What is the recommended treatment for acute bronchitis?

Treatment of Acute Bronchitis

Antibiotics are not recommended for routine treatment of acute bronchitis in immunocompetent adults, as it is primarily a viral illness that resolves without antibiotic therapy. 1

Diagnosis and Differentiation

Acute bronchitis is characterized by an acute cough with or without phlegm production lasting up to 3 weeks with a normal chest radiograph. Before establishing this diagnosis, it's essential to exclude:

• Pneumonia
• Common cold
• Acute asthma
• Exacerbation of COPD 1

Pneumonia should be ruled out if any of the following are present:

• Heart rate >100 beats/min
• Respiratory rate >24 breaths/min
• Oral temperature >38°C
• Focal chest examination findings 2, 1

Treatment Approach

First-Line Management

1. Patient Education:

   • Explain the viral nature of the illness
   • Set realistic expectations for cough duration (typically 2-3 weeks)
   • Discuss risks of unnecessary antibiotic use 1, 3

2. Symptomatic Relief:

   • Antitussive agents may be considered for short-term symptomatic relief of coughing (Grade C recommendation) 2, 1
   • Options include dextromethorphan or codeine for temporary cough suppression 1
   • Honey (one teaspoon) can be used to relieve cough in patients with viral bronchitis 1

3. Environmental Modifications:

   • Eliminate environmental cough triggers (dust, dander)
   • Avoid respiratory irritants including smoke exposure 1

What NOT to Use Routinely

• Antibiotics: Not indicated for routine treatment as they provide minimal benefit (reducing cough by only about half a day) while exposing patients to risks of adverse effects 2, 1, 3
• Beta-agonist bronchodilators: Not recommended for most patients with acute bronchitis (Grade D recommendation) 2
• Mucokinetic agents: Not recommended due to no consistent favorable effect on cough (Grade I recommendation) 2
• Inhaled corticosteroids: No evidence supporting routine use 1
• Oral corticosteroids: Not recommended for routine use 1
• NSAIDs: Not recommended specifically for bronchitis treatment 1

Special Considerations

When to Consider Antibiotics

Antibiotics should only be considered in specific situations:

1. Pertussis (whooping cough): Macrolide antibiotics (e.g., erythromycin) are indicated for confirmed or suspected pertussis to reduce transmission (Grade A recommendation) 2
2. Patients at high risk for pneumonia: Particularly those ≥65 years old 4
3. Worsening bronchitis with suspected bacterial superinfection 1

Bronchodilator Consideration

In select adult patients with wheezing accompanying the cough, treatment with β-agonist bronchodilators may be useful (Grade C recommendation) 2

Common Pitfalls in Management

1. Overuse of antibiotics: Despite guidelines, 65-80% of patients with acute bronchitis receive antibiotics unnecessarily 2, 1

2. Failure to distinguish between acute bronchitis and pneumonia: Careful assessment of vital signs and physical examination findings is essential 1

3. Unrealistic expectations: Not informing patients about the typical duration of cough (2-3 weeks) often leads to unnecessary follow-up visits and antibiotic prescriptions 1, 3

4. Inappropriate use of mucokinetic agents/expectorants: These have not shown consistent favorable effects 2, 1

Recurrent Episodes

For patients with recurrent bronchitis episodes, consider:

• Cough variant asthma (found in 65% of patients with recurrent bronchitis)
• Bronchiectasis
• Chronic bronchitis (productive cough for ≥3 months in 2 consecutive years)
• Non-asthmatic eosinophilic bronchitis 1

By following these evidence-based recommendations, clinicians can provide appropriate care for patients with acute bronchitis while avoiding unnecessary antibiotic use and its associated risks.