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 62-year-old male with a significant smoking history presents with a 6-day history of dry cough and low-grade fever. You suspect acute bronchitis. Which of the following is the most appropriate initial management?
A
Azithromycin 500mg day 1, then 250mg daily for 4 days
Hint:
Antibiotics which are usually not indicated in the treatment of acute bronchitis
B
Amoxicillin 875mg twice daily for 7 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.
E
Chest x-ray and sputum culture
Hint:
These are typically reserved for patients with suspected complications, signs of pneumonia, or those who aren't improving with supportive care.
Question 1 Explanation: 
Acute bronchitis is usually caused by viruses and resolves on its own. Management focuses on symptom relief. Increased fluids help loosen secretions, and ibuprofen provides fever reduction and pain control.
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. On physical exam, his lungs are clear bilaterally, and his O2 sat is 100% on room air. What is the most appropriate next step in the management of this patient?
A
Prescribe a macrolide antibiotic
B
Obtain a chest x-ray
Hint:
While a chest x-ray might be considered in certain cases (e.g. ruling out pneumonia), it's not necessary in this case as the patients PE is normal and O2 sat is 100% on RA.
C
Administer an oral corticosteroid
Hint:
Corticosteroids might have a role in reducing inflammation in some bronchitis cases, but they are not routinely used as initial treatment, especially when bacterial infection is possible.
D
Pulmonary function tests
Hint:
Pulmonary function tests in acute bronchitis are not necessary, except in very serious cases.
E
Order a sputum culture
Hint:
Sputum cultures can be helpful to pinpoint the specific bacteria involved, but it's not always necessary upfront when empiric antibiotic therapy is appropriate.
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
Streptococcus pneumoniae
Hint:
The same bugs that cause upper respiratory infections cause acute bacterial bronchitis: H. influenzae, M. Catarrhalis and S. Pneumonia
B
Respiratory viruses
C
Haemophilus influenzae
Hint:
The same bugs that cause upper respiratory infections cause acute bacterial bronchitis: H. influenzae, M. Catarrhalis and S. Pneumonia
D
Mycoplasma pneumoniae
Hint:
Causes "atypical" pneumonia and can occasionally include a bronchitis component, but usually isn't the single-leading reason for an acute uncomplicated bronchitis-like picture.
E
Moraxella catarrhalis
Hint:
The same bugs that cause upper respiratory infections cause acute bacterial bronchitis: H. influenzae, M. Catarrhalis and S. Pneumonia
Question 3 Explanation: 
In most cases (65%) of acute bronchitis, the dominant culprits are viral pathogens. Viral infections account for the vast majority of these infections, especially in previously healthy individuals, as indicated by the patient's presentation.
Question 4
Which of the following is recognized as an effective preventive measure against acute bronchitis?
A
Starting Oseltamivir 75 mg within the first two days of symptom onset
Hint:
Starting Oseltamivir 75 mg within the first two days of symptom onset is aimed at treating influenza rather than serving as a prophylaxis for acute bronchitis. While it can reduce the severity and duration of influenza, it is not a preventive measure for bronchitis itself.
B
Receiving the influenza vaccination
C
Using inhaled corticosteroids regularly
Hint:
Using inhaled corticosteroids is typically part of the treatment regimen for chronic respiratory conditions like asthma or COPD to reduce inflammation and prevent exacerbations, not as a prophylaxis for acute bronchitis.
D
Vitamin C daily
Hint:
Common misconception about cold prevention despite lack of strong evidence
E
Amoxicillin pulse dosing
Hint:
Not a recommended preventive measure
Question 4 Explanation: 
The influenza vaccine is an effective prophylaxis against acute bronchitis, particularly because influenza is a common cause of respiratory infections that can lead to bronchitis. By preventing influenza, the vaccine indirectly reduces the risk of developing secondary complications such as acute bronchitis.
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References: Merck Manual · UpToDate

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