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 45-year-old female presents to the clinic with a 5-day history of cough and feeling generally unwell. She reports the cough started as a dry, irritating cough but has since progressed to a productive cough with yellowish sputum. She denies any shortness of breath or wheezing but mentions mild chest discomfort with coughing. She also reports a low-grade fever and malaise. On examination, her temperature is 37.8°C (100.4°F), her respiratory rate is 18 breaths per minute, and her oxygen saturation is 98% on room air. Scattered rhonchi are heard throughout all lung fields. A diagnosis of acute bronchitis is made. The patient is advised about the viral nature of most acute bronchitis cases, meaning antibiotics are not indicated. She is counseled on symptomatic management, including increased fluid intake, rest, and over-the-counter cough suppressants and analgesics as needed for comfort. She is advised to return if symptoms worsen or if she develops shortness of breath, high fever, or persistent symptoms beyond a few weeks. A follow-up phone call in a week is scheduled to assess her progress.

Acute bronchitis is an inflammation of the bronchial tubes (the airways that carry air to the lungs). It typically develops from a cold or other respiratory infection and is characterized by the production of mucus (sputum), coughing, and sometimes shortness of breath and wheezing

  • Symptoms include cough that may be productive (yellow sputum), white nasal discharge, sore throat, and fatigue
  • Auscultation of the lungs may reveal scattered rhonchi and wheezes
  • A low-grade fever is common - but a high fever is unusual in acute bronchitis. If your patient has a fever, consider pneumonia
  • (95%) of acute bronchitis are 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?
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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References: Merck Manual · UpToDate

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