What is the treatment approach for bronchitis?

Treatment Approach for Bronchitis

The treatment approach for bronchitis should be differentiated based on whether it is acute or chronic, with antibiotics generally not recommended for acute bronchitis but indicated for certain exacerbations of chronic bronchitis. 1, 2

Acute Bronchitis Treatment

First-line Management

• Acute bronchitis is self-limiting and primarily requires supportive care without antibiotics 1, 2, 3
• Patient education about expected cough duration (typically 10-14 days after office visit) is crucial 2, 3
• Consider referring to the illness as a "chest cold" rather than bronchitis to reduce patient expectation for antibiotics 2

Symptomatic Treatment

• Short-acting β-agonists like albuterol may be beneficial in reducing cough duration and severity in patients with evidence of bronchial hyperresponsiveness 2
• Ipratropium bromide may improve cough in some patients 2
• For bothersome cough, dextromethorphan or codeine are recommended for short-term symptomatic relief 1, 2

When to Consider Antibiotics

• Antibiotics should not be prescribed for uncomplicated acute bronchitis unless pneumonia is suspected 1, 2
• Consider antibiotics only in specific high-risk populations, such as patients aged ≥75 years with fever 2
• If acute bronchitis worsens, consider antibiotic therapy if a complicating bacterial infection is thought likely 1

Chronic Bronchitis Treatment

Bronchodilator Therapy

• Short-acting β-agonists should be used to control bronchospasm and may reduce chronic cough 1, 2
• Ipratropium bromide should be offered to improve cough 1, 2
• Theophylline should be considered to control chronic cough with careful monitoring for complications 1

Anti-inflammatory Therapy

• Combined therapy with a long-acting β-agonist and an inhaled corticosteroid should be offered to control chronic cough 1, 2
• Inhaled corticosteroids should be offered to patients with chronic bronchitis and FEV1 <50% predicted or those with frequent exacerbations 1, 2
• Long-term maintenance therapy with oral corticosteroids is not recommended due to lack of evidence for improvement and significant risk of side effects 1

Mucokinetic Agents

• Currently available expectorants have not been proven effective and should not be used 1
• N-acetylcysteine has shown some benefit in improving overall symptoms and reducing exacerbation risk, but is not approved in the United States 1

Management of Acute Exacerbations of Chronic Bronchitis

Assessment

• Immediate antibiotic therapy is recommended for exacerbations of chronic obstructive bronchitis with chronic respiratory insufficiency 1
• For exacerbations of chronic obstructive bronchitis, antibiotic therapy is recommended if at least two of the Anthonisen triad criteria are present (increased dyspnea, increased sputum production, increased sputum purulence) 1, 4

Bronchodilator Therapy

• Short-acting β-agonists or anticholinergic bronchodilators should be administered during acute exacerbations 1, 2
• If the patient does not show a prompt response, the other agent should be added after the first is administered at the maximal dose 1
• Theophylline should not be used for treatment of acute exacerbations 1

Corticosteroid Therapy

• A short course (10-15 days) of systemic corticosteroid therapy should be given for acute exacerbations 1, 2
• IV therapy in hospitalized patients and oral therapy for ambulatory patients have both proven effective 1

Antibiotic Selection

• First-line antibiotics for infrequent exacerbations include amoxicillin, first-generation cephalosporins, macrolides, pristinamycin, and doxycycline 1
• For frequent exacerbations (≥4 per year) or severe disease, second-line antibiotics such as respiratory fluoroquinolones or high-dose amoxicillin/clavulanate are recommended 1, 4, 5

Common Pitfalls to Avoid

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

Special Considerations

• Tiotropium bromide is indicated for long-term maintenance treatment of COPD including chronic bronchitis, but not for acute deteriorations 6
• For patients with chronic bronchitis who continue to smoke, the most effective intervention is smoking cessation 1