What is the treatment approach for bronchitis?

Treatment Approach for Bronchitis

Routine antibiotic treatment is not recommended for uncomplicated acute bronchitis, regardless of cough duration, as most cases are viral in origin and self-limiting. 1, 2

Diagnosis and Classification

Acute Bronchitis

• Defined as an acute respiratory infection with cough (with/without phlegm) lasting up to 3 weeks
• Typically self-limited, resolving in 2-3 weeks
• Rule out pneumonia, which is uncommon in the absence of:
  • Fever
  • Tachycardia
  • Tachypnea
  • Asymmetrical lung sounds 2, 1

Chronic Bronchitis

• Defined as productive cough occurring on most days for at least 3 months and for at least 2 consecutive years 2
• Requires ruling out other respiratory or cardiac causes of chronic productive cough

Treatment Algorithm for Acute Bronchitis

1. First-line approach: Supportive care only

   • Patient education about expected cough duration (2-3 weeks) 1, 3
   • Refer to the condition as a "chest cold" rather than "bronchitis" to reduce antibiotic expectations 1
   • Hydration and avoidance of respiratory irritants 1

2. Symptomatic relief options:

   • Short-term use of codeine or dextromethorphan for cough relief 2, 1
   • Consider bronchodilators only in patients with wheezing 1
   • Evidence does not support the use of antitussives, honey, antihistamines, anticholinergics, NSAIDs, or corticosteroids 3

3. Antibiotics:

   • Not recommended for uncomplicated acute bronchitis 2, 1, 3
   • May only decrease cough duration by approximately 0.5 days while exposing patients to antibiotic-related adverse effects 3, 4
   • Only consider antibiotics if pertussis is suspected 2, 5

Treatment Algorithm for Chronic Bronchitis

1. Stable chronic bronchitis:

   • Short-acting β-agonists for bronchospasm, dyspnea, and potentially chronic cough 2
   • Ipratropium bromide to improve cough 2
   • Consider theophylline for cough control with careful monitoring for complications 2
   • Long-acting β-agonist with inhaled corticosteroid for chronic cough 2

2. Acute exacerbation of chronic bronchitis (AECB):

   • Short-acting β-agonists or anticholinergic bronchodilators 2
   • Do not use theophylline during acute exacerbations 2
   • Short course (10-15 days) of systemic corticosteroids 2
   • Antibiotics only when at least two Anthonisen criteria are present:
     • Increased dyspnea
     • Increased sputum volume
     • Increased sputum purulence 1, 6

3. Antibiotic selection for AECB when indicated:

   • For moderate exacerbation: newer macrolide, extended-spectrum cephalosporin, or doxycycline 6
   • For severe exacerbation: high-dose amoxicillin/clavulanate or respiratory fluoroquinolone 6
   • For patients with COPD and respiratory failure (FEV1 <35%): immediate antibiotic treatment 1

Special Considerations

• Inhaled corticosteroids: Only recommended for chronic bronchitis with FEV1 <50% or frequent exacerbations 2
• Mucokinetic agents: Not proven effective and not recommended 2
• Postural drainage and chest percussion: Not proven effective and not recommended 2
• Elderly patients (≥65 years) or those with comorbidities require closer monitoring 1
• Persistent cough >3 weeks: Consider chest radiography to rule out other causes 2

Common Pitfalls to Avoid

1. Overuse of antibiotics: Despite recommendations against routine use, antibiotics are frequently prescribed for acute bronchitis. This contributes to antibiotic resistance without significantly improving outcomes 1, 3

2. Misdiagnosis: Failing to differentiate bronchitis from pneumonia, asthma, or COPD exacerbation can lead to inappropriate treatment 1, 5

3. Inadequate patient education: Patient satisfaction depends more on effective communication about the condition and expected recovery time than on receiving antibiotics 1

4. Inappropriate use of theophylline: While useful for stable chronic bronchitis, theophylline should not be used during acute exacerbations 2

5. Relying on sputum color: The presence or absence of colored (e.g., green) sputum does not reliably differentiate between bacterial and viral infections 5