What is the treatment for bronchitis?

Treatment of Bronchitis

For acute bronchitis, symptomatic treatment is recommended without antibiotics, while chronic bronchitis requires bronchodilators such as short-acting β-agonists and ipratropium bromide as first-line therapy. 1, 2

Acute Bronchitis Treatment

First-Line Approach

• Avoid antibiotics - The American College of Chest Physicians recommends against antibiotics for uncomplicated acute bronchitis (Grade D recommendation) 2
• Patient education - Inform patients about:
  • Expected cough duration (2-3 weeks)
  • Viral nature of most cases (>90%)
  • Refer to the condition as a "chest cold" rather than "bronchitis" to reduce antibiotic expectations 2

Symptomatic Relief

• Hydration and avoidance of respiratory irritants 2
• Cough suppressants - Short-term use of codeine or dextromethorphan for symptomatic relief (Grade C recommendation) 2
• Bronchodilators - Consider for patients with wheezing 2

Special Circumstances

• Suspected pertussis - Macrolide antibiotics (e.g., azithromycin) with 5-day isolation 2
• Acute exacerbation with bacterial infection - Antibiotics indicated only when at least two Anthonisen criteria are present:
  • Increased dyspnea
  • Increased sputum volume
  • Increased sputum purulence 2
  • First-line: Amoxicillin
  • Second-line: Amoxicillin-clavulanate 2

Chronic Bronchitis Treatment

Bronchodilator Therapy

1. Short-acting β-agonists - First-line therapy to control bronchospasm and relieve dyspnea; may also reduce chronic cough (Grade A recommendation) 1
2. Ipratropium bromide - Should be offered to improve cough (Grade A recommendation) 1
3. Theophylline - Consider for cough control with careful monitoring for complications (Grade A recommendation) 1

For Acute Exacerbations of Chronic Bronchitis

• Short-acting β-agonists or anticholinergic bronchodilators - First-line therapy during acute exacerbations 1
• If no prompt response, add the other agent after first is administered at maximal dose 1
• Avoid theophylline during acute exacerbations (Grade D recommendation) 1
• Systemic corticosteroids - Beneficial for COPD exacerbations 1
• Antibiotics - Appropriate for patients with increased dyspnea, sputum volume, and purulence 3

Advanced Therapy Options

• Long-acting bronchodilators - For maintenance treatment of COPD/chronic bronchitis:
  • Tiotropium (anticholinergic) - Indicated for long-term, once-daily maintenance treatment 4
  • Salmeterol (LABA) combined with inhaled corticosteroid - For maintenance treatment and reducing exacerbations in COPD patients with a history of exacerbations 5

Mucokinetic Agents and Corticosteroids

• Limited evidence for mucokinetic agents or inhaled corticosteroids for cough control in chronic bronchitis 1
• Combined therapy with long-acting β-agonist and inhaled corticosteroid may reduce exacerbation rate and cough in COPD 1
• Inhaled corticosteroids recommended when:
  • Airflow obstruction is severe (FEV1 < 50%)
  • History of frequent exacerbations 1

Important Considerations

• Smoking cessation is the most effective way to reduce or eliminate cough in patients with chronic bronchitis 1
• Avoid expectorants - Beneficial effects not proven for chronic bronchitis 1
• Avoid mucokinetic agents during acute exacerbations 1
• Monitor closely patients with underlying conditions (COPD, heart failure, immunosuppression) or elderly patients (≥65 years) 2
• For patients with moderate to severe renal impairment receiving tiotropium, monitor for anticholinergic effects 4

Common Pitfalls to Avoid

1. Overuse of antibiotics for acute bronchitis - Most cases (>90%) are viral and antibiotics provide minimal benefit while increasing resistance 2, 6
2. Relying on sputum color to determine need for antibiotics - Green sputum does not reliably indicate bacterial infection 7
3. Using theophylline during acute exacerbations - Not recommended due to side effects and lack of benefit 1
4. Neglecting bronchodilators in chronic bronchitis - These are the cornerstone of therapy 1
5. Failing to differentiate between acute bronchitis, pneumonia, asthma, and COPD exacerbation 2