiration, or exposure to an airway irritant. Recurrent tracheobronchitis may also be seen in patients with tracheostomy or with certain forms of immunodeficiency. In all of these patient groups, chronic bronchitis should not be the primary diagnosis because it does not describe the pathology of the underlying disorder. Patients with chronic bronchitis have more mucus than normal because of either increased production or decreased clearance. Coughing is the mechanism by which excess secretion is cleared.

Defining chronic bronchitis and its prevalence in childhood has been complicated by the significant clinical overlap with asthma. In adults, chronic bronchitis is defined as daily production of sputum for at least 3 months in 2 consecutive years. Some have applied this definition to childhood chronic bronchitis. Others limit the definition to a productive cough that lasts more than 2 weeks despite medical therapy. Chronic bronchitis also has been defined as a complex of symptoms that includes cough that lasts more than 1 month or recurrent productive cough that may be associated with wheezing or crackles on auscultation. These are working definitions of asthma, as well.

Pathophysiology

Acute bronchitis leads to the hacking cough and phlegm production that often follows upper respiratory tract symptoms. This occurs because of the inflammatory response of the mucous membranes within the lungs' bronchial passages. If the patient is in otherwise good health, the mucous membrane returns to normal, heralding recovery from the initial active infection, which usually lasts for several days.

In adults, chronic bronchitis results from hypersecretion of mucus in the bronchi due to hypertrophy of submucosal mucus-producing glands and increased numbers of goblet cells within the epithelium. In most patients, this results from exposure to cigarette smoke. Mucociliary clearance is delayed because of excess mucus production and loss of ciliated cells, leading to a productive cough.

In children, chronic bronchitis follows either an endogenous response (eg, excessive inflammation) to acute airway injury or continuous exposure to certain noxious environmental agents (eg, allergens or irritants). An airway that undergoes such an insult responds quickly with bronchospasm and cough, followed by inflammation, edema, and mucus production. This helps explain the fact that chronic bronchitis in children is often actually asthma.

The role of irritant exposure, particularly cigarette smoke and airborne particulates, in recurrent (wheezy) bronchitis and asthma is becoming clearer. Kreindler et al (2005) demonstrated that the ion transport phenotype of normal human bronchial epithelial cells exposed to cigarette smoke extract is similar to that of cystic fibrosis epithelia, in which sodium is absorbed out of proportion to chloride secretion in the setting of increased mucus production. These findings suggest that the negative effects of cigarette smoke on mucociliary clearance may be mediated through alterations in ion transport. McConnell et al (2003) noted that organic carbon and nitrogen dioxide airborne particulates were associated with the chronic symptoms of bronchitis among children with asthma in southern California.

A chronic or recurrent insult to the airway epithelium, such as recurrent aspiration or repeated viral infection, may contribute to chronic bronchitis in childhood. Following damage to the airway lining, chronic infection by commonly isolated airway organisms may occur. The most common bacterial pathogen that causes lower respiratory tract infections in children of all age groups is Streptococcus pneumoniae. Nontypeable Haemophilus influenzae and Moraxella catarrhalis may be significant pathogens in preschoolers (aged <5 y), while Mycoplasma pneumoniae may be significant in school-aged children (aged >5-18 y).

Children with tracheostomies are often colonized with an array of flora, including alpha- and gamma-hemolytic streptococci. With acute exacerbations of tracheobronchitis in these patients, pathogenic flora may include Pseudomonas aeruginosa and Staphylococcus aureus (including methicillin-resistant strains), among other pathogens. Children predisposed to oropharyngeal aspiration, particularly those with compromised protective airway mechanisms, may become infected with oral anaerobic strains of streptococci.

Frequency

United States

Data collected from the National Ambulatory Care Survey 1991 Summary showed that 2,774,000 office visits by children younger than 15 years resulted in a diagnosis of bronchitis. Although the report did not separate diagnoses into acute or chronic bronchitis, the frequency of visits made bronchitis just slightly less common than otitis media and slightly more common than asthma. However, in children, asthma is often underdiagnosed and is frequently misdiagnosed as chronic or recurrent bronchitis. Since 1996, 9-14 million Americans have been diagnosed with chronic bronchitis annually.

International

Bronchitis, both acute and chronic, is prevalent throughout the world and is one of the top 5 reasons for childhood physician visits in countries that track such data. The incidence of bronchitis in British schoolchildren is reported to be 20.7%. Weigl et al (2005) noted an overall increase in hospitalization for lower respiratory tract infection (laryngotracheobronchitis, bronchitis, wheezing bronchitis, bronchiolitis, bronchopneumonia, pneumonia) among German children; this is consistent with observations among children from the United States, United Kingdom, and Sweden. The incidence rate of bronchitis in children in this German cohort was 28%.

Mortality/Morbidity

Acute bronchitis is almost always a self-limited process in the otherwise healthy child. However, it frequently results in absenteeism from school and work. Chronic bronchitis is manageable with proper treatment and avoidance of known triggers (eg, tobacco smoke). Proper management of any underlying disease process, such as asthma, cystic fibrosis, immunodeficiency, congestive heart failure, bronchiectasis, or tuberculosis, is also key.

Race

Bronchitis has no racial predisposition. However, differences in population prevalences have been identified; for example, because of the association of chronic bronchitis with asthma and the concentration of asthma risk factors in inner-city populations, this population group is at higher risk.

Sex

• Acute bronchitis: Incidence is equal in males and females.
• Chronic bronchitis: Incidence is difficult to state precisely because of the lack of a definitive diagnosis and the considerable overlap with asthma. However, in recent years, the prevalence rate of chronic bronchitis has been reported to be consistently higher in females than in males.

Age

• Acute (typically wheezy) bronchitis occurs most commonly in children younger than 2 years, with another peak seen in children aged 9-15 years.
• Chronic bronchitis affects people of all ages but is more prevalent in persons older than 45 years.

CLINICAL

Section 3 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Acknowledgments
• Multimedia
• References

History

• Acute bronchitis begins as a respiratory tract infection that manifests as the common cold. Symptoms often include coryza, malaise, chills, slight fever, sore throat, and back and muscle pain. The cough in these children is usually accompanied by an initial watery nasal discharge. After several days, the nasal discharge becomes thicker and colored or opaque. It then becomes clear again and has a mucoid watery consistency before it spontaneously resolves within 7-10 days. Purulent nasal discharge is common with viral respiratory pathogens and, by itself, does not imply a bacterial etiology to the infection.
• • Initially, the cough is dry and may be harsh or raspy sounding. The cough then loosens and becomes productive. Children younger than 5 years rarely expectorate. In this age group, sputum is usually seen in vomitus (ie, posttussive emesis). Parents frequently note a rattling sound in the chest.
  • Hemoptysis, a burning discomfort in the chest, and dyspnea may be present.
• Brunton et al (2004) notes that adult patients with chronic bronchitis have a history of persistent cough that produces yellow, white, or greenish sputum on most days for at least 3 months of the year and for more than 2 consecutive years. Wheezing and reports of breathlessness are also common. Pulmonary function testing in these adult patients reveals irreversible reduction in maximal airflow velocity.
• Recurrent episodes of acute or chronic bronchitis are unusual and should alert the health care provider to the likelihood of asthma. In particular, bronchitis is often diagnosed repeatedly in children in whom asthma has remained undiagnosed for many years. Similarly, in taking a family history for asthma in parents or siblings, determining whether their history includes multiple episodes of bronchitis is important. Multiple episodes of bronchitis may suggest previously undiagnosed asthma in a parent or sibling. The diagnosis of "asthmatic bronchitis" or "wheezy bronchitis" is simply asthma. For more detail on taking the history of pediatric patients with recurrent cough, wheezing, and shortness of breath, see Asthma.
• Recurrent episodes of acute or chronic bronchitis may be associated with immunodeficiency.
• • Ozkan (2005) studied immunoglobulin A (IgA) and immunoglobulin G (IgG) deficiency in children who presented with recurrent sinopulmonary infection. The overall frequency of antibody defects was found to be 19.1%. IgA deficiency was observed in 9.3%, IgG subclass deficiency was observed in 8.4%, and both IgA and IgG subclass deficiencies were observed in 1.4%. The prevalence of IgA and/or IgG subclass deficiency was 25% in patients with recurrent upper respiratory tract infections, 22% in patients with recurrent pulmonary infections, and 12.3% in patients with recurrent bronchiolitis.
  • Common variable immunodeficiency
    • Common variable immunodeficiency is the most frequent of the primary hypogammaglobulinemias. Kainulainen et al (2001) conducted a nationwide survey of all patients with common variable immunodeficiency who were receiving immunoglobulin replacement therapy in Finland. Sinopulmonary infections were the most common clinical presentation. Sixty-six percent had recurrent pneumonia, 60% had recurrent maxillary sinusitis, and 45% had recurrent bronchitis. The mean interval from the time of onset of symptoms to diagnosis was 8 years. Seventeen percent had evidence of chronic lung damage at the time of diagnosis, highlighting the importance of early recognition in the prevention of chronic pulmonary sequelae.
    • To improve the recognition of common variable immunodeficiency, the authors suggest consideration of this condition in patients with recurrent sinopulmonary infection. In addition to a low serum IgG concentration, measurement of specific antibody production is recommended to establish the diagnosis.

Physical

• Lungs may sound normal. Crackles, rhonchi, or large airway wheezing, if any, tends to be scattered and bilateral.
• The pharynx may be injected.

Causes

Acute bronchitis is generally caused by respiratory infections; approximately 90% are viral in origin, and 10% are bacterial.

Chronic bronchitis may be caused by repeated attacks of acute bronchitis, which can weaken and irritate bronchial airways over time, eventually resulting in chronic bronchitis. Industrial pollution is also a common cause; however, the chief culprit is heavy long-term cigarette smoke exposure.

The most common causes of both acute and chronic bronchitis in the pediatric population are as follows:

• Viral infection
• • Adenovirus
  • Influenza
  • Parainfluenza
  • Respiratory syncytial virus
  • Rhinovirus
  • Coxsackievirus
  • Herpes simplex virus
• Secondary bacterial infection as part of an acute upper respiratory infection (extremely rare in nonsmokers without cystic fibrosis)
• • S pneumoniae
  • M catarrhalis
  • H influenzae (nontypeable)
  • Chlamydia pneumoniae (Taiwan acute respiratory [TWAR] agent)
  • Mycoplasma species
• Air pollutants, such as occur with smoking and from second-hand smoke
• Allergies
• Chronic aspiration or gastroesophageal reflux
• Fungal infection

DIFFERENTIALS

Section 4 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Acknowledgments
• Multimedia
• References

Other Problems to be Considered

Retained foreign body
Bronchopulmonary allergy
Immunosuppression

WORKUP

Section 5 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Acknowledgments
• Multimedia
• References

Lab Studies

• For maximal cost effectiveness, diagnostic laboratory tests should be performed in steps.
• • Patients with uncomplicated acute respiratory illness who are cared for in an outpatient setting need little, if any, laboratory evaluation.
  • For hospitalized children, serum C-reactive protein screen, respiratory culture, rapid diagnostic studies, and serum cold agglutinin testing (at the appropriate age) help to classify whether the infection is caused by bacteria, the atypicals, or viruses. Obtain a blood or sputum culture if antibiotic therapy is a consideration.
  • For the child admitted to the hospital with a possible chlamydial, mycoplasmal, or viral lower respiratory tract infection for which specific therapy is considered, examine nasopharyngeal secretions for Chlamydia species and for antigens of respiratory syncytial, parainfluenza, and influenza viruses to guide appropriate antimicrobial selection. Serum immunoglobulin M (IgM) levels may be helpful.
  • For the child who has been intubated, collect a specimen of deep respiratory secretions for Gram staining, chlamydial and viral antigen assays, and bacterial and viral cultures.
  • A clinical response to daily high-dose oral corticosteroids may be considered as a diagnostic and therapeutic trial to confirm asthma.
  • A negative sweat test result using pilocarpine iontophoresis should exclude cystic fibrosis. Many states are now using CFTR mutational analyses in newborn screening programs.
  • Evidence of reversible airflow obstruction revealed by pulmonary function testing confirms the diagnosis of asthma.
  • For children in whom immunodeficiency is suspected, measurement of total serum immunoglobulins, IgG subclasses, and specific antibody production is recommended to establish the diagnosis.

Imaging Studies

• Chest radiography
• • Chest radiographs generally appear normal in patients with uncomplicated bronchitis.
  • Abnormal findings are minimal and may include atelectasis, hyperinflation, and peribronchial thickening. Focal consolidation is not usually present. These findings are similar to the radiographic findings in patients with asthma.
  • Radiographic findings may help exclude other diseases or complications, particularly when abnormalities in either vital signs or pulse oximetry findings are present.

Other Tests

• Pulmonary function tests may show airflow obstruction that is reversible using bronchodilators. Bronchial challenge, such as with exercise or with histamine or methacholine exposure, may demonstrate the airway hyperreactivity characteristic of asthma.

Procedures

• A diagnosis of chronic bronchitis is suggested by fiberoptic bronchoscopy findings in which the airways appear erythematous and friable.
• Bronchoalveolar lavage may be useful in establishing an infectious cause.

Histologic Findings

Bronchoalveolar lavage may reveal numerous monocytic or polymorphonuclear inflammatory cells. In children with chronic aspiration of gastric contents, lipids may be present within macrophages.

TREATMENT

Section 6 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Acknowledgments
• Multimedia
• References

Medical Care

Emergency care for acute bronchitis or exacerbation of chronic bronchitis must focus on ensuring that the child is adequately oxygenating. Outpatient care is appropriate unless bronchitis is complicated by severe underlying disease. General measures include rest, use of antipyretics, adequate hydration, and avoidance of smoke. Proper care of the underlying disorder is of paramount importance. Consideration of asthma and adequate therapy are critical to an early response.

Consultations

Referral to a pediatric pulmonologist may be helpful when symptoms persist beyond 2-3 weeks in uncomplicated acute bronchitis or when patients in whom chronic bronchitis is suspected do not respond to initial therapy.

Diet

Increase oral fluid intake when the patient is febrile.

Activity

Instruct the patient to rest until the fever subsides.

MEDICATION

Section 7 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Acknowledgments
• Multimedia
• References

Acute bronchitis

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 upper respiratory infections, and the data that are available suggest little benefit. Data show codeine is little or no better than guaifenesin or dextromethorphan.

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.

While some studies of acute bronchitis have failed to demonstrate the effectiveness of bronchodilators, a trial of inhaled albuterol may provide significant relief of symptoms for some patients.

Chronic bronchitis

Bronchodilator therapy should be considered and instituted; either a beta-adrenergic agonist, such as albuterol or metaproterenol, or theophylline may be effective. Beta-adrenergic agents are less toxic, have a more rapid onset of action than theophylline, and do not require monitoring of levels. Inhaled corticosteroids may be effective.

In the child who continues to cough despite a trial of bronchodilators and in whom the history and physical examination findings suggest chronic 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. Too often, antibiotics are the primary therapy. They usually do not result in a cure and may delay the start of more appropriate asthma therapies.

Drug Category: Analgesic and antipyretic agents

These agents are used to control fever, myalgias, and arthralgias.

Drug Name	Ibuprofen (Ibuprin, Advil, Motrin)
Description	Usual treatment of choice for mild-to-moderate pain if no contraindications exist. Inhibits inflammatory reactions and pain, probably by decreasing activity of cyclooxygenase, which inhibits prostaglandin synthesis.
Adult Dose	400-800 mg PO q4-6h; not to exceed 3.2 g/d
Pediatric Dose	10 mg/kg PO q6-8h; not to exceed 2.4 g/d
Contraindications	Documented hypersensitivity; peptic ulcer disease; recent GI tract bleeding or perforation; renal insufficiency; high risk of bleeding
Interactions	Coadministration with aspirin increases risk of serious NSAID-related side effects; simultaneous administration with low-dose aspirin may decrease aspirin's cardioprotective and stroke-preventive effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, beta-blockers, and diuretic effect of furosemide and thiazides; may increase PT when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; may increase phenytoin or lithium serum levels
Pregnancy	B - Usually safe but benefits must outweigh the risks.
Precautions	Monitor PT closely in patients on anticoagulants; caution in patients with congestive heart failure, hypertension, and decreased renal or hepatic function

Drug Category: Corticosteroids, systemic

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 FEV1 or PEF is 50% of the predicted or personal best values; then, the dose is changed to twice daily. This usually occurs within 48 hours.

Drug Category: Bronchodilators

Studies have found that bronchodilators relieve symptoms of bronchitis, and they have been found superior to antibiotics in this setting. However, in these trials, patient numbers were disappointingly small, given how commonly acute bronchitis is diagnosed.

Drug Category: Antibiotics

Studies have focused on healthy individuals or patients with chronic obstructive lung disease (COLD). Patients with chronic obstructive pulmonary disease (COPD) or limited cardiopulmonary reserve, such as patients with asthma, may experience a very limited beneficial effect.

Drug Name	Clarithromycin (Biaxin)
Description	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 Dose	250-500 mg PO bid
Pediatric Dose	7.5 mg/kg PO bid
Contraindications	Documented hypersensitivity; patients taking pimozide, astemizole, cisapride, or terfenadine
Interactions	May result in toxic clarithromycin levels and death if administered with pimozide; may cause adverse cardiovascular effects, including death, cardiac arrest, ventricular fibrillation, torsade de pointes, and other ventricular effects if taken with astemizole or cisapride; may increase serum digoxin concentrations as a result of effects of gut flora that metabolize digoxin in >10% of patients; may increase plasma levels of disopyramide, causing arrhythmias and increasing QTc intervals; may cause acute ergot toxicity characterized by severe peripheral vasospasm and dysesthesia, necessitating monitoring in patients taking ergot alkaloids May increase risk of severe myopathy or rhabdomyolysis associated with HMG-CoA reductase inhibitors; may increase levels of tacrolimus, increasing risk of adverse effects such as nephrotoxicity; levels may be increased significantly by fluconazole; levels of both clarithromycin and omeprazole may be increased if taken together; antimicrobial effects may be decreased or frequency of adverse GI tract effects may be increased by rifabutin or rifampin; may increase levels of certain benzodiazepines, prolonging CNS-depressant effects; may increase carbamazepine concentrations
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	Consider pseudomembranous colitis in patients who present with diarrhea; increased risk of secondary infections if therapy is prolonged; monitor coagulation functions if patient is taking anticoagulant

Drug Name	Azithromycin (Zithromax)
Description	Treats mild-to-moderately severe infections caused by susceptible strains of microorganisms; indicated for chlamydial and gonorrheal infections of genital tract.
Adult Dose	500 mg PO on day 1, then 250 mg PO on days 2-5
Pediatric Dose	10 mg/kg/d PO on day 1, followed by 5 mg/kg on days 2-5; not to exceed adult dose
Contraindications	Documented hypersensitivity; hypersensitivity to erythromycin; patients taking pimozide; hepatic impairment; prolonged QTc interval; pneumonia; elderly or debilitated patients
Interactions	May increase theophylline and digoxin levels and toxicity; may potentiate anticoagulant effects of warfarin; may increase cyclosporine levels, increasing risk of nephrotoxicity, neurotoxicity, and other toxic effects; peak serum levels, but not absorption, is reduced by antacids containing aluminum or magnesium
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	Use caution in patients with prolonged QTc intervals; may result in bacterial or fungal overgrowth of nonsusceptible organisms, which may lead to secondary infection, especially if therapy is prolonged or repeated; may increase hepatic enzyme levels or cause cholestatic jaundice; use caution in patients with impaired hepatic function

Drug Name	Tetracycline (Sumycin)
Description	Inhibits bacterial protein synthesis by binding with 30S and, possibly, 50S ribosomal subunits of susceptible bacteria. Treats susceptible bacterial infections of both gram-positive and gram-negative organisms, as well as mycoplasmal, chlamydial, and rickettsial infections; less effective than erythromycin in mycoplasmal, chlamydial, and Bordetella pertussis infections.
Adult Dose	250-500 mg PO qid
Pediatric Dose	<8 years: Not recommended >8 years: 25-50 mg/kg/d PO divided qid
Contraindications	Documented hypersensitivity to minocycline or tetracycline; severe hepatic dysfunction
Interactions	Bioavailability may be decreased by antacids containing aluminum, calcium, magnesium, or bismuth subsalicylate; may increase hypoprothrombinemic effects of anticoagulants, necessitating careful monitoring of PT; may decrease pharmacologic effects of oral contraceptives, causing breakthrough bleeding and increased risk of pregnancy
Pregnancy	D - Unsafe in pregnancy
Precautions	Never administer outdated tetracycline, since degradation products are highly nephrotoxic and can cause Fanconilike syndrome; photosensitivity reaction may occur after prolonged exposure to sunlight or tanning equipment; decrease doses in renal impairment (consider serum drug level determinations in prolonged therapy); tooth discoloration if used during tooth development (last one half of pregnancy through age 8 y)

Drug Name	Doxycycline (Vibramycin)
Description	Broad-spectrum bacteriostatic antibiotic that inhibits protein synthesis.
Adult Dose	100 mg PO bid on day 1, then 100 mg PO qd/bid for at least 6 d
Pediatric Dose	<8 years: Not recommended >8 years: <45 kg: 5 mg/kg/d PO/IV divided bid on day 1, followed by 2.5-5 mg/kg/d PO/IV qd or divided bid; not to exceed 200 mg/kg/d >45 kg: 200 mg/d PO/IV divided bid on day 1, followed by 100-200 mg/kg/d PO/IV qd or divided bid Infuse IV over 1-4 h
Contraindications	Documented hypersensitivity; severe hepatic dysfunction
Interactions	May increase PT in patients taking warfarin, necessitating monitoring of PT and dose adjustment if indicated; reduces activity of penicillin; absorption decreased by antacids, bicarbonate, calcium, and iron supplements
Pregnancy	D - Unsafe in pregnancy
Precautions	Caution in hepatic or renal disease; may increase cranial pressure; may cause GI tract symptoms, photosensitivity, hemolytic anemia, and hypersensitivity reactions; infuse IV over 1-4 h; avoid exposure to direct sunlight; tooth discoloration if used during tooth development (last one half of pregnancy through age 8 y)

Drug Name	Amoxicillin-clavulanic acid (Augmentin)
Description	Semisynthetic bactericidal beta-lactam antibiotic that inhibits cell wall synthesis. It contains amoxicillin combined with clavulanate, a beta-lactamase inhibitor.
Adult Dose	250-500 mg PO q8h
Pediatric Dose	<3 months: 30 mg/kg/d PO divided q12h >3 months: 40-80 mg/kg/d PO divided q12h
Contraindications	Documented hypersensitivity; PKU (contains phenylalanine); penicillin allergy
Interactions	Coadministration with warfarin or heparin increases risk of bleeding
Pregnancy	B - Usually safe but benefits must outweigh the risks.
Precautions	Can produce false-positive result on dipstick test for urine glucose; increases risk of rash in patients with mononucleosis or in patients taking allopurinol; diarrhea may occur; adjust dose with renal impairment

Drug Category: Antivirals

Influenza vaccinations offer coverage for influenza A and B, thereby providing greater protection from bronchitis in the appropriate populations. In past years, amantadine and rimantadine have been useful during epidemics of influenza A. Amantadine and rimantadine are currently not recommended by the CDC for influenza because of resistance. During the 2005-2006 influenza season, laboratory testing by the CDC on the predominant strain of influenza (H3N2) currently circulating in the United States showed resistance to these drugs. Zanamivir (Relenza) and oseltamivir (Tamiflu) are effective for influenza A and B. For more information, see CDC information for health care professionals on antiviral agents for influenza.

Drug Name	Zanamivir (Relenza)
Description	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 oral inhalation device. Circular foil discs that contain 5-mg blisters of drug are inserted into supplied inhalation device.
Adult Dose	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 Dose	Treatment: <7 years: Not established >7 years: Administer as in adults Prophylaxis: <5 years: Not established >5 years: Administer as in adults
Contraindications	Documented hypersensitivity, obstructive airway disease
Interactions	None reported
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	Monitor respiratory status; may cause bronchospasm; caution in breastfeeding

Drug Category: Corticosteroids, inhaled

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 response 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).

Drug Name	Fluticasone (Flovent)
Description	Has extremely potent vasoconstrictive and anti-inflammatory activity. Has a weak hypothalamic-pituitary-adrenocortical axis inhibitory potency when applied topically.
Adult Dose	Low dose: 88-264 mcg/d (44 mcg/inhalation, 2-6 inhalations q24h or 110 mcg/inhalation, 2 inhalations q24h) Medium dose: 264-660 mcg/d (110 mcg/inhalation, 2-6 inhalations q24h) High dose: >660 mcg/d (110 mcg/inhalation, > 6 inhalations q24h or 220 mcg/inhalation, > 3 inhalations q24h)
Pediatric Dose	Low dose: 88-176 mcg/d (44 mcg/inhalation, 2-4 inhalations q24h) Medium dose: 176-440 mcg/d (110 mcg/inhalation, 2-4 inhalations q24h) High dose: >440 mcg/d (110 mcg/inhalation, > 4 inhalations q24h or 220 mcg/inhalation, 2 inhalations q24h)
Contraindications	Documented hypersensitivity; fungal, viral, and bacterial skin infections
Interactions	Coadministration with barbiturates, phenytoin, and rifampin decreases effects of triamcinolone
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	Inhaled corticosteroids can cause oral thrush and hoarseness (can prevent by rinsing mouth after dosing and by using with MDI spacer); large doses (>800 mcg/d) have adverse systemic effects, including growth retardation and HPA inhibition; high-dose long-term therapy has been associated with HPA inhibition and may retard growth

Drug Name	Budesonide (Rhinocort, Pulmicort Turbuhaler, Pulmicort Nebules)
Description	Alters level of inflammation in airways by inhibiting multiple types of inflammatory cells and decreasing production of cytokines and other mediators involved in the asthmatic response.
Adult Dose	Oral inhalation: 200-400 mcg bid initially; may increase to 800 mcg bid
Pediatric Dose	Oral inhalation: 200 mcg bid initially; may increase to 400 mcg bid Nebulizer: 0.25 mg/d to 0.5 mg bid; dose and frequency of nebulization depends on whether patient was previously treated with inhaled or oral corticosteroids
Contraindications	Documented hypersensitivity
Interactions	None reported
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	Inhaled corticosteroids can cause oral thrush and hoarseness (can prevent by rinsing mouth after dosing or using with MDI spacer); large doses (>800 mcg/d) have adverse systemic effects, including growth retardation and HPA inhibition; do not mix nebulizer solution with other nebulized medications; administer nebulized solution using tight-fitting mask or mouthpiece; not for treatment of acute attack

FOLLOW-UP

Section 8 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Acknowledgments
• Multimedia
• References

Further Outpatient Care

• If anti-inflammatory therapy has been started, continue therapy until the child is asymptomatic for at least 1 week. Bronchodilators can be used as needed.
• Resolution of symptoms, normal findings on physical examination, and normal pulmonary function findings indicate the end of acute treatment.
• Patients in whom asthma is diagnosed may be candidates for "controller" therapy, which consists of daily inhaled corticosteroid therapy, antihistamines, or leukotriene inhibitors.
• Patients with defined hypogammaglobulinemia may need periodic immunoglobulin replacement treatments. These are best coordinated with the assistance of pediatric allergy/immunology or pulmonary specialists.

Complications

• Complications are extremely rare and should prompt evaluation for anomalies of the respiratory tract, including immune deficiencies. Complications may occur as follows:
• • Bronchiectasis
  • Bronchopneumonia
  • Acute respiratory failure

Prognosis

• Acute bronchitis usually heals completely, with excellent prognosis. Patients with chronic bronchitis and established diagnoses of asthma, structural airway disease, or immunodeficiency need careful periodic monitoring to minimize further lung damage and progression to chronic irreversible lung disease.

Patient Education

• Prevention
• • Instruct patients regarding the need for immunization against pertussis, diphtheria, and influenza, which reduces the risk of bronchitis due to the causative organisms.
  • Instruct patients to avoid passive environmental tobacco smoke.
  • Instruct patients to avoid air pollutants, such as wood smoke, solvents, and cleaners.
  • Instruct patient to obtain medical attention for prolonged respiratory infections.
• Attendance at school or daycare facilities
• • Instruct parents that children may attend school or daycare without restrictions except during episodes of acute bronchitis with fever.
  • Instruct parents that children may return to school or daycare when signs of infection have decreased, appetite returns, and alertness, strength, and a feeling of well being allow.
• For excellent patient education resources, see eMedicine's Asthma Center and Procedures Center. Also, visit eMedicine's patient education articles Asthma and Bronchoscopy.

ACKNOWLEDGMENTS

Section 9 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Acknowledgments
• Multimedia
• References

The authors and editors of eMedicine gratefully acknowledge the contributions of previous author Christine D Dittmer, MD to the development and writing of this article.

MULTIMEDIA

Section 10 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Acknowledgments
• Multimedia
• References

Media file 1:  Normal airway color and architecture (in a child with mild tracheomalacia).
	View Full Size Image
Media type:  Photo

Media file 2:  Airway of a child with chronic bronchitis shows erythema, loss of normal architecture, and swelling.
	View Full Size Image
Media type:  Photo

REFERENCES

Section 11 of 11

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Acknowledgments
• Multimedia
• References

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Article Last Updated: Oct 30, 2006