What is the first-line treatment for bronchitis?

First-Line Treatment for Bronchitis

The first-line treatment for acute bronchitis is symptomatic therapy with albuterol (a short-acting β-agonist bronchodilator) to reduce the duration and severity of cough in immunocompetent adults. 1

Acute Bronchitis Management

Primary Treatment Approach

• Albuterol has demonstrated consistent benefit in randomized controlled trials, with approximately 50% fewer patients reporting cough after 7 days of treatment 1
• Bronchodilator therapy should be prioritized as it has proven effectiveness in reducing cough duration and severity in acute bronchitis 1, 2
• Antitussives containing dextromethorphan or codeine may provide modest effects on cough severity and duration as adjunctive therapy 1

Antibiotic Considerations

• Antibiotics are NOT recommended for routine use in uncomplicated acute bronchitis as they provide minimal benefit (reducing cough by only about half a day) while carrying potential adverse effects 1, 3
• Antibiotics should only be considered if bronchitis worsens and a complicating bacterial infection is suspected 1
• Despite evidence against their use, studies show that family physicians frequently prescribe antibiotics for acute bronchitis (63% as first-line treatment), highlighting a significant gap between evidence and practice 4

Supportive Measures

• Low-cost and low-risk interventions such as elimination of environmental cough triggers and vaporized air treatments are reasonable complementary options 1
• Patient education about the natural course of illness is crucial - patients should be informed that cough typically lasts 10-14 days after the office visit 1, 3

Management of Chronic Bronchitis

For patients with chronic bronchitis, the treatment approach differs:

• Short-acting β-agonists (like albuterol) should be used to control bronchospasm, relieve dyspnea, and may reduce chronic cough 1
• Ipratropium bromide should be offered to improve cough in stable patients with chronic bronchitis 1
• For acute exacerbations of chronic bronchitis (AECB), supportive care should be provided to all patients, which may include bronchodilators, oxygen, hydration, systemic corticosteroids, and chest physical therapy 5

Antibiotic Use in Chronic Bronchitis

• Antibiotics for AECB should be reserved for patients with at least one key symptom (increased dyspnea, sputum production, or sputum purulence) AND one risk factor (age ≥65 years, FEV1 <50% predicted, ≥4 AECBs in 12 months, or comorbidities) 5
• For moderate exacerbations, a newer macrolide, extended-spectrum cephalosporin, or doxycycline is appropriate 5
• For severe exacerbations, high-dose amoxicillin/clavulanate or a respiratory fluoroquinolone should be used 5

Common Pitfalls to Avoid

• Prescribing antibiotics for uncomplicated acute bronchitis despite evidence showing lack of benefit 1, 3
• Failing to distinguish between acute bronchitis and exacerbations of chronic bronchitis, which require different management approaches 1, 5
• Not providing realistic expectations about illness duration, leading to unnecessary follow-up visits or antibiotic requests 1
• Overlooking bronchodilator therapy as first-line treatment, despite demonstrated benefit in reducing cough duration and severity 1, 4
• Missing pneumonia diagnosis - pneumonia should be suspected in patients with tachypnea, tachycardia, dyspnea, or lung findings suggestive of pneumonia, warranting chest radiography 3
• Failing to consider pertussis in patients with cough persisting for more than two weeks accompanied by paroxysmal cough, whooping, post-tussive emesis, or recent pertussis exposure 3