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Bronchitis - Chronic in Acute Exacerbation

Overview
Contents

Overview
Diagnosis
Evaluation
Goals of Therapy
Non-Pharmacological Therapy
Pharmacological Therapy
Patient Education
Guideline References

OVERVIEW

Acute Exacerbation of Chronic Bronchitis (AECB)

Chronic bronchitis is a clinical diagnosis of sputum expectoration on most days during at

least 3 consecutive mth for >2 consecutive yr

Symptoms of exacerbation include the following:

Exacerbation is usually considered if at least 2 major criteria are present or depending on the
definition used, the presence of at least 1 major & 1 minor symptom for at least 2 consecutive
day

Refer to Symptoms for more information on Acute Exacerbation of Chronic Bronchitis

Top

Diagnosis

Tests used to diagnose patients w/ bronchitis who are experiencing exacerbation include chest
radiography, pulmonary function tests, arterial blood gas level, & sputum exam
Refer to Diagnosis and Evaluation for more information

Diagnosis

Diagnosis is typically based on clinical presentation

Clinical Presentation
History

History of chronic bronchitis w/ acute onset of symptoms which include the

following:
o Major criteria: increase in sputum volume, increase in sputum purulence &
increased dyspnea
o Minor criteria: wheezing, sore throat, cough & symptoms of a common cold
eg nasal congestion/discharge, fever, 20% increase in resp rate or HR above
baseline
Exacerbation is usually considered if at least 2 major criteria are present or depending
on the definition used, the presence of at least 1 major & 1 minor symptom for at least
2 consecutive days

Physical Exam

There are no characteristic physical findings in AECB but the following physical
findings may be found:
o Increased resp rate
o Increased wheezing
o Diffuse crackles w/o localization, may be present
Consider the possibility of pneumonia if there is evidence of consolidation (eg
localized crackles, bronchial breath sounds, dullness on percussion)
Elevated body temp usually suggests viral infection or underlying pneumonia as a
cause of an AECB

Risk Factors for Exacerbations

Tracheobronchial infections (eg influenza, streptococcal infection)

Environmental exposures (eg air pollution)
Noncompliance w/ O2 therapy or pulmonary rehabilitation program

Further Investigations
Chest X-Ray

Chest x-ray is not helpful in making the diagnosis of AECB

o May consider if needed to exclude other diseases that may complicate the
condition eg pneumonia or chronic heart failure (CHF)

Gram Stain/Culture
 Sputum Gram stain & culture should be limited to patients w/ end-stage COPD,
frequent exacerbations or bronchiectasis in whom the presence of more virulent &/or
resistant bacteria is more likely
o Gram stain/culture has a limited role in the investigation of AECB since 30-
50% of chronic bronchitis sufferers are colonized w/ non-encapsulated
Haemophilus influenzae, Streptococcus pneumoniae & Moraxella catarrhalis

Pulmonary Function

Pre-morbid forced expiratory volume in 1 sec (FEV1) values are a predictor of

adverse outcomes during an AECB but it is not necessary to perform FEV1 during the
actual exacerbation
o There is no clear correlation between transient falls in lung function & the
severity of exacerbation
o Objective measurements of pulmonary function should be done after the
recovery of patients w/ AECB

Arterial Blood Gas

Measurement of O2 saturation (+/- blood gases) is recommended in moderate to

severe cases to guide therapy

Evalution

Severe Exacerbation

Severe exacerbation is considered when all 3 major criteria are present::

o Increase in sputum volume, increase in sputum purulence & increased dyspnea
Patients w/ severe exacerbations are more likely to benefit from antibiotic treatment

Moderate Exacerbation

Moderate exacerbation is considered when 2 of the 3 major criteria are present

These patients may benefit from antibiotic treatment

Mild Exacerbation

Mild exacerbation is considered when 1 of the major criteria is present along w/ at

least 1 minor criteria
Studies have shown that antibiotics are generally no more effective than placebo in
these patients

Top

Treatment
Management of chronic bronchitis includes treatment of acute exacerbation & therapies to
achieve long-term control of symptoms

Lifestyle changes such as cessation of tobacco use, avoidance of triggering factors, &
regular exercise may help reduce the risk for exacerbations
Treatment options used for management of acute exacerbations include
bronchodilators, corticosteroid hormones, & antibiotics

Refer to Patient Education for information on Non-pharmacological Therapy

Refer to Treatment for more information on Pharmacological Therapy

Below is the overview of the disease management of ACUTE EXACERBATION OF

CHRONIC BRONCHITIS:
Top
Treatment
Goals of Therapy

Rapid resolution of symptoms

Prevent transient loss of pulmonary function
Reduce the bacterial burden in the lower resp tract
Prevent relapse or lengthen the time between exacerbations
Re-evaluation of the disease to reduce the risk of future exacerbations

Top

Non-Pharmacological Therapy

Lifestyle Modification
Smoking Cessation

A discussion of smoking behavior & the setting of a specific cessation date should be
part of every physician-patient encounter
Patients presenting w/ AECB should be encouraged to stop smoking since it is the
most effective way to reduce the risk of future morbidity from chronic bronchitis
It can lead to dramatic symptomatic benefits for patients w/ chronic bronchitis eg
stopping cough in 94-100%; when coughing stops, it can occur in as quickly as 4 wk
in 54% of patients

Reduction/Elimination of Irritants

Reduction or elimination of any source of irritants that may worsen lower airway
inflammation
o Includes environmental pollutants (eg dust, pollutants & second-hand smoke)
& occupational irritants

Patient Education

Educate patient about the nature of the chronic bronchitis (the progressive nature & its
potential impact on future lifestyle & function)
Review w/ the patient the signs of onset of infection (eg increased purulence,
viscosity or volume of secretions) that should be treated early
Discuss measures that may limit the spread of viral infections (eg hand washing)
Encourage patients to exercise regularly
o Although not accompanied by measurable improvement in lung function, it
will increase exercise tolerance & improve the patients sense of well-being

Supportive Therapy
Hydration

Maintain adequate hydration to prevent excessive mucus viscosity

Nutritional Programs

There are no direct or measurable effects on lung function in treating malnutrition but
subjective relief & objective improvement in strength & exercise performance do
occur
o Dietary supplementation should be considered if patient is malnourished (body
wt <85% of ideal) or experiencing early satiety
Advise patient to obtain nutritional counseling to reduce wt if obese

Oxygen Therapy

Cornerstone of COPD exacerbation treatment

Low-flow O2 should be administered if hypoxemia is present
Excess use of O2 should be avoided as this may lead to progressive hypercapnia,
either by decreasing hypoxic ventilatory drive or by worsening ventilation-perfusion
mismatching w/in the lung
Once O2 therapy is initiated, arterial blood gas should be monitored 30-60 min later to
ensure satisfactory oxygenation without acidosis or CO2 retention
Goal of supplemental O2 therapy should be arterial blood gas at or just above 60
mmHg

Noninvasive Positive Pressure Ventilation

Frequently used for inpatient management of AECB patients who are significantly
hypoxemic or w/ a serum pH <7.3
Improves ventilation & lower pCO2 levels & may be a means of avoiding intubation

Top

Pharmacological Therapy

1. Bronchodilators

Bronchodilators should be used for the treatment of dyspnea accompanying an

exacerbation

1.1. Short-Acting Anticholinergics (Inhaled)

Eg Ipratropium bromide
Effects: An effective bronchodilator w/ a slower onset of action & a slightly longer
duration of action compared to short-acting beta2-agonists, but no appreciable
difference between the two in terms of effects on pulmonary function
o Decreased cough frequency & sputum volume have been noted in patients
using Ipratropium
o Side effects may be fewer compared to Salbutamol
Available in metered-dose inhalers (MDIs) & nebulizer soln
 o There is no significant difference in pulmonary function outcomes between
delivery system, but in most situations, MDIs w/ an appropriate spacer would
be preferred

1.2. Short-Acting Beta2-Agonists (Inhaled)

Short-acting inhaled beta2-agonists are usually the preferred bronchodilators

o Addition of anticholinergics is recommended should there be no prompt
response w/ inhaled beta2 agonists
Produce effective bronchodilatation w/ a faster onset of action than anticholinergics,
but no appreciable difference between the two in terms of effects on pulmonary
function
Available in MDI & nebulizer soln
The role of long-acting beta2-agonists has not been studied in AECB therefore are not
recommended for treatment of the condition at the present time

1.3. Methylxanthines

The use of methylxanthines in AECB does not appear to be indicated

o The addition of Aminophylline to inhaled bronchodilators does not appear to
improve FEV1
Patients already on methylxanthines should continue the medications but monitor for
drug interactions w/ antibiotics

2. Corticosteroid Hormones

The use of oral or parenteral steroids is supported for most patients w/ moderate to
severe AECB
Action: Reduce airway edema & mucus hypersecretion
Effects: Rapid improvement in pre- & post-bronchodilator FEV1, rapid recovery of
partial pressure of O2, decreased treatment failures, shorter hospitalization rates, speed
up recovery in AECB & may reduce the frequency of exacerbations & likelihood of
relapse

2.1. Inhaled Corticosteroid Hormones

Recommended when airflow obstruction is severe or very severe (ie FEV1 <50%) &
when there is a history of frequent exacerbations
May be given in stable patients w/ chronic bronchitis together w/ a long-acting beta2-
agonist to control chronic cough

2.2. Systemic Corticosteroid Hormones

Beneficial in cases of significant pulmonary compromise, particularly if the patient

requires hospitalization
Treatment is recommended for 5-14 days
The exact dose & duration of therapy should be individualized
o Eg the use of high-dose & prolonged steroids must be carefully weighed in the
elderly patients
 o Prednisone PO is usually used initially at a dosage of 0.5-1.0 mg/kg/day &
then tapered at a rate & duration based on response
Methylprednisolone 40-125 mg IV 8-12 hrly or Hydrocortisone 100 mg IV 6-8 hrly
may be used initially in severely ill patients or in patients who are unable to take oral
medications
In studies, the major side effect in the steroid-treated group was hyperglycemia

3. Empiric Antibiotic Therapy

Based on the current available evidence, antibiotic therapy should be given in patients w/
exacerbations of COPD if:

With presence of the 3 cardinal symptoms (increased dyspnea, increased sputum

purulence & increased sputum volume)
Two of the cardinal symptoms are present w/ increased sputum purulence as one of
the 2 symptoms
The exacerbation is severe requiring mechanical ventilation (invasive or noninvasive)

Therapy should be based on local resistance patterns along w/ patient risk stratification to
prevent therapeutic failure

Some studies have shown that severity of bronchitis is an important determinant of

the type of pathogen
o S pneumoniae predominates in patients w/ mild exacerbation
o H influenzae & M catarrhalis are the frequent pathogens as FEV1 declines &
patients have more frequent exacerbations &/or comorbid diseases
o P aeruginosa may be present in those w/ severe airway restriction
Antibiotics used should have significant in vitro & in vivo activity against the
pathogens most commonly associated w/ AECB, including H influenzae, S
pneumoniae & M catarrhalis
In patients w/ more severe airway obstruction, coverage may need to be extended to
include other potential pathogens eg Gram-negative bacilli
Aminopenicillins, Co-trimoxazole & Doxycycline are considered 1st-line antibiotics
for AECB
Amoxicillin/clavulanic acid, macrolides, 2nd- or 3rd-generation cephalosporins &
quinolones are good alternatives in areas w/ increasing antibiotic resistance to older
agents

3.1. Aminopenicillins

Recommendation for treatment of simple AECB w/ aminopenicillins is justified since

there are no clinical or pharmacoeconomic studies showing the advantage of more
potent agents
Studies showing the effectiveness of these agents are >10 yr old & were performed
prior to the current concerns regarding antibiotic resistance
No activity against atypical & beta-lactamase-producing pathogens, limited activity
against Enterobacteriaceae
High dose is effective against Penicillin-resistant S pneumoniae

Adverse Reactions:
 o Hypersensitivity reactions (rash, urticaria, pruritus, severe reactions eg
anaphylaxis can occur); GI effects (diarrhea, N/V, rarely antibiotic-associated
diarrhea/colitis); Other (candidal infections)
o Rarely hematologic effects; renal & hepatic effects have occurred; high doses
may be associated w/ CNS effects (encephalopathy, convulsions)

Special Instructions:
o Avoid in patients w/ Penicillin allergy
o Use w/ caution in patients w/ renal impairment

Dosage Guidelines:1

A. Amoxicillin (Amoxycillin)

500 mg PO 8 hrly

B. Ampicillin

500 mg PO 6 hrly

C. Piperacillin

2-4 g IM/IV 6-8 hrly

Max dose: 24 g/day

D. Ticarcillin

200-300 mg/kg/day IV divided 4-6 hrly

3.2. Aminopenicillin/Beta-lactamase Inhibitors

Covers major bacterial pathogens including beta-lactamase-producing pathogens,

moderate activity against Enterobacteriaceae, but no activity against atypical
pathogens
High dose of Aminopenicillin component is effective against Penicillin-resistant S
pneumoniae
Short-term effectiveness of Amoxicillin/clavulanic acid is equivalent to that of
macrolides & quinolones

Adverse Reactions:
o Hypersensitivity reactions (rash, urticaria, pruritus, severe reactions eg
anaphylaxis can occur); GI effects (diarrhea, N/V, rarely antibiotic-associated
diarrhea/colitis); Other (candidal infections)
o Rarely hematologic effects; renal & hepatic effects have occurred; high doses
may be associated w/ CNS effects (encephalopathy, convulsions)

Special Instructions:
o Avoid in patients w/ Penicillin allergy
o Use w/ caution in patients w/ renal impairment
 Dosage Guidelines:1

3.2.1. Aminopenicillins w/ or w/o Beta-Lactamase Inhibitors

A. Amoxicillin/clavulanic acid (Co-amoxiclav, Amoxicillin/clavulanate)

625 mg PO 8-12 hrly or

750 mg PO 8 hrly or
1 g PO 12 hrly

B. Ampicillin/sulbactam (Sultamicillin: Pro-drug of Ampicillin/sulbactam, the 2 drugs

are linked chemically w/ a double ester)

375-750 mg PO 12 hrly

3.2.2. Antipseudomonal Penicillins w/ or w/o Beta-Lactamase Inhibitors

A. Piperacillin/tazobactam

2.25-4.5 g IM/IV 6-8 hrly

B. Ticarcillin/clavulanic acid (Ticarcillin/clavulanate)

1.6-3.2 g IV 6-8 hrly

3.3. Cephalosporins (2nd & 3rd Generation)

If resistant S pneumonia & H influenzae is a concern, selected 2nd & 3rd generation
cephalosporins may be preferred over older agents
Offer enhanced stability against beta-lactamases of H influenzae, H parainfluenzae &
M catarrhalis & improved efficacy against Penicillin-susceptible S pneumoniae &
Methicillin-susceptible S aureus

Adverse Reactions:
o Hypersensitivity reactions (urticaria, pruritus, rash, severe reactions eg
anaphylaxis can occur); GI effects (diarrhea, N/V, rarely antibiotic-associated
diarrhea/colitis); Other (candidal infections)
o High doses may be associated w/ CNS effects (encephalopathy, convulsions);
rarely hematologic effects; hepatic & renal effects have occurred
o Prolonged prothrombin time (PT), prolonged activated partial thromboplastin
time (aPTT), &/or hypoprothrombinemia (w/ or w/o bleeding) have been
reported & occur most frequently w/ N-methylthiotetrazole (NMTT) side
chain-containing cephalosporins

Special Instructions:
o May be taken w/ food to decrease gastric distress
o Use w/ caution in patients allergic to Penicillin, there may be 10% chance of
cross sensitivity
o Use w/ caution in patients w/ renal impairment

Dosage Guidelines:1
3.3.1. Cephalosporins (2nd Generation)
A. Cefaclor

250-500 mg PO 8 hrly or
375-500 mg PO 12 hrly
Max dose: 4 g/day

B. Cefprozil

500 mg PO 12 hrly

C. Cefuroxime

250-500 mg PO 12 hrly

3.3.2. Cephalosporins (3rd Generation)

A. Cefdinir

100 mg PO 8 hrly
up to 300 mg PO 12 hrly

B. Cefditoren

100 mg PO 8 hrly or
200 mg PO 12 hrly

C. Cefetamet

500 mg PO 12 hrly

D. Cefixime

100-200 mg PO 12 hrly

E. Cefpodoxime

100-200 mg PO 12 hrly

F. Ceftibuten

400 mg/day PO 24 hrly or divided 12 hrly

3.4. Co-trimoxazole [Sulfamethoxazole (SMZ) & Trimethoprim (TM)]

Recommendation for treatment of simple AECB w/ Co-trimoxazole is justified since

there are no clinical or pharmacoeconomic studies showing the advantage of more
potent agents
o Studies showing the effectiveness of this agent are >10 yr old & were
performed prior to the current concerns regarding antibiotic resistance
 Covers major bacterial pathogens, no activity against atypical pathogens & resistance
in S pneumoniae is common; resistance limits its usefulness
May be an acceptable alternative for patients who are allergic to Penicillin

Adverse Reactions:
o GI effects (N/V, anorexia, diarrhea, rarely antibiotic- associated
diarrhea/colitis, glossitis); Dermatologic effects (rash, pruritus,
photosensitivity); Hypersensitivity reactions can range from mild (eg rash) to
severe/life-threatening (eg Stevens-Johnson syndrome); Urogenital
(crystallization in the urine)
o Rarely hematologic effects which may be more common if given for long
periods or w/ high doses; rarely hepatic effects, renal effects; aseptic
meningitis has occurred

Special Instructions:
o Maintain adequate fluid intake
o Contraindicated in patients allergic to sulfonamides
o Use w/ extreme caution or not at all in patients w/ hematological disorders esp
megaloblastic anemia due to folic acid deficiency
o Use w/ caution in patients w/ renal impairment or severe hepatic dysfunction
& w/ caution in patients w/ folate deficiency (may consider administration of
Folinic acid)

Dosage Guidelines:1

A. Co-trimoxazole [Sulfamethoxazole (SMZ) & Trimethoprim (TM)]

800 mg SMZ & 160 mg TM PO 12 hrly

3.5. Doxycycline

Recommendation for treatment of simple AECB w/ Doxycycline is justified since

there are no clinical or pharmacoeconomic studies showing the advantage of more
potent agents
o Studies showing the effectiveness of this agent are >10 yr old & were
performed prior to the current concerns regarding antibiotic resistance
Covers major bacterial & atypical pathogens, but S pneumoniae resistance is common
Alternative to quinolones & macrolides when atypical coverage is required
Acceptable as an alternative for patients who are allergic to Penicillin, cephalosporins
& newer macrolides

3.6. Advanced Macrolides & Ketolide

If resistant S pneumoniae & H influenzae are a concern, advanced macrolides may be

preferred over older agents
Active against atypical pathogens, not active against Enterobacteriaceae, &
macrolide-resistant S pneumoniae is common but this does not appear to reduce
clinical effectiveness
o Ketolide is effective against macrolide-resistant strains of S pneumoniae
Reasonable option in beta-lactam allergic patients
 Adverse Reactions:
o GI effects (N/V, abdominal discomfort, diarrhea & other GI disturbances,
antibiotic-associated diarrhea/colitis); Other (candidal infections)
o Hypersensitivity reactions are uncommon (urticaria, pruritus, rash, rarely
anaphylaxis); rarely cardiotoxicity, hepatotoxicity; dose-related
tinnitus/hearing loss has occurred w/ some macrolides
o Azithromycin & Clarithromycin tend to cause less GI disturbances than
Erythromycin

Special Instructions:
o May take w/ food to decrease gastric distress
o Use w/ caution in patients w/ hepatic dysfunction

Dosage Guidelines:1

A. Erythromycin

1,000-2,000 mg/day PO divided 6-8 hrly

B. Roxithromycin

150 mg PO 12 hrly or
300 mg PO 24 hrly

Advanced Macrolides
A. Azithromycin

500 mg PO 24 hrly x 3 days

500 mg PO 24 hrly x 1 day followed by 250 mg PO 24 hrly x 4 days

B. Clarithromycin

250-500 mg PO 12 hrly
Extended-release: 500-1000 mg PO 24 hrly

Ketolide

Adverse Reactions:
o GI effects (N/V, diarrhea, flatulence, abdominal pain, taste disturbances); CNS
effects (dizziness, headache, insomnia, drowsiness); Hypersensitivity reactions
o Visual disturbances have occurred; rarely hepatic effects; rarely hematologic
effects; CV effects including QT prolongation; & isolated cases of erythema
multiforme & pseudomembranous colitis

Special Instructions:
o Avoid in patients w/ hypersensitivity to macrolide antibiotics, in patients w/
family history or congenital QT prolongation & in patients w/ myasthenia
gravis
 o Use w/ caution in patients w/ coronary heart disease (CHD), arrhythmias & in
patients w/ hypokalemia or hypomagnesemia, renal impairment, patients w/
history of hepatitis/jaundice

Dosage Guidelines:1

A. Telithromycin

800 mg PO 24 hrly x 5 days

3.7. Quinolones

Has good tracheobronchial penetration

Cover all major bacterial & atypical pathogens as well as Enterobacteriaceae & some
agents cover P aeruginosa
Quinolones w/ enhanced activity to drug-resistant S pneumoniae are preferred
o Eg Levofloxacin, Moxifloxacin
Ciprofloxacin
o Considered 1st-line agents in ambulatory AECB patients only if P aeruginosa
coverage is required
o Least active against S pneumoniae & should not be used routinely in the
management of AECB; most active against P aeruginosa

Adverse Reactions:
o GI effects (N/V, diarrhea, abdominal pain, dyspepsia, diarrhea, rarely
antibiotic-associated diarrhea/colitis); CNS effects (headache, dizziness, sleep
disorders, restlessness, drowsiness); Dermatologic effects (rash, pruritus,
photosensitivity); hypersensitivity reactions can range from mild (eg rash) to
severe/life-threatening (eg Stevens- Johnson syndrome)
o Rarely hematologic effects; hepatic & renal effects
o Some quinolones have the potential to prolong the QT interval

Special Instructions:
o Administer at least 2 hr before or 3 hr after Al- or Mg-containing antacids,
dietary supplements containing Zn or Fe or buffered ddI preparations
o Avoid exposure to strong sunlight or tanning beds
o Use w/ caution in patients w/ epilepsy or history of CNS disorders, in patients
w/ impaired renal or hepatic function & in those w/ G6PD deficiency

Dosage Guidelines:1

A. Ciprofloxacin

500-750 mg PO 12 hrly

B. Levofloxacin

500 mg PO/IV 24 hrly x 7 days

C. Lomefloxacin
 400 mg PO 24 hrly

D. Moxifloxacin

400 mg PO/IV 24 hrly x 5 days

E. Ofloxacin

400 mg PO 12 hrly

F. Sitafloxacin hydrate

50 mg PO 12 hrly x 3-7 days

Max dose: 100 mg PO 12 hrly

G. Sparfloxacin

400 mg PO 24 hrly x 1 day followed by 200 mg PO 24 hrly x 5-10 days

3.8. Tetracyclines

Adverse Reactions:
o GI effects (N/V, diarrhea, antibiotic-associated diarrhea/colitis has occurred,
dysphagia, esophageal ulceration has occurred when taken w/ an insufficient
amount of liq); Dermatologic effects (photosensitivity); Other (candidal
infections, discoloration of teeth, interference w/ bone growth in young
infants/pregnant women)
o Rarely renal dysfunction, hepatotoxicity, hematologic effects, intracranial
pressure w/ headache & visual disturbances; hypersensitivity reactions have
occurred
Special Instructions:
o Avoid long exposure to sunlight or tanning beds
Take w/ plenty of fluid while sitting or standing & well before retiring
to bed
o Avoid in children 8 yr & pregnant women; avoid in patients w/ systemic
lupus erythematosus (SLE)
o Use w/ caution in renal or hepatic impairment

Dosage Guidelines:1

A. Doxycycline

200 mg/day PO 24 hrly or divided 12 hrly

B. Minocycline

100 mg PO 12 hrly

C. Tetracycline
 250-500 mg PO 6 hrly

4. Other Pharmacotherapy Agents

Expectorants/cough suppressants have not been shown to improve lung function or

hasten the clinical recovery but may produce a subjective improvement
Chronic use of mucolytics helps reduce the frequency of exacerbations & days of
illness but does not improve ventilatory function
Chest physiotherapy has not been shown to improve lung function or hasten clinical
recovery in AECB
There is still no evidence supporting the use of leukotriene receptor antagonists in
AECB

4.1. Cough & Cold Preparations A. Acetylcysteine (N-acetylcysteine)

Adverse Reactions:
o GI disturbances, N/V; Hypersensitivity reactions (bronchospasm, rashes);
Other effect (hypotension)
Special Instructions:
o Use w/ caution in patients w/ gastric or duodenal ulcer
Dosage Guidelines:
o 200 mg PO 8 hrly

B. Ambroxol

Adverse Reactions:
o GI disturbances, N/V; Hypersensitivity reactions (bronchospasm, rashes);
Other effect (hypotension)
Special Instructions:
o Use w/ caution in patients w/ gastric or duodenal ulcer
Dosage Guidelines:
o 60-120 mg PO divided 8-12 hrly
o Extended-release: 75 mg PO 24 hrly

C. Bromhexine

Adverse Reactions:
o GI disturbances, N/V; Hypersensitivity reactions (bronchospasm, rashes);
Other effect (hypotension)
Special Instructions:
o Use w/ caution in patients w/ gastric or duodenal ulcer
Dosage Guidelines:
o 8-16 mg PO 6-8 hrly

D. Carbocisteine (Carbocysteine)

Adverse Reactions:
o GI disturbances, N/V; Hypersensitivity reactions (bronchospasm, rashes);
Other effect (hypotension)
Special Instructions:
 o Use w/ caution in patients w/ gastric or duodenal ulcer
Dosage Guidelines:
o Initial dose: 750 mg PO 6-8 hrly, then 1.5 g/day PO in divided doses

E. Cyclidrol (Sobrerol)

Adverse Reactions:
o GI effect (stomach pain); Hypersensitivity reaction (rashes)
Special Instruction:
o Use w/ caution in patients w/ renal failure
Dosage Guidelines:
o 200 mg PO 12 hrly or up to 800 mg daily in divided doses

F. Erdosteine

Adverse Reactions:
o GI disturbances (GI discomfort, rarely taste alterations); Other effects (rarely
headache, dyspnea, urticaria, erythema, dermatitis)
Special Instruction:
o Contraindicated in patients w/ hepatic cirrhosis, hepatic impairment,
cystathionine-synthetase enzyme deficiency & severe renal failure
Dosage Guidelines:
o 300 mg PO 8-12 hrly

G. Guaifenesin

Adverse Reactions:
o GI disturbances (GI discomfort, N/V)
Special Instruction:
o Use w/ caution in patients w/ persistent or chronic cough, asthma, chronic
bronchitis or emphysema
o Discontinue use if cough persists for >7 days w/ fever, rash or persistent
headache
Dosage Guidelines:
o 600 mg PO 12 hrly or 200 mg 4 hrly
o Max dose: 1200 mg in 24 hr

H. Levodropropizine

Adverse Reactions:
o CNS effect (somnolence, faintness, clouding of consciousness, dizziness,
headache); Other effects (palpitation, GI disturbance)
Special Instructions:
o Use w/ caution in patients w/ excessive mucus dischange, limited mucociliary
function, hepatic dysfunction, renal insufficiency, & diabetes
Dosage Guidelines:
o 60 mg PO 8 hrly

1
Unless otherwise indicated, length of therapy should be for 7-10 days
 Top

Prevention - Immunizations

Influenza Vaccine

The use of an annual influenza vaccine for all patients w/ chronic bronchitis is
strongly recommended
o Patients w/ chronic lung disease have a higher risk of complications from
influenza infection
See Influenza Disease Management Chart for complete details

Pneumococcal Vaccine

It is recommended that pneumococcal vaccine be administered at least once to

patients w/ chronic bronchitis
o Consider repeating vaccine every 5-10 yr in high-risk patients
Pneumococcal vaccine is safe & may reduce invasive pneumococcal infection in
patients w/ COPD

All dosage recommendations are for non-pregnant & non-breastfeeding women, non-elderly
adults w/ normal renal & hepatic function unless otherwise stated.

Not all products are available or approved for above use in all countries.

Products listed above may not be mentioned in the disease management chart but have
been placed here based on indications listed in regional manufacturers product information.

Specific prescribing information may be found in the latest MIMS & MIMS.com

Brands available in: Hong

Kong Indonesia Malaysia Philippines Singapore Thailand Vietnam

Bronchitis-Chronic Symptoms

Version: 3 Sep 2014

Guideline References:

1. Alberta Medical Association. Guideline for the management of acute exacerbation of

chronic bronchitis. http://www.albertadoctors.com/resources/cpg/guidelines/aecb.pdf.
Nov 2001
2. Balter MS, La Forge J, Low DE, et al. Canadian guidelines for the management of
acute exacerbations of chronic bronchitis. Can Respir J. 2003 Aug;10(Suppl B):3B-
32B. PMID: 12944998
3. Dever LL, Shashikumar K, Johanson WG Jr. Antibiotics in the treatment of acute
exacerbations of chronic bronchitis. Expert Opin Investig Drugs. 2002 Jul;11(7):911-
925. PMID: 12084002
4. Global Initiative for Chronic Obstructive Lung Disease. Global strategy for the
diagnosis, management, and prevention of chronic obstructive pulmonary disease.
http://www.goldcopd.org/uploads/users/files/GOLDReport_April112011.pdf. 2010.
Accessed 09 Sep 2011
5. Grossman RF. Guidelines for the treatment of acute exacerbations of chronic
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