Acute bronchitis

Question 1

What are the most common presenting complaints in clinics?

Answer 1

• URI and LRIs

Question 2

Definition of acute bronchitis?

Answer 2

• inflammation of large bronchi (medium sized airways) in the lungs that is usually caused by viruses or bacteria and may last several days or weeks
• often called a chest cold

Question 3

What is the etiologies of acute bronchitis?

Answer 3

- viral: 80-90%
same viruses that cause URIs:
coronavirus
rhinovirus
RSV
adenovirus
bacteria: 10-20%
strep pneumoniae 
H. flu
Chlamydia pneumoniae (college students and military)
mycoplasma pneumoniae (college students and military)
- less common cause: whooping cough: bordetella pertussis , illness can still develop in those who were vaccinated

Question 4

Pathophys of acute bronchitis?

Answer 4

• inflammation of bronchial wall
• increased mucous production along with edema of bronchus
• infection clears in several days but the repair of bronchial wall may take several weeks (because of insult to airway and continual sloughing of airway epithelium)
• half of all pts continue to cough for 3-6 weeks due to period of repair
• PFTs: demonstrate bronchial obstruction similar to asthma but as sxs abate, PF returns to normal

Question 5

Clinical features of acute bronchitis?

Answer 5

• cough is hallmark of lower respiratory infection
• sxs usually begin 3-4 days after URI such as cold or flu
• fever: usually mild (less than 101)
• cough: main sx, may be nonproductive initially and after a few days becomes productive. May keep awake at night or worsen when lies down
• streaks of blood - breaking blood vessels
• clear, yellow, or green
• malaise
• sensation of tightness, burning or dull pain in chest that is worse with breathing deeply or coughing
• hoarseness
• wheezing

Question 6

Dx of acute bronchitis?

Answer 6

-H&P
- appearance: shouldn’t appear toxic
coughing during exam, on pulm exam: look at throat, percussion (may have abnorm. breath sounds)
- vital signs to include O2 sats (may do ortho BP to see if pt is dehydrated)

Question 7

What are impt things to think about and ask the pt during the exam?

Answer 7

• duration of sxs, associated sxs
• miss any work, school?
• any underlying lung disease: COPD, emphysema, asthma, bronchiectasis
• smoking
• when was last time you were on abx, how many x a year do you get this?
  hx:
  any chronic illness that may result in immune compromise
  immunization hx
  ill contacts (work in daycare)

Question 8

When do you need a CXR for a pt presenting with acute bronchitis?

Answer 8

• pt is really unwell
• pt prone to pneumonia due to underlying disease, age or alcoholism (aspirating risk)
• hx of pneumonia
• tobacco use

Question 9

impt parts of management?

Answer 9

• fluids: want to keep secretions in bronchial tubes less viscous and easier to expel by coughing
• pt education

Question 10

2 categories of management?

Answer 10

• sx management

- abx therapy

Question 11

Sx management?

Answer 11

• antitussives: codeine, dextromethorphane or hydrocodone cough syrup tessalon perles: Rx, orally, numbs coughing reflex
• expectorants: guifenisen (mucinex)
• inhalers: if wheezing may be beneficial
  B2 agonists - bronchodilation albuterol: 2 pufs 4-6 hrs prn (stim cilia to become more active to loosen up mucus)
  -this can make pt very shaky and nervous, instruct on proper technique (spacer recommended)
• get anti-tussive with guaifenesin syrup (guaifenesin + codeine)
  phenergan with codeine
  DM

Question 12

What pt needs abx?

Answer 12

if pertussis expected: macrolide
what about smoking hx - makes them immunocompromised
- so once you dx with acute bronchitis - and pt doesnt have chronic lung disease then ask if pt is immunocompromised - if yes than consider abx but if no just do sx tx, if pt does have chronic lung disease - go to abx therapy

Question 13

abx therapy for moderate ABECB and or any of the following: pts younger than 65, FEV1 greater than 50%, no cardiac disease, or less than 3 exacerbations a year?

Answer 13

- azithro - 500 mg 1st day then 350 next 4
or
- clarithro 250-500 mg BID for 7-14 days
or 
- doxy 100 mg BID for 7 days
or
- trimethoprim-sulfamethoxazole 1 tablet BID for 10-14 days
or
- cefuroxime 250-500 mg q12 hr 10 days
or
- cefdinir 300 mg BID for 5-10 days
or
- cefpodoxime 200 mg q12 hr for 10 days
* if recent abx exposure w/in 3 months - use alt. class

Question 14

Severe ABECB and or anyone of following: age older than 65, FEV1 less than 50%, cardiac disease, or more than 3 exacerbations a year?

Answer 14

• consider hospitalization
• amox-clav (augmentin)
  or
  levo
  or
  gemifloxacin
  or
  moxiflocacin
• if at risk for pseudomonas infection consider sputum culture and tx with cipro
• if recent exposure within 3 months, use alt class

Question 15

Need for ICS for airway inflammation in acute bronchitis?

Answer 15

• high dose inhaled corticosteroids may be benefit short term but not for every pt
• likely will need oral steroid burst for pts who have exacerbation of chronic bronchitis or an asthma exacerbation secondary to acute bronchitis
• may be able to prevent asthma exacerbation by increasing ICSx 1 month

Question 16

Preferred tx regimen for TB?

Answer 16

• initial phase: Daily INH, RIF, PZA, and EMB for 2 months

- continuation phase: Daily INH and RIF for 4 more months or twice weekly INH and RIF x 4 months