What is the treatment approach for bronchitis?

Treatment Approach for Bronchitis

Antibiotics should not be prescribed for uncomplicated acute bronchitis as it is primarily caused by viruses, while treatment should focus on symptomatic relief with bronchodilators and cough suppressants as needed. 1, 2

Classification of Bronchitis

• Acute bronchitis: Self-limited inflammation of large airways with cough lasting up to 6 weeks 1
• Chronic bronchitis: Cough with sputum production occurring on most days for at least 3 months of the year and for at least 2 consecutive years 3, 1

Management of Acute Bronchitis

First-line Approach

• Avoid prescribing antibiotics for uncomplicated acute bronchitis unless pneumonia is suspected 3, 1
• Provide realistic expectations for cough duration (typically 10-14 days after office visit) 3
• Consider referring to the illness as a "chest cold" rather than bronchitis to reduce patient expectation for antibiotics 3, 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, 4
• Ipratropium bromide may improve cough in some patients 1, 4
• Dextromethorphan or codeine are recommended for short-term symptomatic relief of bothersome cough 3, 1
• Consider low-cost, low-risk actions such as elimination of environmental cough triggers and vaporized air treatments 3

Management of Chronic Bronchitis

Bronchodilator Therapy

• Short-acting β-agonists should be used to control bronchospasm and may reduce chronic cough 3, 4
• Ipratropium bromide should be offered to improve cough 3, 4

Anti-inflammatory Therapy

• Long-acting β-agonists combined with inhaled corticosteroids should be offered to control chronic cough 3, 4
• Inhaled corticosteroids should be offered to patients with chronic bronchitis and FEV1 <50% predicted or those with frequent exacerbations 3, 4

Management of Acute Exacerbations of Chronic Bronchitis

Bronchodilator Therapy

• Short-acting β-agonists or anticholinergic bronchodilators should be administered during acute exacerbations 3, 4
• If the patient does not show a prompt response, the other agent should be added after the first is administered at the maximal dose 3

Antibiotic Therapy

• Antibiotics are recommended for acute exacerbations of chronic bronchitis with chronic respiratory insufficiency 3
• Antibiotics should be considered when at least two of the three Anthonisen criteria are present (increased dyspnea, increased sputum volume, increased sputum purulence) 3, 5
• First-line antibiotics for infrequent exacerbations include amoxicillin, first-generation cephalosporins, macrolides, pristinamycin, or doxycycline 3
• Second-line antibiotics may be used for frequent exacerbations (≥4 per year) or treatment failures 3

Corticosteroid Therapy

• A short course of systemic corticosteroids is effective for acute exacerbations 4

Treatments Not Recommended

• Theophylline is not recommended for acute exacerbations of chronic bronchitis 3, 4
• Expectorants are not recommended for either stable chronic bronchitis or acute bronchitis 3, 4
• Postural drainage and chest percussion have not been proven beneficial and are not recommended 3
• Long-term prophylactic antibiotic therapy is not recommended in stable chronic bronchitis patients 4

Patient Communication Strategies

• Explain that patient satisfaction depends more on the quality of the clinical encounter than on receiving antibiotics 3, 1
• Discuss the risks of unnecessary antibiotic use, including side effects and development of antibiotic resistance 3, 1
• Personalize the risk of unnecessary antibiotic use by informing patients that previous antibiotic use increases their likelihood of carrying and being infected with antibiotic-resistant bacteria 3

Common Pitfalls to Avoid

• Prescribing antibiotics based solely on presence of colored sputum, as purulent sputum does not necessarily indicate bacterial infection 1
• Failing to distinguish between acute bronchitis and pneumonia 1
• Overuse of expectorants and mucolytics which lack evidence of benefit 1
• Not considering underlying conditions that may be exacerbated by bronchitis (asthma, COPD, cardiac failure) 1