QUEST Integration - Asthma - Comprehensive Management

Clinical practice guidelines serve as an educational reference, and do not supersede the clinical judgment of the treating physician with respect to appropriate and necessary care for an individual patient. In the event HMSA policies differ from the clinical practice guidelines, for benefit purposes, HMSA policies shall supersede the clinical practice guidelines.

Guideline summary

• This guideline applies to immunocompetent adults
• Focus on ruling out serious illness
• Avoid prescribing antibiotics for uncomplicated acute bronchitis
• Keep high index of suspicion for pneumonia in elderly and those with chronic lung disease

Introduction

 Acute bronchitis consistently ranks among the 10 conditions that account for most ambulatory office visits. In the United States, approximately 5 percent of adults self-report an episode of acute bronchitis annually, and up to 90 percent of these patients seek medical care. Most uncomplicated cases occur in otherwise healthy adults.

Goals/desired outcomes

• Focus on ruling out serious illness, particularly pneumonia, when evaluating adults with an acute cough illness or a presumptive diagnosis of uncomplicated acute bronchitis.
• Avoid prescribing antibiotics for uncomplicated acute bronchitis, regardless of duration of cough. If Bordetella pertussis infection is suspected (an unusual circumstance), a diagnostic test should be performed and antimicrobial therapy initiated. This recommendation applies to immunocompetent adults without complicating comorbid conditions, such as chronic lung or heart disease.
• Remember that effective communication between the physician and the patient contributes to patient satisfaction more than antibiotic treatment.

Diagnosis

Diagnosis of acute bronchitis usually is appropriate when the patient presents with an acute respiratory tract infection in which cough, with or without phlegm, is a predominant feature. Using cough, sore throat, rhinorrhea, and other symptoms suggestive of acute upper respiratory tract infection may result in inconsistent diagnoses.

• In the absence of severe airflow obstruction, limit evaluation for possible chronic asthma or cough-variant asthma to patients with cough illness lasting longer than three weeks. The diagnosis of cough-variant asthma generally is reserved for patients with persistent cough (>2-3 weeks duration) that worsens at night or after exposure to cold; lack of wheezing; and in most cases, normal results in pulmonary function.
• A review of evidence-based studies concluded that absence of abnormalities in vital signs (heart rate >100 beats/min, respiratory rate >24 breaths/min, or oral temperature >38°C) and chest auscultatory examination (e.g., rales, egophony or fremitus) sufficiently reduces likelihood of pneumonia, making further diagnostic testing unnecessary. Purulent sputum occurs when inflammatory cells or sloughed mucosal epithelial cells are present and can result from either viral or bacterial infection.
• High index of suspicion for pneumonia remains warranted in the elderly and patients with chronic lung disease.

Summary: Guidelines for the Management and Diagnosis of Asthma [PDF]

Full Report: Guidelines for the Management and Diagnosis of Asthma [PDF]

Treatment summary

• Routine antibiotic treatment of uncomplicated acute bronchitis is not recommended.
• Is it difficult to distinguish bacterial from viral bronchitis on clinical grounds except on suspicion of pertussis.
• Influenza is the most common pathogen.
• Symptomatic treatment and reassurance are the preferred initial management strategy.

Educational strategies summary

• Provide realistic expectations for the duration of the cough (typically 10-14 days).
• Use the term "chest cold" rather than "bronchitis."
• Explain about the current epidemic of antibiotic resistant pathogens.
• Prescribe symptom-based therapies.

Treatment

Treatment Algorithm [PDF]

• Antibiotic treatment of uncomplicated acute bronchitis is not recommended, regardless of duration of cough. Randomized placebo-controlled trials have failed to support a role for antibiotic treatment of uncomplicated acute bronchitis. No consistent effect has been shown on duration or severity of illness, or on potential complications such as the development of pneumonia. Three meta-analyses reported no effect on illness duration, limits of activity or loss of work. All concluded that routine antibiotic treatment of acute bronchitis in adults is not justified.
• Studies to date have been unable to distinguish bacterial bronchitis from viral bronchitis on clinical grounds, except on suspicion of pertussis. However, clinicians should limit suspicion and treatment of adult pertussis to adults with a high probability of exposure to pertussis (e.g., during documented outbreaks). Antimicrobial therapy for suspected pertussis in adults is recommended primarily to decrease shedding of the pathogen and spread of the disease. Public health implications for pertussis include diagnostic testing at local or state health departments.
• Influenza is the most common pathogen isolated in patients with uncomplicated acute bronchitis. Inhaled (zanamivir) and oral (oseltamivir) formulations of neuraminidase inhibitors have demonstrated some efficacy in reducing illness duration in adults with naturally acquired influenza A and B, if treatment begins within 48 hours (preferably <30 hours) of symptom onset. The result is about one day less of illness, and about a half-day sooner return to normal activity. Accurate clinical diagnoses of influenza outside the annual outbreak period is difficult, and as a result, diagnostic testing for influenza during this period may be considered for epidemiological purposes.
• Symptomatic treatment and reassurance are the preferred initial management strategy for patients with uncomplicated acute bronchitis, beginning with identification of symptoms most bothersome to the patient. If cough is the major symptom, the efficacy of bronchodilators for bronchial hyper-responsiveness has been demonstrated. Efficacy of antitussive treatment will depend on the cause of the cough illness. Acute or early cough due to colds or other viral upper respiratory tract infections does not appear to be alleviated by dextromethorphan or codeine. However, these drugs may be efficacious in treating chronic cough (duration >three weeks), cough associated with underlying lung disease, or experimentally induced cough. For uncomplicated acute bronchitis with an average duration of cough of two to three weeks, the two agents will have a modest effect on severity and duration. Other low-cost and low-risk actions, such as using a vaporizer and eliminating environmental triggers, are reasonable options.

Asthma Medications Table 2009 [PDF]

Patient satisfaction and education

• Patient satisfaction regarding care for acute bronchitis depends more on communication between the physician and patient than whether an antibiotic is prescribed. Discuss the lack of efficacy of antibiotics with the patient and stop prescribing antibiotics for this condition as a standard practice. The patient's expectation of receiving antibiotics may derive from previous experiences; however, mounting evidence indicates that patient satisfaction is less dependent on the receipt of antibiotics and more dependent on the quality of the encounter. Following are recommended educational strategies:
• Provide realistic expectations for the duration of the patient's cough, which will typically last 10 to 14 days. Convey a sense of partnership and develop a symptom-based treatment plan with the patient (or caregiver) that describes the expected course of the illness over time with instructions to return if symptoms persist or worsen.
• Refer to the illness as a "chest cold" rather than bronchitis. Studies indicate that the term "chest cold" is less associated with antibiotic therapy.
• Personalize the risk of unnecessary antibiotic use. Antibiotics commonly have harmful side effects (gastrointestinal symptoms, taste alterations) and more rarely, adverse drug reactions. Previous antibiotic use increases the likelihood of carriage and infection with antibiotic-resistant bacteria.
• Explain that the current epidemic of antibiotic resistance among community bacterial pathogens is a major public health concern.
• Prescribe analgesics, decongestants and/or other symptom-based therapies, as appropriate.
• Emphasize the importance of adequate hydration and nutrition.
• Consider providing "care packages" containing nonantibiotic therapies.

Clinical practice guidelines serve as an educational reference, and do not supersede the clinical judgment of the treating physician with respect to appropriate and necessary care for an individual patient. In the event HMSA policies differ from the clinical practice guidelines, for benefit purposes, HMSA policies shall supersede the clinical practice guidelines.

Sources

1. Snow, S.; Mottur-Pilson, C.; Gonzales, R.; Principles of Appropriate Antibiotic Use for Treatment of Acute Bronchitis in Adults. Annals of Internal Medicine. 2001; 134:518-520.

Revision History