What is the management plan for bronchitis?

Management of Bronchitis

The management of bronchitis should focus on symptom relief for acute bronchitis and appropriate pharmacotherapy for chronic bronchitis, with antibiotics reserved only for specific indications such as acute exacerbations of chronic bronchitis or suspected pertussis. 1, 2

Diagnosis and Classification

• Acute bronchitis is defined as self-limited inflammation of the large airways with cough lasting up to 3-6 weeks, often accompanied by mild constitutional symptoms 1, 2
• Chronic bronchitis is diagnosed in adults with history of chronic cough and sputum expectoration occurring on most days for at least 3 months and for at least 2 consecutive years, after ruling out other respiratory or cardiac causes 3, 2
• The presence of purulent sputum does not indicate bacterial infection and is not an indication for antibiotics 1, 2
• Pneumonia should be ruled out in patients with tachycardia (heart rate >100 beats/min), tachypnea (respiratory rate >24 breaths/min), fever (oral temperature >38°C), or abnormal chest examination findings 1

Management of Acute Bronchitis

Antibiotic Treatment

• Antibiotics should not be routinely prescribed for acute bronchitis as they provide minimal benefit (reducing cough by only about half a day) while exposing patients to adverse effects 1, 4
• For confirmed or suspected pertussis (whooping cough), a macrolide antibiotic should be prescribed and patients should be isolated for 5 days from the start of treatment 1

Symptomatic Treatment

• β2-agonist bronchodilators should not be routinely used for cough in most patients with acute bronchitis 1
• In select adult patients with wheezing accompanying the cough, β2-agonist bronchodilators may be useful 1, 5
• Antitussive agents such as codeine or dextromethorphan are occasionally useful and can be offered for short-term symptomatic relief of bothersome cough 3, 1
• Mucokinetic agents are not recommended as there is no consistent favorable effect on cough 3

Patient Education

• Inform patients that cough typically lasts 10-14 days after the office visit 1, 5
• Referring to the condition as a "chest cold" rather than bronchitis may reduce patient expectation for antibiotics 1
• Patient satisfaction depends more on physician-patient communication than whether an antibiotic is prescribed 1, 6

Management of Chronic Bronchitis

Non-Pharmacological Interventions

• Avoidance of respiratory irritants is the most effective means to improve or eliminate the cough of chronic bronchitis; 90% of patients will have resolution of their cough after smoking cessation 3, 2
• Smoke-free workplace and public place laws should be enacted in all communities 3
• The clinical benefits of postural drainage and chest percussion have not been proven, and they are not recommended 3

Pharmacological Treatment for Stable Chronic Bronchitis

• Short-acting β-agonists should be used to control bronchospasm and relieve dyspnea; in some patients, it may also reduce chronic cough 3, 2
• Ipratropium bromide should be offered to improve cough 3, 2
• Treatment with theophylline should be considered to control chronic cough with careful monitoring for complications 3
• Long-acting β-agonists combined with inhaled corticosteroids (ICS) should be offered to control chronic cough 3, 2
• ICS therapy should be offered to patients with an FEV1 of < 50% predicted or for those with frequent exacerbations 3, 2
• There is no role for long-term prophylactic therapy with antibiotics in stable patients 3
• Long-term maintenance therapy with oral corticosteroids should not be used due to lack of evidence for improvement and high risk of side effects 3

Management of Acute Exacerbations of Chronic Bronchitis

• Antibiotics are recommended for acute exacerbations; patients with severe exacerbations and those with more severe airflow obstruction at baseline are most likely to benefit 3, 7
• For acute exacerbations, therapy with short-acting β-agonists or anticholinergic bronchodilators should be administered. If the patient does not show a prompt response, the other agent should be added after the first is administered at the maximal dose 3
• A short course (10 to 15 days) of systemic corticosteroid therapy should be given; IV therapy in hospitalized patients and oral therapy for ambulatory patients have both proven to be effective 3
• Theophylline should not be used for treatment of acute exacerbations 3
• There is no evidence that expectorants are effective during acute exacerbations 3

Antibiotic Selection for Acute Exacerbations of Chronic Bronchitis

• For moderate exacerbations, a newer macrolide (like azithromycin), extended-spectrum cephalosporin, or doxycycline is appropriate 7, 8
• For severe exacerbations, high-dose amoxicillin/clavulanate or a respiratory fluoroquinolone should be used 8
• Azithromycin (500 mg once daily for 3 days) has shown clinical cure rates of 85% for acute exacerbations of chronic bronchitis 7

Common Pitfalls to Avoid

• Prescribing antibiotics for acute bronchitis 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 3
• Not considering underlying conditions that may be exacerbated by bronchitis (asthma, COPD, cardiac failure) 2
• Using theophylline for acute exacerbations of chronic bronchitis 3