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Pharmacologc and nonpharmacologic therapeutic choices for acute bronchitis.
Citation preview
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5Acute BronchitisAnas Bahnassi PhD
Pharmacotherapy of Infectious DiseasesA Case-Based Approach
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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.
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Introduction
• Acute Bronchitis:Should be differentiated from the common cold, acute exacerbation of chronic bronchitis, asthma, andcommunity acquired pneumonia. It is self-limiting and symptoms usually resolve within 10-14 days
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A non-bacterial cause is present in more than 90% of acute bronchitisEtiologic 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.
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
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Goals of Therapy
• First “Do No Harm”• Rule out serious illness: pneumonia.• Minimize symptoms
• Limit the unnecessary use of antibiotics
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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.
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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.
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Management of Acute Bronchitis
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
Yes
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Therapeutic ChoicesNonpharmacolgic
• 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.
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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 overdosePreferred in children
$
Ibuprofen 300-400 mg TID-QID (Max 2.4g/d)
GI side effects, heartburn
ASA/Anticoagulants 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 ChoicesPharmacolgic
• Analgesics: APAP, Ibuprofen can be used for symptomatic relief
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Antitussive Dose ADR DI Comments Cost
Codeine Adutls + Children>12yr10-20mg q4-6hMax 120mg/d
SedationVomitingConstipa-tion
Additive sedation (CNS depressants)
Use with caution in elderly or debilitated patients
$
Dextromethorphan
30mg q6-8h PRN
Rare, nausea, drowsiness, dizziness.
Caution with CNS depressantsStop MAOI for 2wks prior start.
Not recommended for patients with asthma.
$
Therapeutic ChoicesPharmacolgic
• Antitussives: May provide short symptomatic relief but doesn’t shorten the duration of illness
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B-aginists Dose ADR DI Comments Cost
SalbutamolMDI(100ug/p)Diskus (200ug/p)
Diskus: 1 P TID-QIDMDI: 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
$$$$$
TerbutalineTurbohaler
1-2 p TID-QID max of 6 p/d
Same Same Same $$$
Therapeutic ChoicesPharmacolgic• Bronchodilators: Use is not supported in the absence of airflow
obstruction.• Adults with cough and wheezing may benefit from the treatment.
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Therapeutic ChoicesPharmacolgic
• 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.
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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.
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Pharmacotherapy:Infectious Diseases:
Anas Bahnassi PhD
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