(中文部分使用GOOGLE翻譯) (原文在下面)
急性支氣管炎
患者通常會出現持續超過 5 天的咳嗽，並且可能伴隨痰液產生。咳嗽通常會在 3 週內消失，但也可能持續長達 8 週。急性支氣管炎通常由病毒引起，有限的證據支持使用抗生素治療其他健康成年人的急性支氣管炎。服用抗生素不會顯著改變後續就診時出現的咳痰或活動受限；然而，它們的使用有增加副作用的趨勢。[ 6 ]
對於患有多種合併症的老年患者，抗生素治療急性支氣管炎的作用可能有限，儘管這通常是病毒性的，因此閾值應該較低。
症狀治療包括視情況使用止咳藥（右美沙芬或可待因）、黏液溶解劑和支氣管擴張劑（沙丁胺醇）。
無潛在心臟或肺部疾病且持續咳嗽超過 14 天的患者應接受百日咳評估。
慢性支氣管炎
慢性支氣管炎通常定義為連續 2 年至少 3 個月在每個月的大部分時間出現咳嗽和咳痰。慢性支氣管炎是由於氣道黏液分泌過多（即發炎、氧化壓力、感染）和清除減少（即纖毛功能差、氣道閉塞、呼吸肌無力）而導致的。這是一種表現各異的現象，最常見於有吸入暴露（例如吸煙）的個體，並且通常與慢性阻塞性肺病（COPD）同時發生。
不建議經驗性抗生素治療。儘管以其抗炎特性而聞名的慢性大環內酯療法可以減少慢性阻塞性肺病（COPD）的惡化，但它對基線慢性支氣管炎患者並沒有顯示出任何額外的益處。
一項對939 名患有COPD、慢性支氣管炎且基線血液嗜酸性粒細胞計數≥300 個細胞/μL 的患者進行的3 期隨機試驗表明，白細胞介素4 受體α 拮抗劑dupilumab 可減少病情加重(34%) 和呼吸道症狀嚴重程度，並改善與安慰劑相比，1和生活品質。 [ 13 ] 然而，dupilumab 尚未獲得美國食品藥物管理局的批准用於此應用。
減少黏液產生
戒菸和避免環境刺激物會減少杯狀細胞的刺激和增生。
抗膽鹼能藥物透過作用於毒蕈鹼受體來減少黏液分泌；然而，請謹慎使用，因為它們可能會使呼吸道脫水，使分泌物更難咳出。
吸入性糖皮質激素可減少炎症，進而減少黏液的產生。
PDE-4抑制劑（例如羅氟司特）可以透過減少黏液分泌來減少伴隨慢性支氣管炎的患者的COPD惡化。慢性阻塞性肺病全球倡議。 COPD 診斷、管理和預防全球策略 (GOLD) 指南建議，對於 FEV 1 < 預測值 50% 且在過去 12 個月內至少有一次因病情加重住院的 COPD 患者，請考慮添加羅氟司特。[ 12 ]
PDE-4抑制劑（例如羅氟司特）可以透過減少黏液分泌來減少伴隨慢性支氣管炎的患者的COPD惡化。慢性阻塞性肺病全球倡議。 COPD 診斷、管理和預防全球策略 (GOLD) 指南建議，對於 FEV 1 < 預測值 50% 且在過去 12 個月內至少有一次因病情加重住院的 COPD 患者，請考慮添加羅氟司特。[ 12 ]
促進粘液排出
胸部物理治療或撲動閥等物理操作可能有助於增強剪切應力，以幫助黏液分解和清除（可用的證據很少）。
胸部物理治療或撲動閥等物理操作可能有助於增強剪切應力，以幫助黏液分解和清除（可用的證據很少）。
甲基黃嘌呤和短效β受體激動劑可增加氣道管腔直徑，增強纖毛跳動頻率，並透過活化囊性纖維化跨膜調節劑促進黏液水合作用。
直接吸入高滲透壓鹽水以補充氣道水分並促進咳嗽（顯示益處的證據很少）。
祛痰藥（例如癒創甘油醚）會透過迷走神經增加氣道分泌物，從而在短期內改善黏液清除（未發現長期益處）。
慢性支氣管炎急性細菌性惡化
在所有慢性支氣管炎急性細菌性惡化 (ABECB) 病例中，不到一半的病例中發現了細菌病原體。安東尼森標準通常用於限定急性惡化的嚴重程度。考慮三個臨床因素：呼吸困難、痰液和痰膿性。對於中度（3 種症狀中的 2 種）或重度（所有 3 種症狀）惡化，建議使用抗生素治療。痰液顏色的變化也被認為是 ABECB 中潛在病理微生物存在的強烈預測因子。綠色和黃色痰比白色痰更有可能呈現培養陽性。
對於輕度 ABECB，不建議使用抗生素。患者應接受門診對症治療並監測症狀是否惡化。
2021 年，美國醫師學會 (ACP) 建議，對於具有細菌感染臨床症狀的慢性阻塞性肺病 (COPD) 急性惡化和急性單純性支氣管炎患者，抗生素治療應限制在 5 天。[ 14 ]
用於治療中度 ABECB 和/或以下任何一種情況的抗生素方案：年齡 < 65 歲、FEV1 > 50% 預測、無心臟病或每年< 3 次急性惡化：
第一天口服阿奇黴素500 毫克，然後接下來 4 天每天口服 250 毫克，或
克拉黴素250-500 mg PO BID，持續 7-14 天或
多西環素100 mg PO BID，持續 7 天或
甲氧芐啶-磺胺甲噁唑(160 mg/800 mg) 1 DS 錠劑 PO BID，持續 10-14 天或
頭孢呋辛250-500 mg PO q12h 持續 10 天或
頭孢地尼300 mg PO BID，持續 5-10 天或
頭孢泊肟200 mg PO q12h 持續 10 天
如果 3 個月內接觸過抗生素，請使用替代類別。
甲氧芐啶-磺胺甲噁唑(160 mg/800 mg) 1 DS 錠劑 PO BID，持續 10-14 天或
頭孢呋辛250-500 mg PO q12h 持續 10 天或
頭孢地尼300 mg PO BID，持續 5-10 天或
頭孢泊肟200 mg PO q12h 持續 10 天
如果 3 個月內接觸過抗生素，請使用替代類別。
嚴重 ABECB 和/或任何以下情況：年齡 ≥65 歲、FEV 1 ≤ 預測值的 50%、心臟病或每年 ≥3 次急性加重，考慮住院治療。抗生素治療方案包括[ 10 ]：
阿莫西林克拉維酸（875 毫克/125 毫克）1 片，每日兩次，口服，持續 7-10 天或
每天口服左氧氟沙星 750 毫克，持續至少 7 天或
莫西沙星400 mg 口服，每日 5 天
如果有假單胞菌感染的風險，請考慮進行痰液培養並每天口服左氧氟沙星 750 mg PO，持續 14 天。[ 11 ]
如果最近 3 個月內接觸過抗生素，請使用替代類。
Empiric Therapy Regimens for Bronchitis
Empiric therapeutic regimens for bronchitis are outlined below, including those for acute bronchitis, chronic bronchitis, and acute bacterial exacerbation of chronic bronchitis. [1, 2, 3, 4, 5, 6, 7, 8, 9]
See Bronchitis and Chronic Obstructive Pulmonary Disease for full discussions of these topics.
Acute bronchitis
Patients typically present with a cough that lasts more than 5 days and may be associated with sputum production. Cough usually resolves within 3 weeks but may linger for up to 8 weeks. Acute bronchitis is typically caused by viruses and there is limited evidence to support the use of antibiotics for treating acute bronchitis in otherwise healthy adults. Antibiotic administration does not significantly alter presence of productive cough or activity limitations at follow-up doctor visits; however, there is a trend toward increased adverse effects with their use. [6]
There may be a limited role for antibiotic treatment of acute bronchitis in elderly patients with multiple comorbidities, although this typically is viral so the threshold should be low.
Symptomatic treatment includes the use of cough suppressants (dextromethorphan or codeine), mucolytics, and bronchodilators (albuterol), where appropriate.
Patients without underlying heart or lung disease who present with a persistent cough lasting more than 14 days should be evaluated for pertussis.
Chronic bronchitis
Chronic bronchitis is typically defined as cough and sputum production on most days of the month for at least 3 months of the year for 2 consecutive years. Chronic bronchitis results from excessive airway mucus due to increased production (ie, inflammation, oxidative stress, infection) and decreased clearance (ie, poor ciliary function, airway occlusion, respiratory muscle weakness). It is a phenomenon with variable presentations that is most common in individuals with inhalation exposures, such as smoking, and often coincides with chronic obstructive pulmonary disease (COPD).
Empiric antibiotic therapy is not recommended. Although chronic macrolide therapy, known for its anti-inflammatory properties, reduces COPD exacerbations, it does not show any additional benefit in patients with baseline chronic bronchitis.
A phase 3 randomized trial of 939 patients with COPD, chronic bronchitis and a baseline blood eosinophil count ≥300 cells/μL has shown that interleukin-4 receptor alpha antagonist, dupilumab, reduced exacerbations (34%) and respiratory symptom severity as well as improved FEV1 and quality of life when compared to placebo. [13] However, dupilumab has not yet been approved by the US Food and Drug Administration for this application.
Reduce mucus production
Smoking cessation and avoidance of environmental irritants will decrease goblet cell stimulation and hyperplasia.
Anticholinergics decrease mucus secretion via their action on the muscarinic receptors; however, use with caution as they may dehydrate airways making secretions more difficult to expectorate.
Inhaled glucocorticoids reduce inflammation and thus mucus production.
PDE-4 inhibitors (eg, roflumilast) may decrease COPD exacerbations in patients with concomitant chronic bronchitis by decreasing mucus secretions. The Global Initiative for Chronic Obstructive Lung Disease. Global strategy for diagnosis, management, and prevention of COPD (GOLD) guidelines recommend considering adding roflumilast in patients with COPD, FEV1< 50% predicted, and at least one hospitalization for an exacerbation in the past 12 months. [12]
Facilitate mucus elimination
Physical maneuvers such as chest physical therapy or flutter valve may help to augment shear stressors to aid mucus breakdown and clearance (minimal evidence available).
Methylxanthines and short-acting beta agonists increase airway lumen diameter, intensify ciliary beat frequency, and promote mucus hydration via activation of the cystic fibrosis transmembrane regulator.
Inhaled hypertonic saline directly to rehydrate airways and promotes cough (minimal evidence to show benefit).
Expectorants (eg, guaifenesin) vagally medicate increase in airway secretions improving mucus clearance in the short term (no long-term benefit found).
Acute bacterial exacerbation of chronic bronchitis
Bacterial pathogens are identified in less than half of all acute bacterial exacerbation of chronic bronchitis (ABECB) cases. The Anthonisen Criteria is typically used to qualify severity of acute exacerbations. Three clinical factors are considered: dyspnea, sputum volume, and sputum purulence. Antibiotic treatment is recommended for moderate (2 of 3 symptoms) or severe (all 3 symptoms) exacerbations. Change in sputum color has also been recognized to be a strong predictor of presence of potentially pathologic microorganisms in ABECB. Green and yellow sputum are more likely than white sputum to be culture positive.
For mild ABECB no antibiotics are recommended. Patients should receive outpatient symptomatic therapy and be monitored for worsening symptoms.
In 2021, the American College of Physicians (ACP) recommended that antibiotic treatment should be limited to 5 days in patients with COPD exacerbations and acute uncomplicated bronchitis who have clinical signs of a bacterial infection. [14]
Antibiotic regimens for the treatment of moderate ABECB and/or any one of the following: age < 65 years, FEV1 >50% predicted, no cardiac disease, or < 3 exacerbations per year include:
Azithromycin 500 mg PO on first day then 250 mg PO daily for next 4 days or
Clarithromycin 250-500 mg PO BID for 7-14 days or
Doxycycline 100 mg PO BID for 7 days or
Trimethoprim-sulfamethoxazole (160 mg/800 mg) 1 DS tablet PO BID for 10-14 days or
Cefuroxime 250-500 mg PO q12h for 10 days or
Cefdinir 300 mg PO BID for 5-10 days or
Cefpodoxime 200 mg PO q12h for 10 days
If there has been antibiotic exposure within 3 months, use an alternative class.
Severe ABECB and/or anyone of the following: age ≥65 years, FEV1 ≤ 50% predicted, cardiac disease, or ≥3 exacerbations per year, consider hospitalization. Antibiotic regimens include [10] :
Amoxicillin-clavulanate (875 mg/125 mg) 1 tablet PO BID for 7-10 days or
Levofloxacin 750mg PO daily for at least 7 days or
Moxifloxacin 400 mg PO daily for 5 days
If at risk for Pseudomonas infection consider sputum culture and treatment with levofloxacin 750 mg PO daily for 14 days. [11]
If recent antibiotic exposure within 3 months, use alternative class.
