What are the management options for bronchitis?

Management of Bronchitis

Antibiotics should not be prescribed for uncomplicated acute bronchitis as they provide minimal benefit and may cause adverse effects. 1

Diagnosis and Assessment

Acute bronchitis is a self-limited inflammation of the large airways (bronchi) characterized by cough lasting up to 6 weeks, with or without sputum production, and often accompanied by mild constitutional symptoms 1.

Key diagnostic considerations:

• Distinguish bronchitis from pneumonia, which requires different management
• Pneumonia is unlikely in the absence of all of the following: tachycardia (>100 beats/min), tachypnea (>24 breaths/min), fever (>38°C), and abnormal chest examination findings 1
• The presence of purulent sputum or change in sputum color does not signify bacterial infection 1
• More than 90% of cases in otherwise healthy patients are caused by viruses 1

Management Algorithm

Step 1: Rule out pneumonia and other serious conditions

• If tachypnea, tachycardia, dyspnea, or abnormal lung findings are present, consider chest radiography to rule out pneumonia 1
• Consider pertussis in patients with cough >2 weeks accompanied by paroxysmal cough, whooping, or post-tussive emesis 1

Step 2: Patient education

• Explain that bronchitis is usually viral and typically lasts 2-3 weeks 1, 2
• Emphasize that antibiotics are not effective for viral infections and may cause adverse effects 1
• Discuss that the color of sputum (green or yellow) does not indicate bacterial infection 1

Step 3: Symptomatic treatment

For uncomplicated acute bronchitis, consider:

1. Cough suppressants:

   • Dextromethorphan or codeine may provide modest effect on severity and duration of cough 1

2. Bronchodilators:

   • Albuterol has shown benefit in reducing cough duration and severity in some trials 1
   • Consider a trial of bronchodilators in patients with wheezing or bothersome cough 1
   • Not recommended for patients without evidence of bronchial hyperresponsiveness 1, 3

3. Other supportive measures:

   • Elimination of environmental cough triggers (dust, dander) 1
   • Vaporized air treatments in low-humidity environments 1
   • Adequate hydration 3

Special Considerations for Acute Exacerbation of Chronic Bronchitis (AECB)

For patients with chronic bronchitis experiencing an acute exacerbation:

1. Supportive care for all patients:

   • Bronchodilators
   • Oxygen if needed
   • Hydration
   • Consider systemic corticosteroids
   • Chest physical therapy 4

2. Antibiotics should be reserved for patients with:

   • At least one key symptom (increased dyspnea, sputum production, or sputum purulence) AND
   • At least one risk factor (age ≥65 years, FEV1 <50% predicted, ≥4 AECBs in 12 months, or comorbidities) 4

3. Antibiotic selection when indicated:

   • Moderate exacerbation: newer macrolide, extended-spectrum cephalosporin, or doxycycline
   • Severe exacerbation: high-dose amoxicillin/clavulanate or respiratory fluoroquinolone 4

Common Pitfalls to Avoid

1. Inappropriate antibiotic use:

   • Acute bronchitis leads to more inappropriate antibiotic prescribing than any other acute respiratory tract infection in adults 1
   • Antibiotics provide minimal benefit (reducing illness by about half a day) while risking adverse effects including allergic reactions, nausea, vomiting, and C. difficile infection 2

2. Misinterpreting sputum color:

   • Yellow or green sputum does not indicate bacterial infection; purulence is due to inflammatory cells or sloughed mucosal epithelial cells 1

3. Overuse of bronchodilators:

   • β-agonists have not been shown to benefit patients without asthma or chronic obstructive lung disease 1
   • Treatment should be individualized in patients without clinical evidence of bronchial hyperresponsiveness 1

4. Inadequate patient education:

   • Failure to explain the expected duration of symptoms can lead to unnecessary return visits and antibiotic requests 3

By following these evidence-based recommendations, clinicians can provide appropriate care for patients with bronchitis while avoiding unnecessary antibiotics and focusing on symptomatic relief and patient education.