A 34-year-old teacher sits forward on the stretcher, coughing hard enough to bring tears to her eyes. For 10 days, the cough has shifted from dry and irritating to productive of scant yellow sputum; she has no measured fever but feels “worn out.” Her lungs have scattered rhonchi that partially clear with coughing, and her oxygen saturation is 98% on room air. The question is whether this is a self-limited airway illness—or the pneumonia that cannot be missed.

— What’s your move? Read on.

Before you read
  • When do antibiotics help, and when do they only cause harm?
  • Which symptomatic treatments have meaningful benefit?

When to Think of It

Acute cough, usually lasting 1–3 weeks, with or without sputum, after an upper-respiratory prodrome; rhonchi or wheeze may be present. Colored sputum does not reliably indicate bacterial infection.

Sick or Not Sick

The key fork is pneumonia versus uncomplicated bronchitis. Assess vital signs, oxygenation, work of breathing, focal lung findings, mental status, and comorbidity; chest imaging is indicated when pneumonia is clinically plausible, not automatically for every cough.

The First Fifteen Minutes

  • Hypoxemia or respiratory distress → oxygen by nasal cannula 1–6 L/min, titrated to 92–96% (88–92% if chronic CO₂ retention), because increasing inspired oxygen corrects impaired gas exchange.
  • Bronchospasm with wheeze → albuterol 2.5 mg nebulized or 4–8 puffs by MDI with spacer, because β₂-mediated bronchodilation reduces airflow obstruction.
  • Prominent pleuritic discomfort or fever → acetaminophen 1,000 mg PO/IV every 6 hours as needed, maximum 4 g/day (use ≤3 g/day with liver disease or heavy alcohol use), because it reduces pain and fever.
  • Suspected pertussis with paroxysmal cough, inspiratory whoop, post-tussive emesis, or a compatible exposure → azithromycin 500 mg PO/IV once, then 250 mg daily on days 2–5, because macrolide therapy reduces transmission; verify local guidance and QT/drug-interaction risk.
  • Do not give antibiotics for uncomplicated acute bronchitis; they do not meaningfully shorten cough.

Definitive Care & Disposition

Supportive care, hydration, honey for adults, smoking/vaping cessation, and clear return precautions are usually sufficient. Chest radiography is appropriate for fever, tachycardia, tachypnea, hypoxemia, focal crackles, pleuritic pain, frailty, or diagnostic uncertainty. Admit when pneumonia or another serious process produces hypoxemia, sepsis, respiratory failure, or inability to maintain hydration; treat COPD/asthma exacerbation according to that diagnosis.

How This One Kills

Calling colored sputum “bacterial bronchitis” and prescribing antibiotics can delay recognition of pneumonia while exposing the patient to C. difficile infection, allergic reactions, QT prolongation, and resistance.
The Differential — What Else Looks Like This
  • Pneumonia — fever, tachypnea, hypoxemia, focal crackles, or infiltrate; confusing it with bronchitis delays antibiotics and admission.
  • Asthma/COPD exacerbation — recurrent obstructive symptoms with diffuse wheeze and reduced airflow; missing it leaves bronchospasm untreated.
  • Pertussis — prolonged paroxysms, whoop, or post-tussive emesis; missing it permits transmission and complications.
  • Heart failure — orthopnea, edema, JVP elevation, diffuse crackles; treating as infection delays diuresis and ventilatory support.

The Second-Day Story

Older adults, immunocompromised patients, and those taking antipyretics may have little fever or sputum despite pneumonia. A new functional decline, confusion, unexplained tachypnea, hypoxemia, or focal examination abnormality should override a reassuring cough history; use chest imaging and reassessment rather than the absence of fever as a rule-out test.
Back to Our Patient
Back to the 34-year-old teacher: her normal oxygenation, stable vital signs, lack of focal findings, and cough following a viral prodrome make uncomplicated acute bronchitis most likely. She does not need routine antibiotics or imaging; she receives symptomatic counseling, hydration advice, and return precautions for dyspnea, persistent fever, hypoxemia, or clinical worsening. She is discharged with outpatient follow-up if the cough persists beyond the expected course.
Patient Presentation to Attending
How you’d present this patient on the floor — tight, pertinent positives and negatives, no rambling
“This is a 34-year-old previously healthy teacher with 10 days of cough after an upper-respiratory illness. The cough is now intermittently productive of yellow sputum, but she denies dyspnea, hemoptysis, pleuritic pain, or measured fever. She is afebrile, normocardic, saturating 98% on room air, and has scattered rhonchi that clear with coughing without focal crackles or increased work of breathing. My assessment is uncomplicated acute bronchitis rather than pneumonia, asthma, or heart failure. I plan supportive care without antibiotics, symptomatic treatment as needed, and return precautions for worsening breathing, fever, chest pain, or persistent symptoms.”

Study Directive

  • Practice distinguishing bronchitis from pneumonia using vital signs and focal examination findings in five mock cases.
  • Review local chest-radiography indications and antibiotic stewardship guidance.
  • Write a discharge script that includes expected cough duration and four return precautions.
  • Reassess one patient with cough after 10 minutes of bronchodilator therapy and document objective response.

Recent Literature

  • Review or guideline Acute Bronchitis: Rapid Evidence Review
    Mulhem E, Patalinghug E, Eraqi H · Am Fam Physician, 2025 · PMID 40106287 · cited 1×
    A current evidence review for diagnosing uncomplicated acute bronchitis, excluding pneumonia, counseling about expected cough duration, and avoiding antibiotics or other low-value therapies.