What is the management plan for bronchitis?

Management of Bronchitis

The most effective way to manage bronchitis is to avoid respiratory irritants, with smoking cessation providing resolution in 90% of chronic bronchitis cases, while acute bronchitis is primarily treated symptomatically as antibiotics are not recommended for uncomplicated cases. 1, 2

Types of Bronchitis

Acute Bronchitis

• Definition: Acute cough lasting up to 3 weeks, may include sputum production
• Cause: Primarily viral (>90% of cases) including influenza, parainfluenza, RSV, coronavirus, adenovirus, and rhinovirus 1
• Diagnosis: Clinical diagnosis based on symptoms; diagnostic testing not indicated unless concern for pneumonia, influenza, or COVID-19 3

Chronic Bronchitis

• Definition: Cough and sputum expectoration occurring on most days for at least 3 months of the year and for at least 2 consecutive years 2
• Cause: Interaction between noxious inhaled agents (cigarette smoke, industrial pollutants) and host factors 2

Management of Acute Bronchitis

First-line Approach

1. Patient Education:

   • Inform patients about typical cough duration (2-3 weeks)
   • Explain viral nature of most cases
   • Refer to condition as "chest cold" rather than "bronchitis" to reduce antibiotic expectations 1

2. Symptomatic Relief:

   • Hydration and avoidance of respiratory irritants 1
   • Short-term use of codeine or dextromethorphan for cough relief (Grade C recommendation) 2, 1
   • Bronchodilators only if wheezing is present (Grade C recommendation) 1

3. Antibiotic Considerations:

   • Routine antibiotics are NOT recommended for uncomplicated acute bronchitis (Grade D recommendation) 2, 1, 3
   • Exception: Suspected pertussis - macrolide antibiotics with 5-day isolation 1

Management of Chronic Bronchitis

First-line Approach

1. Avoidance of Respiratory Irritants:

   • Smoking cessation is the most effective intervention (90% resolution rate) 2, 4
   • Avoid passive smoke exposure and workplace hazards 2

2. Pharmacologic Therapy for Stable Chronic Bronchitis:

   • Short-acting β-agonists for bronchospasm and dyspnea (Grade A recommendation) 2
   • Ipratropium bromide to improve cough (Grade A recommendation) 2
   • Long-acting β-agonist with inhaled corticosteroid (ICS) for cough control (Grade A recommendation) 2
   • ICS therapy for patients with FEV1 <50% predicted or frequent exacerbations (Grade A recommendation) 2
   • Theophylline may be considered for cough control with careful monitoring (Grade A recommendation) 2

3. NOT Recommended:

   • Long-term prophylactic antibiotics (Grade I recommendation) 2
   • Oral corticosteroids for maintenance therapy (Grade E/D recommendation) 2
   • Expectorants (Grade I recommendation) 2
   • Postural drainage and chest percussion (Grade I recommendation) 2

Management of Acute Exacerbations of Chronic Bronchitis

Definition

• Sudden clinical deterioration with increased sputum volume, sputum purulence, and/or worsening shortness of breath 2

Treatment

1. Bronchodilator Therapy:

   • Short-acting β-agonists or anticholinergic bronchodilators (Grade A recommendation) 2
   • If no prompt response, add the other agent at maximal dose 2
   • Do not use theophylline during acute exacerbations (Grade D recommendation) 2

2. Antibiotic Therapy:

   • Recommended for patients with severe exacerbations or severe airflow obstruction (Grade A recommendation) 2, 5
   • Indicated when at least two Anthonisen criteria are present (increased dyspnea, increased sputum volume, increased sputum purulence) 1
   • Options:
     • First-line: Amoxicillin for infrequent exacerbations 1
     • Second-line: Amoxicillin-clavulanate for frequent exacerbations or treatment failures 1
     • Alternative: Fluoroquinolones for patients with co-morbid illness, severe obstruction, age >65 years, or recurrent exacerbations 5

3. Corticosteroid Therapy:

   • Short course (10-15 days) of systemic corticosteroids (Grade A recommendation) 2
   • IV therapy for hospitalized patients, oral therapy for ambulatory patients 2

4. NOT Recommended:

   • Expectorants (Grade I recommendation) 2
   • Postural drainage and chest percussion (Grade I recommendation) 2

Special Considerations

• Elderly patients (≥65 years) or those with underlying conditions (COPD, heart failure, immunosuppression) require closer monitoring 1
• Children with wet/productive cough persisting >4 weeks after bronchiolitis may benefit from 2 weeks of antibiotics targeted to common respiratory bacteria 1
• Cough suppressants (codeine, dextromethorphan) are recommended only for short-term symptomatic relief 2, 1

Common Pitfalls to Avoid

1. Overuse of antibiotics for uncomplicated acute bronchitis, which does not affect clinical course and contributes to antibiotic resistance 1, 3
2. Failure to distinguish between acute bronchitis, pneumonia, asthma, and COPD exacerbation 1, 3
3. Inadequate patient education about expected cough duration, leading to unnecessary follow-up visits and antibiotic prescriptions 1
4. Using oral corticosteroids for long-term maintenance therapy in chronic bronchitis, which has high risk of serious side effects 2

By following these evidence-based guidelines, clinicians can effectively manage both acute and chronic bronchitis while minimizing unnecessary antibiotic use and optimizing patient outcomes.