ACUTE BRONCHITIS - McGraw-Hill Professional

118
ACUTE BRONCHITIS
The Collegiate Cough Level II
Jessica Helmer Brady, PharmD, BCPS
Justin J. Sherman, MCS, PharmD
INSTRUCTOR’S GUIDE TO
CHANGES IN THIS EDITION
•
New coauthor (Dr Brady) added.
CASEBOOK
Patient Presentation
• An entirely different case has been created for this edition,
which includes a new patient with a different HPI, PMH, SH,
medications, allergies, physical examination, and laboratory
findings. The patient in question is a 21-year-old college student
living on campus. One dorm mate was recently hospitalized
with pneumonia. The focus is on distinguishing between
pneumonia and acute bronchitis.
• Uncontrolled hypertension has been removed as a concomitant
problem in this case.
• The patient is an occasional smoker. She does not express the
need for assistance in quitting, but the opportunity presents
itself to discuss smoking cessation.
• Sexual/reproductive health issues for a sexually active young
woman are an added factor in this case.
INSTRUCTOR’S GUIDE
Optimal Plan
• New evidence for medications targeting symptoms of acute
bronchitis, particularly evidence for inefficacy of bronchodilators
except in certain subgroups.
• Discussion added regarding the need for HPV and influenza
vaccination.
References
• Updated and revised.
CASE SUMMARY
Allie Comeaux, a 21-year-old college student, is being seen at her
university’s Student Health Center for complaints of a productive,
purulent cough and sore throat for the past 5 days. The patient
denies any fever, chills, or myalgias. She expresses concern that a
dorm mate was recently hospitalized with pneumonia. She is displeased
with her disruptive cough that caused a professor to ask her
to leave a class. She believes an antibiotic will rid her of her cough.
Acute bronchitis is an acute infection of the large airways predominated
by cough with or without phlegm production that
lasts for up to 3 weeks. 1 It is self-limited and the ninth most common
diagnosis among outpatients. 2 Once pneumonia is ruled
out, antibiotic therapy is inappropriate. Also, bacterial causes of
acute bronchitis or respiratory syncytial virus (RSV) can be largely
ruled out in the absence of known acute community outbreaks. 1
Accumulating data on supportive care show that there is no benefit,
with the exception of patients who present with wheezing. 3 These
patients, or those with an obstructive airway disease, may benefit
from being prescribed a β 2 -agonist. Patient education and follow-up
are important to ensure that a further reevaluation of the diagnosis
is not necessary.
QUESTIONS
Problem Identification
1.a. Create a list of the patient’s drug therapy problems.
• Acute bronchitis that may require supportive treatment for
specific symptoms.
• Once pneumonia has been ruled out, education is needed to
address why the patient does not require an antibiotic prescription.
• Tobacco abuse; need for and possible approaches to assist with
smoking cessation should be discussed with the patient.
• Taking a drug (albuterol) for which there is no medical indication
(and which was not prescribed for the patient).
• Indication for immunizations that she has not received (influenza
and HPV series, if desired).
• Sexual/reproductive health issues; the patient is sexually active
and admits to inconsistent use of barrier protection/contraception.
Although alternate forms of contraception may help
regulate the patient’s irregular menstrual cycle and may be
more “preferable” to the patient, the importance of sexually
transmitted infection (STI) prevention through consistent use
of barrier protection must be discussed with the patient.
1.b. What information (signs, symptoms, laboratory values)
indicates the presence or severity of acute bronchitis?
• Uncomplicated acute bronchitis presents as cough, either productive
or nonproductive, and other accompanying symptoms,
such as wheezing, rhinorrhea, or sore throat. It is important to
be able to differentiate between acute bronchitis and pneumonia.
However, presence of purulent sputum does not accurately
distinguish between these two diseases. In fact, purulence can
result from either viral or bacterial infections and simply indicates
that inflammatory cells or sloughed epithelial cells are
present in the mucosal region. 4
• Four well-designed prospective studies have shown that absence
of certain elevated vital signs and auscultation for focal consolidation
can rule out pneumonia. Pneumonia can be excluded
if: (1) heart rate is

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SECTION 16 Infectious Diseases
documented on college campuses and on military bases—are
associated with a higher incidence of a bacterial cause. 1
• Another influenzalike illness that should be ruled out is severe
acute respiratory syndrome, which is highly infectious and
has spread worldwide since being first seen in China in 2002.
Health care workers are at high risk of exposure with severe
acute respiratory syndrome, and symptoms include a nonproductive
cough, fever, myalgias, and dyspnea. 2 These, of course,
are symptoms not found in this case.
1.c. What additional information must be considered before
deciding whether antimicrobial therapy is indicated?
• As described previously (see question 1.b.), the absence of
certain vital signs combined with a finding of no focal consolidation
on auscultation greatly reduces the likelihood of pneumonia.
In contrast, if any of the vital signs are elevated (i.e.,
heart rate is >100 beats/min, respiratory rate is >24 breaths/
min, or body temperature is >38°C/100.4°F), or if there is a
high index of clinical suspicion or prolonged cough, a chest
radiograph could be ordered to definitively rule out pneumonia
with an absence of an infiltrate. 2
Desired Outcome
2. What are the goals of pharmacotherapy in this case?
• Relieve the symptoms of uncomplicated acute bronchitis.
• Although the patient would not be given an antibiotic, the
patient should be counseled to explain why that particular
expectation may not be met in this case.
• Educate the patient about self-treatment—both over-the-counter
(OTC) and nonmedication strategies that are available.
• Educate the patient about the dangers of using medications for
which there is no medical indication and which have been prescribed
for someone other than the patient.
• Offer appropriate pharmacotherapy for the most optimal
chance to succeed during a current smoking cessation attempt
(if needed/desired by the patient).
• Consider appropriate patient-specific medications/immunizations
to address her sexual/reproductive health issues.
Therapeutic Alternatives
3.a. What nondrug therapies might be useful for this patient?
• Eliminating environmental cough triggers such as dust and dander
and providing vaporized air treatments are low-cost and
low-risk actions that can help attenuate severity of symptoms. 4
Vaporized air treatments may be useful in environments that
have low humidity (e.g., high-altitude climates). Expectoration
can also be enhanced by increasing fluid intake. However, evidence
for the degree of benefit provided with these measures has
not been substantiated by randomized, controlled clinical trials. 4
• The patient should be encouraged to discontinue cigarette
smoking during the illness, with strong urging for continued
total abstinence. Counseling the patient to stop smoking may
be more effective if she is approached during this episode of
acute bronchitis. 2 Advice should include that smoking cessation
is the single most important action that the patient can
take to protect her health now and in the future. Benefits should
be discussed, including an incrementally decreased risk of lung
cancer, stroke, heart attack, and chronic lung diseases with each
year of smoking cessation.
✓ An action plan should be discussed with the patient if
she indicates a sincere desire to stop smoking. To give this
Copyright © 2011 by The McGraw-Hill Companies, Inc. All rights reserved.
patient an optimal chance for success, components of this
action plan should include smoking cessation medication;
behavioral, cognitive, and stress management therapy given
either as a group or individually; and group and/or family
support.
✓ The STAR approach is one method of a quit plan, which
includes:
Set a quit date within 2 weeks.
Tell family and friends about the quit attempt and request
their support.
Anticipate challenges to a planned quit attempt, including
nicotine withdrawal symptoms.
Remove tobacco products from the environment, and
avoid smoking prior to the quit date in places where she
spends much of her time.
✓ Follow-up with the patient is essential after the quit date
because the most intense withdrawal symptoms are experienced
within 48 hours after the quit date. Ideally, follow-up
should be in person; however, reaching the patient by telephone
is also an effective method.
• Examples of behavioral techniques include:
✓ Because she admits to smoking during social situations,
she should be encouraged to avoid the places/people with
which she associates her smoking habits while actively trying
to quit. She should be encouraged to ask friends who use
tobacco to refrain around her while she is trying to quit.
✓ Many smokers feel compelled to smoke within the first 30
minutes of awakening. They should be encouraged to switch
their morning routines at this time, such as showering or
going for a walk first before making coffee, which is a technique
sometimes called “scrambling.”
✓ Since cigarettes often are smoked after a meal, smokers
may subconsciously use this to signal the end of the meal.
The patient should set an ending time prior to the meal,
and then push away from the table and go for a walk at the
designated time.
✓ Smokers often miss the hand-to-mouth routine of smoking
when they stop. They should be encouraged to substitute
when they experience cravings, including the following: use
hard, sugarless candy, suck on a straw, or have raw vegetables
such as carrots to chew.
• Examples of cognitive techniques include:
✓ Avoid allowing a craving to lead to a slip by encouraging the
patient to refocus her thoughts. The patient could be trained
to think of the command “STOP!” or to snap a rubber band
around the wrist whenever cravings begin.
✓ Patients can use a visualization exercise to focus on something
else rather than on the craving.
• Consistent use of barrier contraceptives to prevent pregnancy
and STIs.
3.b. What feasible pharmacotherapeutic alternatives are available
for treatment of uncomplicated acute bronchitis?
• Antibiotics are inappropriate and ineffective for this patient
because ≥90% of cases of uncomplicated acute bronchitis are
attributed to nonbacterial causes. Several meta-analyses have
reached the following conclusion: routine antibiotic treatment
of acute bronchitis does not impact severity or duration of illness,
time lost from work, limitation of activity, or the likelihood
of developing pneumonia. Therefore, antibiotic use is not
recommended. 2

• β -Adrenergic agonist bronchodilators have not consistently
2
shown benefit for patients with symptoms of acute bronchitis,
per a recent Cochrane review. 3 Daily cough scores were
not consistently diminished, nor were the number of patients
coughing reduced after 7 days of treatment. However, a subgroup
of patients who were wheezing or had airflow obstruction
at presentation did benefit from a bronchodilator. Since
this patient did not experience wheezing, she is not likely to
benefit from bronchodilator use.
• Anticholinergics have not been conclusively shown to be effective
for relieving the symptoms of acute bronchitis. 2
• Inhaled corticosteroids are not very effective for this indication
because of the delay in onset of action. 2
• Antitussives (e.g., codeine, dextromethorphan) are of uncertain
benefit in uncomplicated acute bronchitis, since they have
not been systematically studied in adequate trials. However,
antitussives have been useful in reducing subjective cough
scores and can be offered for short-term relief of symptoms. 2
Antitussives should be instituted cautiously in this patient
because her cough is productive. Suppression of cough may
inhibit expectoration of mucus.
• Antipyretics and analgesics (e.g., acetaminophen, aspirin, ibuprofen)
may be effective for symptoms of lethargy, fever, and
malaise. 1
• Expectorants (e.g., guaifenesin) are of questionable clinical effectiveness
for the symptoms of acute bronchitis but may be used
to increase expectoration. 1
TablE 118-1 Advantages and Disadvantages of Smoking Cessation Medications
3.c. What are the most likely alternatives for smoking cessation?
• Considerations for smoking cessation medications should
include: (1) the degree of success during past attempts at cessation
with a particular medication, (2) possible adverse effects
or drug interactions, (3) whether the medication is available
OTC or is prescription-only, and (4) other advantages or disadvantages
as outlined in Table 118-1.
3.d. What sexual/reproductive health considerations are applicable
to this patient?
• The instructor is referred to the textbook chapter for a complete
discussion of therapeutic options. The patient reports
inconsistent use of condoms as her means of birth control. In
addition to the risk of pregnancy from inconsistent condom
use, the patient is at risk for STIs, including HIV. She should
be counseled regarding these risks and the need for consistent
condom use, regardless of the use of other birth control
methods.
• HPV vaccination for the prevention of cervical cancer (and
genital warts if HPV4 vaccine is administered).
3.e. What psychosocial considerations are applicable to this
patient?
• Although clinicians may be aware that antibiotics are not indicated
for uncomplicated acute bronchitis, they may perceive that
the patient or caregiver expects a prescription. However, studies
suggest that an office encounter concluding with receipt of
antibiotic treatment does not necessarily correlate with increased
Smoking Cessation
Medication Advantages Disadvantages
Nicotine patch Easy for patients to use Pruritus is relatively common
Can be obtained OTC
Nicotine levels more consistent
Discontinue with “step-down” therapy
Avoid in patients with certain dermatologic conditions
Nicotine gum Adjustable use with specific schedule to follow Proper chewing technique must be used
Can be obtained OTC Not appropriate for denture wearers
Has been shown to delay weight gain for some patients Acidic beverages can decrease efficacy if used within 15 min before
May be good for adjunct therapy with longer-acting medication using lozenge
Nicotine lozenge No need to “chew and park” like gum Not appropriate for denture wearers
Adjustable use with specific schedule to follow Acidic beverages can decrease efficacy if used within 15 min before
Can be obtained OTC
May be good for adjunct therapy with longer-acting medication
chewing gum
Nicotine inhaler Adjustable use with specific schedule to follow
Great choice for patients needing “hand-to-mouth” routine
Discontinue with “step-down” therapy
Available by prescription only
Patient dependence is possible
Initial mouth or throat irritation
Avoid in patients with severe reactive airway disease
Acidic beverages can decrease efficacy
Nicotine nasal spray Adjustable use with a specific schedule Available by prescription only
Discontinue with “step-down” therapy Potential for mouth or throat irritation
Avoid in patients with severe reactive airway disease
Bupropion SR Oral medication, easy to use twice daily by mouth Available by prescription only
May delay weight gain Timing is crucial (must begin at least 1 week prior to quit date)
Can also be used for depression Avoid in patients with high seizure risk
Multiple medication interactions
Contraindicated in pregnancy
Varenicline Oral medication, easy to use twice daily by mouth Available by prescription only
No problems in patients with seizure risk Timing is crucial (must begin at least 1 week prior to quit date)
No known medication interactions Pregnancy class C
OTC, over-the-counter.
Copyright © 2011 by The McGraw-Hill Companies, Inc. All rights reserved.
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Acute Bronchitis

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SECTION 16 Infectious Diseases
patient satisfaction. Rather, the time spent interacting with the
patient explaining the condition and the treatment plan is more
conducive to increasing satisfaction. 2 Furthermore, one study
suggests that when a patient is told their diagnosis is “bronchitis,”
they are more dissatisfied with not receiving an antibiotic than
when the terms “chest cold” or “viral infection” are used. 5 Thus,
more benign-sounding labels for the patient may improve satisfaction
with not being prescribed an antibiotic. Therefore, taking
time to counsel the patient and considering what terminology to
use are important for alleviating potential patient dissatisfaction
with not receiving an antibiotic.
Optimal Plan
4.a. What drugs, dosage form, dose, schedule, and duration of
therapy are best to alleviate this patient’s symptoms of acute
bronchitis?
• For this patient, symptomatic treatment is the most appropriate
approach.
• Antibiotics have no role in the management of this patient
because they are not useful for treating uncomplicated acute
bronchitis. The patient does not present with abnormal vital
signs and chest congestion, so treatment for possible pneumonia
with antibiotics is not appropriate.
• Treatment should include attempts to enhance expectoration
by increasing fluid intake and using air humidifiers.
• Since this patient did not have wheezing at presentation, cough
relief would not likely be achieved through the use of a bronchodilator,
such as inhaled albuterol. Also, the inappropriate
use of a medication that was not prescribed for the patient
should be addressed.
• Dextromethorphan could be considered for supplemental use
for cough, along with guaifenesin to help increase expectoration.
Combination dextromethorphan/guaifenesin products
may be given (e.g., Robitussin DM or generic equivalent two
teaspoonfuls Q 4 h), or the drugs may be given separately (e.g.,
long-acting Delsym Suspension two teaspoonfuls Q 12 h or
Humibid one to two tablets Q 12 h).
• Acetaminophen 650 mg Q 4–6 h can be given for pain relief as
needed.
4.b. What medication and dosage should be recommended for
this patient’s smoking cessation plan?
• At this time, the patient is not interested in smoking cessation
but should be encouraged to seek the help of a health care professional
for any future cessation attempts. Smoking cessation
should be addressed at any and all follow-up visits. Table 118-1
illustrates various smoking cessation options for this patient.
Outcome Evaluation
5. What clinical and laboratory parameters are necessary to evaluate
the therapy for achievement of the desired outcome and to
detect or prevent adverse effects?
• Uncomplicated acute bronchitis is usually self-limited, and this
patient does not have a history of chronic bronchitis. Therefore,
this presentation is not likely to be an acute exacerbation of
chronic bronchitis. However, if the cough persists, the clinician
should consider a possible change in diagnosis. For example,
an emerging case of chronic bronchitis should be considered
if patients have cough and sputum production on most days
of the month for at least 3 months of the year during 2 consecutive
years. 6 In such patients, there would be a progressive
worsening of symptoms and air flow.
Copyright © 2011 by The McGraw-Hill Companies, Inc. All rights reserved.
• Also, if the cough persists for >3 weeks, the patient’s diagnosis
should be reevaluated. Other diagnoses that should be considered
at that time would be postinfectious cough, upper respiratory
cough syndrome due to several rhinosinus conditions,
asthma, and gastroesophageal reflux disease. 7
Patient Education
6. What information should be provided to the patient to enhance
adherence, ensure successful therapy, and minimize adverse
effects?
General information:
• You have what is known as acute bronchitis. This disorder is
usually caused by a virus that we cannot specifically identify.
Because antibiotics are effective only against bacteria, they will
not be helpful to you in this situation. Also, using antibiotics
without a clear indication may increase the chance of your
becoming infected with resistant bacteria. An epidemic of antibiotic
resistance exists, and this is caused when antibiotics are
prescribed for conditions without clear benefit.
• The cough may last for 10–14 days after this clinic visit. We
can give you some medicine to help relieve the cough, but do
not expect it to go away entirely very quickly. Although most
symptoms should resolve on their own, the cough will need to
be reevaluated if it lasts for longer than 3 weeks.
• If your symptoms of cough and sore throat do not decrease
within the next 2 weeks, please make a follow-up appointment
at the clinic to be examined again by a physician.
• The onset of new symptoms such as shortness of breath and
new fever may indicate a bacterial infection; also, if fluid comes
up with coughing, this could be a sign of reflux; please let us
know if any of these new symptoms occur.
Dextromethorphan/guaifenesin:
• This medicine can be used to help decrease your cough and
loosen the phlegm or mucus in your lungs. Take two teaspoonfuls
every 4 hours if needed to help control your cough.
• If your cough continues for more than 3 weeks, do not continue
using this product. Instead, contact your physician for
continued treatment advice. A persistent cough could be a sign
of a serious condition.
• Do not take more than six doses in a 24-hour period.
Acetaminophen extra-strength tablets:
• Acetaminophen can be used to help treat minor aches or pains
or relieve fever.
• Take two tablets by mouth every 4–6 hours as needed. Do not
take more than eight tablets per day.
• Do not take this for pain for more than 10 days or for fever
more than 3 days without consulting your physician.
• Do not drink alcohol while you are taking this medication.
m FOLLOW-UP QUESTION
1. What vaccinations should this patient receive?
• The patient should receive the influenza vaccine each fall prior
to the start of flu season.
• The patient is also eligible to receive the HPV vaccination series if
she so chooses. HPV vaccination is recommended by the Advisory
Committee on Immunization Practices (ACIP) at age 11 or 12
years with catch-up vaccination at ages 13–26 years. Ideally, the
vaccine should be administered before potential exposure to

HPV through sexual activity; however, females who are sexually
active should still be vaccinated consistent with age-based recommendations.
Sexually active females who have not been infected
with any of the four HPV types (types 6, 11, 16, 18 that HPV4
[Gardasil] prevents) or any of the two HPV types (types 16, 18
that HPV2 [Cervarix] prevents) receive the full benefit of the
vaccination. Vaccination is less beneficial for females who have
already been infected with one or more of the HPV types. 8
REFERENCES
1. Braman SS. Chronic cough due to acute bronchitis: ACCP evidencebased
clinical practice guidelines. Chest 2006;129:95S–103S.
2. Wenzel RP, Fowler AA. Acute bronchitis. N Engl J Med 2006;355:
2125–2130.
3. Smucny J, Flynn C, Becker L, Glazier R. β 2 -agonists for acute bronchitis.
Cochrane Database Syst Rev 2006;(4).
4. Gonzales R, Bartlett JG, Besser RE, et al. Principles of appropriate
antibiotic use for treatment of uncomplicated acute bronchitis: background.
Ann Intern Med 2001;134:521–529.
5. Phillips TG, Hickner J. Calling acute bronchitis a chest cold may
improve patient satisfaction with appropriate antibiotic use. J Am
Board Fam Pract 2005;18:459–463.
6. Brunton S, Carmichael BP, Colgan R, et al. Acute exacerbation of
chronic bronchitis: a primary care consensus guideline. Am J Manag
Care 2004;10:689–696.
7. Irwin RS, Baumann MH, Boulet L, et al. Diagnosis and management
of cough executive summary: ACCP evidence-based clinical practice
guidelines. Chest 2006;129:1S–23S.
8. Centers for Disease Control and Prevention. Recommended adult
immunization schedule—United States, 2010. MMWR 2010;
59(1):1–4.
Copyright © 2011 by The McGraw-Hill Companies, Inc. All rights reserved.
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