What is the best management for acute bronchitis?

Best Management for Acute Bronchitis

Antibiotics should not be prescribed for uncomplicated acute bronchitis unless pneumonia is suspected, as they provide minimal benefit while exposing patients to adverse effects. 1, 2

Diagnosis and Assessment

• 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 1, 3
• More than 90% of cases are caused by respiratory viruses, with fewer than 10% having bacterial infections 2
• Pneumonia should be ruled out before diagnosing uncomplicated bronchitis by assessing for:
  • Tachycardia (heart rate >100 beats/min)
  • Tachypnea (respiratory rate >24 breaths/min)
  • Fever (oral temperature >38°C)
  • Abnormal chest examination findings (rales, egophony, or tactile fremitus) 1, 2
• The presence of purulent sputum or a change in its color does not signify bacterial infection 1, 2

Treatment Approach

Antibiotic Management

• Antibiotics are not recommended for routine treatment of acute bronchitis 1, 2, 4
• Antibiotics may decrease cough duration by only about half a day while exposing patients to adverse effects 2, 4
• Exception: Consider antibiotics only for confirmed or suspected pertussis (whooping cough), where a macrolide antibiotic should be prescribed 2

Symptomatic Relief

• Cough suppressants (dextromethorphan or codeine) may provide modest effects on severity and duration of cough 1, 2
• β2-agonists like albuterol should not be routinely used but may be beneficial in select patients with evidence of bronchial hyperresponsiveness (wheezing or bothersome cough) 1, 2, 3
• Low-cost interventions such as elimination of environmental cough triggers and vaporized air treatments (particularly in low-humidity environments) are reasonable options 1, 2
• Evidence does not support the use of expectorants, mucolytics, antihistamines, NSAIDs at anti-inflammatory doses, or systemic corticosteroids 2, 4

Patient Education and Communication

• Inform patients that cough typically lasts 10-14 days after the office visit 1, 2
• Consider referring to the condition as a "chest cold" rather than bronchitis to reduce patient expectation for antibiotics 1, 2
• Patient satisfaction depends more on physician-patient communication than whether an antibiotic is prescribed 1, 2, 5
• Discuss the risks of unnecessary antibiotic use, including side effects and contribution to antibiotic resistance 2, 5

Common Pitfalls to Avoid

• Prescribing antibiotics based solely on presence of colored sputum 1, 2
• Failing to distinguish between acute bronchitis and pneumonia 1, 2
• Overuse of expectorants and mucolytics which lack evidence of benefit 1, 3
• Not providing realistic expectations about the duration of symptoms 1, 2
• Using bronchodilators in patients without evidence of bronchial hyperresponsiveness 2, 3

Special Considerations

• Patients with comorbidities like COPD, heart failure, or immunosuppression may require different management approaches 2, 3
• Consider antiviral agents for influenza-related bronchitis if within 48 hours of symptom onset 2
• For patients at high risk of complications, closer follow-up may be warranted 2