Rosen & Barkin's 5-Minute Emergency Medicine Consult (115 page)

• Complaints that may precede upper respiratory tract infection (URTI) symptoms:
  
  • Malaise
    
  • Chills
    
  • Myalgias
    
  • Coryza (rhinitis)
    
  • Sore throat
    
• Onset of URTI symptoms:
  
  • Mild dyspnea
    
  • Cough, initially dry and nonproductive
    
  • Cough, later becomes mucoid or mucopurulent
    
  • Chest pain or burning related to cough
    
  • Initial symptoms improve after 3–5 days, with 1–3 wk of residual cough and malaise
    

• Fever, not usually above 102°F (38.5°C)
  
• Tachypnea
  
• Mild hemoptysis
  
• Ronchi (wheezing)
  
• Rales (crackles)
  

• Influenza A and B testing if identification of these organisms is required for treatment or reporting
  
• Evaluate for pertussis:
  
  • Acute cough illness lasting 14 days or more in a person with paroxysmal cough, post-tussive vomiting, or inspiratory whoop
    
  • 14 days or more of cough within an outbreak setting
    

• Influenza A and B testing may help immediately confirm clinical suspicion.
  
• In most cases, no specific test will help make the diagnosis immediately.
  
• Viral or bacterial cultures are rarely helpful.
  
• CBC may show leukocytosis, but is a nonspecific finding.
  
• Pertussis may be confirmed using PCR testing, but diagnosis will be delayed.
  

CXR:

• No evidence of consolidation
  
• Indications:
  
  • Shortness of breath
    
  • Hypoxia
    
  • Chest pain
    
  • Heart rate >100 beats/min
    
  • Respiratory rate ≥24 breaths/min
    
  • Temperature ≥38°C
    
  • Focal findings on chest exam
    
  • Elderly patient with multiple comorbid conditions
    
  • Hypoxia
    
  • 14 days or more of cough
    

Pulmonary function tests are frequently abnormal.

• Acute and subacute <8 wk:
  
  • Pneumonia
    
  • Reactive airway disease
    
  • Aspiration
    
  • Acute sinusitis
    
  • Bacterial tracheitis
    
  • Occupational exposure
    
• Chronic >8 wk:
  
  • Asthma
    
  • GERD
    
  • Chronic bronchitis
    
  • Bronchiectasis
    
  • ACE inhibitor use
    
  • Bronchogenic carcinoma
    
  • Carcinomatosis
    
  • Sarcoidosis
    
  • Left ventricular failure
    
  • Aspiration syndrome
    
  • Psychogenic/habit
    

TREATMENT

• Maintain adequate oxygenation
  
• Bronchodilators if wheezing is present
  

• Aggressive initial management of these patients is seldom required.
  
• Administer oxygen if the patient is hypoxic.
  
• Fluids may be administered if the patient is dehydrated.
  

• Bronchitis is usually a viral process, but may be bacterial and there is no practical test to distinguish between the 2:
  
  • Because this is usually a viral process, treatment is symptomatic:
    
    • Cough suppressants may be considered.
      
    • β-Adrenergic inhaler for patients with evidence of airflow obstruction
      
• Amantadine may be used in known outbreaks of influenza A, although local patterns of resistance should be reviewed.
  
• Oseltamivir (Tamiflu) and zanamivir (Relenza) may be considered in patients with recent onset of influenza.
  
• Antibiotics:
  
  • Generally, antibiotics are not indicated (even when secretions are purulent).
    
  • In healthy patients with no underlying lung disease, antibiotics may help some patients get better slightly faster, but weighed against the many people it does not help, cost, side effects, and resistance, antibiotics are not recommended.
    
  • Consider use in those patients who have recurrence of fever after initial improvement.
    
• Symptomatic control with antipyretics and analgesics
  
• Although patients should be encouraged to stop smoking, the use of tobacco is not an indication for antibiotics unless the patient has a known history of emphysema.
  

• Aggressive initial management of these patients is seldom required.
  
• Administer oxygen if the patient is hypoxic.
  
• Fluids may be administered if the patient is dehydrated.
  
• Repeated bouts in children should lead to referral for complete evaluation of the respiratory tract.
  

• Albuterol Inhaler may be used for those with evidence of airflow obstruction.
  
• Amantadine: 100 mg/d PO, must be given within 48 hr of symptom onset
  
• Oseltamivir (Tamiflu) and zanamivir (Relenza) within 48 hr of symptom onset for influenza-related bronchitis:
  
  • Zanamivir: 10 mg inhalation q12h (peds: >7 yr 10 mg or 2 inhalations q12h) × 5 d
    
  • Oseltamivir: 75 mg PO BID (peds: 2 mg/kg) × 5 d
    
• Erythromycin should be given to proven cases of pertussis and to household contacts of those with proven pertussis.
  
• Yearly influenza vaccinations should be encouraged in health care providers and in the high-risk populations (elderly, immunocompromised, chronic lung disease).
  

• Use of acetaminophen rather than aspirin for analgesia
  
• Antibiotic considerations are the same as in adults.
  

FOLLOW-UP

• Underlying significant cardiopulmonary compromise
  
• Significant hypoxia
  
• Ill patient with unclear diagnosis
  

• No pulmonary compromise should be present.
  
• Instruct patients, particularly high-risk patients, to return if no improvement or worsening of symptoms occurs.
  
• Bed rest
  
• Fluids
  
• Aspirin or acetaminophen
  

• No follow-up is needed in those patients that improved.
  
• Patients should be instructed to return to the ED for onset of shortness of breath and should see their doctor if not improved after 2–3 wk.
  

Patients with high fever or significant pulmonary symptoms should be evaluated for pneumonia.

• Aagaard E, Gonzales R. Management of acute bronchitis.
  Infect Dis Clinic North Am
  . 2004;18:919–937.
  
• Becker LA, Hom J, Villasis-Keever M, et al. Beta2-agonists for acute bronchitis.
  Cochrane Database of Syst Rev.
  2011;(7):CD001726. doi:10.1002/14651858.CD001726.pub4.
  
• Camargo CA Jr, Rachelefsky G, Schatz M. Managing asthma exacerbations in the emergency department. Summary of the National Asthma Education and Prevention Program Expert Panel Report 3 guidelines for the management of asthma exacerbations.
  Proc Am Thorac Soc.
  2009;6(4):357–366.
  
• Rollins DR, Beuther DA, Martin RJ. Update on infection and antibiotics in asthma.
  Curr Allergy Asthma Rep
  . 2010;10:67–73.
  
• Smith SM, Fahey T, Smucny J, Becker LA. Antibiotics for acute bronchitis.
  Cochrane Database of Syst Rev.
  2014; Issue 3. Art. No.: CD000245. DOI: 10.1002/14651858.CD000245.pub3.
  
• Stephens MM, Nashelsky J. Clinical Inquiries. Do inhaled beta-agonists control cough in URIs or acute bronchitis?
  J Fam Pract
  . 2004;53:662–663.
  

See Also (Topic, Algorithm, Electronic Media Element)

• Cough
  
• Dyspnea
  
• Pneumonia, Adult
  
• Pneumonia, Pediatric
  

CODES

• 466.0 Acute bronchitis
  
• 466.11 Acute bronchiolitis due to respiratory syncytial virus (RSV)
  
• 490 Bronchitis, not specified as acute or chronic
  

BASICS