What are the treatment options for bronchitis?

Treatment of Bronchitis

For acute bronchitis, antibiotics should not be prescribed unless pneumonia is suspected, as viruses cause over 90% of infections; instead, symptomatic therapy and patient education about expected cough duration (10-14 days) are recommended. 1, 2

Diagnosis and Classification

• Acute bronchitis is defined as self-limited inflammation of large airways with cough lasting up to 6 weeks, often with mild constitutional symptoms 1
• Chronic bronchitis is defined as cough with sputum production occurring on most days for at least 3 months of the year and for at least 2 consecutive years 1
• Purulent sputum does not indicate bacterial infection; it results from inflammatory cells or sloughed mucosal epithelial cells 1
• Pneumonia should be ruled out before diagnosing uncomplicated bronchitis by assessing for tachycardia, tachypnea, fever, and abnormal chest examination findings 1

Management of Acute Bronchitis

First-line Approach

• Provide realistic expectations for cough duration (typically 10-14 days after the office visit) 3, 1
• Consider referring to the illness as a "chest cold" rather than bronchitis to reduce patient expectation for antibiotics 1
• Explain that patient satisfaction depends more on the quality of the clinical encounter than on receiving antibiotics 3, 1

Symptomatic Treatment

• Short-acting β-agonists like albuterol may reduce cough duration and severity in patients with evidence of bronchial hyperresponsiveness 3, 1
• Approximately 50% fewer patients report the presence of cough after 7 days of treatment with albuterol 3
• Ipratropium bromide may improve cough in some patients 1, 4
• Dextromethorphan or codeine are recommended for short-term symptomatic relief of bothersome cough 1, 5
• Low-cost and low-risk actions such as elimination of environmental cough triggers (dust, dander) and vaporized air treatments may help, particularly in low-humidity environments 3

Antibiotic Use

• Antibiotics should not be prescribed for uncomplicated acute bronchitis unless pneumonia is suspected 1, 2
• The American College of Physicians recommends that antibiotics may be considered only in specific high-risk populations, such as patients aged ≥75 years with fever 1
• Antibiotic use for acute bronchitis leads to more inappropriate prescribing than any other acute respiratory tract infection in adults 1
• Meta-analyses suggest only a small benefit (approximately 0.5 days reduction in cough duration) from antibiotics, which must be weighed against the risk of side effects and increasing antibiotic resistance 6, 2

Management of Chronic Bronchitis

Bronchodilator Therapy

• Short-acting β-agonists should be used to control bronchospasm and may reduce chronic cough 1, 4
• Ipratropium bromide should be offered as first-line therapy to improve cough in stable chronic bronchitis patients 5, 4
• Long-acting β-agonists combined with inhaled corticosteroids should be offered to control chronic cough 1, 4

Anti-inflammatory Therapy

• Inhaled corticosteroids should be offered to patients with chronic bronchitis and FEV1 <50% predicted or those with frequent exacerbations 1, 4
• Long-term oral corticosteroids are not recommended due to lack of benefit and significant side effects 5

Supportive Measures

• Avoidance of respiratory irritants, especially smoking cessation, is crucial and can lead to resolution of cough in 90% of patients with chronic bronchitis 5, 4

Management of Acute Exacerbations of Chronic Bronchitis

• Short-acting β-agonists or anticholinergic bronchodilators should be administered during acute exacerbations 1, 4
• A short course (10-15 days) of systemic corticosteroids is effective for acute exacerbations 1
• Antibiotics are recommended for acute exacerbations of chronic bronchitis, particularly for patients with severe exacerbations and those with more severe airflow obstruction at baseline 4, 7
• Patients should have 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) to receive antibiotics 7

Common Pitfalls to Avoid

• Prescribing antibiotics based solely on presence of colored sputum 1
• Failing to distinguish between acute bronchitis and pneumonia 1
• Overuse of expectorants, mucolytics, and antihistamines which lack evidence of benefit 1, 4
• Not considering underlying conditions that may be exacerbated by bronchitis (asthma, COPD, cardiac failure, diabetes) 1
• Using theophylline for acute exacerbations of chronic bronchitis 4