Acute Bronchitis and Asthma PDF

Acute Bronchitis Acute bronchitis is an acute and self-limited inflammation of the trachea and major bronchi, generally characterized by cough lasting 1 to 3 weeks without evidence of bronchial consolidation or underlying cardiopulmonary disease. (Buttaro, et.al, 2021). Acute Bronchitis: ac...

Acute Bronchitis Acute bronchitis is an acute and self-limited inflammation of the trachea and major bronchi, generally characterized by cough lasting 1 to 3 weeks without evidence of bronchial consolidation or underlying cardiopulmonary disease. (Buttaro, et.al, 2021). Acute Bronchitis: acute lower respiratory infection of thr large airways (bronchi) with no evidence of pneumonia (high fever, chills, productive cough, green-rust sputum, pleuritic chest pain with cough). Usually self limited. Highest incidence in late fall and winter. Causes include adenovirus, flu, covid, RSV, parainfluenza, and human metapneumovirus. The patient presents with a persistent cough for a number of weeks Causes/Incidence: Viral causes for 90% cases commonly Influenza A and B viruses, Rhinovirus, Corona virus, Adenovirus Bacterial causes: Streptococcus pneumoniae, Hemophilus influenzae (most common), Moraxella catarrhalis, Mycoplasma pneumoniae Increased incidence in smokers Most common in patients >50 years old Clinical Presentation of Acute Bronchitis p. 487, 202 Signs and Symptoms Cough- with or without sputum production is the most common symptom reported with acute bronchitis. Characterized as dry and nonproductive, but progresses to productive as illness evolves. Cough may also produce a burning, substernal pain with inspiration. Headache Wheezing, rhonchi, coarse rales may persist Common prodromal symptoms: rhinorrhea, sore throat, malaise, low grade fever Will have normal vital signs High grade fever is uncommon and warrants further evaluation *cough and normal vital signs (in the absence of tachypnea, tachycardia, crackles, and egophony), are strongly suggestive of acute bronchitis and minimize likelihood of pneumonia. Physical Exam of Acute Bronchitis No evidence of lung consolidation Breath sounds clear to auscultation Resonance to percussion Upper airway rhonchi clear with coughing Afebrile to low-grade temperature (viral) Elevated temperature (bacterial) Labs & Diagnostics of Acute Bronchitis Usually none indicated If diagnosis is unclear (suggestive of pneumonia, cold asthma, or COPD exacerbation) CXR useful with possibility of Community Acquired Pneumonia (CAP). Only when egophony/fremitus seen on xray, heart rate is greater than 100, respiratory rate greater than 24 and temperature greater than 100.4 Sputum C&S not helpful C-reactive protein – elevated >10 mcg/dl indicates likelihood of pneumonia Differential Diagnosis of Acute Bronchitis Acute Bronchitis if cough > 7 days If cough lasts > 3 weeks: Asthma & bronchiolitis but is present < 3 weeks (acute inflammations of small airway and Consider Acute Bronchitis is cough present with wheezing, tachypnea, respiratory and sputum production on most distress, and hypoxemia), sinusitis, COPD, GERD, days of the month for three months HF, Flu, Pertussis (paroxysmal cough > 2 of the year for two consecutive years weeks), Pneumonia, PE, viral pharyngitis Chronic Bronchitis Upper Respiratory Infection (URI) Bronchiectasis- bronchial dilation and chronic cough Treatment of Acute Bronchitis Supportive: Humidifiers, antipyretics, increase fluid intake. Should resolve within a couple weeks Smoking cessation Use cough suppressant judiciously (antitussives): Benzonatate or dextromethorphan PRN Analgesics for fever, chest soreness B2 adrenergic agonists for wheezing (albuterol) if history of asthma Antibiotics for bacterial infections only (like pertussis): Macrolides, Doxycycline, Trimethoprim-sulfamethoxazole. Avoid Azithromycin in: QT prolongation, torsade's de pointes, bradyarrhythmia's, uncompensated HF, those taking drugs known to prolong QT (antiarrhythmics), those with hypokalemia, hypomagnesemia No antibiotic prescription is recommended for immunocompetent adults for a productive cough attributed to acute bronchitis Need for hospitalization when: progressive dyspnea, oxygen saturation < 90%, or signs of sepsis Need for reevaluation: Do not respond to symptomatic treatment and symptoms last > 3 weeks (get a chest xray) Asthma p. 491 A chronic inflammatory disorder of the airways characterized by increased responsiveness of the tracheobronchial tree to various stimuli, resulting in episodic reversible narrowing and inflammation of the airways. Airflow obstruction is often reversible spontaneously or with treatment Causes/ Incidence Dust mites, pets, cockroaches, indoor molds, exercise, cigarette smoke Asthma most common chronic respiratory disorder among all age groups worldwide Prevalence highest among non-Hispanic children and Poor adults.  Clinical Presentation Heart rate>110 bpm Hallmark: Episodic wheezing Pulsus paradoxus associated with dyspnea, cough, and sputum production >12mm Hg Respiratory distress at rest Hyperresonance Difficulty speaking in Cough sentences Diaphoresis Chest tightness Use of accessory muscles Respiratory rate >28 bpm Remember ! This Photo by Unknown Author is licensed under CC BY-SA-NC Clinical hallmarks of asthma include episodic wheezing associated with dyspnea, cough, and sputum production Ominous signs include fatigue, absent breath sounds, paradoxical chest/abdominal movement, inability to maintain recumbency, cyanosis, and others. The 4 objectives of the physical examination of the patient Diagnosis is based on with Asthma Demonstration of episodic symptoms of airflow obstruction (wheeze, cough, SOB) Evidence that airflow obstruction is at least partially reversible Exclusion of other conditions from the differential diagnosis Assessment of Asthma Severity Classification of Intermittent Asthma Persistent Mild (associated with expiratory wheezing), Moderate (heard both expiratory and inspiratory, during inspiratory only or no wheezing at all), Severe Asthma (labored respirations diaphoresis, anxiety, and breathlessness (e.g. cannot finish a sentence)) Identification of adverse effects of medications: Beta 2 adrenergic and theophylline: tachycardia and tremors. Inhaled corticosteroids: thrush and dysphonia. Oral (systemic) corticosteroids: central adiposity, hypertension, ecchymoses, cataracts, kyphosis, muscle weakness, AMS Identification of concomitant medical problems Associated with asthma: nasal polyps, allergic rhinitis, sinusitis, eczema GERD, diabetes, glaucoma, hypertension are comorbidities Asthma Labs and Diagnostics Diagnosis is based on 3 components: demonstration of episodic symptoms (wheeze, cough, shortness of breath), evidence that airflow obstruction is partially reversible, and exclusion of other conditions for differential diagnosis CBC Slight elevation of WBC with eosinophilia for pts. with asthma PFTs, Spirometry, Peak Flow PFTs Typical of obstructive dysfunction Spirometry at time of diagnosis to confirm diagnosis of asthma (reduced FEV1 and Fev1/FVC ratio). FEV1 measured after inhalation of bronchoconstrictor agonist aerosol ECG not used in routine diagnosis Sputum cultures Arterial blood and other serum analysis CXR usually normal, may show hyperinflation with severe exacerbation (not used in diagnosis unless being admitted to hospital) Asthma Differential Diagnosis Upper Respiratory System (Croup, vocal cord dysfunction- VCD) Lower Respiratory System (Pneumonia, COPD) Cardiovascular system (Valvular disease, Cardiomyopathy) Gastrointestinal system (GERD) Patients with asthma typically present younger, may help to distinguish between conditions such as COPD Hospitalization if forced expiratory volume in 1 second (FEV1) is less than 30% or at least 40% predicted value after 1 hour of vigorous therapy Hospitalization may also be recommended if peak flow is less than 60L per min initially or does not improve to 50% predicted value after 1 hour of treatment  Preferred Asthma Treatment for Adults Buttaro, pp. 497 1. Controller medication: ICS/LABA/systemic Step 4 Medium dose ICS + corticosteroids 2. Reliever medication: SABA/low dose ICS- formoterol/short acting anticholinergics LABA Step 1 Short acting beta 2 agonist (SABA) For moderate asthma (daily Albuterol (Proventil), levalbuterol (Xopenex) PRN symptoms, FEV1 60-80% Intermittent asthma (< 2/week) predicted Step 2 Low-dose inhaled corticosteroids (ICS) Budesonide (Pulmicort), fluticasone (Flovent HFA) triamcinolone (Azmacort) Step 5 High-dose ICS + Step 3 Low-dose ICS+long acting beta 2 agonist LABA (LABA) Consultation recommended Salmeterol (Serevent), formoterol (Peforomist) Combination preparations: For severe asthma (daily, nonstop Fluticasone+salmeterol = Advair symptoms) Formoterol+budesonide = Symbicort for mild, persistent asthma (> 2/week) Step 6 High-dose ICS + Overall Goals of Asthma Provide ongoing maintenance and prevention- obesity, comorbidities such as gerd, OSA, rhinitis, and rhinosinusitis (use intranasal glucocorticoids for rhinitis symptoms) Preventing symptoms Maintaining near-normal pulmonary function Minimizing pharmacotherapy (may aggravate coexisting conditions). Beta blockers and aspirin can adversely effect asthma Minimizing the need for ED visits and hospitalizations Asthma Patient Education Patients and families need education about the following: The disease Monitoring for symptoms and preventing exacerbations Environmental triggers and strategies for minimizing them Individualized asthma management plan Possible side effects of medications to report to the PCP The use of peak flow meter Proper inhaler technique (spacers to improve medication delivery)  A patient develops a dry, nonproductive cough and is diagnosed with bronchitis. Several days later, the cough becomes productive with mucoid sputum. What may be prescribed to help with symptoms? a. Antibiotic therapy b. Antitussive medication c. Bronchodilator treatment d. Mucokinetic agents  ANS: B Antitussive medications are occasionally useful for short-term relief of coughing. Antibiotic therapy is generally not needed and should be avoided unless a bacterial cause is likely. Bronchodilator medications show no demonstrated reduction in symptoms and are not recommended. Mucokinetic agents have no evidence to support their use.  An adult patient who had pertussis immunizations as a child is exposed to pertussis and develops a runny nose, low-grade fever, and upper respiratory illness symptoms without a paroxysmal cough. What is recommended for this patient? a. A prescription for a macrolides b. Isolation if paroxysmal cough develops c. Pertussis vaccine booster d. Symptomatic care only  ANS: A Adults previously immunized against pertussis may still get thedisease without theclassic whooping cough sign seen in children and are contagious from thebeginning of thecatarrhal stage of runny nose and common cold symptoms. Macrolide antibiotics are useful for reducing symptoms and for decreasing shedding of bacteria to limit spread of thedisease. Patients should be isolated for 5 days from thestart of treatment. Pertussis vaccine booster will not alter thecourse of thedisease once exposed. Symptomatic care only will not reduce symptoms or decrease disease spread.  A 35-year old patient develops acute viral bronchitis. Which is the focus for the management of symptoms in this patient? a. Trimethoprim-sulfamethoxazole therapy b. Antibiotic therapy c. Supportive care d. Antitussive therapy  ANS: C. The mainstay of treatment in acute bronchitis is directed toward symptom reduction and supportive care. Data suggest that 85% of patients diagnosed with acute bronchitis will improve without specific treatment. Trimethoprim-sulfamethoxazole is prescribed for pertussis when macrolides are not an option. Antibiotic therapy is not effective in treating viral acute bronchitis.  A patient is seen in clinic for an asthma exacerbation. The provider administers three nebulizer treatments with little improvement, noting a pulse oximetry reading of 90% with 2 L of oxygen. A peak flow assessment is 70%. What is the next step in treating this patient? a. Administer three more nebulizer treatments and reassess. b. Admit to the hospital with specialist consultation. c. Give epinephrine injections and monitor response. d. Prescribe an oral corticosteroid medication  ANS: B Patients having an asthma exacerbation should be referred if they fail to improve after three nebulizer treatments or three epinephrine injections, have a peak flow less than 70% and a pulse oximetry reading less than 90% on room air. Giving more nebulizer treatments or administering epinephrine is not indicated. thepatient will most likely be given IV corticosteroids; oral corticosteroids would be given if thepatient is managed as an outpatient  An adult develops chronic cough with episodes of wheezing and shortness of breath. The provider performs chest radiography and other tests and rules out infection, upper respiratory, and gastroesophageal causes. Which test will the provider order initially to evaluate the possibility of asthma as the cause of these symptoms? a. Allergy testing b. Methacholine challenge test c. Peak expiratory flow rate (PEFR) d. Spirometry  ANS: D Spirometry is recommended at the time of initial assessment to confirm the diagnosis of asthma. Allergy testing is performed only if allergies are a possible trigger. The methacholine challenge test is performed if spirometry is inconclusive. PEFR is generally used to monitor asthma symptoms.  A patient diagnosed with asthma calls the provider to report having a peak flow measure of 75%, shortness of breath, wheezing, and cough, and tells the provider that the symptoms have not improved significantly after a dose of albuterol. The patient uses an inhaled corticosteroid medication twice daily. What will the provider recommend? a. Administering two more doses of albuterol b. Coming to the clinic for evaluation c. Going to the emergency department (ED) d. Taking an oral corticosteroid  ANS: A The patient is experiencing an asthma exacerbation and should follow the asthma action plan (AAP) which recommends three doses of albuterol before reassessing. The peak flow is above 70%, so ED admission is not indicated. The patient may be instructed to come to the clinic for oxygen saturation and spirometry evaluation after administering the albuterol. An oral corticosteroid may be prescribed if the patient will be treated as an outpatient after following the AAP  A patient presents to an emergency department reporting chest pain. thepatient describes thepain as being sharp and stabbing and reports that it has been present for several weeks. Upon questioning, theexaminer determines that thepain is worse after eating. thepatient reports getting relief after taking a friend’s nitroglycerin during one episode. What is themost likely cause of this chest pain? a. Aortic dissection pain b. Cardiac pain c. Esophageal pain d. Pleural pain  ANS: C Pain that is constant for weeks or is sharp and stabbing is not likely to be cardiac in origin. Both esophageal and cardiac causes will be attenuated with sublingual nitroglycerin. Aortic dissection will cause an abrupt onset with thegreatest intensity at thebeginning of thepain. Pleural pain is usually related to deep breathing or cough.  A high school athlete reports recent onset of chest pain that is aggravated by deep breathing and lifting. A 12- lead electrocardiogram in theclinic is normal. theexaminer notes localized pain near thesternum that increases with pressure. What will theprovider do next? a. Order a chest radiograph. b. Prescribe an antibiotic. c. Recommend an NSAID. d. Refer to a cardiologist.  ANS: C This patient has symptoms consistent with chest wall pain because chest pain occurs with specific movement and is easily localized. Since theECG is normal, there is no need to refer to a cardiologist. thepatient does not have symptoms of pneumonia, so a radiograph or antibiotic is not needed. NSAIDs are recommended for comfort.  A patient recovering from a viral infection has a persistent cough 6 weeks after theinfection. What will theprovider do? a. Perform chest radiography to assess for secondary infection b. Perform pulmonary function and asthma challenge testing c. Prescribe a second round of azithromycin to treat thepersistent infection d. Reassure thepatient that this is common after such an infection  ANS: D Postinfection cough is common after a viral infection and may persist up to 8 weeks after theinfection; this type of cough generally needs no intervention. It is not necessary to perform chest radiography unless secondary infection is suspected. Antibiotics are not indicated. Unless thecough persists after 8 weeks, asthma testing is not indicated  A nonsmoking adult with a history of cardiovascular disease reports having a chronic cough without fever or upper airway symptoms. A chest radiograph is normal. What will theprovider consider initially as thecause of this patient’s cough? a. ACE inhibitor medication use b. Chronic obstructive pulmonary disease c. Gastroesophageal reflux disease d. Psychogenic cough  ANS: A About 10% of patients taking ACE inhibitors will develop chronic cough. COPD, GERD, and psychogenic causes are possible, but given this patient’s cardiovascular history, thepossibility of ACE inhibitor- induced cough should be investigated initially.  A young adult patient develops a cough persisting longer than 2 months. theprovider prescribes pulmonary function tests and a chest radiograph, which are normal. thepatient denies abdominal complaints. There are no signs of rhinitis or sinusitis and thepatient does not take any medications. What will theprovider evaluate next to help determine thecause of this cough? a. 24-hour esophageal pH monitoring b. Methacholine challenge test c. Sputum culture d. Tuberculosis testing  ANS: B Chronic cough without other symptoms may indicate asthma. If PFTs are normal, a methacholine challenge test may be performed. 24-hour esophageal pH monitoring is sometimes performed to evaluate for GERD, but this patient does not have abdominal symptoms and this test is usually not performed because it is inconvenient. Sputum culture is not indicated. TB is less likely.