What is the treatment approach for bronchitis?

Treatment Approach for Bronchitis

For uncomplicated acute bronchitis, antibiotics are generally not indicated and treatment should focus on symptomatic relief with bronchodilators, antitussives, and supportive care. 1

Distinguishing Types of Bronchitis

• Acute Bronchitis: Self-limiting inflammation of the tracheobronchial tree, typically lasting 2-3 weeks, most commonly caused by viral infections (>90% of cases) 1, 2
• Chronic Bronchitis: Cough and sputum production occurring on most days for at least 3 months of the year and for at least 2 consecutive years 1
• Acute Exacerbation of Chronic Bronchitis (AECB): Worsening of symptoms in patients with chronic bronchitis, often requiring different treatment approaches 1

Treatment for Acute Bronchitis

First-Line Management

1. Patient Education:

   • Explain that the condition is typically viral and self-limiting 1
   • Provide realistic expectations for cough duration (typically 10-14 days after office visit) 1
   • Refer to the condition as a "chest cold" rather than bronchitis to reduce antibiotic expectations 1

2. Bronchodilator Therapy:

   • Albuterol has demonstrated consistent benefit in reducing duration and severity of cough 1
   • Approximately 50% fewer patients report cough after 7 days of treatment 1

3. Antitussive Agents:

   • Preparations containing dextromethorphan or codeine have modest effects on severity and duration of cough 1
   • Recommended for short-term symptomatic relief 1

4. Environmental Modifications:

   • Eliminate environmental cough triggers (dust, dander) 1
   • Consider vaporized air treatments, particularly in low-humidity environments 1

What to Avoid

• Antibiotics: Not indicated for uncomplicated acute bronchitis as >90% of cases are viral 1, 2
• Expectorants: No evidence of effectiveness in chronic bronchitis 1
• Postural drainage and chest physiotherapy: Clinical benefits not proven 1

Treatment for Chronic Bronchitis

First-Line Management

1. Avoidance of Respiratory Irritants:

   • Most effective way to reduce or eliminate cough 1
   • Smoking cessation is essential 1

2. Pharmacological Treatment:

   • Short-acting β-agonists to control bronchospasm and relieve dyspnea 1
   • Ipratropium bromide to improve cough 1
   • Consider theophylline to control chronic cough (with careful monitoring for complications) 1
   • Long-acting β-agonist combined with inhaled corticosteroid for cough control 1

Treatment for Acute Exacerbation of Chronic Bronchitis

Assessment

• Evaluate for Anthonisen triad criteria: increased dyspnea, increased sputum volume, and increased sputum purulence 1

Treatment Algorithm

1. For Simple Chronic Bronchitis Exacerbation:

   • Immediate antibiotic therapy not recommended 1
   • Consider antibiotics only if fever (>38°C) persists for more than 3 days 1

2. For Exacerbation of Chronic Obstructive Bronchitis:

   • Immediate antibiotic therapy only if at least two Anthonisen criteria are present 1
   • Short-acting β-agonists or anticholinergic bronchodilators 1
   • If no prompt response, add the other agent at maximal dose 1

3. For Exacerbation with Chronic Respiratory Insufficiency:

   • Immediate antibiotic therapy recommended 1
   • Inhaled bronchodilators, oral antibiotics, and oral/IV corticosteroids 1
   • Do not use theophylline for acute exacerbations 1

Antibiotic Selection (When Indicated)

• First-line antibiotics (for infrequent exacerbations with FEV1 ≥35%):

  • Amoxicillin is the reference compound 1
  • First-generation cephalosporins are an alternative 1
  • Macrolides, pristinamycin, or doxycycline for beta-lactam allergies 1

• Second-line antibiotics (for frequent exacerbations or treatment failure):

  • Newer macrolides, extended-spectrum cephalosporins for moderate exacerbations 3
  • High-dose amoxicillin/clavulanate or respiratory fluoroquinolones for severe exacerbations 3

Common Pitfalls to Avoid

• Overuse of antibiotics: Patient satisfaction depends more on physician-patient communication than antibiotic prescription 1
• Misdiagnosis: Ensure bronchitis is differentiated from pneumonia and asthma, which require different treatments 2
• Ignoring smoking status: Smokers may have longer recovery times and different treatment needs 4
• Inadequate symptom management: Failure to address bothersome cough can lead to patient dissatisfaction and unnecessary antibiotic requests 1