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Three Part Question

In [adults with acute bronchitis with cough as a major symptom] are [inhaled beta2-agonists (i.e. albuterol, levalbuterol or salbutamol) better than standard symptomatic therapy] in regards to [improvement in severity or duration of the cough]?

Clinical Scenario

A 45-year-old woman presents to the ED with acute bronchitis. She requests medicine for severe cough. You wonder if there is sufficient evidence to support the use of inhaled beta-2-agonists for the treatment of cough in patients with acute bronchitis.

Search Strategy

Medline 1950-10/08 using the OVID interface, Cochrane Library (2008), PubMed
[(Bronchitis/th) AND (exp Acute disease)]. LIMIT to human AND English

Search Outcome

271 papers were found, only two (2) randomized, placebo-controlled trials have examined the effect of Beta-2-agonists administered by aerosol for cough associated with acute bronchitis.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Melbye, H., Aasebo, U., and Straume, B. 1991 Norway	Non-pregnant adult (ages 18 to 69 years) patients presenting to a general practitioner (most in the emergency ward) for a respiratory infection who were still suffering from a cough after seven (7) days Exclusion: Patients with known pneumonia, tonsillitis, asthma, chronic obstructive pulmonary disease, chronic bronchitis, and heart disease. Also excluded were those patients with possible sinusitis without dyspnea or wheezes on auscultation, patients with oral temperatures >38-degrees centigrade or FEV1 <60% of predicted, and patients started on antibiotics within 3 days.	Randomized double-blinded, placebo-controlled trial of Fenoterol 0.2 mg inhaled vs inhaled placebo	Daytime cough decrease vs placebo	62% vs. 43% (p = NS, 0.10)	Study was conducted in the "Chest Clinic" at a University Hospital. Patients were told to follow-up at the University Hospital if they continued to have discomfort from cough or dypsnea after 10 days of illness, which narrows the patient spectrum substantially (104 patients, 60 of which were eligible). Also, the staff "actively recruited" patients with known lower respiratory tract infection for the study (35 recruited, 22 eligible) Small sample size (N = 73)
			Nighttime cough decrease vs placebo	76% vs. 70% (p = NS, 0.62)
			Sputum production decrease vs placebo	65% vs. 33% (p = 0.03)
			FEV1 (% predicted) increase vs placebo	5.1% vs 0.5% (p = 0.006)
Hueston, William J. Nov. 1994 USA	Adult patients aged 18 to 65 attending two community-based family practice centers in Wisconson and Kentucky.	46 patients in a double-blind, randomized placebo-controlled trial, with four (4) study groups: albuterol MDI or placebo inhaler, AND erythromycin (250 mg) or placebo	Decrease in percentage of patients still coughing after 7 days vs. placebo	61% vs 91%, P=0.02	Only 46 patients enrolled (study suspended early due to statistically significant results of primary study outcome = resolution of cough)
			Ability to return to work vs placebo	78% vs. 52%, P=0.05

Comment(s)

There is very limited evidence in regards to the benefit of inhaled bronchodilators for improving symptoms of acute bronchitis. A few of the observations taken from these studies are: 1) Both studies had at least a trend towards improving various symptoms of acute bronchitis, although the sample sizes in both studies were small and statistical significance was rarely achieved; 2) The side effects from the bronchodilators (e.g.albuterol) are mild; 3) Both studies excluded patients with known bronchoconstrictive lung disease and other historical factors, who, likely, would have a greater benefit with brochodilators in acute cough/acute bronchitis.

Clinical Bottom Line

In patients with acute bronchitis there is insufficient evidence to recommend the routine use of brochodilators for symptomatic relief, BUT there may be certain subgroups of patients with hyperactive airways (asthmatics, smokers, etc.) who may benefit more than the patients examined in the reviewed studies.

References

1. Melbye, H., Aasebo, U., and Straume, B. Symptomatic Effect of Inhaled Fenterol in Acute Bronchitis: A Placebo-Controlled Double-Blind Study Family Practice 1991, Vol. 8, No. 3, pp 216-22
2. Hueston, William J. Albuterol Delivered by Meter-Dose Inhaler to Treat Acute Bronchitis The Journal of Family Practice 1994, Vol. 39, No. 5, pp 437-40