Will Steroids Help With Bronchitis?

Overview

Bronchitis is the most common acute respiratory tract infection during the early years of life.¹ Acquired respiratory viruses cause bronchitis, and viral infection has demonstrated substantial morbidity in children.² Ongoing investigation on bronchitis calls for further evidence on its therapeutic management, namely via the use of newly-emerging steroids. Systematic reviews have assessed the use of corticosteroids in the past yet have failed to provide convincing evidence that supports acute or chronic management of bronchitis.³ Thus, routine use of steroids is not recommended in current clinical practice guidelines.⁴ Despite conflicting literature, some reports have shown oral or parenteral corticosteroids and inhaled corticosteroids to be efficacious in treating bronchitis.⁵ This article discusses what bronchitis is, the effectiveness of steroid use in treatment, and further treatment options.

About Bronchitis

Bronchitis is an infection of the lower respiratory tract whereby the main airways of the lungs (bronchial tubes) become inflamed and irritated. Patients with bronchitis have a viral respiratory infection with transient inflammatory changes that trigger the production of mucus and obstruction of the airways.⁶ Bronchitis can affect individuals of all ages, but it is most common in younger children.⁷ 

Types of bronchitis

Bronchitis is described as being either acute bronchitis or chronic bronchitis. Acute bronchitis is caused by the same viruses that cause the common cold. It is a temporary inflammation of the airways that manifests as a sore throat, runny nose or sinus infection. Inflammation irritates the lungs, causing a cough accompanied by mucus production for up to three weeks.

Chronic bronchitis, a type of chronic obstructive pulmonary disease (COPD), is characterised by persistent and irreversible inflammation in the bronchial tubes, resulting in a mucus-producing cough on most days of the month for at least three months a year. The inflamed bronchial tubes over-produce mucus, leading to persistent coughing and obstruction of the airways. Inflammation can last several months.⁸

In summary, true bronchitis is characterised by an infection of the bronchial tubes with resultant bronchial and pleural oedema and mucus formation⁹. Patients will then develop a persistent cough and may show signs of airway inflammation or bronchial obstruction, such as:

• Wheezing: the high-pitched whistling sound made with difficulty breathing. 
• Dyspnea on exertion: shortness of breath during exhalation. Individuals feel they cannot breathe fast or deep enough while exercising or exerting physical effort.

Causes

Bronchitis has many known causes; it is not limited to infection only. The leading causes include:

• Viral infection: viruses are the most common cause of bronchial inflammation in otherwise healthy individuals with acute and chronic bronchitis.¹⁰ The most common viruses are enterovirus, influenza A and B, coronavirus, respiratory syncytial, and rhinovirus.¹⁰ Studies have shown that non-viral agents cause acute bronchitis in very few cases, with certain bacteria responsible for respiratory infection.¹¹ 
• Smoking: incidence of chronic bronchitis is greater in smokers when compared to non-smokers.⁷ In an early 1954 study, the incidence of bronchitis increased severely with increased smoking.¹² It was unlikely to have arisen by chance. In addition, these authors found that over 50% of smokers had aggravated their bronchitis with continued tobacco inhalation and that a large proportion who quit regular smoking alleviated the severity of their bronchitis. 
• Chemical/inhalant exposure: frequent exposure to harmful materials may increase the risk of chronic bronchitis and COPD.⁷ Inhalation of dust, textiles, ammonia, acids, chlorine and flavourings has been shown to exacerbate bronchitis¹³, commonly referred to as ‘occupational bronchitis’. Another study also concluded that certain occupations increased morbidity and mortality from bronchitis, which shares irritant inhalant exposure at work and in the surrounding environment.¹⁴ 
• Pollution: high concentrations of air pollutants are positively associated with increased prevalence of bronchial asthma and chronic bronchitis.¹⁵ Short-term and long-term exposure to pollutants has increased the risk of COPD in large populations.¹⁶ Conversely, when the concentration of contaminants decreases, the adverse health effects minimise.
• Other underlying respiratory issues: bronchitis can occur in response to severe asthma and can be secondary to mucosal injury.¹⁷ Bronchitis is now a well-defined feature of bronchial asthma, cough variant asthma and COPD. Asthma also determines the severity of bronchitis, increasing exacerbations of the disease.¹⁸

Symptoms

The most prevalent bronchitis symptoms include infection of the bronchial tree with residual bronchial oedema and mucus formation. Individuals will develop a persistent cough and possible signs of bronchial obstruction, such as wheezing or dyspnea. Bronchial obstruction produces symptoms similar to mild asthma.¹⁹ In one study, reduced forced expiratory volume and vital capacity were synonymous with bronchitis symptoms.²⁰

Figure: Symptoms of Acute and Chronic Bronchitis

Created by Aastha Malik

Diagnosis

Patients with acute bronchitis have an associated viral respiratory infection with temporary changes that produce mucus and airway obstruction. 

A cough is the most predominant symptom of bronchitis.²¹ Practitioners must conduct thorough investigations to ensure correct and accurate diagnoses; a cough is commonly confused with other respiratory disorders. At least 90% of acute bronchitis cases are viral,²¹ and yet antibiotics are routinely prescribed, suggesting a need for further investigation into effective diagnostic and treatment options. 

Differential diagnosis should include non-pulmonary causes of cough and dyspnea to distinguish other diseases. For example, a cough, dyspnea and wheezing are symptoms of cognitive heart failure.²² In addition, reflux oesophagitis with chronic aspiration can induce inflammation of the bronchial tubes, accompanied by coughing or airway obstruction. Coughs and obstructions are symptoms synonymous with tumours and cancerous sites in the respiratory tract.²³

COPD symptoms worsen at night,²⁴ which can also help with diagnostic criteria. Therefore, it is imperative that practitioners ask patients about night coughing and should conduct spirometry tests to detect wheezing.

Treatment for bronchitis

Steroids

Effect of steroids on chest infections

Corticosteroids have been widely used to prevent lung injury caused by pneumonia due to pharmacological effects on systematic inflammation.²⁵ A 2020 study endorsed the benefits of low-dose corticosteroid treatment for critically ill patients with 2019-CoV.²⁶ In addition, corticosteroid treatment effectively inhibited respiratory inflammation, which allowed increased time for controlling pneumonic infection and preventing secondary organ damage.²⁶ Thus, corticosteroids have synergistic effects when coupled with other treatment options against severe novel coronavirus pneumonia.

Will steroids help with bronchitis?

Many systematic reviews have assessed the effectiveness of different treatment options for bronchitis.²⁶ Such studies have evaluated corticosteroids, beta-agonists, adrenaline, antibiotics and ribavirin in treating acute bronchitis.

A 2003 study investigated several treatment options that proved efficacious for bronchitis management,²⁷ including bronchodilators (adrenaline, salbutamol, alone or combined), oral and parenteral corticosteroids (dexamethasone) and inhaled corticosteroids (budesonide).²⁷ Subgroup analysis examining the use of bronchodilators and steroids showed positive effects. Administration of adrenaline with steroids demonstrated a statistically significant reduction in bronchitis severity by 33%. When accompanied by other bronchodilators (salbutamol), the pairing with steroids showed a similar magnitude of effects (32%).²⁷ Overall, a significant difference in bronchitis severity followed the administration of steroids with bronchodilators.

Steroids and salbutamol have shown benefits compared with placebo over extended follow-up periods (3-12 hours).  

In contrast, however, a 2019 study concluded otherwise.²⁸ This double-blinded, randomised trial compared the duration and severity of a bronchitis-induced cough and lower respiratory tract symptoms following the administration of steroids. Mean symptoms severity scores were not significantly different on days 2 to 4. Steroids had not reduced the duration of coughing either. Thus, researchers finalised that steroids do not help improve patient-orientated or clinical outcomes in nonasthmatic acute bronchitis.

Antibiotics 

Antibiotic treatment does not affect the severity of acute bronchitis due to the nature of the disease. As a viral-induced infection, antibiotics are used to treat bacterial infections and thus are ineffective against bronchitis.²² Despite clinical understanding that antibiotics are ineffective for acute and chronic bronchitis, antibiotics continue to be prescribed to meet patient expectations rather than treat any symptoms.²⁹

Vaccines 

Administration of the H influenza vaccine in those with chronic bronchitis and COPD showed a slight reduction in the acute exacerbation of chronic bronchitis, however, the results were not significant.³⁰ Vaccines did not affect mortality rate, quality of life, recurrence of chronic bronchitis exacerbations or the severity of exacerbations.³⁰ Patients should also have the flu and pneumonia vaccines annually to prevent bronchial infection.³¹  

Oxygen therapy 

High-flow oxygen therapy has been increasingly used in patients with chronic bronchitis when normal breathing becomes difficult. Among infants treated with standard and high-flow oxygen therapy, results showed an escalation of care and alleviation of bronchitis symptoms.³²

Surgery

Lung volume reduction surgery in those with bronchitis-induced tissue damage has improved lung function effectively.³³ Lung histopathology in patients with severe damage to the alveoli (due to widespread inflammation) was efficacious in improving respiratory readings, such as Forced Expiratory Volume (FEV), six months post-surgery.³³

Bronchodilator medications 

Administered orally or inhaled via aerosol sprays, bronchodilator medications, specifically adrenaline and salbutamol, help to relieve symptoms of chronic bronchitis and other COPDs by ‘dilating’ (opening up) the bronchial tubes to aid airflow into the lungs.²⁷ Bronchodilators help maintain and maximise breathing efficacy.

Pulmonary rehabilitation (Brief)

Pulmonary rehabilitation (PR) is a non-pharmacological treatment for COPD that involves patient assessment, exercise training, education, nutritional intervention, and psychosocial support.³⁴ PR positively affects dyspnea, pulmonary mobility, and psychological state and reduces hospital admissions.³⁴ 

Lifestyle changes and home remedies 

It is important to note that bronchitis cannot be cured. However, the symptoms can be treated using more unconventional medicine techniques such as lifestyle changes and home remedies. Examples of lifestyle changes include:

• Smoking cessation: smoking cessation slows the rate of decline in lung function, alleviates symptoms and can reduce exacerbations of bronchitis and COPDs.³⁵
• Breathing techniques: active breathing cycles with postural and autogenic drainage have been effective in patients with chronic bronchitis.³⁶ Drainage is facilitated by strategies such as adopting a forward-lean sitting position and pursed lip breathing, both of which have alleviated dyspnea.³⁷
• Increasing physical activity: those with bronchitis tend to be physically inactive due to difficulty when breathing. Exercise maintains one’s fitness and has been shown to help facilitate normal breathing, restore functional exercise capacity, and reduce hospitalisation and mortality rates.³⁸ 
• Optimise pharmacotherapy: providing guidance and education regarding medication use, including inhaler techniques, has reduced exacerbations and hospitalisations in those with COPD.³⁹

Whilst the literature is limited, it has been suggested that some home remedies can be beneficial in helping alleviate the symptoms of bronchitis. Examples include:

• Gargling salt water: this can help break down mucus and reduce inflammation in the throat.
• Staying hydrated: water helps prevent dehydration and thins out mucus in the lungs, making breathing easier.
• Steam: the easiest way to use steam is to have a shower or inhalation over a bowl of hot water. Steam breaks up the mucus in the lungs, thus making it easier to breathe.
• Ginger: the anti-inflammatory properties of ginger have reportedly reduced pain and inflammation in those with upper respiratory tract infections, coughs and bronchitis.⁴⁰

Summary

In summary, bronchitis is a lower respiratory tract viral infection that causes inflammation, phlegmy cough and difficulty breathing. It has been suggested that steroids may be effective in treating bronchitis. However, the evidence is conflicting, and insufficient in scale, and the current conclusions have coupled the use of steroids with other medications. Therefore, studies on the use of steroids alone must be conducted. Whilst there are no known cures, some home remedies and lifestyle intervention strategies have successfully alleviated bronchitis symptoms and overall severity.