Does bronchitis require treatment?

Treatment of Bronchitis: Evidence-Based Approach

Bronchitis treatment depends on whether it is acute or chronic, with most cases of acute bronchitis not requiring antibiotic treatment while chronic bronchitis often requires targeted management of symptoms and exacerbations. 1

Acute Bronchitis Management

Antibiotic Therapy

• Routine antibiotic treatment of uncomplicated acute bronchitis is NOT recommended, regardless of cough duration. 2, 1
• Antibiotics should be reserved only for specific circumstances:
  • Suspected pertussis infection (uncommon) 2, 1
  • High-risk populations such as patients ≥75 years with fever 1
  • Patients with cardiac failure, according to European Respiratory Society 1

Symptomatic Treatment

• Short-acting β-agonists (like albuterol) may be beneficial for reducing cough duration and severity in patients with evidence of bronchial hyperresponsiveness 1
• Antitussives containing dextromethorphan or codeine are recommended for short-term symptomatic relief of bothersome cough 2, 1
• Ipratropium bromide may improve cough symptoms in some patients 1
• Elimination of environmental cough triggers and vaporized air treatments may help, especially in low-humidity environments 2

Patient Communication

• Provide realistic expectations for cough duration (typically 10-14 days after the office visit) 2, 1
• Refer to the illness as a "chest cold" rather than bronchitis to reduce patient expectation for antibiotics 2, 1
• Patient satisfaction depends more on physician-patient communication than on receiving antibiotics 2
• Explain the risks of unnecessary antibiotic use, including side effects and development of antibiotic resistance 2, 1

Chronic Bronchitis Management

Regular Treatment

• Short-acting β-agonists should be used to control bronchospasm and may reduce chronic cough 1
• Ipratropium bromide should be offered to improve cough symptoms 1
• Long-acting β-agonists combined with inhaled corticosteroids should be offered to control chronic cough 1
• Inhaled corticosteroids should be offered to patients with chronic bronchitis and FEV1 <50% predicted or those with frequent exacerbations 1

Management of Acute Exacerbations of Chronic Bronchitis

• Antibiotic therapy is indicated for exacerbations when patients have:
  • At least one key symptom (increased dyspnea, sputum production, sputum purulence) AND
  • At least one risk factor (age ≥65 years, FEV1 <50% predicted, ≥4 exacerbations in 12 months, or comorbidities) 3
• Antibiotic selection should be based on severity:
  • Moderate exacerbation: newer macrolide, extended-spectrum cephalosporin, or doxycycline 3
  • Severe exacerbation: high-dose amoxicillin/clavulanate or respiratory fluoroquinolone 3
• Short-acting bronchodilators (β-agonists or anticholinergics) should be administered during acute exacerbations 1
• A short course (10-15 days) of systemic corticosteroids is effective for acute exacerbations 1

Diagnostic Considerations

• Acute bronchitis is defined as self-limited inflammation of the 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 1
• Purulent sputum does not indicate bacterial infection; it results from inflammatory cells or sloughed mucosal epithelial cells 1
• Pneumonia should be ruled out before diagnosing uncomplicated bronchitis by assessing for tachycardia, tachypnea, fever, and abnormal chest examination findings 2, 1

Common Pitfalls to Avoid

• Prescribing antibiotics based solely on presence of colored sputum 1, 4
• 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
• Using theophylline for acute exacerbations of chronic bronchitis 1

Special Considerations

• In patients with obstructive chronic bronchitis with chronic respiratory insufficiency (FEV1 <35% and hypoxemia at rest), immediate antibiotic therapy is recommended for exacerbations 2
• For exacerbations of simple chronic bronchitis, antibiotic therapy is only recommended if fever (>38°C) persists for more than 3 days 2
• For exacerbations of chronic obstructive bronchitis (FEV1 between 35% and 80%), immediate antibiotic therapy is only recommended if at least two of the three Anthonisen criteria are present (increased dyspnea, increased sputum volume, increased sputum purulence) 2