PANCE Blueprint Pulmonary (10%)

Acute bronchitis (ReelDx)

REEL-DX-ENHANCED-PAID-MEMBERS-ONLY

Acute Bronchitis

26 y/o female with acute onset of cough and dyspnea during pregnancy

Patient will present as → a 23-year-old-female  with a one-week history of cough productive of whitish sputum. This was preceded one week prior by a URI. She denies chills, night sweats, shortness of breath, or wheeze. Temperature is 99.9°F (37.7°C).

Acute bronchitis is defined by a cough which persists for MORE THAN 5 DAYS

  • Fever is unusual in acute bronchitis if your patient has a fever consider pneumonia
  • (95%) of acute bronchitis is viral
  • Bacterial causes of acute bronchitis include:
    • M. Catarrhalis (the common bacterial cause of acute bronchitis)
    • H. influenzae
    • S. Pneumoniae

Chest X-Ray if diagnosis is uncertain or symptoms have persisted despite conservative treatment

Since most cases (95%) are viral symptomatic treatment is the cornerstone of management:

  • Supportive measures include hydration, expectorants, analgesics, β2-agonists, and cough suppressants as needed (not recommended for children).
  • For acute exacerbations of chronic bronchitis, in which bacterial causes are more likely, empiric first-line treatment is a second-generation cephalosporin; second-line treatment is a second-generation macrolide or trimethoprim-sulfamethoxazole.
  • Antibiotics are indicated for the following: elderly patients, those with underlying cardiopulmonary diseases and a cough for more than 7 to 10 days, and any patient who is immunocompromised.
Question 1
A 63-year-old male, heavy smoker, presents to your office with a low-grade fever and sudden onset of dry cough for the past 6 days. You diagnose him with acute bronchitis. What is the most appropriate management at this time?
A
Amoxicillin/clavulanic acid 875 mg two times per day for 10 days
Hint:
antibiotics which are usually not indicated in the treatment of acute bronchitis
B
Doxycycline 100 mg PO two times per day for 14 days
Hint:
antibiotics are usually not indicated in the treatment of acute bronchitis
C
Increased fluids and ibuprofen
D
Give the patient an albuterol inhaler
Hint:
Albuterol, is a beta-agonist used as a bronchodilator (usually in asthma); here, it should be used only if there is evidence of bronchoconstriction.
Question 1 Explanation: 
Acute bronchitis is defined by a cough which persists for more than five days. The most common cause of acute bronchitis is a viral infection (90% of cases). Therefore, supportive therapy such as increased fluids (cough results in increased fluid loss) and ibuprofen (antipyretic) is the most appropriate approach.
Question 2
You advise your patient from question one to take antipyretic drugs and get some rest.  He returns to your office 5 days later feeling worse and now has a fever with a cough productive of purulent sputum. What is the most appropriate next step in the management of this patient?
A
Treat with a macrolide antibiotic
B
Administer penicillin intramuscularly
Hint:
Penicillin would not be an appropriate treatment for acute bacterial bronchitis
C
Influenza titers
Hint:
Influenza titers are not necessary if you suspect a bacterial etiology.
D
Pulmonary function tests
Hint:
Pulmonary function tests in acute bronchitis are not necessary, except in very serious cases.
Question 2 Explanation: 
A purulent, productive cough may be bacterial in origin (although purulent sputum is not the definite sign of bacterial infection). Given the length of this patient's symptoms > 12 days and fever (fever is unusual in bronchitis) it would be reasonable to treat with antibiotics empirically. (beta-lactam, macrolide first line)
Question 3
What is the most common cause of acute bronchitis?
A
H. influenzae
Hint:
The same bugs that cause upper respiratory infections cause acute bacterial bronchitis: H. influenzae, M. Catarrhalis and S. Pneumonia
B
Viral infection
C
Fungal infection
Hint:
Fungi are usually not considered when acute bronchitis is the diagnosis, you may be more suspicious in a patient who is immunocompromised.
D
Allergic reaction
Hint:
Acute bronchitis is not an allergic reaction.
Question 3 Explanation: 
95% of all acute bronchitis cases are caused by viruses
Question 4
Which of the following can be considered an effective prophylaxis for acute bronchitis?
A
Oseltamivir 75 mg on day two of symptoms
Hint:
Although oseltamivir (Tamiflu) given within 2 days of symptom onset for Influenza A/B may decrease symptom duration it is not considered prophylaxis.
B
Influenza vaccine
C
Inhaled corticosteroids
Hint:
corticosteroids are never used as prophylaxis for an infection.
D
Nystatin
Hint:
this antifungal medication is never used in acute bronchitis.
Question 4 Explanation: 
The most common cause of acute bronchitis are viruses, influenza included.
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