What is the management plan for bronchitis?

Management Plan for Bronchitis

Antibiotics should not be prescribed for uncomplicated acute bronchitis as it is primarily caused by viruses in over 90% of cases and antibiotics do not improve outcomes. 1

Distinguishing Between 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 when other respiratory causes are excluded 1
• Often part of COPD
• Caused by interaction between inhaled agents (cigarette smoke, pollutants) and host factors

Diagnostic Approach

1. Rule out pneumonia - pneumonia is unlikely in the absence of ALL of the following:

   • 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) 1

2. Important clinical considerations:

   • Purulent sputum (green or yellow) does NOT signify bacterial infection 1
   • Purulence is due to inflammatory cells or sloughed mucosal epithelial cells

Management of Acute Uncomplicated Bronchitis

1. Avoid antibiotics

   • Do not perform testing or initiate antibiotic therapy unless pneumonia is suspected 1
   • Systematic reviews found limited evidence to support antibiotic use and a trend toward increased adverse events 1
   • Refer to the condition as a "chest cold" rather than bronchitis when discussing with patients 1

2. Symptomatic relief options:

   • Cough suppressants (dextromethorphan or codeine) for short-term symptomatic relief 1
   • Expectorants (guaifenesin)
   • First-generation antihistamines (diphenhydramine)
   • Decongestants (phenylephrine)
   • β-agonists (albuterol) - only for patients with underlying asthma or COPD 1
   • Consider environmental modifications (elimination of dust, dander, vaporized air treatments) 1

3. Patient education:

   • Provide realistic expectations for cough duration (typically 10-14 days after office visit) 1
   • Explain that antibiotics have side effects and can lead to antibiotic resistance 1

Management of Chronic Bronchitis

1. First-line intervention:

   • Avoidance of respiratory irritants (tobacco smoke, workplace hazards) is the most effective way to improve or eliminate cough in chronic bronchitis 1
   • 90% of patients will have resolution of cough after smoking cessation 1

2. Pharmacologic therapy for stable chronic bronchitis:

   • Short-acting β-agonists to control bronchospasm and relieve dyspnea 1
   • Ipratropium bromide to improve cough 1
   • Long-acting β-agonist coupled with inhaled corticosteroid (ICS) for cough control 1
   • Consider theophylline for cough control (with careful monitoring for complications) 1
   • Central cough suppressants (codeine, dextromethorphan) for short-term symptomatic relief 1

3. NOT recommended for stable chronic bronchitis:

   • Long-term prophylactic antibiotics 1
   • Oral corticosteroids 1
   • Expectorants 1
   • Postural drainage and chest percussion 1

Management of Acute Exacerbation of Chronic Bronchitis

1. Diagnosis of exacerbation:

   • Sudden deterioration with increased cough, sputum production, sputum purulence, and/or worsening shortness of breath 1

2. Treatment approach:

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

3. NOT recommended for exacerbations:

   • Theophylline 1
   • Expectorants 1
   • Postural drainage and chest percussion 1

Communication Strategies

When discussing treatment with patients:

• Explain that most bronchitis cases are viral and self-limiting
• Set realistic expectations about symptom duration
• Emphasize that antibiotics won't help viral infections and may cause harm
• Focus on symptom relief rather than "cure"

Common Pitfalls to Avoid

1. Prescribing antibiotics for uncomplicated acute bronchitis (leads to antibiotic resistance)
2. Failing to distinguish between acute bronchitis and pneumonia
3. Assuming purulent sputum indicates bacterial infection
4. Not addressing smoking cessation in patients with chronic bronchitis
5. Using theophylline for acute exacerbations (not recommended)
6. Using expectorants despite lack of evidence for effectiveness