What is the management plan for bronchitis?

Management of Bronchitis

The management of bronchitis should be tailored based on whether it is acute or chronic, with antibiotics generally not recommended for uncomplicated acute bronchitis but indicated for acute exacerbations of chronic bronchitis in specific situations. 1, 2

Diagnosis and Classification

• Acute bronchitis is defined as self-limited inflammation of the large airways with cough lasting up to 6 weeks 1
• Chronic bronchitis is diagnosed in adults with history of cough and sputum production occurring on most days for at least 3 months of the year for 2 consecutive years 2, 1
• 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

Non-Pharmacological Management

• 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 2, 3
• Elimination of environmental cough triggers and vaporized air treatments may be reasonable options 3

Pharmacological Management

• Antibiotics should not be prescribed for uncomplicated acute bronchitis unless pneumonia is suspected 2, 1, 4
• Short-acting β-agonists may be beneficial in reducing cough duration and severity in patients with evidence of bronchial hyperresponsiveness 1, 3
• Dextromethorphan or codeine are recommended for short-term symptomatic relief of bothersome cough 1, 5
• Antitussive agents are occasionally useful for short-term symptomatic relief 2
• Mucokinetic agents are not recommended due to lack of consistent favorable effect on cough 2

Management of Chronic Bronchitis

Non-Pharmacological Management

• Avoidance of respiratory irritants is the most effective means to improve or eliminate chronic bronchitis cough; 90% of patients will have resolution of their cough after smoking cessation 2, 1
• Smoke-free workplace and public place laws should be enacted in all communities 2
• Postural drainage and chest percussion are not recommended as clinical benefits have not been proven 2, 5

Pharmacological Management

• Short-acting β-agonists should be used to control bronchospasm and relieve dyspnea; may also reduce chronic cough 2, 1
• Ipratropium bromide should be offered to improve cough 2, 1
• Treatment with theophylline should be considered to control chronic cough with careful monitoring for complications 2
• Long-acting β-agonists combined with inhaled corticosteroids should be offered to control chronic cough 2, 1
• Inhaled corticosteroids should be offered to patients with FEV1 < 50% predicted or those with frequent exacerbations 2, 1
• There is no role for long-term prophylactic therapy with antibiotics in stable patients 2
• Long-term maintenance therapy with oral corticosteroids should not be used 2
• Currently available expectorants lack evidence of effectiveness and should not be used 2

Management of Acute Exacerbations of Chronic Bronchitis

Diagnosis of Exacerbation

• Characterized by deterioration of symptoms with increased cough, sputum production, sputum purulence, and/or shortness of breath, often preceded by upper respiratory tract infection symptoms 2, 5

Treatment

• Antibiotics are recommended for acute exacerbations; patients with severe exacerbations and those with more severe airflow obstruction at baseline are most likely to benefit 2, 6, 7
• Short-acting β-agonists or anticholinergic bronchodilators should be administered during acute exacerbations 2
• If the patient does not show a prompt response to one bronchodilator, the other agent should be added after the first is administered at the maximal dose 2
• A short course (10-15 days) of systemic corticosteroids is effective for acute exacerbations 2, 1
• Theophylline should not be used for treatment of acute exacerbations 2
• Expectorants lack evidence of effectiveness during acute exacerbations 2

Antibiotic Selection for Acute Exacerbations

• For moderate severity exacerbations: newer macrolides, extended-spectrum cephalosporins, or doxycycline 7
• For severe exacerbations: high-dose amoxicillin/clavulanate or a respiratory fluoroquinolone 7
• Consider local resistance patterns among common respiratory pathogens (Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis) 8, 7
• Azithromycin has shown clinical success rates of 85% for acute exacerbations of chronic bronchitis 6

Common Pitfalls to Avoid

• Prescribing antibiotics based solely on presence of colored sputum (purulent sputum does not necessarily indicate bacterial infection) 1, 3
• Failing to distinguish between acute bronchitis and pneumonia 1, 9
• Overuse of expectorants and mucolytics which lack evidence of benefit 2
• Not considering underlying conditions that may be exacerbated by bronchitis 1
• Using theophylline for acute exacerbations of chronic bronchitis 2