Chronic venous insufficiency

Author : Dr Ralph Gonzales Professor of Medicine University of California San Francisco

2008-07-19

Chronic venous insufficiency : Swelling in the Lower Legs

What Is Chronic Venous Insufficiency?

Chronic venous insufficiency (CVI) is by far the most common cause of lower leg swelling, affecting up to 2% of the entire population, and up to 20% of elderly persons. About 2.5 million people in the US suffer from CVI. Chronic swelling in the lower leg predisposes the person to decreased oxygen deliver to the skin, which can lead to increased susceptibility for skin rashes, infection and leg sores. One in five people with CVI will develop a lower leg ulcer (sore) at some point in time. Once they develop, leg sores can be very difficult to heal, some taking months to years to heal with intensive treatments.

Both right and left ankle and lower leg swelling is generally present in all patients with CVI; it tends to be the symptom that leads to the diagnosis. Patients with CVI also frequently report “heavy legs,” itching, and gnawing discomfort or pain. Symptoms tend to be worse towards the end of the day, and best upon awakening in the morning.

Skin changes develop in stages in relation to the severity and duration of CVI. A bronze tanning due to hyperpigmentation (where patches of skin become darker than the surrounding skin) is commonly seen in the early stages of CVI, as is statis dermatitis, which refers to inflamed skin that frequently scales and itches. As the condition progresses, tiny white patches call “atrophie blanche” can appear over the areas of hyperpigmentation, and in the final stages of disease a process called lipodermatosclerosis develops. This is where thick brawny skin eventually leads, in advanced cases, to the lower leg resembling an inverted champagne bottle.

Venous valve

What Causes Chronic Venous Insufficiency?

Chronic venous insufficiency is due to insufficient return of blood from the lower leg to the heart. Due to gravity, as the blood pools in the legs the pressure increases within the system of veins through which blood flows as it returns to the heart. When standing, normal venous pressure in the legs is 80 mm Hg in deep veins and 20–30 mm Hg in surface veins (the ones often referred to as varicose veins when they develop venous insufficiency). The reason that the surface veins in the leg normally have lower blood pressure than the deep leg veins is because there are one-way valves that allow the body to push the blood back to the heart and lungs, and protect the surface veins and skin from high pressures. While the one-way valves keep the blood moving one direction, it’s the calf and other leg muscles that do the majority of work of returning venous blood from the legs to the heart by squeezing the veins during walking or contraction.

When the valves and/or muscles fail, venous hypertension results. Chronic exposure to elevated venous pressure in the lower legs leads to leakage of fluid, inflammation and decreased oxygen delivery to the skin. These changes account for the brawny, fibrotic skin changes observed in patients with CVI, and the predisposition toward skin ulceration (sores), particularly on the inside ankle area.

While aging is the most common cause of CVI, leg clots (deep venous thrombosis or DVT) are another important cause, especially when CVI has developed in just one leg. Other risk factors that increase a person’s chances for developing CVI besides a history of blood clots in the legs include family history of varicose veins, obesity, pregnancy and previous leg injury. Studies have not been conclusive about prolonged standing or sitting as risk factors for developing CVI.

  

When Should I See a Doctor If I Have Developed New Leg Swelling?

The development of new lower leg swelling is a condition that should be evaluated by a health care provider. In general, the slow and gradual onset of leg swelling at the end of the day that is absent upon awakening is very likely to represent venous insufficiency. However, one should seek evaluation more urgently if the swelling has developed more rapidly (such as hours-to-days), and especially if the swelling involves only one leg and is not due to an obvious injury. Lower legs can swell in response to increased pressure in the venous or lymphatic systems, to conditions that increase the leakiness of capillaries (the tiny vessels that connect arteries to veins), to low levels of protein in the blood, and to local injury or infection.

Besides CVI, other causes of new leg swelling include:

· Deep venous thrombosis (leg clot)

· Cellulitis (skin infection)

· Baker’s cyst rupture (located behind the knee)

· Calf muscle tear or rupture

· Lymphedema (fluid retention caused by a compromised lymphatic system)

· Congestive heart failure

· Liver failure with cirrhosis

· Kidney failure, particularly nephritic syndrome (which excretes protein in the urine)

· Drug reactions, especially to calcium channel blockers, minoxidil, or thioglitazones.

Swelling of the entire leg or swelling of one leg three centimeters more than the other suggests deep venous obstruction or clot. (In normal persons, the left calf is slightly larger than the right as a result of normal anatomy.) Because many of the conditions above can be life-threatening, it is important to be evaluated by a medical provider as quickly as possible.

How Do You Diagnose Chronic Venous Insufficiency?

An ultrasound test can identify many causes of lower leg swelling, including CVI. Persons without an obvious cause of new leg swelling in a single limb (e.g., calf strain) should have an ultrasound performed, since leg clots can be diagnosed with ultrasound and are difficult to exclude on clinical grounds alone. It is common to also perform a urine test to look for protein losses in the urine, and blood tests to examine kidney and liver function. In patients with suspected heart disease, an echocardiogram (an ultrasound of the heart) might be ordered to assess for congestive heart failure.

Bear in mind that not all persons with lower leg swelling need an ultrasound test. If the swelling is on both sides, mild (restricted to feet and ankles), gets better with leg elevation or sleep, and is associated with skin changes such as hyperpigmentation or stasis dermatitis, then it is reasonable to assume this is CVI and see how it responds to treatment with compression stockings (see below).

Treatment of Chronic Venous Insufficiency

1. Behavioral treatments

a. Leg elevation. Persons should try to elevate legs above the heart for 15 to 30 minutes, two to three times daily, as well as in bed.

b. Walking. Regular walking and exercise can help to improve the return of venous blood to the heart.

2. Compression Therapy

a. Elastic compression. This is the main treatment for uncomplicated CVI. Graduated compression stockings work by increasing the pressure in your leg tissues and veins in order to counteract the increased pressure that has developed as a result of the faulty vein valves. They tend to have the highest pressure at the ankle (where ulcers are most prone to develop), and the pressure tapers down to normal as it reaches the knee.
      
A wide variety of stockings are effective in decreasing leg swelling. Some stockings have zippers that make them easier to apply for elderly or debilitated patients and some have an open-toe. Compression stockings should be put on with awakening in the morning, before venous pressures rise and cause swelling, and removed at night. Compression stockings should generally be replaced every 4-6 months if used every day, or every 6-9 months if used with an alternate pair.

Although you can buy stockings from many drug stores and medical supply companies, your doctor should provide you with a “prescription” that includes the amount of tension to be applied by the compression, the size (based on your calf circumference) and the length.

Severity of venous insufficiency                     Ankle Tension

· Swelling without complications                     20-30 mm Hg

· Swelling with complications                            30-40 mm Hg

(such as dermatitis or prior ulcer)

· Swelling with recurrent ulcers                        40-50 mm Hg



Calf Circumference                                               Stocking Size*

· 12 inches                                                                     Small

· 15 inches                                                                     Medium

· 17.5 inches                                                                 Large

*These are based on T.E.D. hose. Other scales might be used by different manufacturers.

For most people, knee-high stockings are all they will need. Thigh-high stockings are appropriate for persons with swelling that affects the entire leg, but these are much more difficult to keep in place.

b. Unna Boot. The most common initial treatment for lower leg sores due to CVI is a foot/lower leg cast popularly known as an “Unna Boot” (named after a German dermatologist). These are easy-to-apply paste-gauze boots (like a cast) that are impregnated with zinc or other compounds. They harden within a few minutes to hours of application, and they are replaced weekly until the ulcer is healed. Elastic compression stockings with bandages around the leg ulcer could also be used for the purpose of promoting wound healing, but the advantage of the Unna Boot is that it is easier to apply constant pressure and medication (zinc) over several days without requiring dressing changes.

In addition, because the Unna Boot is essentially a rigid cast, it only applies pressure in an amount that is equal to the severity of leg swelling. Therefore, if the swelling decreases substantially at night (which is common), the Unna Boot doesn’t continue to apply pressure. In contrast, compression stockings still continue to apply some pressure at night, which could be dangerous for patients that also have peripheral arterial disease, ie, blockage of blood vessels that deliver blood to the lower leg.

c. Other Types of Compression. There are other types of compression devices that include compression pumps and orthosis devices, but these are expensive, bulky and limit mobility. They are primarily used under unique circumstances that preclude the use of compression stockings.

3. Systemic Therapy (pills)

a. Diuretics (water pills). It is best to avoid diuretic therapy (such as hydrochlorothiazide or furosemide (Lasix), unless the patient has medical conditions that cause the body to retain water, such as congestive heart failure, pulmonary hypertension, cirrhosis, or nephrotic syndrome. This is because while the legs appear swollen and overloaded with fluid, the actual circulation (blood flow) is relatively underloaded, because fluid is leaking from the circulatory system to the tissues in the legs. Therefore, use of diuretics under these conditions, which reduce blood volume and blood pressure, may lead to dizziness, low blood pressure and reduced blood flow to the kidneys causing acute kidney failure.

b. Horse chestnut seed extract (Venostat). Available over-the-counter in health food stores, horse chestnut seed extract has been shown in well-performed studies to be equivalent to compression stockings and can be quite useful in patients who are not able to walk or exercise. It is believed to work by reducing the inflammation that results when blood pools in the legs for too long. While appearing safe in these studies, we do not have long-term safety experience with this therapy.

c. Hydroxyethlylrutosides (Venorutin). Although not studied as extensively as horse chestnut seed extract, there is ample evidence that these therapies also help reduce swelling.

4. Invasive Treatments.

Invasive treatments, particularly those requiring surgery, are generally reserved for patients failing the more conservative therapies above. With the exception of valve reconstruction, all of these treatments involve with superficial venous system.

a. Vein removal (stripping) or ablation. Vein removal can be accomplished surgically (i.e., “stripping”), but is now more frequently performed using heat or laser ablation as an outpatient or office procedure. Heat and laser ablation basically destroy the veins that are insufficient, sending venous blood to veins with normal functioning valves. All procedures have fairly high success rates for controlling leg swelling when the deep vein valves have normal function, and there are no head-to-head trials that demonstrate one method of removal/ablation is superior to the other.

Another technique of vein ablation is called injection sclerotherapy, where the clinician injects a toxic substance into the vein that plugs-up the interior of the vessel and it eventually dissolves. Scientific studies support the use of injection sclerotherapy for recurrent varicose veins following surgery and for tiny “spider” or “thread” veins.

b. Ligation and stripping. This surgical procedure involves ligating (or tying-off) the saphenous vein in the thigh where it enters the deep venous system (saphenofemoral junction). This procedure has been the standard treatment for severe CVI for many years, and is effective at controlling symptoms, swelling and ulcer recurrence. By removing the insufficient vein, blood in the leg that needs to return to the heart pursues other routes of return such as the perforator veins.

c. Valve reconstruction. This is a fairly intensive procedure that is reserved for patients with severe CVI who have difficulty controlling ulcers and symptoms.

d. Subfascial endoscopic perforator surgery (SEPS). This procedure is useful for patients with difficult-to-control CVI who have incompetent perforator veins in the calf. The perforator veins are one of the communication points between the high pressure deep venous system and the normally low pressure superficial venous system. Clinical trials have shown it to be effective at reducing ankle ulcer recurrence when the main cause of CVI is due to incompetent perforator veins. This surgical technique is performed through a small endoscope (tube) that is introduced at a site far away from the affected tissue so that problems with wound healing are less likely to develop than with local surgery, and basically ligates (ties-off) the incompetent perforator veins which reduces the transmission of the high pressure from the deep venous system to the superficial system.

Complications

Ulcers. Lower leg ulcers (sores) are common in patients with advanced CVI, often occurring over the inside ankle bone. Any skin breakdown in a patient with CVI needs to be evaluated by a healthcare provider.

Typical venous ulcers are shallow, can become quite large, and are located on the lower 1/3 of the lower leg. Ulcers or wounds that are very painful, deep, or that occur in the foot or in the top half of the lower leg may be due to other causes, such as infection, arterial insufficiency, or diabetes. Venous ulcers should be treated in partnership with a wound specialist. They often require long-term treatment with Unna Boot’s and dressing changes, and may take several months to heal. Patients with non-healing ulcers and recurrent venous ulcers may require vein surgery in order to achieve prolonged control of the ulcer.

The best preventive measures that patients with CVI can perform to reduce their risk of leg ulcers is to exercise and elevate their legs daily, and to wear compression stockings that have the appropriate tension.

Infection (skin and/or bone). Chronic swelling of the lower leg leads to changes that weaken the immune system in the legs, and increases the potential for skin infections. Infections can develop after a minor nick or injury introduces germs to the area, or they can develop as a secondary infection of a leg sore. Signs of infection include severe pain, deep tissue involvement and fever. Untreated infections can lead to deeper, recalcitrant infections of bone or muscle, and can also lead to more severe blood stream infections (sepsis). Treatment usually includes topical or oral antibiotics, and meticulous wound care to keep the area protected and clean around leg sores, when present.

Prevention Of Chronic Venous Insufficiency

No studies have demonstrated that regular walking, exercise or routine use of compression stockings prevent the develop of CVI in persons with normal venous systems and no symptoms of CVI, with the exception of one important group—those with deep venous thrombosis.

Prevention of post-thrombotic syndrome and CVI. There is very good evidence that about 30% to 50% of persons who develop a confirmed deep venous thrombosis in the leg (particularly the thigh) are at increased risk for development of post-thrombotic syndrome which includes chronic pain, swelling and immobility of the affected limb over the next 2 years. The use of compression stockings in persons with deep venous thrombosis has been shown to decrease the development of post-thrombotic syndrome by as much as 50%.

Prevention of CVI in persons with prolonged sitting or standing all day. For all other groups of patients at risk for CVI, we have little additional evidence to guide recommendations for prevention.

Compression stockings (12–18 mm Hg at the ankle) are effective in preventing lower leg swelling and asymptomatic thrombosis (clotting) associated with long airline flights in low- to medium-risk persons, as well as in women with pregnancy associated varicose veins. Compression stockings have also been shown to reduce lower leg venous pressure and reactive oxygen stress in persons with jobs that require prolonged standing. However, studies have been inconclusive about whether use of compression stockings prevents the actual development of CVI (i.e., venous valvular incompetence) among persons at increased risk for future development of CVI.

Similarly, studies have not shown that regular walking or leg elevation prevent CVI in persons with normal venous systems (although of clear benefit once CVI has developed). Nonetheless, regular walking and exercise have important health benefits for the prevention of heart disease, diabetes and obesity.

References

Bamigboye AA et al. Interventions for varicose veins and leg oedema in pregnancy. Cochrane Database Syst Rev. 2007 Jan 24;(1):CD001066.

 [PMID: 17253454]

Barwell JR et al. Comparison of surgery and compression with compression alone in chronic venous ulceration (ESCHAR study): randomised controlled trial. Lancet. 2004 Jun 5;363 (9424):1854–9.

 [PMID: 15183623]

Bergan JJ et al. Chronic venous disease. N Engl J Med. 2006 Aug 3;355(5):488–98.

 [PMID: 16885552]

O’Brien JG et al. Treatment of edema. Am Fam Physician. 2005 Jun 1;71(11):2111–7.

 [PMID: 15952439]

Palfreyman SJ et al. Dressings for healing venous leg ulcers. Cochrane Database Syst Rev. 2006 Jul 19;3:CD001103.

 [PMID: 16855958]

Bronchitis (acute)

Author : Dr Ralph Gonzales Professor of Medicine University of California San Francisco

2008-07-16

What is Bronchitis?

Source : CDC

• Bronchitis refers to inflammation of the airways of the lung, which is usually manifested by cough.

• When illness lasts < 3-6 weeks, it is referred to as “acute bronchitis”

• “Chronic bronchitis” refers to patients with underlying lung disease who have cough and phlegm production regularly for > 6 months (a topic for a separate knol).

The term “bronchitis” refers to inflammation of the bronchus or bronchiolar portions of the lung. It can result from a wide variety of causes that include infections, environmental exposures, and allergic reactions, and is especially troublesome for individuals who have chronic lung disease. The main feature of bronchitis is cough. Individuals with chronic lung disease who have a daily cough with phlegm production are often diagnosed with “chronic bronchitis.” In this Knol, we will deal primarily with bronchitis in adults who do not have chronic bronchitis, also referred to as “acute” bronchitis.

Acute bronchitis is most commonly caused by a viral respiratory infection in patients who have no underlying lung disease. The National Health Interview Survey reports that 1 in 20 adults experience 1 or more episodes of acute bronchitis each year, and the vast majority of these individuals will seek medical attention.

Technically, the term “acute bronchitis” applies to individuals who have been coughing for less than 3-6 weeks and in whom pneumonia or any other obvious cause has been excluded. For patients who cough for longer than 6 weeks, and who have persistent or chronic cough, additional tests and/or treatments should be pursued to identify some other cause of the cough—such as postnasal drip, asthma, or gastroesophageal reflux disease (heartburn).

Because other acute respiratory tract infections such as sinusitis or pharyngitis can also have cough as a symptom, I tend to reserve the diagnosis of acute bronchitis for patients for whom the cough is the dominant symptom (or “chief complaint”). I also reserve acute bronchitis for patients who have been sick for at least 5-7 days, because patients who have been sick only 2 or 3 days with cough illness often resolve by the end of 1 week. Some doctors prefer to use the term “bronchitis” only when sputum production and/or wheezing accompany the cough. Wheezing refers to high-pitched lung sounds that are audible or sometimes heard only by stethoscope, and that usually occur on expiration. Other respiratory symptoms that are common (but not as dominant) among patients diagnosed with acute bronchitis include nasal congestion, sore throat, and low-grade fevers.

What Causes Bronchitis?

• Viruses (> 90%)

• Bacteria (< 10%)

• Allergic and Environmental Exposures (<10%)

Acute bronchitis is usually the result of sequential processes: 1) infection (or exposures) causing inflammation of the airways, and 2) airway inflammation causing cough.

Step 1: Infection

Viruses appear to cause the vast majority of cases of acute bronchitis, although on many occasions there is no specific agent identified. Non-infectious causes include asthma, allergy, and occupational exposures. The specific viruses most frequently associated with acute bronchitis in adults, in descending order of frequency, are influenza, parainfluenza, respiratory syncytial virus (RSV), coronavirus, adenovirus, and rhinoviruses. In children, RSV is the most common cause. Persons at high risk for severe reactions to viral respiratory infections include the elderly, persons in nursing homes, and those living with chronic medical conditions such as heart failure, cancer, or other debilitating disease processes. This underscores the importance of influenza vaccination for persons in these high-risk groups.

A newly discovered virus, human metapneumovirus, has also been shown to cause acute bronchitis. As with most of the viruses above, human metapneumovirus is primarily an illness of the winter months, and most commonly causes significant illness in young children, the immunocompromised, and in elderly individuals. The exact contribution of human metapneumovirus to the burden of acute bronchitis in the US, however, appears to be low.

Bacteria are an uncommon cause (<10% of cases) of acute bronchitis in the general population, with the notable exception of specific outbreaks of Bordetella pertussis, Chlamydia pneumoniae, or Mycoplasma pneumoniae. Some studies have reported the presence of Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis in adults with acute bronchitis; however, these findings are questionable because these studies generally failed to exclude patients with underlying lung disease (who are susceptible to different kinds of infections than persons without chronic lung disease), failed to distinguish between colonization and infection, or did not adequately differentiate patients with pneumonia from those with acute bronchitis when determining causative agents.

In the US, we have now firmly established that people immunized against pertussis as children are still susceptible to infection with pertussis as adolescents and adults—the result of waning immunity. For this reason, the CDC now recommends that all adolescents receive a pertussis “booster” with their 11-12 year vaccination for tetanus, and at least one more time with their regularly scheduled tetanus booster (every 10 years) before age 65.

Step 2: Bronchial Hyperresponsiveness

The hacking cough that characterizes acute bronchitis is primarily due to hyperreactive bronchial airways that follow the initial infection. Infection of the bronchial airways causes inflammation, destruction, and sloughing of the cells that line the airways. Thus, early in the course of acute bronchitis, patients will report fevers, fatigue, congestion, and cough (the "catarrhal" period). After 5-7 days, the fever and fatigue usually resolve, but the cough persists and seems to become more bothersome. At this stage of disease, the bronchial airways have become hyperreactive to many different types of stimuli such as dust, smoke, perfumes, and cold air that previously would not have elicited any. The key symptom that patients experience with hyperreactive airways is cough. Wheezing suggests more severe bronchospasm, but is not a necessary finding for hyperreactivity and abnormal breathing tests to present.

Figure: Illness Duration and Illness Features

Day 0 ------------------> Day 7 -------------------> Day 14 -------------------> Day 21

catarrhal period                               bronchial hyperresponsiveness period

In research studies where pulmonary function tests are performed on consecutive patients with acute bronchitis, breathing abnormalities are found in approximately 40% of patients. These abnormalities are identical to those observed in patients with asthma, except that they will resolve within 2-3 months (by definition) in most patients. Suspicion and work-up for asthma should be reserved for patients with cough lasting longer than 3-6 weeks. On the other hand, recurrent episodes of "acute bronchitis" may suggest underling asthma and could justify more aggressive treatment and evaluation earlier in the acute bronchitis episode.

Who Gets Bronchitis?

-Smokers
-Exposure to Children

Persons who are more frequently exposed to respiratory viruses at school, work or home are also more likely to acquire the infection. This includes children in school and day care, as well as adults who work or take care of children (eg, parents).

A second group of people who are more likely to “catch” a respiratory infection when exposed is those who have weakened immune systems. Of course, people who have conditions that suppress their immune system such as HIV or AIDS, and people who take medications or treatments that suppress their immune system such as prednisone, methotrexate, and chemotherapy, are more likely to acquire and have severe responses to viral respiratory infections. However, a much larger group of otherwise healthy people at increased risk for acquiring respiratory infections are those who smoke cigarettes, those who are sleep deprived, and those who are experiencing excess emotional or physical stress.

How Do I Know if I Have Bronchitis? 

Development of a new cough illness that has lasted for more than 5-7 days is the first clue that you could have bronchitis, especially if it began with other symptoms of a cold or sinus infection such as runny nose, fevers, and fatigue. Coughing up phlegm and mild wheezing on expiration are other common findings in patients with acute bronchitis. It is also common for patients to report that the cough is worse at night, when they are exposed to cold air, perfumes, or smoke, and when they try to exercise.

When Should I Seek Care for Bronchitis?

The most important condition that could cause all of the same symptoms as acute bronchitis is pneumonia, which could be life-threatening if left untreated. I have provided a list of some of the symptoms or conditions that should lead you to contact a health care provider. These symptoms may indicate pneumonia, may put you at increased risk of developing pneumonia, or may indicate another more serious illness:

• Fever

• High fever (>102 F.) outside of flu season or when known flu is not circulating.

• Fever (>100 F.) that lasts more than 5 days.

• Feeling short of breath or winded at rest or with mild exertion

• Cough producing blood
• Cough lasting more than 3 weeks
• Light-headedness or feeling faint
• Confusion or not thinking clearly
• Severe headache, ear pain, sinus pain, or chest pain
• Fast pulse (>100 beats per minute at rest in adult)
• Prior history of pneumonia
• Suppressed immune system due to underlying conditions or medications
• Congestive heart failure, chronic lung disease, cirrhosis/liver disease, chronic kidney disease, sickle cell anemia
• Possible exposure to tuberculosis

The key things that currently can only be done at the doctor’s office are the accurate measurement of your vital signs (temperature, heart rate, blood pressure, and oxygen levels in your blood), and physical examination of your heart and lungs. If your cough has lasted more than 3 weeks, then your health care provider may order a chest x-ray.

What Treatments Are Available For Acute Bronchitis?

1. The Antibiotic Myth.

The public frequently expects or demands, and doctors frequently prescribe, antibiotics for acute bronchitis even though 10 different clinical trials that have been published in the medical literature do not show any major benefit to antibiotic treatment with regard to cough severity, cough duration, or illness resolution. Unless your doctor suspects pneumonia, pertussis, or that you have been exposed to a Chlamydia or Mycoplasma outbreak, antibiotics are not likely to have any benefit for you. On some occasions, patients who think they have acute bronchitis actually have sinusitis, and for some of these patients antibiotic treatment is warranted.

The Antibiotic Travesty - Unnecessary antibiotic use for viral respiratory infections contributes to many millions of antibiotic prescriptions in the US (the last estimate being > 20 million in 1998). This contributes to the emergence and epidemic of new strains of bacteria that are resistant to common antibiotics. We have already seen this in bacteria that cause ear and respiratory tract infections, skin infections, intestinal infections, and urinary tract infections. Many experts believe that we are close to returning to the “pre-antibiotic era” – we will have created an environment in which we have no defenses against bacteria --if we do not get this problem under control.

Using antibiotics also increases the individual’s personal risk of acquiring and spreading resistant bacteria. Although most persons do not feel sick when they are colonized with resistant bacteria, they spread these germs to their family and friends through hand-to-hand/casual contact… and increase the chances that a new infection among these persons will be caused by resistant bacteria.

2. Effective Treatments

• Rest. There is good evidence that sleep deprivation, and emotional and physical stress suppress the body’s immune system and increase the severity and duration of these illnesses. For example, research studies show that persons with high levels of emotional stress are more likely to get sick when exposed to a respiratory virus; and that up to 50% of persons completing marathons will catch a cold afterward. Although there are no studies that have rigorously compared rest with no rest, there is a strong rationale for recommending that persons get enough sleep and do not physically overexert themselves when they have acute bronchitis.

• Hydration and Humidifier. Although never studied in persons with acute bronchitis in the community, studies of hospitalized patients show that humidified air can improve mobilization of lung secretions. I recommend to all patients that they try to stay well-hydrated (ie, drink at least 8 cups, or 2 liters of fluids per day), and that persons living at high altitude (>5000 ft above sea level) or whose homes use a lot of dry heat in the winter use a humidifier at night..

• Dextromethorphan. This medication can be purchased over-the-counter, can be found in many different brands of cough syrup, and does not generally cause drowsiness. Research studies show that it can have a mild-to-modest benefit on cough frequency and severity.

• Albuterol Inhaler. This is a prescription medication that is most commonly used in patients with asthma to reverse tightening of their airways. Because tightening of the airways is present in up to half of all adults with acute bronchitis, it makes sense that this medication can help. In patients diagnosed with acute bronchitis, it decreases total cough duration by about 1 day. I reserve albuterol treatment for patients seeking cough relief who have been sick for at least 7 days. Albuterol does not help seem to help patients with nonspecific cough illness who have been sick fewer than 7 days.

• Pelargonium sidioides. This is an herbal therapy derived from a South African geranium plant. It is available in the US from a variety of producers. When started within 48 hours of illness onset, studies in Germany and Russia have reported a big decrease in cough and illness duration… greater than any other published treatments for acute bronchitis. However, the validity of these results is suspect because the principal manufacturer of the formulation (EPs 7630; Iso-Arzneimittel, Ettlingen, Germany) would not provide approval for our research group at UCSF to confirm their study’s findings in a US patient population.

• Anti-influenzal Therapy. There are 4 treatments available in the US, and all must be started within 48 hours (and preferably within 30 hours) of illness onset in order to be beneficial. Amantadine, rimantadine, zanamivir, and oseltamivir have all been shown to decrease illness duration by approximately 1 day, and may lead to a ½ day quicker return to normal activities. Side effects are more common with rimantadine (most commonly, altered mentation) than with the neuraminidase inhibitors. Currently, the US Centers for Disease Control (CDC) recommend use of either zanamivir or oseltamivir as first-line treatment of influenza.

3. Ineffective Treatments

• Antibiotics (see above). Antibiotics might be effective if you have chronic lung disease, have been exposed to pertussis, or have a suppressed immune system.

• Guaifenesin. This is the active ingredient in Robitussin and many other over-the-counter formulations. Manufacturers claim that is is effective in loosening and helping to mobilize your lung secretions. But well-designed research studies do not show it to be beneficial.

• Echinacea. Research studies have shown no difference between Echinacea (all types) and placebo.

• Zinc gluconate and zinc acetate. For cough illness, there is no evidence that zinc works. For the common cold, there is 1 study that showed benefit, but several other studies that showed no benefit.

• Vitamin C. Even at appropriate doses (1 gram/day), studies show that Vitamin C is no better than placebo at improving illness resolution with the common cold or acute bronchitis.

What Can I Do to Prevent Getting Acute Bronchitis?

• Hand Hygiene. The germs that cause acute bronchitis are spread not only by respiratory droplets (from a cough), but just as commonly by hand contact. After you have touched a contaminated surface, you inoculate yourself with the germs when you touch or itch your eyes, nose, or mouth. Therefore, wash or disinfect your hands frequently when you’re in public or in close contact with sick persons. The CDC recommends the following techniques:

• Wet hands with running water; place soap in palms; rub together to make a lather; scrub hands vigorously for 20 seconds (about the time it takes to sing “Happy Birthday twice through”; rinse soap off hands.
• If possible, turn off the faucet by using a disposable paper towel.

• Dry hands with a disposable paper towel. Do not dry hands on clothing.

• Assist young children with washing their hands.

• Quit Smoking and Avoid Second Hand Smoke. Tobacco smoke impairs the lungs’ natural immune defenses, and increases susceptibility to catching colds and other respiratory viruses. Tobacco smokers are also more likely to get severe bacterial infections, and these complicate routine acute bronchitis.

•  Influenza vaccination. Preventing flu is perhaps the best thing you can do to prevent at least 1 episode (but not all potential episodes) of acute bronchitis.

• Pertussis booster. This is a new recommendation that all health care providers should be following. When you receive your next scheduled tetanus shot (routinely, or when you have a cut or skin wound), the new tetanus booster also includes a pertussis booster. If you are someone who works in health care settings, or in childcare settings/schools, check with your health care provider sooner.

• Vitamin C. Although ineffective for treatment of cough illness after it has developed, Vitamin C (1 gm/day) has been shown to help prevent cold and other respiratory tract infections among persons with increased physical stress (such as the malnourished or post-marathon).

What are Complications of Acute Bronchitis?

Besides difficulty sleeping, painful coughing, and being a nuisance to people around you, persons with acute bronchitis can rarely develop complications that should lead them to consult their health care provider, such as:

• Rib Fractures. This usually manifests as severe, localized pain with inspiration (breathing in).

• Vomiting. Recurrent vomiting associated with severe coughing spasms warrants stronger cough suppression.

• Pneumonia. Even if you do not have pneumonia at the initial doctor’s visit, the viruses that cause acute bronchitis can put you at increased risk for developing a subsequent bacterial pneumonia. After 3-5 days if your cough illness begins to get worse instead of better (such as difficulty breathing, fever, or nausea and vomiting), see a doctor right away.

What if My Acute Bronchitis/Cough Doesn’t Go Away After 3-6 Weeks?

A very small proportion of patients who look like they have acute bronchitis may, in fact, have other conditions that are causing their persistent cough. The most common of these are asthma, postnasal drip, and gastroesophageal reflux disease (GERD; also commonly known as heartburn). If you cough and produce phlegm for more than 6 months, you have likely developed chronic bronchitis.

Where Can I get More Information?

The Centers for Disease Control and Prevention http://www.cdc.gov/drugresistance/community/files/ads/cough.htm

The American College of Chest Physicians http://chestnet.org/patients/guides/cough.php

References

Aagaard E, Gonzales R. Management of Acute Bronchitis. Infectious Disease Clinics in North America, 2004;18:919-37.  PMID: 15555832

Bent S, Saint S, Vittinghoff E, Grady D. Antibiotics in acute bronchitis: a meta-analysis.
Am J Med. 1999 Jul;107(1):62-7.  PMID: 10403354

Douglas RM, Hemilä H, Chalker E, Treacy B. Vitamin C for preventing and treating the common cold. Cochrane Database Syst Rev. 2007 Jul 18;(3):CD000980.  PMID: 17636648

Fiore AE, Shay DK, Haber P, Iskander JK, Uyeki TM, Mootrey G, Bresee JS, Cox NJ; Advisory Committee on Immunization Practices (ACIP), Centers for Disease Control and Prevention (CDC).  Prevention and control of influenza. Recommendations of the Advisory Committee on Immunization Practices (ACIP), 2007. MMWR Recomm Rep. 2007 Jul 13;56(RR-6):1-54.  PMID: 17625497

Gonzales R, Bartlett JG, Besser RE, Cooper RJ, Hickner JH, Hoffman JR, Sande MA. Principles of appropriate antibiotic use for treatment of uncomplicated acute bronchitis: background. Clinical Practice Guideline, Part 2.  Annals of Internal Medicine, 2001;134:521-529. PMID: 11385346

 Gonzales R.  Curbside Consultation: Patients’ preconceptions and convictions about antibiotics. American Family Physician, 2005;72:1900-03.  (no PMID)

Irwin RS, Baumann MH, Bolser DC, Boulet LP, Braman SS, Brightling CE, Brown KK, Canning BJ, Chang AB, Dicpinigaitis PV, Eccles R, Glomb WB, Goldstein LB, Graham LM, Hargreave FE, Kvale PA, Lewis SZ, McCool FD, McCrory DC, Prakash UB, Pratter MR, Rosen MJ, Schulman E, Shannon JJ, Smith Hammond C, Tarlo SM; American College of Chest Physicians (ACCP). Diagnosis and management of cough executive summary: ACCP evidence-based clinical practice guidelines. Chest. 2006 Jan;129(1 Suppl):1S-23S.  PMID: 16428686