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 wheezing. Her temperature is 99.9°F.
Acute bronchitis is defined by a cough that 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
- Bacteria, such as Mycoplasma pneumoniae, Bordetella pertussis, and Chlamydia pneumoniae, cause less than 5% of cases and sometimes occur in outbreaks
Chest X-Ray if the 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 patients who desire medication for cough offer over-the-counter medications such as dextromethorphan or guaifenesin rather than other medications
- Reserve use of inhaled beta-agonists, such as albuterol, for patients with wheezing and underlying pulmonary disease
- 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 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?
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 | |
Doxycycline 100 mg PO two times per day for 14 days Hint: antibiotics are usually not indicated in the treatment of acute bronchitis | |
Increased fluids and ibuprofen | |
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?
Treat with a macrolide antibiotic | |
Administer penicillin intramuscularly Hint: Penicillin would not be an appropriate treatment for acute bacterial bronchitis | |
Influenza titers Hint: Influenza titers are not necessary if you suspect a bacterial etiology. | |
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?
H. influenzae Hint: The same bugs that cause upper respiratory infections cause acute bacterial bronchitis: H. influenzae, M. Catarrhalis and S. Pneumonia | |
Viral infection | |
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. | |
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?
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. | |
Influenza vaccine | |
Inhaled corticosteroids Hint: corticosteroids are never used as prophylaxis for an infection. | |
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.
There are 4 questions to complete.
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References: Merck Manual · UpToDate
