Diagnosis: Acute Bronchitis
This patient has acute bronchitis, a self-limited viral respiratory infection that does NOT require antibiotic therapy. 1
Clinical Presentation
The constellation of productive cough, muscle aches (myalgia), fatigue, low-grade fever, and bilateral rhonchi is classic for acute bronchitis—an acute respiratory infection manifested by cough with or without sputum production lasting up to 3 weeks. 1 These constitutional symptoms (fever, muscle aches, fatigue) frequently accompany the respiratory symptoms in acute bronchitis. 1
Critical Diagnostic Considerations
Rule out pneumonia first: The absence of infiltrate on chest radiograph distinguishes acute bronchitis from pneumonia. 1 Obtain a chest X-ray only if there are clinical features suggesting pneumonia: new focal chest signs on examination, fever >4 days, dyspnoea/tachypnoea, or vital sign abnormalities. 1, 2 This patient's bilateral rhonchi (not focal consolidation) and low-grade fever make pneumonia less likely, but imaging may still be warranted based on clinical judgment.
Distinguish from asthma: Approximately one-third of patients presenting with acute cough are misdiagnosed with acute bronchitis when they actually have acute asthma. 1 If this patient has had two or more similar episodes in the past 5 years, consider underlying asthma (65% of such patients have mild asthma). 1
Consider pertussis: If the patient develops paroxysmal coughing, post-tussive vomiting, or inspiratory whooping sound, obtain a nasopharyngeal culture for Bordetella pertussis. 1, 2 If confirmed, prescribe a macrolide antibiotic and isolate the patient for 5 days from treatment start. 1
Treatment Protocol
What NOT to Do
Do NOT prescribe antibiotics. Routine antibiotic treatment for acute bronchitis is not justified and should not be offered—the infection is viral, not bacterial. 1 The widespread inappropriate use of antibiotics for acute bronchitis must be curtailed. 1
Do NOT prescribe inhaled bronchodilators or expectorants. There is no role for these therapies in uncomplicated acute bronchitis. 1
Recommended Treatment
Symptomatic relief only:
Antitussive agents (codeine or dextromethorphan) can be offered for short-term symptomatic relief of coughing, though they are only occasionally useful. 1
First-generation antihistamine plus decongestant (e.g., brompheniramine/pseudoephedrine) has been shown in controlled trials to decrease cough severity and hasten resolution in viral respiratory infections. 1
Naproxen (nonsteroidal anti-inflammatory drug) has demonstrated benefit for cough in controlled studies. 1
Reassurance that this is a self-limited condition expected to resolve within 3 weeks. 1, 2
When to Reassess
If cough persists 3-8 weeks (subacute cough): Consider post-infectious cough and treat with inhaled ipratropium bromide as first-line therapy. 2, 3 Reassure the patient that spontaneous resolution is expected. 2
If cough persists >8 weeks (chronic cough): Reclassify as chronic cough and initiate systematic evaluation starting with treatment for upper airway cough syndrome (UACS), then asthma, then GERD if prior treatments fail. 2, 3
Common Pitfalls to Avoid
Prescribing antibiotics reflexively based on productive sputum or low-grade fever—these are typical viral features and do not indicate bacterial infection. 1
Missing underlying asthma in patients with recurrent episodes—prospectively evaluate whether this is an isolated event or predictor of chronic disease. 1
Failing to recognize the 3-week and 8-week thresholds that change the diagnostic approach and treatment strategy. 2, 4
Overlooking pertussis in patients with characteristic paroxysmal cough, especially if there are household contacts with similar symptoms. 1, 2