What treatment should I order for a patient presenting with symptoms of bronchitis?

Management of Acute Bronchitis

For patients with symptoms of acute bronchitis, no routine medications or investigations should be ordered initially, as acute bronchitis is typically a self-limiting viral condition that resolves without specific treatment. 1

Initial Assessment and Diagnosis

• Acute bronchitis is a clinical diagnosis characterized by acute cough due to inflammation of the trachea and lower airways, typically lasting about 2-3 weeks 2, 3
• Rule out other conditions such as pneumonia, asthma, or COPD exacerbation before diagnosing acute bronchitis 1
• The absence of the following findings makes pneumonia unlikely and eliminates the need for chest radiography:
  • Heart rate >100 beats/min
  • Respiratory rate >24 breaths/min
  • Oral temperature >38°C
  • Focal chest examination findings (rales, egophony, fremitus) 1
• Purulent sputum does not reliably indicate bacterial infection and should not be used as a criterion for antibiotic therapy 1, 2

Recommended Management Approach

Investigations

• No routine investigations are recommended for uncomplicated acute bronchitis, including:
  • Chest x-ray
  • Spirometry
  • Peak flow measurement
  • Sputum cultures
  • Viral PCR
  • Serum inflammatory markers (CRP, procalcitonin) 1

Treatment

1. Antibiotics:

   • Antibiotics are not recommended for routine treatment of acute bronchitis in immunocompetent adults 1
   • Antibiotics may reduce cough duration by only approximately 0.5 days but expose patients to adverse effects 3
   • Consider antibiotics only if:
     • The condition worsens significantly
     • A complicating bacterial infection is suspected
     • Pertussis is suspected (to reduce transmission)
     • The patient is at high risk for pneumonia (e.g., age ≥65 years) 1, 2

2. Bronchodilators:

   • β2-agonist bronchodilators should not be routinely prescribed for cough in acute bronchitis 1
   • May be considered in select adult patients with wheezing accompanying the cough 1
   • In clinical trials, albuterol has shown some benefit in reducing duration and severity of cough in patients with bronchial hyperresponsiveness 1

3. Symptomatic Relief:

   • Antitussive agents may provide short-term symptomatic relief of coughing in selected cases 1
   • Mucokinetic agents are not recommended as they have not shown consistent favorable effects on cough 1
   • Evidence does not support the use of honey, antihistamines, anticholinergics, NSAIDs, or corticosteroids for symptom management 3

Special Considerations

• If symptoms persist or worsen, consider reassessment and targeted investigations such as:

  • Chest x-ray
  • Sputum for microbial culture
  • Peak expiratory flow measurements
  • Complete blood count
  • Inflammatory markers 1

• Consider alternative diagnoses if symptoms persist:

  • Approximately 65% of patients with recurrent episodes of acute bronchitis may have underlying mild asthma 1
  • Other potential diagnoses include cough-variant asthma, COPD, or bronchiectasis 1

Patient Education

• Explain that acute bronchitis is typically viral and self-limiting 2, 3
• Inform patients about the expected duration of cough (2-3 weeks) 3
• Discuss that antibiotics are generally ineffective and may cause adverse effects 3
• Describing acute bronchitis as a "chest cold" may help reduce patient expectations for antibiotics 3

When to Consider Antibiotics

• For patients with acute bronchitis who have significant worsening of symptoms 1
• When bacterial superinfection is suspected based on clinical deterioration 1
• In cases of suspected pertussis to reduce transmission 2
• For high-risk patients (elderly, immunocompromised) who may be at increased risk for developing pneumonia 2

If antibiotics are deemed necessary, azithromycin has shown clinical success rates of 85% in treating acute exacerbations of chronic bronchitis, comparable to other antibiotics, with potentially fewer gastrointestinal side effects 4.