What is the treatment for bronchitis?

Treatment of Bronchitis

Antibiotics should not be prescribed for acute bronchitis unless pneumonia is suspected or the patient has specific risk factors. 1 Most cases of bronchitis are viral in origin and antibiotics provide minimal benefit while contributing to antibiotic resistance.

Types of Bronchitis and Diagnosis

Acute Bronchitis

• Self-limited inflammation of large airways (bronchi) with cough lasting up to 6 weeks 1
• Primarily viral in origin (>90% of cases) 1
• Must be distinguished from pneumonia, common cold, and exacerbation of chronic bronchitis 1

Chronic Bronchitis

• Defined as cough and sputum production occurring most days for at least 3 months of the year for at least 2 consecutive years 1
• Often associated with smoking or exposure to other respiratory irritants 1

Treatment Algorithm for Acute Bronchitis

1. Rule out pneumonia: Pneumonia is unlikely in the absence of all of the following: tachycardia (>100 beats/min), tachypnea (>24 breaths/min), fever (>38°C), and abnormal chest exam findings 1

2. Supportive care only (no antibiotics):

   • Cough suppressants for symptomatic relief: dextromethorphan or codeine 1
   • Possible symptomatic relief with expectorants (guaifenesin), first-generation antihistamines, decongestants, or β-agonists, though evidence is limited 1
   • Patient education about the viral nature of the illness and expected duration (typically up to 3 weeks) 1

3. Special circumstances for antibiotic use:

   • Suspected pertussis (whooping cough): macrolide antibiotic (e.g., azithromycin) and isolation for 5 days 1
   • Note: Purulent sputum (yellow/green) does NOT indicate bacterial infection and is not an indication for antibiotics 1

Treatment Algorithm for Chronic Bronchitis

1. First-line approach: Avoidance of respiratory irritants (smoking cessation, avoiding environmental pollutants) 1

2. Pharmacologic therapy:

   • Short-acting inhaled β-agonists 1
   • Inhaled ipratropium bromide 1
   • Combined regimen of long-acting β-agonist with inhaled corticosteroid 1
   • Central cough suppressants (codeine, dextromethorphan) for short-term symptomatic relief 1

3. For acute exacerbations of chronic bronchitis:

   • Inhaled bronchodilators 1
   • Oral antibiotics (if increased dyspnea, sputum production, and purulence) 1, 2
   • Oral or IV corticosteroids in severe cases 1

Common Pitfalls to Avoid

1. Inappropriate antibiotic use: More than 70% of acute bronchitis visits result in antibiotic prescriptions despite evidence against their use 1

2. Misdiagnosis: Ensure proper differentiation from pneumonia, asthma, and COPD exacerbations 1

3. Overreliance on sputum color: Yellow or green sputum does not indicate bacterial infection; it's due to inflammatory cells or sloughed mucosal epithelial cells 1

4. Prolonged cough: If cough persists beyond 3 weeks, consider alternative diagnoses 1

5. Ignoring smoking cessation: For chronic bronchitis, the most effective intervention is smoking cessation and avoidance of respiratory irritants 1

Special Considerations

• Elderly patients (≥65 years) and those with comorbidities may be at higher risk for complications and might benefit from closer monitoring 2

• β-agonists have not shown benefit in patients without asthma or chronic obstructive lung disease 1

• Tiotropium is indicated for maintenance treatment of COPD including chronic bronchitis but is not indicated for acute deteriorations 3

By following these evidence-based guidelines, unnecessary antibiotic use can be reduced while still providing effective symptomatic relief for patients with bronchitis.