Recommendations for a patient with acute bronchitis. Acute bronchitis clinical guidelines for differential diagnosis in outpatient settings. The choice of drugs for the treatment of acute bronchitis

This clinical practical guide created working group Alberta Medical Association.

Definition and general information about acute bronchitis

Acute bronchitis: acute inflammation bronchial tree. Acute bronchitis in adults and children (as well as bronchiolitis in infants) almost always has a viral etiology. Meta-analyses have proven the ineffectiveness of antibiotics in acute bronchitis. Unjustified use of antibiotics in acute bronchitis leads to bacterial resistance.

Sometimes symptoms acute bronchitis falsely mistaken for whooping cough symptoms, resulting in a misdiagnosis.

Prevention of acute bronchitis

Limiting the possibility of contracting viral infections (for example, through personal hygiene). Stop smoking, including passive.

Diagnosis of acute bronchitis

Acute bronchitis is diagnosed based on sudden appearance cough, along with:

Important: yellow/green sputum is an indicator inflammatory process and optionally means bacterial and infection.

Inspection

May be present fever body, but the duration of this state should be no more than 3 days. Auscultation is usually normal, but the presence of breath sounds is mandatory.

Important: evidence of consolidation (localized crackles, bronchial breath sounds, thud on percussion) should alert to possible pneumonia.

Research

Routine tests (eg, sputum flora, lung function test, or serology) are not indicated because do not facilitate diagnosis. X-ray of organs chest only indicated if pneumonia is suspected on the basis of examination and medical history.

Treatment of acute bronchitis

Antibiotics are NOT indicated for the treatment of acute bronchitis.

These recommendations are systematically supplemented statements designed to help the doctor and patient make the right decision in specific situations. clinical setting. They should be used as an adjunct to an objective clinical examination.

Corticosteroids (both sprays and oral) are NOT recommended due to lack of evidence of their effectiveness in acute bronchitis. Expectorants are also generally NOT recommended due to limited efficacy.

Differential diagnosis of acute bronchitis

Observation and practical guidance

Only one prolonged cough viral etiology does not require antibiotic treatment

• 45% of patients suffer from cough after 2 weeks;
• 25% of patients suffer from cough after 3 weeks.

whooping cough causes prolonged cough and vomiting.

• symptoms worsen or new symptoms appear;
• cough is not cured even after 1 month;
• there are relapses (>3 episodes per year)

Acute bronchitis is diagnosed based on the medical history and clinical examination.

Acute bronchitis continues to be treated with antibiotics, although there is little evidence to support their effectiveness against this disease.

In acute bronchitis, doctors continue to prescribe antibiotics, although they have not been shown to be effective in this case. According to some estimates, in 50-79% of cases of confirmed diagnosis of acute bronchitis, the doctor prescribes antibiotics. In a study of 1398 outpatient consultations of children<14 лет с жалобой на кашель, бронхит был диагностирован в 33% случаев и в 88% из них были назначены антибиотики.

Eight double-blind, randomized, placebo-controlled studies have been published on the efficacy of antibiotics for acute bronchitis in patients over 8 years of age. A meta-analysis of 6 studies found that there is no evidence to justify the use of antibiotics in acute bronchitis.

Four studies evaluating erythromycin, doxycycline, or TMP/SMX demonstrated minimal improvement in symptoms and/or loss of time in the antibiotic group.

An additional 4 trials showed no difference in outcomes between patients taking placebo and those taking erythromycin or doxycycline.

Several pediatric studies have evaluated the feasibility of using antibiotics in the treatment of cough. None of these have been proven to be effective. Antibiotics do not prevent secondary infection of the lower respiratory tract. A meta-analysis of trials evaluating the effectiveness of antibiotics in preventing bacterial infections in SARS showed that antibiotics do not prevent or reduce the severity of bacterial infection.

The results of lung function tests for mild asthma and acute bronchitis are similar. Thus, it has been hypothesized that bronchodilators may provide symptomatic relief to patients with bronchitis.

There is evidence that bronchodilators are effective in acute bronchitis, and their use reduces the duration of the cough to a maximum of 7 days, unlike antibiotics. Hueston studied the efficacy of aerosolized salbutamol against acute bronchitis in patients receiving erythromycin or placebo. After 7 days, the examination showed that patients treated with salbutamol coughed less than patients taking placebo. When the analysis was stratified by erythromycin use, the difference between salbutamol and control patients only increased. Cough suppressants are often used in the treatment of acute bronchitis. They provide symptomatic relief but do not shorten the duration of the illness. A recent review of randomized, double-blind, placebo-controlled trials confirmed the symptomatic use of codeine, dextromethorphan, and diphenhydramine in the treatment of bronchitis. One double-blind study of 108 patients compared the efficacy of the oral dextromethorphan-salbutanol combination with dextromethorphan. The authors did not find a statistically significant difference between the 2 groups in terms of the nature of the cough during the day, as well as the amount of sputum and expectoration.

Bronchitis is associated with other respiratory infections such as the common cold, flu, or pneumonia. The condition is associated with inflammation of the airways in the lungs. In accordance with the observation of specialists, bronchitis is more often observed in children and the elderly, due to relatively weak immunity. Good hygiene and some home remedies are considered helpful in treating the disease.

Bronchitis can be of two types, namely, acute bronchitis and chronic bronchitis. In acute bronchitis, severe symptoms are observed, but the illness does not last long. On the other hand, chronic bronchitis is a long-term disease. Symptoms may be moderate or severe and occur repeatedly. Bronchitis often develops after a cold or flu.

Preventive measures to prevent bronchitis are simple and straightforward. They must be strictly observed, therefore, each patient must adhere to all recommendations for bronchitis.

How is smoking related to bronchitis?

Everyone knows that smoking causes bronchitis. The air passages of smokers are constantly exposed to tobacco smoke, as a result they become inflamed and bronchitis develops. Smokers are ten times more likely to get the disease than non-smokers. It is very difficult for smokers to undergo treatment, because the first thing you need to do is quit smoking, and this is not so easy. If smokers suffer from acute bronchitis and continue to smoke, the cilia in the lungs are permanently damaged, resulting in chronic bronchitis. Chronic bronchitis is a stable type of disease that lasts for a long time and is a precursor to lung cancer. Heavy smokers who have been smoking for 10 years are under high risk get bronchitis. Thus, the only way to prevent bronchitis and lung cancer is to stop smoking. After you stop smoking, lung function improves.

It should be remembered that bronchitis is a serious disease. All preventive methods must be followed in order to live a disease-free life. Always remember that prevention is better than cure!

ACUTE BRONCHITIS

Acute bronchitis (AB) is a predominantly infectious inflammatory disease of the bronchi, manifested by a cough (dry or with sputum) and lasting no more than 3 weeks.

ICD-10: J20 Acute bronchitis. Abbreviation: OB - acute bronchitis.

Epidemiology

The epidemiology of acute bronchitis (AB) is directly related to the epidemiology of influenza and other respiratory viral diseases. Usually typical peaks of increase in the frequency of occurrence of diseases are the end of December and the beginning of March. Special studies on the epidemiology of AB in Russia have not been conducted.

Prevention

one . Attention should be paid to compliance with the rules of personal hygiene A : Frequent hand washing minimizing eye-hand, nose-hand contact. Rationale: most viruses are transmitted by this contact route. Evidence: special studies of these preventive measures in day hospitals for children

and adults showed their high efficiency.

2. Annual influenza prophylaxis reduces the incidence

occurrence of OBA.

Indications for annual influenza vaccination: all persons over 50 years of age persons with chronic diseases, regardless of age persons in closed groups children and adolescents receiving long-term aspirin therapy women in the second and third

Vaccination of middle - aged people reduces the number of influenza episodes and the resulting disability .

Vaccination of medical personnel leads to a decrease in mortality among elderly patients.

3 .Drug prevention antiviral drugs during the epidemic period reduces the frequency and severity of influenza C.

Indications for drug prophylaxis

In a proven epidemic period in non-immunized individuals with a high risk of influenza - taking rimantadine (100 mg 2 times a day per os) or amantadine (100 mg 2 times a day per os).

In the elderly and patients with renal insufficiency, the dose of amantadine is reduced to 100 mg per day due to possible neurotoxicity.

Efficiency . Prevention is effective in 80% of individuals. Screening: no data.

Classification

There is no generally accepted classification. By analogy with other acute respiratory diseases, etiological and functional classification signs can be distinguished.

Etiology (Table 1). Usually, 2 main types of OB are distinguished: viral and bacterial, but other (more rare) etiological variants (toxic, burns) are also possible; they rarely occur in isolation, are usually a component of a systemic lesion, and are considered within their respective diseases.

Functional classification OB, taking into account the severity of the disease, has not been developed, since uncomplicated OB usually proceeds stereotypically and does not require a distinction in the form of a classification according to severity.

Diagnostics

The diagnosis of "acute bronchitis" is made in the presence of an acute cough that lasts no more than 3 weeks (regardless of the presence of sputum), in the absence of signs of pneumonia and chronic lung diseases that can cause coughing.

The diagnosis is based on the clinical picture, the diagnosis is made by exclusion.

The cause of the clinical syndrome of AB is various infectious agents (primarily viruses). These same agents can also cause other clinical syndromes that occur simultaneously with OB. Below is a summary of the data (Table 2) characterizing the main symptoms in patients with OB.

Given in table. 2 The diverse clinical symptoms of AB suggest the need for careful differential diagnosis of coughing patients.

Possible causes of prolonged cough associated with disease-

mi of the respiratory system: bronchial asthma chronic bronchitis

chronic lung infections, especially tuberculosis sinusitis postnasal drip syndrome gastroesophageal reflux sarcoidosis cough due to connective tissue diseases and their treatment asbestosis, silicosis

"farmer's lung" side effect of drugs (ACE inhibitors,

Acute bronchitis

Table 2 . The frequency of clinical signs of acute bronchitis in adult patients

β-blockers, nitrofurans) lung cancer pleurisy

heart failure.

Modern standard methods(clinical, radiological)

cal, functional, laboratory) make it quite easy to make a differential diagnosis.

Prolonged cough in patients with arterial hypertension and heart disease

■ ACE inhibitors. If the patient is taking an ACE inhibitor, it is very likely that this drug is causing the cough. The alternative is to select another ACE inhibitor or switching to angiotensin II receptor antagonists, which usually do not cause cough.

■ β-blockers(including selective) can also cause cough, especially in patients predisposed to atopic reactions or with hyperreactivity of the bronchial tree.

■ Heart failure. It is necessary to examine the patient for the presence of heart failure. First sign of heart failure mild degree- cough at night. In this case, first of all, it is necessary to conduct an x-ray of the chest organs.

Prolonged cough in patients with connective tissue diseases

■ Fibrosing alveolitis- one of possible causes cough (sometimes in combination with rheumatoid arthritis or scleroderma). The first step is to take a chest x-ray. Typical find - pulmonary fibrosis, but in the early stages it may be radiologically invisible, although the diffusing capacity of the lungs, reflecting the exchange of oxygen in the alveoli, may already be reduced, and dynamic spirometry may reveal restrictive changes.

■ Influence of drugs. Cough may be due to exposure to drugs (a side effect of gold preparations, sulfasalazine, penicillamine, methotrexate).

Chronic cough in smokers. Most probable causes- prolonged acute bronchitis or chronic bronchitis. It is necessary to be aware of the possibility of cancer in middle-aged patients, especially in those over 50 years of age. It is necessary to find out if the patient has hemoptysis.

Acute bronchitis

Acute bronchitis

Prolonged cough in people of certain occupations

Asbestosis. It is always necessary to be aware of the possibility of asbestosis if the patient has worked with asbestos First, chest X-ray and spirometry are performed (restrictive changes are detected) If asbestosis is suspected, specialists should be consulted.

Farmer's Lung. Employees Agriculture suspect farmer's lung (hypersensitivity pneumonitis due to moldy hay exposure) or bronchial asthma Initial chest x-ray, home PEF measurement, spirometry (including bronchodilator test) If farmer's lung is suspected, specialist advice should be sought.

Occupational bronchial asthma , starting with a cough, can develop in humans various professions associated with exposure to chemical agents, solvents (isocyanates, formaldehyde, acrylic compounds, etc.) in car repair shops, dry cleaners, plastic manufacturing, dental laboratories, dental offices etc.

Prolonged cough in patients with atopy, allergies or in the presence of hypersensitivity to acetylsalicylic acid

The most likely diagnosis is bronchial asthma.

Most common symptoms- transient shortness of breath and separation of mucous sputum.

Primary studies: measurement of PSV at home spirometry and a test with bronchodilators, if possible - determination of hyperreactivity of the bronchial tree (provocation with inhaled histamine or methacholine hydrochloride), assessment of the effect of inhaled corticosteroids.

Prolonged cough and fever with purulent sputum

Tuberculosis should be suspected, and in patients with lung disease, the possibility of developing an atypical pulmonary infection caused by atypical mycobacteria. Vasculitis (eg, periarteritis nodosa, Wegener's granulomatosis) may begin with such manifestations. It is also necessary to remember about eosinophilic pneumonia.

Primary investigations: chest x-ray, smear and sputum culture, complete blood count, determination of the content C-reactive protein in blood serum (may increase with vasculitis).

Other causes of persistent cough

■ Sarcoidosis. Chronic cough may be the only manifestation of pulmonary sarcoidosis. Primary investigations include: chest X-ray (hilar hyperplasia) lymph nodes, infiltrates in the parenchyma) the level of ACE in the blood serum.

■ Nitrofurans (subacute pulmonary reaction to nitrofurans): ask the patient if he has taken nitrofurans to prevent infections urinary tract in subacute cases, eosinophilia may not be present.

■ Pleurisy. Cough may be the only manifestation of pleurisy. To identify the etiology should be carried out: a thorough objective examination of the puncture and biopsy of the pleura.

■ Gastroesophageal reflux- common cause chronic cough found in 40% of coughing individuals. Many of these patients complain of reflux symptoms (heartburn or a sour taste in the mouth). However, 40% of individuals whose cough is caused by gastroesophageal reflux do not show symptoms of reflux.

■ Postnasal drip syndrome(postnasal drip syndrome - leakage of nasal mucus into the respiratory tract). The diagnosis of postnasal drip may be suspected in patients who describe a sensation of mucus running down the throat from the nasal passages or a frequent need to "clear" the throat by coughing. In most patients, the discharge from the nose is mucous or mucopurulent. At allergic nature postnasal drip, eosinophils are usually found in the nasal secretion. Postnasal drip can be caused by general cooling, allergic and vasomotor rhinitis, sinusitis, annoying factors environment and drugs (for example, ACE inhibitors).

Differential Diagnosis

The most important in the differential diagnosis of OB are pneumonia, bronchial asthma, acute and chronic sinusitis.

■ Pneumonia. It is fundamentally important to differentiate OB from pneumatic

breathing, in patients with bronchial asthma in the study of the function external respiration reversible bronchial obstruction is detected in tests with β2-agonists or in a test with methacholine. However, in 33% tests with β2-agonists and in 22% with methacholine can be false positive. If false is suspected positive results functional testing The best way diagnosis bronchial asthma- carrying out a trial therapy for a week with the help of β2-agonists, which, in the presence of bronchial asthma, should stop or significantly reduce the severity of coughing.

Whooping cough is not a very common, but very important cause for epidemiological reasons. acute cough. Whooping cough is characterized by: cough lasting at least 2 weeks, coughing paroxysms with a characteristic inspiratory "scream" and subsequent vomiting without other visible reasons. in the diagnosis of pertussis

whooping cough is laboratory-proven.

Adults immunized against whooping cough childhood often do not show classic pertussis infection.

Availability of anamnestic and clinical data on contacts with children who were not immunized (for organizational or religious reasons) against whooping cough.

Identify risk groups among those in contact with infectious agents for adequate diagnosis.

Despite immunization during adolescence and childhood, whooping cough remains an epidemic risk due to suboptimal immunization in some children and

adolescents and due to a gradual (within 8–10 years after immunization) decrease in pertussis immunity.

Below (Table 4) are the main differential diagnostic signs of acute bronchitis.

Cough is the most common symptom of acute bronchitis. However, studies show that most patients with acute bronchitis are treated with inappropriate or ineffective drugs.

Cough is the most common symptom that brings patients to the doctor's office. As a rule, these patients are diagnosed with acute bronchitis.

Acute bronchitis must be differentiated from other common diagnoses such as pneumonia and asthma because these conditions require special methods treatments not indicated for bronchitis. Bronchitis symptoms usually last about three weeks. The presence or absence of colored (eg) sputum does not reliably distinguish between bacterial or viral infections of the lower respiratory tract. Viruses are responsible for more than 90% of acute bronchitis infections.

Why are antibiotics not effective for acute bronchitis?

Therefore, antibiotics are generally not prescribed for the treatment of acute bronchitis. They should only be used if whooping cough is suspected to reduce the risk of transmission or if the patient is exposed to increased risk development of pneumonia (for example, in patients older than 65 years). Typical treatments for acute bronchitis have not been shown to be always effective. Therefore, the FDA does not recommend the use of many drugs in children under 6 years of age. Pelargonium supplementation may help reduce the severity of symptoms of acute bronchitis in adults. Because patient expectations for antibiotics and therapy for symptom control differ from evidence-based recommendations, effective communication strategies must be implemented to ensure the best possible outcome. safe methods treatment while maintaining patient satisfaction.

Cough is the most common symptom of acute bronchitis. However, studies show that most patients with acute bronchitis are treated with inappropriate or ineffective drugs. Recently, the FDA issued a warning about the dangers of some commonly used drugs. This highlights the importance of evidence-based application only, effective methods bronchitis treatment.

A - consistent, good quality, focused on patient evidence; B - inconsistent or limited quality focused on patient evidence; C- consensus, disease-targeted evidence, customary practice, expert opinion, or case series (Source: www.aafp.org)

Diagnosis of acute bronchitis

Acute bronchitis is a self-limited infection with cough as the main symptom. This infection can be difficult to distinguish from other diseases that commonly cause coughing. The most common differential diagnosis acute cough: 1) acute bronchitis, 2) allergic rhinitis 12 ) sinusitis, 13) viral syndrome.

Colds often cause coughing. However, nasal congestion and runny nose pass, like a cold, in 7-10 days. The symptoms of acute bronchitis usually persist for about three weeks.

Pneumonia can usually be ruled out in patients without fever, tachypnea, or tachycardia. However, coughing may be the only symptom initial pneumonia in the elderly. Therefore more low threshold for the use of chest x-ray should be retained in these patients. The presence or absence of colored (eg, green) sputum does not reliably distinguish between bacterial and viral infections of the lower respiratory tract.

pathogens in acute bronchitis

Pathogens in bronchitis are rarely identified. AT clinical research pathogen identification occurs in less than 30% of cases. In about 90% of cases, acute bronchitis is caused by viruses. Because viral culture yields are generally low and results rarely affect clinical planning, procedure serological study not recommended for bronchitis. Influenza virus testing may be done when the risk is considered intermediate and the patient presents within 36 hours of symptom onset. During the peak flu season, testing is generally not helpful because the chance of flu is high. Conversely, the positive predictive value is too low to be useful outside of influenza season.

The most common infectious etiology of acute bronchitis: 1) viruses, 2) adenovirus, 3) coronavirus, 4) influenza A and B, 5) metapneumovirus, 6) parainfluenza virus, 7) respiratory syncytial virus, 8) rhinovirus, 9) bacteria, 10) whooping cough, 11) chlamydia pneumonia, 12) mycoplasma pneumonia.

Diagnostic testing during bronchitis flares may also be considered in some clinical scenarios. Mycoplasma pneumonia and chlamydia pneumonia have bacterial etiology which may affect young people. Bordetella whooping cough, the causative agent of whooping cough, can also lead to acute bronchitis. Whooping cough testing should be done in unvaccinated patients with a cough that is paroxysmal, has a "convulsive" sound, or lasts longer than three weeks.

Treatment of acute bronchitis

Treatment of acute bronchitis is generally divided into two categories: antibiotic therapy and symptomatic treatment. Physicians appear to be deviating from the evidence-based medical practice in the treatment of bronchitis more than in the diagnosis of the condition.

Antibiotics for the treatment of acute bronchitis

Because of the risk of antibiotic resistance and because of the bacterium, antibiotics should not be used in the treatment of acute bronchitis, especially in younger patients who are not suspected of having whooping cough. Although 90% of bronchitis infections are caused by viruses, approximately two-thirds of patients in the US with this diagnosis are treated with antibiotics. The patient's expectations lead to the prescription of antibiotics. The study found that 55% of patients believe that antibiotics are effective for treating viral upper respiratory tract infections, and that almost 25% of patients self-treated upper respiratory tract infections with antibiotics left over from previous infections. The American College of Lung Medicine does not recommend the use of conventional antibiotics for the treatment of patients with acute bronchitis.

Clinical data confirm that antibiotics do not significantly change the symptoms of acute bronchitis. They may provide only a minimal benefit compared to the risk of antibiotics themselves. A meta-analysis examining the effect of antibiotics in patients with acute bronchitis showed a reduction in cough at follow-up, but no change in patients' activity restrictions. The meta-analysis also showed harm caused by the adverse effects of antibiotics. In a study of 230 patients diagnosed with acute bronchitis (i.e. having a cough for 2 to 14 days) who received azithromycin or a low dose of vitamin C, more than half of the patients had heat or purulent sputum. The results did not differ between the two groups; 89% percent in both groups had clinical improvement.

Although antibiotics are not recommended for routine use in patients with bronchitis, they may be considered in certain situations. When whooping cough is suspected in the etiology of cough, it is necessary to prescribe as soon as possible macrolide antibiotics to decrease transmission. However, antibiotics do not reduce the duration of symptoms. Antivirals for the treatment of influenza infection may be prescribed within 36 hours of the onset of influenza symptoms for patients at high risk. The argument for using antibiotics for acute bronchitis is that it may reduce the risk of subsequent pneumonia. In one large study, 1 in 119 patients aged 16 to 64 and 1 in 39 patients aged 65 or older needed to be treated to prevent pneumonia within a month of an episode of acute bronchitis.

Because of the clinical uncertainty that can arise in distinguishing acute bronchitis from pneumonia, there are serological markers that are an indication for antibiotic use. Two studies in the department emergency care showed that treatment decisions based on procalcitonin levels helped reduce antibiotic use (83% versus 44% in one study, and 85% versus 99% in another study) with no difference in clinical outcomes.

The choice of drugs for the treatment of acute bronchitis

Because antibiotics are not recommended for the routine treatment of acute bronchitis, doctors face the challenge of ensuring symptom control as the viral syndrome progresses. General Methods treatments include cough suppressants, expectorants, inhalers, drugs and alternative methods treatment. Several small Cochrane studies and reviews help guide therapy for symptom control.

The ACCP guidelines suggest that it may be appropriate to use antitussive drugs (eg, codeine, dextromethorphan, or hydrocodone) despite the lack of a consistent evidence base for their use, given their benefit in patients with chronic bronchitis. Studies have shown that dextromethorphan is not effective in suppressing cough in children with bronchitis. These data, combined with the risk of developing side effects in children, including death, prompted the American Academy of Pediatrics and the FDA to recommend against the use of antitussives. medicines in children under two years of age. The FDA subsequently recommended that antitussive drugs should not be used in children under the age of six.

The results in a Cochrane review do not support the routine use of beta-agonist inhalers in patients with acute bronchitis. However, a group of patients with wheezing during illness responded to this therapy. Another Cochrane review reported that there may be some benefit with high dose, episodic inhaled corticosteroids, but no benefit occurred with low dose, with preventive therapy. There are no data supporting the use of oral corticosteroids in patients with acute bronchitis and without asthma.

Alternative treatment for acute bronchitis

Many patients also use over-the-counter, alternative medications to relieve bronchitis symptoms. Studies have evaluated the benefits of echinacea, pelargonium, and honey. Trials of echinacea in patients with bronchitis have yielded conflicting results. Although the studies showing positive results were very small.

Several randomized trials have evaluated pelargonium as a therapy for bronchitis. In one randomized trial, patients who took pelargonium for bronchitis were cured on average two days earlier than those who took placebo.

One recent study examines the effectiveness of dark honey in relieving symptoms in children with bronchitis compared to dextromethorphan or placebo. Although the authors concluded that the symptom scores of dark honey patients were superior to those of placebo patients, the clinical benefit was small.

Reducing unnecessary prescriptions in the treatment of acute bronchitis

Many patients with bronchitis expect medication to relieve symptoms, and doctors face the difficult task of convincing patients that most medications are ineffective for treating acute bronchitis. Careful word choice and communication skills can help reduce antibiotic prescriptions.

Methods for managing patient expectations in the treatment of symptoms of acute bronchitis: 1) Define the diagnosis as "cold" or " viral infection upper respiratory tract." 2) Set realistic expectations for the duration of symptoms (about three weeks). 3) Explain that antibiotics do not significantly reduce the duration of symptoms and that they can cause adverse effects and lead to antibiotic resistance. 4) Pelargonium can be used to treat cough in adults.

The diagnosis of bronchitis is usually clinical.

Diffuse nature of wheezing, low temperature, the absence of toxicosis, percussion changes and leukocytosis make it possible to exclude pneumonia and make a diagnosis of bronchitis without resorting to chest x-ray.

Complaints and anamnesis

Acute bronchitis (viral) - occurs predominantly in preschool children school age. It is characterized by an acute onset with subfebrile (rarely febrile) temperature, catarrhal symptoms(cough, rhinitis). Cough can appear from 2-3 days of illness. Clinical signs bronchial obstruction (expiratory dyspnea, wheezing, wheezing) are absent. Signs of intoxication are usually absent, usually lasting 5-7 days. At infants with RS-viral infection and in older people - with adenovirus infection - it can last up to 2 weeks. Cough lasting ≥2 weeks in schoolchildren may be indicative of pertussis infection.

Bronchitis due to Mycoplasma pneumoniae . Possible persistent febrile temperature in the absence of toxicosis, redness of the conjunctiva ("dry conjunctivitis" with usually scanty other catarrhal phenomena). Uncommon signs of obstruction. Without treatment, fever and wheezing can persist for up to 2 weeks.

Chlamydial bronchitis due to C. trachomatis observed in children aged 2-4 months with intranatal infection from the mother. The condition is disturbed a little, the temperature is usually normal, the cough intensifies within 2-4 weeks, sometimes paroxysmal "whooping cough", but without reprisals. Shortness of breath is moderate. In favor of chlamydial infection, there are signs of urogenital pathology in the mother, persistent conjunctivitis in the 1st month of the child's life.

Chlamydial bronchitis due to C. pneumoniae , in adolescents is rarely diagnosed, sometimes occurs with bronchial obstruction. Clinical picture it may be accompanied by pharyngitis and lymphadenitis, however, it has not been studied enough due to the difficulties of etiological diagnosis.

Acute bronchitis with bronchial obstruction syndrome : repeated episodes of bronchial obstruction syndrome are observed quite often - against the background of another respiratory infection and require the exclusion of bronchial asthma in the patient. They, as a rule, are accompanied by wheezing and prolongation of expiration, which appear as early as 1-2 days of illness. The respiratory rate rarely exceeds 60 in 1 minute, dyspnea may not be expressed, but sometimes its sign is the child's anxiety, a change in posture in search of the most comfortable. Not infrequently oxygenation is not reduced. The cough is unproductive, the temperature is moderate. The general condition thus usually remains satisfactory.

Physical examination

In acute bronchitis, evaluation is recommended general condition the child, the nature of the cough, examination of the chest (pay attention to the retraction of the intercostal spaces and the jugular fossa on inspiration, the participation of auxiliary muscles in the act of breathing); percussion and auscultation of the lungs, assessment of the state of the upper respiratory tract, counting the respiratory rate and heart rate. In addition, a general routine examination of the child is recommended.

Comment:

In acute bronchitis (viral) - auscultatory in the lungs can be detectedscattered dry and moist rales. There is no bronchial obstruction. Atthere are usually no signs of intoxication.

Bronchitis caused by Mycoplasma pneumoniae. on auscultation of the lungs - an abundancecrepitating and small bubbling rales on both sides, but, unlike the virusleg bronchitis, they are often asymmetrical, with a predominance in one of the lungs. Notseldom bronchial obstruction is defined.

Chlamydial bronchitis caused by C. trachomatis: auscultation in the lungssmall and medium bubbling rales are sewn.

Chlamydial bronchitis due to C. pneumoniae: auscultatory in the lungs whobronchial obstruction can be detected. Can be detected magnifiedlymph nodes and pharyngitis.

Acute bronchitis with bronchial obstruction syndrome: auscultatorywhistling wheezing against the background of an extended exhalation.

Laboratory diagnostics

In typical cases of acute bronchitis in children, routine laboratory research.

Comment:In acute bronchitis, changes in general analysis blood, as a rule, are insignificant, the number of leukocytes<15∙109/л. Diagnostic value for pneumonia is leukocytosis above 15x109/l, increased levels of C-reactive protein (CRP) >30 mg/l and procalcitonin (PCT) >2 ng/ml.

. The routine use of virological and bacteriological research in acute bronchitis caused by M. pneumoniae, because in most cases, the results do not affect the choice of therapy. Specific IgM antibodies appear only by the end of the second week of illness, polymerase chain reaction(PCR) can reveal carriage, and an increase in IgG antibodies indicates earlier past infection.