Acute Bronchitis: A Case Study

INTRODUCTION

Acute bronchitis is an inflammation of the mucous membranes lining the tracheo-bronchial tree.

Diagnosed on the basis of a rapid onset of a cough with an otherwise unremarkable pulmonary

history, it often presents with sputum production, dyspnea, and wheezing. According to one

study, the prevalence of acute bronchitis affects nearly 44 out of every 1000 adults older than 16

yrs of age annually with 82 percent of the reported cases occurring during the fall and winter

months.1

PATHOPHYSIOLOGY/ETIOLOGY

Acute bronchitis is usually caused by infections, such as those caused

by Mycoplasma species, Chlamydia pneumoniae, Streptococcus pneumoniae, Moraxella

catarrhalis, and Haemophilus influenza, and by viruses, such as influenza, para influenza,

adenovirus, rhinovirus, and respiratory syncytial virus. Exposure to irritants, such as pollution,

chemicals, and tobacco smoke, may also cause acute bronchial irritation (Fayyaz 2009).3During

an episode, the mucous membrane becomes irritated and edematous followed by decreased

muco-ciliary function. As the airways become infiltrated with debris and irritation increases, the

response is copious secretion of mucus and the characteristic development of a bronchitis cough.2

CLINICAL MANIFESTATIONS

The most commonly observed clinical presentation of and thus complaint associated with acute

bronchitis is cough and sputum production. It begins early with the onset of an acute respiratory

infection and becomes more prominent as the disease/infection progresses.3 Other signs and

symptoms include; sore throat, rhinorrhea, rhinitis, headache, malaise, fever

(influenza/pneumonia), chest pain, dyspnea, and wheezing. Symptoms usually present within

two days of the infection and usually last for less than 3 weeks in 50% of patients, but more than

1 month in 25% of patients.4 Diagnosis of acute bronchitis is a clinical one as there seems to be

no one reliable test to confirm it. Cultures are often obtained to isolate viral or bacterial

infections. Sputum cytology and CBC are also common diagnostic tests used. Chest radiograph

is used to rule out acute pneumonia, and bronchoscopy may be utilized in suspected foreign body

aspiration, tumors, or tuberculosis.

TREATMENT

Since acute bronchitis is regarded to as a mild self-limiting illness5 therapy is generally aimed for

symptomatic relief. Management usually consists of antimicrobials, antivirals, bronchodilators,

analgesics, anitpyretics, antitussives, and expectorants. Of particular concern, antibiotics have

not demonstrated substantial or consistent benefit in the treatment of acute bronchitis6,7 and

reports show that between 65-80% of patients with acute bronchitis receive an antibiotic despite

this evidence.6 The most recent evidence-based guidelines put forth by the American College of

Chest Physicians suggest central cough suppressants such as codeine and dextromethorphan

should be used as treatment for short-term symptomatic relief of coughing. Beta 2 adrenergic

bronchodilators may be used to treat bronchospasm and wheezing associated with acute

bronchitis; however one systematic review found no significant difference in cough or ability to return

to work between inhaled or oral beta2 agonists and placebo in people with acute bronchitis. 8

CONCLUSION

Acute bronchitis continues to be an important ailment found in clinical practice today and is

usually manifested secondarily to an upper respiratory viral infection that progresses to the lower

respiratory tract. Since acute bronchitis, pneumonia, and chronic bronchitis all overlap in clinical

manifestations, it is important to rule out more severe diseases of the respiratory tract as acute
bronchitis is self limiting and should be treated symptomatically. Furthermore, the continued use

of antibiotics as a first line treatment against a predominantly viral illness raises concern for

increasing the incidence of antibiotic resistant bacteria in the community.

CASE STUDY

The patient is a pleasant, army retired 79 yr old male who was brought in to the emergency room

with symptoms of fever, chills, fatigue, and a 2- week history of cough with production of white

sputum. He complains of moderate loss of appetite for approx 1 week. His present history was

absent for contact with sick individuals or recent illness, and is negative for previous similar

symptoms. His past medical history includes hypothyroidism, seizures, TIA, urinary

incontinence, psoriasis, hx of cancer (esophageal, prostatic, and lymphoma), right/left knee

surgery, laparotomy, prostatectomy, neck surgery for cancer, and dilatation of the esophagus. He

also has a history of OSA and uses CPAP at nighttime. The patient currently takes Aggrenox and

Depakote for seizures, Synthroid, Risperdal, and Zocor. The patient denies any history of

respiratory medicines. He denies any allergies, smoking, alcohol, drug use, or recent travel. A

review of systems was unremarkable with the exception of cough and mild dyspnea. The patient

has two daughters in their 50’s and healthy. He also states he has one brother and three sisters

whom are also healthy. He is married and retired from the army where he served in the Korean

and Vietnam theatres. Physical examination revealed an alert and oriented patient x 3 who

presented in mild distress. His vitals were: Bp 162/61, HR 115, RR 18, and febrile temp of

101.7^F, SpO2 93% on RA. HEENT: mucous membranes were slightly dry. Chest was relatively

clear however; auscultation revealed diminished breath sounds bilaterally and extensive

expiratory wheezes throughout. Cardiovascular, abdomen, and extremities were unremarkable.

Skin: revealed tattoo on left shoulder and papulosquamous areas throughout his body. Arterial
blood gas sampling on RA were: pH 7.49, pCO2 36, pO2 57, and HCO3- 26. Chest radiography

revealed vascular congestion, cardiomegaly, right lower lobe atelectasis and an elevated right

hemi-diaphragm. Lab studies were ordered and revealed an elevated BNP of 24, CK of 85, AST

97, ALT 69, albumin of 3, and glucose of 155. All other lab values were within normal limits.

Respiratory assessment concluded that patient had acute bronchitis and hypoxia. Other clinical

impressions were acute fever and acute mild congestive heart failure.

Question #1: Was the collection of an ABG sample indicated in this case?

A. Yes, explain why?

B. no, explain why?

Question #2: What are the results of the ABG sample?

a. uncompensated metabolic acidosis

b. compensated respiratory acidosis w/ hypoxia

c. acute alveolar hyperventilation w/ hypoxia

d. acute superimposed on a chronic vent failure

Question #3: What is/are the indicated respiratory therapy(ies) at this point?

a. Pt. is stable and needs only monitoring

b. further information is needed to properly assign care

c. start patient on supplemental O2

d. begin supplemental O2 and administer bronchodilator

In the emergency room the patient was given 3 rounds albuterol and atrovent via small volume

nebulizer and started on Rocephin and Zithromax via IV with a bolus of normal saline.

Question #4: Should a sputum sample have been collected on this patient? Why?
After receiving treatment in the emergency room the patient was admitted to the adult floor for

further observation and to rule out recurrence of his cancer. On the floor the patient was placed

on respiratory protocol and received aerosol treatments every six hours as needed for wheezing

and shortness of breath. Oxygen was given at 2LPM via nasal-cannula to treat hypoxia and

maintain SpO2 saturations above 92%. A CT of the patient’s abdomen on the following day was

found to be negative. The patient was discharged on the 4th day after admission stating that he

feels much better. His vitals on discharge were: Bp: 104/54, HR 76, RR 18, and SpO2 98%. He

was discharged only on his home medications and was to follow up with his PCP within a week.

Question #5: What other respiratory therapy was indicated in this case?

SUMMARY

The patient in this case displayed one of the most common complaints that bring individuals into

clinic each year. On admission he was found to be hypoxic and an arterial blood gas sample was

indicated do to his unexplained dyspnea, increased work of breathing, and increased heart rate.

The blood gas sample confirmed a state of hypoxia and an acute alveolar hyperventilation. Thus

the patient was placed on supplemental oxygen and given bronchodilators to correct his

bronchospasm. Question 4 asks if a sputum sample should have been collected; since the patient

had a productive cough, sputum cultures should have been ordered as bronchitis is usually

secondary to an upper respiratory infection and results of the sampling would be useful in

determining the appropriate antibiotic treatment. The last question addresses the need for

hyperinflation therapy to address the atelectasis found on the chest x-ray. Furthermore a follow

up on the case notes in the patient’s file concluded that his significant medical history and co-

morbidities were the result of dioxin (agent Orange) exposure during the Vietnam War.

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