What are the treatment options for bronchitis?

Bronchitis Treatment and Diagnosis

For bronchitis treatment, the most effective approach is to avoid respiratory irritants like tobacco smoke and environmental pollutants, while using targeted symptomatic therapies based on the specific presentation and classification of bronchitis (acute vs. chronic). 1

Diagnosis and Classification

Acute Bronchitis

• Defined as an acute lower respiratory tract infection with predominant cough (with or without sputum) lasting up to 3 weeks
• Normal chest radiograph with absence of fever, tachycardia, tachypnea, or focal chest findings
• Primarily viral in origin (89-95% of cases) 1, 2

Chronic Bronchitis

• Defined as cough and sputum expectoration occurring on most days for at least 3 months of the year and for at least 2 consecutive years 3
• Often associated with smoking or other respiratory irritants
• May progress to COPD with airflow limitation 3

Treatment Approaches

Acute Bronchitis Treatment

1. First-line management:

   • Avoidance of respiratory irritants 1
   • Symptomatic relief with hydration 1
   • Patient education about expected course (typical duration 2-3 weeks) 1

2. For patients with wheezing:

   • Short-acting β-agonist bronchodilators (e.g., albuterol) 1
   • Assess response after 2-3 days 1
   • If wheezing persists, consider adding inhaled corticosteroid 1

3. For troublesome cough:

   • Central cough suppressants (codeine, dextromethorphan) for short-term symptomatic relief 1

4. Antibiotics:

   • NOT recommended for routine use in acute bronchitis 1
   • Only consider if bronchitis worsens with suspected bacterial superinfection 1
   • When absolutely necessary (rare cases), amoxicillin is preferred 1

Chronic Bronchitis Treatment

1. First-line interventions:

   • Smoking cessation (most effective intervention, resulting in 90% cough resolution) 3
   • Avoidance of all respiratory irritants 3

2. Pharmacologic therapy:

   • Short-acting inhaled β-agonists 3
   • Inhaled ipratropium bromide 3
   • Combined regimen of long-acting β-agonist with inhaled corticosteroid (for control of chronic cough) 3

3. For acute exacerbations of chronic bronchitis:

   • Inhaled bronchodilators 3
   • Oral antibiotics (if at least two Anthonisen criteria present: increased dyspnea, sputum volume, and purulence) 3, 4
   • Short course of oral corticosteroids (10-15 days) 3
   • Central cough suppressants for symptomatic relief 3

What NOT to Use

For Stable Chronic Bronchitis:

• Prophylactic antibiotics 3
• Long-term oral corticosteroids 3
• Expectorants (no proven benefit) 3
• Postural drainage or chest physiotherapy 3

For Acute Bronchitis:

• Routine antibiotics (minimal benefit with risks of side effects and resistance) 1, 5
• Expectorants (no proven benefit) 1

Special Considerations

When to Consider Antibiotics

• For acute exacerbations of chronic bronchitis with at least one key symptom (increased dyspnea, sputum production, sputum purulence) AND one risk factor (age ≥65 years, FEV1 <50% predicted, ≥4 exacerbations in 12 months, or comorbidities) 4

When to Refer or Reassess

• If cough persists beyond 3 weeks 1
• If symptoms worsen or new symptoms develop 1
• For patients with underlying conditions (COPD, heart failure, immunosuppression) 1
• For elderly patients (≥65 years) 1

Patient Education

• Refer to acute bronchitis as a "chest cold" rather than "bronchitis" to reduce antibiotic expectations 1
• Explain the typical cough duration of 2-3 weeks and viral nature of most cases 1
• Discuss risks of unnecessary antibiotic use 1

By following these evidence-based approaches, bronchitis can be effectively managed while minimizing unnecessary antibiotic use and focusing on interventions that improve morbidity, mortality, and quality of life.