Acute Bronchitis

A 40-year-old man with no underlying lung disease has a 7-day history of mild shortness of breath with exertion, as well as cough that is now productive of purulent sputum. He reports no paroxysms of cough and no contact with ill persons in his community. He does not appear to be in distress. His temperature is 37°C, his pulse 84 beats per minute, and his respiratory rate 17 breaths per minute. On auscultation of the lungs, no rales are heard; scattered wheezes are heard in the lung bases. How should he be evaluated and treated? Summary and Recommendations The patient described in the vignette most likely has a viral infection causing uncomplicated acute bronchitis. On the basis of data from clinical trials, antibacterial agents are not recommended. Chest radiography is not indicated, given the absence of signs of pneumonia on physical examination. In the absence of an influenza outbreak in the community, no rapid testing for viral causes should be ordered, and no antiviral therapy should be prescribed; influenza is especially unlikely in a patient who is afebrile. In the absence of a history of contact with a person with suspected pertussis (or a person with a history of persistent cough), this diagnosis is unlikely. If paroxysms of cough developed later or if whooping or post-tussive vomiting occurred, testing for pertussis would be reasonable. The patient should be advised that the cough may persist for an additional 10 to 21 days and that infrequently, it persists longer. For his wheezing and shortness of breath with activity, clinical experience suggests that a β2-agonist such as albuterol may provide relief, although data from clinical trials are inconsistent. On the basis of clinical experience, the patient might be offered short-term use of codeine or hydrocodone-containing preparations or inhaled corticosteroids if the cough is persistent, although data from trials to support their use are lacking.