What is the management plan for bronchitis?

Management of Bronchitis

For bronchitis management, the approach differs significantly between acute and chronic forms, with antibiotics recommended only for acute exacerbations of chronic bronchitis in specific situations, while bronchodilators, smoking cessation, and symptom management form the cornerstone of treatment.

Diagnosis and Classification

• Acute bronchitis is defined as self-limited inflammation of large airways with cough lasting up to 3-6 weeks 1, 2
• Chronic bronchitis is diagnosed in adults with cough and sputum production occurring on most days for at least 3 months of the year for 2 consecutive years, after ruling out other respiratory or cardiac causes 3, 2
• Acute exacerbation of chronic bronchitis (AECB) is characterized by sudden deterioration with increased cough, sputum production, purulence, and/or shortness of breath, often preceded by upper respiratory infection symptoms 3, 2
• Purulent sputum does not necessarily indicate bacterial infection; it results from inflammatory cells or sloughed mucosal epithelium 2

Management of Acute Bronchitis

Antibiotic Treatment

• Antibiotics should NOT be routinely prescribed for uncomplicated acute bronchitis as they provide minimal benefit (reducing cough by only about half a day) while exposing patients to adverse effects 1, 4
• Colored sputum (e.g., green) does not reliably indicate bacterial infection and is not an indication for antibiotics 1, 5
• The exception is for confirmed or suspected pertussis (whooping cough), where a macrolide antibiotic should be prescribed 1

Symptomatic Treatment

• Antitussive agents like codeine or dextromethorphan may provide short-term symptomatic relief of coughing 3, 1
• β2-agonist bronchodilators should not be routinely used but may help select patients with wheezing accompanying cough 1, 2
• Evidence does not support the use of expectorants, mucolytics, or antihistamines 2, 4

Patient Education

• Inform patients that cough typically lasts 10-14 days after the office visit 1, 4
• 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, especially smoking cessation, is the most effective intervention; 90% of patients will have resolution of cough after quitting smoking 3, 2
• Smoke-free workplace and public place laws should be enacted in all communities 3
• Postural drainage and chest percussion have not proven beneficial and are not recommended 3

Pharmacological Treatment

• Short-acting β-agonists should be used to control bronchospasm and relieve dyspnea; may also reduce chronic cough 3, 2
• Ipratropium bromide should be offered to improve cough 3, 2
• Long-acting β-agonists combined with inhaled corticosteroids (ICS) should be offered to control chronic cough 3, 2
• ICS therapy should be offered for patients with FEV1 < 50% predicted or those with frequent exacerbations 3, 2
• Theophylline may be considered for cough control with careful monitoring for complications 3
• Long-term prophylactic antibiotic therapy is not recommended 3, 2
• Long-term oral corticosteroids should not be used due to high risk of serious side effects 3

Management of Acute Exacerbations of Chronic Bronchitis

• Antibiotics are recommended for AECB; patients with severe exacerbations and more severe baseline airflow obstruction are most likely to benefit 3, 7
• For AECB, azithromycin (500 mg once daily for 3 days) has shown 85% clinical cure rates, comparable to longer courses of other antibiotics 7, 8
• Short-acting β-agonists or anticholinergic bronchodilators should be administered during acute exacerbations 3, 2
• If the patient doesn't respond promptly to one bronchodilator, add the other agent after administering the first at maximal dose 3
• A short course (10-15 days) of systemic corticosteroids is effective for acute exacerbations 3, 9
• Theophylline should not be used for treatment of acute exacerbations 3

Special Considerations

• Patients with comorbidities like COPD, heart failure, or immunosuppression may require different management approaches 1, 9
• Antibiotics should be considered for AECB in patients with at least one key symptom (increased dyspnea, sputum production, sputum purulence) and one risk factor (age ≥65 years, FEV1 < 50% predicted, ≥4 AECBs in 12 months, or comorbidities) 9
• For severe AECB, high-dose amoxicillin/clavulanate or a respiratory fluoroquinolone is recommended 9
• Increasing bacterial resistance among common respiratory pathogens (S. pneumoniae, H. influenzae, M. catarrhalis) should be considered when selecting antibiotics 8, 9