What are the management options for acute bronchitis?

Management of Acute Bronchitis

Acute bronchitis should be managed symptomatically without antibiotics, as it is primarily viral in origin and antibiotics provide no benefit while exposing patients to potential harm. 1

Diagnosis and Differentiation

• Acute bronchitis is defined as an acute respiratory infection with cough lasting up to 3 weeks, with or without sputum production, and a normal chest radiograph 2
• Rule out pneumonia if the following are present:
  • Heart rate >100 beats/min
  • Respiratory rate >24 breaths/min
  • Oral temperature >38°C
  • Chest examination findings of focal consolidation, egophony, or fremitus 2
• Differentiate from common cold, acute asthma, and exacerbation of COPD 2

First-Line Management

1. No routine investigations are needed (chest x-ray, spirometry, sputum cultures, viral PCR, or inflammatory markers) 2
2. No antibiotics should be prescribed routinely 2, 1
3. Patient education:
   • Explain the viral nature of the illness
   • Refer to it as a "chest cold" rather than "bronchitis" to reduce antibiotic expectations
   • Set realistic expectations for cough duration (10-14 days) 2, 1

Symptomatic Treatment Options

• Antitussive agents (e.g., dextromethorphan, codeine) can be offered for short-term symptomatic relief of coughing 2, 1
• Beta-2-agonist bronchodilators (e.g., albuterol):
  • Not recommended for routine use 2
  • May be beneficial in select patients with wheezing accompanying the cough 2, 1
• Not recommended:
  • Mucokinetic agents/expectorants (no consistent favorable effect) 2
  • Inhaled anticholinergics, inhaled corticosteroids, oral corticosteroids, oral NSAIDs 2

Special Circumstances

• If symptoms worsen or persist beyond 3 weeks:

  • Reassessment and targeted investigations should be considered 2
  • Potential investigations: chest x-ray, sputum culture, peak flow measurements, CBC, inflammatory markers like CRP 2
  • Consider antibiotic therapy if bacterial infection is suspected 2

• For confirmed or suspected pertussis (whooping cough):

  • Prescribe a macrolide antibiotic
  • Isolate patient for 5 days from start of treatment
  • Early treatment (within first few weeks) will reduce coughing paroxysms and prevent disease spread 2

Common Pitfalls to Avoid

1. Unnecessary antibiotic prescribing:

   • 65-80% of patients with acute bronchitis receive antibiotics despite evidence against their use 1
   • Antibiotics provide minimal benefit (reducing cough by only about half a day) 3
   • Risks include antibiotic resistance, adverse effects (including allergic reactions, nausea, vomiting, C. difficile infection) 3, 4

2. Failure to differentiate from pneumonia:

   • Pneumonia requires different management and should be ruled out based on vital signs and physical examination 1

3. Setting unrealistic expectations:

   • Not informing patients about the typical 2-3 week duration of cough can lead to unnecessary follow-up visits and antibiotic prescriptions 1, 5

By following these evidence-based recommendations, clinicians can effectively manage acute bronchitis while reducing unnecessary antibiotic use and improving patient outcomes.