What is the appropriate management for a patient with a history of TEVAR presenting with chest pain, cough, and sore throat, diagnosed with likely acute bronchitis?

Management of a Patient with TEVAR History Presenting with Acute Bronchitis

For a patient with history of TEVAR presenting with chest pain, cough, and sore throat diagnosed with acute bronchitis, the most appropriate management includes azithromycin treatment along with symptomatic relief, while maintaining vigilance for potential TEVAR complications requiring urgent hospital assessment. 1

Antibiotic Management

• Azithromycin is appropriate for this patient with acute bronchitis, particularly given the presence of productive cough, fine crackles on examination, and systemic symptoms (body aches, hot/cold sweats) 1
• The recommended dosing is 500mg on day 1, followed by 250mg daily for 4 additional days, which aligns with the current prescription 2, 3
• While routine antibiotic use is generally not recommended for uncomplicated acute bronchitis, this patient's clinical presentation with crackles on examination suggests a potential bacterial component warranting antimicrobial therapy 1

Symptomatic Management

• Paracetamol and ibuprofen are appropriate for pain relief and fever management 4
• Difflam solution (15ml held for 20 seconds then gargled every 1-3 hours) is appropriate for sore throat relief 4
• Loratadine may help with post-nasal drip symptoms that could be contributing to cough 4
• Antitussive agents (such as dextromethorphan) could be considered for short-term symptomatic relief of coughing if it becomes severe or disruptive to sleep 1, 4

Special Considerations for TEVAR History

• The patient's history of TEVAR for blunt thoracic aortic injury requires special attention, as chest pain in this population could indicate serious complications 5, 6
• Patients with TEVAR are at risk for rare but potentially fatal complications including aortobronchial fistula (ABF) or aortoesophageal fistula (AEF), which can present with chest pain and hemoptysis 6
• The plan to return for urgent hospital assessment if chest pain worsens is critical, as delayed diagnosis of TEVAR complications carries high mortality 6
• The pending CT thoracic aorta from May should be prioritized for completion, as regular imaging surveillance is essential in TEVAR patients 5
• No interval imaging since 2013 is concerning, as long-term outcomes and potential complications of TEVAR require monitoring 5

Respiratory Support

• For patients with productive cough, airway clearance is important 1
• If wheezing develops, a β-agonist bronchodilator may be beneficial 1
• Mucokinetic agents are not routinely recommended as they show inconsistent benefits for acute bronchitis 1

Follow-up Plan

• Close follow-up is warranted given the patient's TEVAR history and current respiratory infection 5, 6
• The patient should be instructed to seek immediate medical attention for:
  • Worsening chest pain 6
  • Development of hemoptysis (which could signal an aortobronchial fistula) 6
  • Fever >38°C or increasing respiratory distress 1
• Completion of the pending CT thoracic aorta is essential for ongoing TEVAR surveillance 5

Potential Pitfalls and Caveats

• Chest pain in TEVAR patients should never be dismissed as merely musculoskeletal or infectious without careful consideration of potential stent-related complications 6
• Hemoptysis in a TEVAR patient is a red flag symptom that requires immediate evaluation for aortobronchial fistula 6
• While treating the acute bronchitis, do not lose sight of the need for regular imaging surveillance in this TEVAR patient, who has gone without imaging since 2013 5
• Antibiotic resistance should be considered when prescribing azithromycin, though its once-daily dosing and 5-day course may improve compliance compared to other regimens 2, 7