What is the management plan for bronchitis?

Management of Bronchitis

Antibiotics should not be prescribed for acute uncomplicated bronchitis as it is primarily caused by viruses (>90% of cases) and antibiotics do not improve outcomes while increasing the risk of adverse effects. 1

Differentiating Types of Bronchitis

Acute Uncomplicated Bronchitis

• Self-limited inflammation of large airways with cough lasting up to 6 weeks
• May be productive or non-productive cough
• Often accompanied by mild constitutional symptoms
• Primarily viral in origin (>90% of cases)

Chronic Bronchitis

• Defined as cough and sputum expectoration occurring on most days for at least 3 months of the year and for at least 2 consecutive years 1
• Caused by interaction between inhaled irritants (cigarette smoke, pollutants) and host factors
• May progress to COPD with airflow limitation

Diagnostic Approach

For Acute Bronchitis:

• Rule out pneumonia - pneumonia is unlikely in the absence of all of the following: 1
  • Tachycardia (heart rate >100 beats/min)
  • Tachypnea (respiratory rate >24 breaths/min)
  • Fever (oral temperature >38°C)
  • Abnormal chest examination findings (rales, egophony, tactile fremitus)
• Note: Purulent sputum (green or yellow) does NOT indicate bacterial infection 1

For Chronic Bronchitis:

• Evaluate for exposures to respiratory irritants (cigarette smoke, passive smoke, workplace hazards) 1
• Consider pulmonary function testing to assess airflow limitation

Management Plan

1. Acute Uncomplicated Bronchitis

First-line approach:

• No antibiotics (Grade A recommendation) 1
• Refer to the condition as a "chest cold" rather than bronchitis when discussing with patients 1
• Provide realistic expectations for cough duration (typically 10-14 days after office visit) 1

Symptomatic relief options:

• Cough suppressants: dextromethorphan or codeine for short-term symptomatic relief 1
• First-generation antihistamines (diphenhydramine)
• Decongestants (phenylephrine)
• Expectorants (guaifenesin) - though evidence for effectiveness is limited 1
• Vaporized air treatments in low-humidity environments 1
• Elimination of environmental cough triggers (dust, dander) 1

Important caveats:

• β-agonists (albuterol) have not shown benefit for patients without asthma or COPD 1
• Symptomatic therapy has not been shown to shorten illness duration 1
• Over-the-counter treatments may cause minor adverse effects (nausea, vomiting, headache, drowsiness) 1

2. Chronic Bronchitis

First-line approach:

• Avoidance of respiratory irritants (tobacco smoke, workplace hazards) - most effective intervention with 90% of patients having resolution of cough after smoking cessation 1

Pharmacologic therapy for stable chronic bronchitis:

• Short-acting β-agonists to control bronchospasm and dyspnea (Grade A recommendation) 1
• Ipratropium bromide to improve cough (Grade A recommendation) 1
• Long-acting β-agonist combined with inhaled corticosteroid (ICS) for cough control (Grade A recommendation) 1
• For patients with FEV1 <50% predicted or frequent exacerbations: ICS therapy (Grade A recommendation) 1
• Theophylline may be considered for cough control with careful monitoring for complications (Grade A recommendation) 1
• Central cough suppressants (codeine, dextromethorphan) for short-term symptomatic relief (Grade B recommendation) 1

NOT recommended for stable chronic bronchitis:

• Long-term prophylactic antibiotics (Grade I recommendation) 1
• Oral corticosteroids (Grade E/D recommendation) 1
• Expectorants (Grade I recommendation) 1
• Postural drainage and chest percussion (Grade I recommendation) 1

3. Acute Exacerbation of Chronic Bronchitis

Defined as: Sudden clinical deterioration with increased sputum volume, purulence, and/or worsening shortness of breath 1

Recommended treatments:

• Short-acting β-agonists or anticholinergic bronchodilators (Grade A recommendation) 1
• Antibiotics, especially for severe exacerbations or those with severe airflow obstruction (Grade A recommendation) 1
• Short course (10-15 days) of systemic corticosteroids (Grade A recommendation) 1

NOT recommended for acute exacerbations:

• Theophylline (Grade D recommendation) 1
• Expectorants (Grade I recommendation) 1
• Postural drainage and chest percussion (Grade I recommendation) 1

Patient Communication Strategies

• Patient satisfaction depends more on physician-patient communication than receiving antibiotics 1
• Explain that antibiotics can increase risk of carrying antibiotic-resistant bacteria 1
• Inform patients about potential antibiotic side effects and rare but serious adverse reactions 1
• Use the term "chest cold" rather than "bronchitis" to reduce expectation for antibiotics 1

Special Considerations

• For suspected pertussis: perform diagnostic tests and initiate antibiotics to decrease pathogen shedding and disease spread 1
• For influenza: consider antiviral agents if within 48 hours of symptom onset 1
• In chronic bronchitis, studies specifically assessing effects of treatments on cough as an outcome are needed 1