What are the management options for bronchitis?

Management of Bronchitis

Antibiotics should not be routinely prescribed for acute bronchitis as over 90% of cases are caused by viruses, and antibiotic therapy has not shown significant benefit in uncomplicated cases. 1

Diagnosis and Classification

• Acute bronchitis is defined as self-limited inflammation of the large airways with cough lasting up to 6 weeks, often accompanied by mild constitutional symptoms 1
• Chronic bronchitis is defined as cough with sputum production occurring on most days for at least 3 months of the year and for at least 2 consecutive years 1
• Purulent sputum (green or yellow) does not indicate bacterial infection; it results from inflammatory cells or sloughed mucosal epithelial cells 1
• Pneumonia should be ruled out before diagnosing uncomplicated bronchitis by assessing for tachycardia, tachypnea, fever, and abnormal chest examination findings 1

Management of Acute Bronchitis

Antibiotic Therapy

• Antibiotics should not be prescribed for uncomplicated acute bronchitis unless pneumonia is suspected 1
• Antibiotics may be considered only in specific high-risk populations:
  • Patients aged ≥75 years with fever
  • Patients with cardiac failure
  • Patients with insulin-dependent diabetes
  • Patients with serious neurological disorders 1
• Antibiotic use for acute bronchitis leads to more inappropriate prescribing than any other acute respiratory tract infection in adults 1

Symptomatic Treatment

1. Bronchodilators:

   • Short-acting β-agonists like albuterol may be beneficial in reducing cough duration and severity in patients with evidence of bronchial hyperresponsiveness (wheezing) 1
   • Ipratropium bromide may improve cough in some patients 1
   • A recent 2023 randomized clinical trial showed that ipratropium bromide was not effective against cough in acute bronchitis 2

2. Cough Suppressants:

   • Dextromethorphan or codeine are recommended for short-term symptomatic relief of bothersome cough 1
   • These agents have modest effects on severity and duration of cough in acute bronchitis 1
   • However, a recent 2023 trial showed dextromethorphan was ineffective against cough in acute bronchitis 2

3. Other Symptomatic Treatments:

   • First-generation antihistamines (diphenhydramine)
   • Decongestants (phenylephrine)
   • Expectorants (guaifenesin) 1
   • However, data supporting these specific therapies are limited, and they have not been shown to shorten illness duration 1
   • Expectorants and mucolytics should not be prescribed in acute lower respiratory tract infections 1

4. Non-pharmacological Approaches:

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

Management of Chronic Bronchitis

1. Bronchodilators:

   • Short-acting β-agonists should be used to control bronchospasm and may reduce chronic cough 1
   • Ipratropium bromide should be offered to improve cough 1
   • Long-acting β-agonists combined with inhaled corticosteroids should be offered to control chronic cough 1

2. Theophylline:

   • Consider for control of chronic cough, but careful monitoring for complications is necessary 1

3. Corticosteroids:

   • Inhaled corticosteroids should be offered to patients with chronic bronchitis and FEV1 <50% predicted or those with frequent exacerbations 1
   • Long-term maintenance therapy with oral corticosteroids is not recommended due to high risk of serious side effects 1

4. Cough Suppressants:

   • Codeine and dextromethorphan are recommended for short-term symptomatic relief 1

Management of Acute Exacerbations of Chronic Bronchitis

• Short-acting β-agonists or anticholinergic bronchodilators should be administered during acute exacerbations 1
• A short course (10-15 days) of systemic corticosteroids is effective for acute exacerbations 1
• Antibiotics may be appropriate for acute exacerbations with increased sputum volume and purulence 3

Patient Communication

• Provide realistic expectations for cough duration (typically 10-14 days after the office visit) 1
• Consider referring to the illness as a "chest cold" rather than bronchitis to reduce patient expectation for antibiotics 1
• Explain that patient satisfaction depends more on the quality of the clinical encounter than on receiving antibiotics 1
• Discuss the risks of unnecessary antibiotic use, including side effects and development of antibiotic resistance 1

Common Pitfalls to Avoid

• Prescribing antibiotics based solely on presence of colored sputum 1
• Failing to distinguish between acute bronchitis and pneumonia 1
• Overuse of expectorants, mucolytics, and antihistamines which lack evidence of benefit 1
• Not considering underlying conditions that may be exacerbated by bronchitis (asthma, COPD, cardiac failure, diabetes) 1
• Using theophylline for acute exacerbations of chronic bronchitis 1