What is the initial approach to managing bronchitis?

Initial Approach to Managing Bronchitis

Antibiotics should not be prescribed for uncomplicated acute bronchitis unless pneumonia is suspected or specific high-risk factors are present. 1, 2

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, 2
• Purulent sputum does not indicate bacterial infection; it results from inflammatory cells or sloughed mucosal epithelial cells 1, 3
• Pneumonia should be ruled out before diagnosing uncomplicated bronchitis by assessing for tachycardia, tachypnea, fever, and abnormal chest examination findings 1, 3

Management of Acute Bronchitis

First-line Approach

1. Symptomatic Treatment

   • Short-acting β-agonists like albuterol may be beneficial in reducing cough duration and severity in patients with evidence of bronchial hyperresponsiveness 1, 2
   • Dextromethorphan or codeine are recommended for short-term symptomatic relief of bothersome cough 1, 2
   • Consider ipratropium bromide to improve cough in some patients 1

2. Patient Education

   • Provide realistic expectations for cough duration (typically 10-14 days after the office visit) 1, 3
   • 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, 2

When to Consider Antibiotics

• Antibiotics may be considered only in specific high-risk populations, such as patients aged ≥75 years with fever 1
• The European Respiratory Society suggests that antibiotics may be considered for patients with cardiac failure 1
• If pertussis is suspected, antibiotics should be used to reduce transmission 4, 3

Management of Chronic Bronchitis

First-line Approach

• 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
• Inhaled corticosteroids should be offered to patients with chronic bronchitis and FEV1 <50% predicted or those with frequent exacerbations 1

For 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 should be reserved for patients 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) 5
• For moderate exacerbations, a newer macrolide, extended-spectrum cephalosporin, or doxycycline is appropriate 5
• For severe exacerbations, high-dose amoxicillin/clavulanate or a respiratory fluoroquinolone should be used 5

Common Pitfalls to Avoid

• Prescribing antibiotics based solely on presence of colored sputum 1, 3
• Failing to distinguish between acute bronchitis and pneumonia 1, 3
• 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

Special Considerations

• In patients with COPD with moderate or severe airflow obstruction and a history of one or more COPD exacerbations during the previous year, a long-acting muscarinic antagonist (LAMA) is preferred over long-acting beta-agonist (LABA) monotherapy to prevent future exacerbations 2
• For patients with chronic bronchitis who have frequent exacerbations despite optimal bronchodilator therapy, roflumilast may reduce exacerbation rates in those with severe COPD associated with chronic bronchitis 6