What is the management approach for bronchitis?

Management Approach for Bronchitis

The management of bronchitis should focus on symptomatic relief and avoidance of unnecessary antibiotics, as over 90% of cases are viral in origin and the condition is typically self-limiting. 1, 2

Diagnosis and Classification

Acute Bronchitis

• Defined as an acute lower respiratory tract infection with cough (with or without sputum) lasting up to 3 weeks
• Normal chest radiograph with absence of fever, tachycardia, tachypnea, or focal chest findings 1
• Must be differentiated from pneumonia, asthma exacerbation, COPD, and common cold

Chronic Bronchitis

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

Management of Acute Bronchitis

First-line Interventions

1. Patient education:

   • Explain the viral nature of most cases (>90%)
   • Inform about typical cough duration (2-3 weeks)
   • Use term "chest cold" rather than "bronchitis" to reduce antibiotic expectations 1

2. Symptomatic relief:

   • Adequate hydration
   • Avoidance of respiratory irritants 1

3. Pharmacologic options:

   • Short-acting β-agonist bronchodilators (like albuterol) for patients with wheezing or bronchospasm 3, 1
   • Antitussives (codeine or dextromethorphan) may provide short-term relief for troublesome cough 1

What NOT to Do

• Antibiotics are generally not indicated for uncomplicated acute bronchitis 1, 2, 4
  • May only decrease cough duration by approximately 0.5 days while exposing patients to antibiotic-related adverse effects 4
• Expectorants have no proven benefit 1
• The FDA recommends against using cough and cold preparations in children younger than six years 2

Management of Chronic Bronchitis

First-line Interventions

1. Smoking cessation - most effective intervention, resulting in 90% cough resolution 3, 1
2. Avoidance of all respiratory irritants 3

Pharmacologic Management

• Short-acting β-agonists to control bronchospasm and relieve dyspnea 3
• Ipratropium bromide to improve cough 3
• Consider theophylline to control chronic cough (with careful monitoring for complications) 3

Management of Acute Exacerbations of Chronic Bronchitis

1. Identify exacerbation: Sudden deterioration with increased cough, sputum production, sputum purulence, and/or shortness of breath 3

2. Treatment:

   • Short-acting β-agonists or anticholinergic bronchodilators 3
   • Antibiotics are recommended for acute exacerbations of chronic bronchitis 3, 5
     • Most beneficial for patients with severe exacerbations and those with more severe airflow obstruction at baseline
     • Consider antibiotics when at least one key symptom (increased dyspnea, sputum volume, or purulence) and one risk factor (age ≥65 years, FEV1 <50% predicted, ≥4 exacerbations in 12 months, or comorbidities) are present 5
   • Appropriate antibiotic choices:
     • Moderate exacerbation: newer macrolide, extended-spectrum cephalosporin, or doxycycline 5
     • Severe exacerbation: high-dose amoxicillin/clavulanate or a respiratory fluoroquinolone 5

Important Caveats

• Purulent sputum alone does not indicate bacterial infection and is not an indication for antibiotics 3
• Long-term prophylactic antibiotics are not recommended for stable chronic bronchitis 3
• Postural drainage and chest percussion have not proven beneficial for either stable chronic bronchitis or acute exacerbations 3
• Patients should seek reassessment if cough persists beyond 3 weeks, worsens, or if new symptoms develop 1
• Patient satisfaction depends more on effective communication about the condition and expected recovery time than on receiving antibiotics 1