82 PART II: PRIMARY CARE DISORDERS
coarse crackles. Given the chronicity of the disease, digital
clubbingandcyanosismaybenoted.Othersignsthatmay
occur over the course of the disease include but are not
limitedtoa delay in sexual maturation,musclewasting,
low body weight, icterus, and a protuberant belly.
26
CFisdiagnosedthroughtwopilocarpineiontophoresis
tests,morecommonlyknownassweattests,obtainedon
consecutivedays.Asodiumchloridelevel>60mEq/Lis
consideredpositiveandisindicativeofCF.Otherdiagnos-
ticstudies,includingDNAevaluation,areavailablewhen
sweat chloride testing is negative in the presence of an
overwhelminglysuggestivehistoryandexamination.
8,25,26
Chest radiography may reveal hyperination, bron-
chiectasis,andeventuallyparenchymalscarring.Onspirom-
etry,evidenceofairowobstructionisoftenpresentearly
inthedisease;however,withtimediminishedlungcapacity
and vital capacity are noted, which are consistent with
restrictive changes and indicative of severe lung disease.
8,26
Management
ManagementofpatientswithCFstemsfromamultidisci-
plinary approach. More than 95 percent of patients die
secondary to complications from lung disease; therefore,
goals of therapy include meticulous pulmonary hygiene
while maintaining nutrition and avoiding GI complica-
tions.
25
Clearingofmucusandmaintenanceofpulmonary
function is promoted through breathing exercises, chest
percussion with postural drainage, inhalation of hypertonic
saline, and bronchodilator therapy.
25,26
Antibiotics, selected
based on culture results and given through a variety of
routes (oral, inhaled, and intravenously) in both short-
termandlong-termcourses,arethemainstayoftherapy.
Intheshorttermthey areindicatedforacuteinfections,
andinthelongtermtheyhelpmaintainlungfunctionand
preventexacerbations.
8,26
Patientsshouldbeuptodateon
all vaccinations and should receive pneumococcal and
yearlyinuenzavaccinations.
8,26
Maintenance of nutrition
and the avoidance of GI complications often involve
pancreatic enzyme and fat soluble vitamin (A, D, E, K)
replacement.
25
Support systems for both the patient and
familymembersshouldbeestablished.
Lifestyle Changes: Practical Tips for Your
Patients
Patients with CF require maintenance of up-to-date
immunizations and the initiation of therapy to pro-
mote good pulmonary hygiene to prevent infection.
Adequate hydration to help mucus thinning and
proper nutrition, with the addition of the needed sup-
plementsforGIfunction,areimportant.
Acute Bronchitis
General Characteristics
Acute bronchitis is dened by inammation of the large
airways(i.e.,tracheaandbronchi)ofthelungs.Itoccursin
approximately5percentofAmericanseachyearandisthe
ninth leading cause of outpatient visits.
30,31
Itismostcom-
monduringthefallandwintermonths
30–32
and in the elderly,
smokers,youngchildren,andthosewithchroniclungdis-
ease.
32
Virusesaretheleadingcauseofbronchitis,account-
ing for nearly 90 percent of all cases.
33
Virusesresponsible
forbronchitisinclude(1)inuenzaAandB,(2)parainu-
enza, (3) respiratory syncytial virus, (4) coronavirus, (5)
adenovirus,(6)rhinovirus,and(7)humanmetapneumovi-
rus. Bothatypicalorganismsandbacterial pathogensmay
beresponsibleintheremainderofthecases.
30–32
Signs, Symptoms, and Diagnosis
AURImayprecedeacutebronchitisbyafewdays.Cough
is the most common symptom and often results from
inammationandhyperreactivityoftheairway.
30,31
Itcan
be nonproductive or productive and is typically worse in
themorning.Thedurationofthe cough must be longer
than5 days for the diagnosis of acute bronchitis,and it
willgenerallybethelastsymptomtodisappear,typically
lasting up to 3 weeks.
30
When cough persists, pertussis
mustbeconsideredasthecausativepathogen.
30
Associated
symptomsincluderhinorrhea,sorethroat,andcoughasso-
ciatedwithchestdiscomfort.
32
Although a low-grade fever
can occur, it is often absent. When a high fever is present,
other diagnoses, such as pneumonia or acute bronchitis
causedbyinuenzaAorB,mustbeconsidered.
30
Physical examination may reveal clear breath sounds
on auscultation, rhonchi that clear with coughing, or an
intermittentwheeze.Rhinorrheaorinjectedpharynxmay
be present.
32
Diagnosisisbasedonathoroughhistoryandphysical
examination.Radiographicandlaboratorydataareseldom
necessary. If pertussis or inuenza is suspected, specic
testingfortheseorganismsshouldtakeplace.
30
Management
The vast majority of cases of acute bronchitis are viral;
therefore,treatmentissupportiveandincludesrest,uid
intake, humidied air, nonsteroidal anti-inammatory
agents,expectorants,andcoughsuppressants.
32–33
Inhaled
bronchodilatorsmaybehelpfulinselectcases.
31
Although
they are often prescribed, the routine use of antibiotics in
uncomplicatedacutebronchitisisnotindicatedorrecom-
mended.Acutebronchitiscausedbypertussisshouldbe
treated with a macrolide antibiotic (i.e., erythromycin,
azithromycin), and those caused by inuenza can be
treatedwithneuraminidaseinhibitorswithin48hoursof
theonsetofsymptoms.
30
Lifestyle Changes: Practical Tips for Your
Patients
Maintenanceofgoodhandwashingprinciplesisimpor-
tant in preventing the spread of viruses, which are the
culpritinthevastmajorityofcasesofacutebronchitis.
Patients who smoke should discontinue smoking
becauseitimpairsproperfunctioningoftherespiratory
tract,makingitmoredifcultforthelungtoriditself
of infectious agents when they are present.

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