The protocol for Bronchitis/Pneumonia:Bronchitis and Pneumonia
Let’s break it down!
Bronchitis and pneumonia are two separate conditions that require different treatments, but for our purposes in the field, we’re going to initially approach them in the same manner. Any time a soldier is suspected of having any lower respiratory infection, this will be the go-to protocol. Here’s an introduction to both diseases:
The term bronchitis means “inflammation of the bronchi“. It’s a common clinical condition that accounts for over 100 million healthcare visits per year. It’s characterized by an acute onset of a persistent cough, with or without sputum production. Although it can technically be caused by some forms of bacteria, such as B. pertussis, it’s almost always exclusively caused by viruses, which don’t require the use of antibiotics. Bronchitis is typically self-limited, resolving within one to three weeks. The video below goes into greater detail about the pathophysiology of bronchitis:
Pneumonia is also a lower respiratory infection, but it’s a much deeper infection characterized by infection and inflammation of the alveoli. While bronchitis is mostly viral, pneumonia is mostly bacterial, although this occasionally deviates as well. Pneumonia accounts for over 4.5 million outpatient/emergency room visits and is the 8th overall cause of death in the US. These patients typically require more extensive treatments, including antibiotics. The video below goes into greater depth about pneumonia:
Differentiating between bronchitis and pneumonia can be difficult, but it’s important that we do our best to try to make the distinction so that we can accurately decide whether our patient needs antibiotic treatment or just symptomatic treatment. Here are a few general things you can look for:
- Fever: both bronchitis and pneumonia patients can present with a fever (>100.4 degrees Fahrenheit), but it’s much more likely to occur in a patient with pneumonia (71-75%)
- Dyspnea (shortness of breath): Much more common in pneumonia (67-75%); bronchitis does not usually present with dyspnea, nor is tachypnea (respiratory rate >20) a common presentation.
- Sputum production: This isn’t a hard clinical marker for differentiating bronchitis and pneumonia, but it is classically more common for pneumonia patients to have excessive sputum production that is darker in color.
The video below is a great 3-minute breakdown summary for differentiating bronchitis from pneumonia:
1. Albuterol (Proventil) MDI 2-4 puffs q4-6hr
Albuterol is a beta 2 agonist that functions as a bronchodilator to increase oxygenation and reduce the frequency of coughing. Although not routinely recommended for pneumonia, it can be helpful as a symptomatic treatment for patients with bronchitis who exhibit any wheezing. Studies have shown that albuterol reduces the frequency of coughing for bronchitis patients at the 7-day mark.
2. Treat symptoms with antitussives, decongestants, expectorants, as needed
Coughing is typically a helpful mechanism in lower respiratory infections as it helps expel unwanted mucous, so the use of antitussive agents (cough suppressants) are not routinely recommended. However, if the patient is experiencing difficulty sleeping at night, then antitussives like Dextromethorphan and Benzonatate can be useful.
Decongestants like Phenylephrine, Pseudoephedrine, and Oxymetazoline work by narrowing the peripheral blood vessels and limiting mucous production. They are not particularly helpful for bronchitis or pneumonia, but they may provide mild symptomatic relief for those experiencing sinus congestion from a preceding upper respiratory infection
Expectorants like Guaifenisen work by breaking down mucous and decreasing its level of viscosity. Although not proven to aid significantly in the recovery of patients with bronchitis or pneumonia, it may help loosen the mucous and make it easier to expel from the respiratory tract.
3. Treat per Pain Management protocol
Myalgia (body aches) and chest pain are common, especially for patients with pneumonia. NSAIDs (Ibuprofen, Naproxen) and/or Tylenol should help manage these pains without the need for any narcotics.
When it comes to antibiotics, we’re specifically looking for signs and symptoms of pneumonia as an indication for their use. This would include many of the things we discussed earlier, such as a fever, dyspnea/tachypnea, or myalgias (body aches).
It’s possible that pneumonia can be caused by viruses (influenza, rhinovirus, coronavirus), but in our setting, we’re going to tailor our treatment to cover for potential bacterial agents. This mostly includes Streptococcus pneumoniae, but also Moraxella catarrhalis, Staphylococcus aureus, and Klebsiella pneumoniae
If the patient cannot tolerate PO medications, then we can jump straight into IV/IM antibiotics. Both Ertapenem (carbapenem antibiotic) and Ceftriaxone (cephalosporin antibiotic) are broad-spectrum agents that will cover for bacterial agents associated with pneumonia. However, having a daily IV or IM drug administration is not the most pleasant.
Any patient with pneumonia or a severe case of bronchitis will likely experience fever/chills. If not already taking Acetaminophen (Tylenol) for pain, adding this into the regimen will help keep the patient more comfortable.
Observation is usually enough for most patients with lower respiratory infections; Routine evacuation for those who look especially miserable. For those with severe shortness of breath or hypoxia, an Urgent evacuation is warranted as these patients can decompensate quickly.
Overall, the prognosis for patients with uncomplicated cases of lower respiratory infections is good. Bronchitis typically clears up after 10-14 days, although some patients may have lingering symptoms for up to 3 weeks. Pneumonia is a bit tougher to shake off, taking up to 8 weeks for most patients to return to baseline.
Good luck out there!
- UpToDate: Overview of community-acquired pneumonia in adults
- UpToDate: Acute Bronchitis in adults
- EMRAP Corependium: Lung Infections
- Advanced Tactical Paramedic Protocols Handbook. 10th ed., Breakaway Media LLC, 2016.