What is the treatment for bronchitis?

Treatment for Bronchitis

The treatment for bronchitis should be tailored according to whether it is acute uncomplicated bronchitis or an exacerbation of chronic bronchitis, with antibiotics generally not indicated for acute bronchitis but recommended for certain cases of chronic bronchitis exacerbations. 1

Acute Bronchitis Treatment

Symptomatic Therapy

• Bronchodilators: Albuterol has demonstrated consistent benefit in reducing duration and severity of cough in randomized controlled trials 1
• Antitussives: Dextromethorphan or codeine may have modest effects on cough severity and duration 1
• Environmental measures:
  • Elimination of environmental cough triggers (dust, dander)
  • Vaporized air treatments in low-humidity environments 1

Antibiotic Therapy

• Not recommended for uncomplicated acute bronchitis 1, 2
• Viruses are responsible for >90% of acute bronchitis infections 2
• Colored sputum (green/yellow) does not reliably indicate bacterial infection 2
• Antibiotics should only be considered if:
  • Pertussis is suspected (to reduce transmission)
  • Patient is at increased risk of developing pneumonia (e.g., ≥65 years old) 2

Chronic Bronchitis Exacerbation Treatment

Indications for Antibiotic Therapy

1. Simple chronic bronchitis:

   • Immediate antibiotics not recommended, even with fever 1
   • Consider antibiotics only if fever (>38°C) persists >3 days 1

2. Obstructive chronic bronchitis (FEV1 35-80%):

   • Immediate antibiotics recommended if at least 2 of 3 Anthonisen criteria present:
     • Increased sputum volume
     • Increased sputum purulence
     • Increased dyspnea 1, 3

3. Obstructive chronic bronchitis with respiratory insufficiency (FEV1 <35%):

   • Immediate antibiotic therapy recommended 1

Recommended Antibiotics

• First-line (for infrequent exacerbations, FEV1 ≥35%):

  • Amoxicillin
  • First-generation cephalosporins
  • Macrolides, pristinamycin, or doxycycline (if allergic to beta-lactams) 1

• Second-line (for treatment failures or frequent exacerbations or FEV1 <35%):

  • Amoxicillin-clavulanate
  • Second/third-generation oral cephalosporins (cefuroxime-axetil, cefpodoxime-proxetil)
  • Respiratory fluoroquinolones 1, 3

• Treatment duration: 7-10 days 1

Other Therapeutic Measures

• Bronchodilators:

  • Short-acting β-agonists improve cough, pulmonary function, and dyspnea 1
  • Ipratropium bromide reduces cough frequency and severity 1
  • For acute exacerbations, use short-acting β-agonists or anticholinergic bronchodilators 1

• Corticosteroids:

  • Oral or IV corticosteroids beneficial for acute exacerbations 1
  • Combined regimen of inhaled long-acting β-agonist and inhaled corticosteroid may improve cough 1

• Not recommended:

  • Prophylactic antibiotics for stable chronic bronchitis 1
  • Postural drainage and chest percussion (insufficient evidence) 1
  • Expectorants (insufficient evidence) 1

Clinical Pearls and Pitfalls

1. Common pitfall: Overuse of antibiotics for acute bronchitis

   • Contributes to antibiotic resistance
   • Provides no benefit in most cases of acute bronchitis 2

2. Diagnostic challenge: Distinguishing bronchitis from pneumonia

   • In absence of abnormal vital signs (heart rate >100/min, respiratory rate >24/min, temperature >38°C), pneumonia is unlikely 4

3. Patient expectations: Effective communication is essential as patients often expect antibiotics despite evidence-based recommendations against their use 1, 2

4. Duration of symptoms: Typical bronchitis symptoms last about three weeks; patients should be informed of this to set appropriate expectations 2

5. Pertussis consideration: May be present in 10-20% of adults with cough illness lasting >2-3 weeks 4