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 symptom management including short-acting bronchodilators and antitussives for symptomatic relief. 1, 2

Classification of Bronchitis

• Acute bronchitis is self-limited inflammation of large airways with cough lasting up to 6 weeks 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 3, 1
• Acute exacerbation of chronic bronchitis (AECB) is characterized by sudden clinical deterioration with increased sputum volume, purulence, and/or worsening shortness of breath 3

Management of Acute Bronchitis

First-Line Treatments

• Avoid respiratory irritants, especially cigarette smoke 1
• Short-acting β-agonists (e.g., albuterol) may reduce 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

Treatments Not Recommended

• Antibiotics should not be prescribed unless pneumonia is suspected 3, 1, 2
• Expectorants lack evidence of benefit in acute bronchitis 3, 4
• Mucolytics and antihistamines lack evidence of benefit 1

Management of Chronic Bronchitis

First-Line Treatments

• 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
• 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 FEV1 <50% predicted or those with frequent exacerbations 3, 1

Treatments Not Recommended

• Long-term prophylactic antibiotic therapy is not recommended in stable chronic bronchitis patients 4
• Theophylline is not recommended for acute exacerbations of chronic bronchitis 3, 4
• Expectorants are not recommended for stable chronic bronchitis 3, 4

Management of Acute Exacerbations of Chronic Bronchitis

First-Line Treatments

• Short-acting β-agonists or anticholinergic bronchodilators should be administered during acute exacerbations 3, 4
• Antibiotics are recommended for acute exacerbations of chronic bronchitis with respiratory insufficiency 3, 5
• A short course (10-15 days) of systemic corticosteroids is effective for acute exacerbations 1, 4

Antibiotic Selection for AECB (when indicated)

• For moderate exacerbations: newer macrolides, extended-spectrum cephalosporins, or doxycycline 5
• For severe exacerbations: high-dose amoxicillin/clavulanate or respiratory fluoroquinolones 5
• Antibiotics should target common pathogens: S. pneumoniae, H. influenzae, and M. catarrhalis 3, 6

Patient Communication

• Provide realistic expectations for cough duration (typically 10-14 days after the office visit) 3, 1
• Consider referring to the illness as a "chest cold" rather than bronchitis to reduce patient expectation for antibiotics 3, 1
• 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

Common Pitfalls to Avoid

• Prescribing antibiotics based solely on presence of colored sputum (purulent sputum does not indicate bacterial infection) 1, 2
• Failing to distinguish between acute bronchitis and pneumonia 1, 2
• Overuse of expectorants, mucolytics, and antihistamines which lack evidence of benefit 3, 1
• Not considering underlying conditions that may be exacerbated by bronchitis (asthma, COPD, cardiac failure) 1
• Using theophylline for acute exacerbations of chronic bronchitis 3, 4