Using the article provided below, respond to the following case studies and the questions posed with each.
Mr. Jones is an otherwise healthy, 80 yo AA male who seeks treatment at your clinic for a cough with an onset of 2 weeks ago. He states the nonproductive cough keeps him awake at night and he feels he is “coughing up a lung” whenever he coughs. His vital signs are Temp 98.7, Ap 80, Resp 26, BP 166/88. His wife states that he has been especially forgetful this past week. His Objective assessment reveals prolonged coughing episodes that do not proceed to bronchospasms, He has dyspnea with minimal exertion and increased tactile fremitus in the right upper lung field. Fine Rales (crackles) can be hear in this area, with the remaining lung field having vesicular lung sounds.
1. What other subjective information would you like to elicit from Mr. Jones?
2. What other objective assessments would you like to perform on Mr. Jones?
3. What is your diagnosis of Mr. Jones? What are your 2 or 3 Differentials?
4. Why did you arrive at this diagnosis? 5. What is your treatment plan for Mr. Jones?
NPR0914_Cover.indd 32 The Nurse Practitioner • Vol. 39, No. 9 www.tnpj.com Evidence-based diagnosis and management of acute bronchitis 2.0 CONTACT HOURS 1.0 CONTACT HOURS Ill us tra tio n by E ra xi on / is to ck © Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. cute bronchitis is a common, self-limiting, respira- tory tract infection characterized primarily by a cough lasting less than 3 weeks.1 Patients frequent- ly present to nurse practitioners (NPs) with acute cough. Although most acute cough illnesses are benign and self- limited, they are extremely bothersome, and several serious differentials must be excluded. Given the common and potentially serious nature of an acute cough, it is critical for NPs to appropriately diagnose and manage acute bronchitis. This article examines the current research-based evidence for diagnosis and management of acute bronchitis. Recom- mendations for the diagnosis and management of acute bronchitis in adults who are not immunocompromised and do not have a serious underlying lung disease (for example, chronic obstructive pulmonary disease [COPD] or bron- chiectasis) are also explored. ■ Epidemiology and pathophysiology Although the exact incidence of acute bronchitis is unknown, it is believed to be an extremely common condi- tion–particularly in the fall and winter months.2 In fact, data from the 2006, 2007, and 2010 National Ambulatory Medical Care Surveys indicate “cough” as the top clinical symptom for which individuals seek care from outpatient healthcare providers.3-5 Over 90% of acute bronchitis cases are viral with eti- ologies, including infl uenza A and B, parainfl uenza, coro- navirus, respiratory syncytial virus, adenovirus, rhinovirus, and human metapneumovirus. Bacterial causes are rare and include Bordetella pertussis, Chlamydia pneumoniae, and Mycoplasma pneumoniae.2 Acute bronchitis stems from infl ammation of the bron- chial epithelium. This infl ammation causes the bronchial and tracheal mucosa to thicken as well as epithelial-cell desquamation and denuding of the basement membrane airway.2,6 One of the most troubling aspects of acute bronchitis is its lengthy nature. A recent meta-analysis of 19 studies found that the mean duration of cough in adults with an acute cough illness was 17.8 days.7 Purulent sputum is also common in acute bronchitis and is the result of sloughing of the tracheobronchial epithelium and inflammatory cells.2,8 Contrary to popular belief, the presence of purulent sputum does not indicate a bacterial infection.9 By Ann Marie Hart, PhD, FNP A Evidence-based diagnosis and management of Abstract: Acute bronchitis is a common respiratory infection seen in primary care settings. This article examines the current evidence for diagnosis and management of acute bronchitis in adults and provides recommendations for primary care clinical practice. Keywords: acute bronchitis, acute cough illness, respiratory tract infection www.tnpj.com The Nurse Practitioner • September 2014 33 acute bronchitis Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 34 The Nurse Practitioner • Vol. 39, No. 9 www.tnpj.com Evidence-based diagnosis and management of acute bronchitis ■ Clinical presentation and diagnosis Cough is the primary symptom of acute bronchitis. By defi nition, adults with acute bronchitis present with a cough illness of less than 3 weeks’ duration.1 Although localized symptoms (such as nasal congestion, runny nose, sore throat) associated with nonspecifi c respiratory infec- tions (colds) may be present with acute bronchitis, sys- temic symptoms such as fever, myalgia, nausea, malaise, and dyspnea are typically absent. However, it is not uncommon for individuals with acute bronchitis to ex- perience bronchospasm and wheezing, especially if there is an underlying history of asthma.10 In order to accurately diagnose and manage acute bronchitis in adults, the NP should perform a history and physical exam that considers the main differential diagno- ses for acute cough illness and primarily focuses on ruling out pneumonia, B. pertussis (commonly referred to as “pertussis”), and infl uenza. (See Differential diagnoses for acute cough illness.) The history should focus on type and length of symptoms, paying particular attention to worri- some systemic symptoms (such as fevers, myalgia, dyspnea) more commonly seen in pneumonia. The physical exam in acute bronchitis is often normal, although low-grade fever (less than 100.4° F [38°C]) and/or wheezing and rhonchi may be present. However, crackles and other signs of lung consolidation (egophony, increased fremitus, dull- ness to percussion) should be absent; the presence of these signs warrants further workup.1,2,10 Procalcitonin is cur- rently being evaluated as a potential serum biomarker for distinguishing between bacterial and viral infections (see Role of procalcitonin in the diagnosis of acute bronchitis). Additional diagnostic tests are usually not warranted in the absence of signs and symptoms of pneumonia, pertus- sis, or infl uenza. Pneumonia. Pneumonia should be considered and ruled out when vital signs are abnormal (pulse greater than 100, respirations greater than 24/minute, or temperature greater than 100.4° F [38°C]) and/or when signs of consolidation are present on lung exam. Systemic symptoms should also warrant suspicion for pneumonia. Older individuals may not mount a fever with infections; therefore, pneumonia should also be considered and ruled out in patients over 75 years of age in the presence of respiratory rate greater than 24/minute, decreased oxygen saturation, decreased mental status, and/or a change in behavior.11 According to the most recent consensus guidelines pub- lished by the Infectious Diseases Society of America and the American Thoracic Society, the presence of an infi ltrate on chest X-ray is considered the gold standard for diagnosing pneumonia.12 However, dehydration may result in a false- negative chest X-ray, and one study found 7% of patients with initial “negative” chest X-rays had fi ndings consistent with pneumonia on repeat chest X-ray.13 Therefore, the absence of infi ltrate on chest X-ray should not supersede clinical judgment in ill-appearing patients suspected of having pneumonia. Pertussis. Pertussis is a highly contagious bacterial respiratory illness with several potentially severe complica- tions, including dehydration, hypoxia, encephalopathy, syncope, seizures, pneumonia, pneumothorax, and rib frac- tures from severe coughing.14 Although pertussis is more common in children, the incidence in adolescents, adults, and older adults has risen dramatically over the past 2 de- cades and needs to be considered and ruled out whenever patients present with acute cough illnesses.15-17 Pertussis should be considered when a cough illness lasts for 2 or more weeks without another apparent cause and includes one or more of the following symptoms: paroxysms of cough, inspiratory “whoop” sound, or posttussive vomiting. Pertussis should also be considered during com- munity outbreaks or when an individual has a close contact with an individual with a confi rmed case of pertussis.18 The actual diagnosis of pertussis is based upon lab testing. For more information regarding pertussis testing, visit: cdc.gov/pertussis/clinical/index.html. Infl uenza. Infl uenza is also a highly contagious respira- tory virus with potentially severe complications in the older adult and in those with underlying metabolic or car- diopulmonary conditions, such as COPD and diabetes. Annual epidemics of infl uenza tend to occur during the fall and winter months in the United States; however, the peak of infl uenza activity can occur as late as April or May. Symp- toms of influenza can include fever, myalgia, headache, Differential diagnoses for acute cough illness1,10 • ACE inhibitor-induced cough • Acute bronchitis • Acute exacerbation of COPD • Acute sinusitis • Asthma • Bronchiectasis • Gastroesophageal refl ux disease • Heart failure • Infl uenza • Nonspecifi c upper respiratory tract infection • Pertussis • Pneumonia • Pulmonary embolus • Upper airway cough syndrome (previously referred to as postnasal drip syndrome) Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. Evidence-based diagnosis and management of acute bronchitis www.tnpj.com The Nurse Practitioner • September 2014 35 malaise, cough, sore throat, and runny nose. Fever and body aches usually last for 3 to 5 days, whereas cough and lack of energy may last for 2 or more weeks. The symptoms of in- fl uenza are nonspecifi c; therefore, infl uenza is often diffi cult to diagnose based on symptoms alone.19 Rapid diagnostic tests can aid clinicians in diagnosing infl uenza but should only be obtained if the results of the testing will impact decision making regarding treatments.20 For more informa- tion on the diagnosis and treatment of infl uenza, visit: cdc. gov/fl u/professionals/index.htm. ■ Management Antibiotics. The management of acute bronchitis is pri- marily supportive and is focused on controlling cough. Antibiotic therapy has a minor role in acute bronchitis, primarily for pertussis. Over the past 30 years, multiple studies have shown little or no improvement when antibi- otics are prescribed for adults with acute bronchitis.21-25 More recently, a 2012 Cochrane systematic review of 15 randomized controlled trials (RCTs) with 2,618 patients, including smokers and nonsmokers, found a statistically signifi cant reduction in cough duration by 0.6 days with antibiotic treatment.26 In addition, a recent 12-country RCT of 2,161 adults diagnosed with acute bronchitis found no difference in duration of symptoms between the amox- icillin versus the placebo group.27 Antibiotics are prescribed over 50% of the time for adults with acute bronchitis who present to primary care clinicians.28,29 Although inappropriate antibiotic use for acute bronchitis and other acute viral respiratory infections has decreased over the past decade, recent studies indicate an increase in prescriptions of broad-spectrum antibiotics for acute bronchitis, a phenomenon that goes against the principles of good antibiotic stewardship and promotes antibiotic resistance.30-33 Symptom management. Cough control is the goal of symptom management for acute bronchitis1; however, there is currently no “best” treatment strategy to facilitate this. Although multiple pharmacologic preparations are available for the treatment of cough, there is a dearth of published research literature related to support them. In addition, results from the available studies have been mixed and/or have shown treatments to be minimally effective. Over-the-counter (OTC) medications. A 2012 Cochrane systematic review of OTC medications for acute cough assessed 18 RCTs with 3,421 adults for the effectiveness of several