What is the treatment approach for bronchitis?

Treatment Approach for Bronchitis

Antibiotics are not recommended for uncomplicated acute bronchitis, regardless of duration of cough, as viruses are responsible for more than 90% of infections. 1, 2, 3

Types of Bronchitis and Diagnosis

• 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 2
• 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
• Evaluation should focus on ruling out serious illness, particularly pneumonia, which is uncommon in healthy adults without vital sign abnormalities or asymmetrical lung sounds 1
• Purulent sputum does not indicate bacterial infection; it results from inflammatory cells or sloughed mucosal epithelial cells 2

Management of Acute Bronchitis

First-line Approach

• Focus on symptomatic relief and patient education about the expected duration of cough (typically 2-3 weeks) 4
• Short-acting β-agonists like albuterol may be beneficial in reducing cough duration and severity in patients with evidence of bronchial hyperresponsiveness 1, 5, 2
• Dextromethorphan or codeine are recommended for short-term symptomatic relief of bothersome cough 1, 5, 2
• Ipratropium bromide may improve cough in some patients with acute bronchitis 5, 2

Antibiotic Considerations

• Antibiotics should not be prescribed unless pneumonia is suspected or pertussis infection is confirmed 1, 3
• The American College of Physicians suggests antibiotics may be considered only in specific high-risk populations, such as patients aged ≥75 years with fever 2
• When discussing treatment with patients, consider referring to the illness as a "chest cold" rather than bronchitis to reduce patient expectation for antibiotics 2

Management of Chronic Bronchitis

First-line Approach

• Avoidance of respiratory irritants (especially smoking cessation) is the cornerstone of therapy, with 90% of patients experiencing resolution of cough after smoking cessation 1, 5
• Short-acting β-agonists should be used to control bronchospasm and may reduce chronic cough 5, 2
• Ipratropium bromide should be offered to improve cough 5, 2
• Long-acting β-agonists combined with inhaled corticosteroids should be offered to control chronic cough 5, 2

Management of Exacerbations

• Exacerbations are characterized by increased sputum volume, sputum purulence, and/or worsening shortness of breath 1
• For exacerbations of chronic bronchitis, treatment includes:
  • Short-acting β-agonists or anticholinergic bronchodilators 5, 2
  • A short course (10-15 days) of systemic corticosteroids 5, 2
  • Antibiotics are recommended for acute exacerbations of chronic bronchitis, particularly for patients with severe exacerbations and those with more severe airflow obstruction at baseline 5, 6

Treatment Algorithm Based on Bronchitis Type

For Acute Bronchitis:

1. Confirm diagnosis by ruling out pneumonia and other serious conditions 1
2. Provide symptomatic treatment:
   • Short-acting β-agonists if wheezing or evidence of bronchial hyperresponsiveness 1, 5
   • Antitussives (dextromethorphan or codeine) for bothersome cough 1, 5
3. Avoid antibiotics unless pertussis is suspected 1
4. Educate patient about expected duration of symptoms (2-3 weeks) 2, 4

For Chronic Bronchitis:

1. Advise smoking cessation and avoidance of respiratory irritants 1, 5
2. Prescribe maintenance therapy:
   • Short-acting β-agonists and ipratropium bromide 5, 2
   • Consider long-acting β-agonists with inhaled corticosteroids for patients with severe disease or frequent exacerbations 5, 2
3. For exacerbations meeting Anthonisen criteria (increased sputum volume, purulence, and/or dyspnea):
   • Intensify bronchodilator therapy 5, 2
   • Consider short course of systemic corticosteroids 5, 2
   • Prescribe appropriate antibiotics if indicated 1, 5, 6

Common Pitfalls to Avoid

• Prescribing antibiotics based solely on presence of colored sputum 2, 3
• Failing to distinguish between acute bronchitis and pneumonia 2, 4
• Overuse of expectorants, mucolytics, and antihistamines which lack evidence of benefit 5, 2
• Not considering underlying conditions that may be exacerbated by bronchitis (asthma, COPD, cardiac failure) 2
• Using theophylline for acute exacerbations of chronic bronchitis 5, 2