What are the treatment options for bronchitis?

Treatment Options for Bronchitis

For bronchitis treatment, short-acting β-agonists and ipratropium bromide should be the first-line therapies for symptom control, with antibiotics reserved only for specific cases of acute exacerbations of chronic bronchitis with evidence of infection. 1, 2

Acute Bronchitis Management

Acute bronchitis is typically self-limiting and viral in origin, with treatment focused on symptom relief:

• Antibiotics should not be prescribed for uncomplicated acute bronchitis as viruses cause more than 90% of infections 1, 2, 3
• Short-acting β-agonists like albuterol may reduce cough duration and severity in patients with evidence of bronchial hyperresponsiveness 1, 2
• Ipratropium bromide may improve cough in some patients 1, 2
• Dextromethorphan or codeine can provide short-term symptomatic relief of bothersome cough 1, 2
• Patient education about expected cough duration (typically 10-14 days after office visit) is essential 2, 4

Chronic Bronchitis Treatment

For chronic bronchitis (cough with sputum production for at least 3 months of the year for 2+ consecutive years):

• Short-acting β-agonists should be used to control bronchospasm and may reduce chronic cough 5, 1
• Ipratropium bromide should be offered to improve cough, with evidence showing reduction in cough frequency, severity, and sputum volume 5, 1, 6
• Theophylline may be considered for chronic cough control, but requires careful monitoring for complications 5
• Long-acting β-agonists combined with inhaled corticosteroids should be offered to control chronic cough 5, 1
• Inhaled corticosteroids are recommended for patients with FEV1 <50% predicted or those with frequent exacerbations 5, 1
• Currently available expectorants lack evidence of effectiveness and should not be used 5, 7

Management of Acute Exacerbations of Chronic Bronchitis

For acute exacerbations of chronic bronchitis:

• Short-acting β-agonists or anticholinergic bronchodilators should be administered during acute exacerbations 5, 1
• If the patient does not show prompt response, the other agent should be added after the first is administered at maximal dose 5
• Theophylline should not be used for acute exacerbations 5, 1
• A short course (10-15 days) of systemic corticosteroids is effective for acute exacerbations 1, 2
• Antibiotics may be indicated for acute exacerbations of chronic bronchitis, particularly in patients with severe exacerbations or more severe airflow obstruction 1, 8
• Antibiotics should be reserved for patients with at least one key symptom (increased dyspnea, sputum production, sputum purulence) and one risk factor (age ≥65 years, FEV1 <50% predicted, ≥4 exacerbations in 12 months, or comorbidities) 8

Common Pitfalls to Avoid

• Prescribing antibiotics based solely on presence of colored sputum - purulent sputum does not necessarily indicate bacterial infection 2, 3
• Failing to distinguish between acute bronchitis and pneumonia - consider pneumonia in patients with tachycardia, tachypnea, fever, and abnormal chest findings 2, 9
• Overuse of expectorants and mucolytics which lack evidence of benefit 5, 2
• Using theophylline for acute exacerbations of chronic bronchitis 5, 2
• Not setting realistic expectations about cough duration (typically 2-3 weeks) 2, 4

Antibiotic Considerations When Indicated

When antibiotics are truly indicated for acute exacerbations of chronic bronchitis:

• For moderate severity exacerbations: a newer macrolide (like azithromycin), extended-spectrum cephalosporin, or doxycycline 8
• For severe exacerbations: high-dose amoxicillin/clavulanate or a respiratory fluoroquinolone 8
• Azithromycin has shown clinical success rates of 85% for acute exacerbations of chronic bronchitis 10