What are the management options for bronchitis?

Management of Bronchitis

Antibiotics should not be prescribed for uncomplicated acute bronchitis, while management of chronic bronchitis should focus on bronchodilators, with antibiotics reserved only for acute exacerbations with evidence of bacterial infection. 1

Classification of Bronchitis

• 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
• 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
• Acute exacerbation of chronic bronchitis is characterized by a period of unstable lung function with worsening airflow and other symptoms 2

Management of Acute Bronchitis

Diagnostic Approach

• Rule out pneumonia before diagnosing uncomplicated bronchitis by assessing for tachycardia, tachypnea, fever, and abnormal chest examination findings 1
• Chest radiography is usually not indicated in healthy, nonelderly adults without vital sign abnormalities or asymmetrical lung sounds 3
• In patients with cough lasting 3 weeks or longer, chest radiography may be warranted to rule out other causes 3

Treatment Recommendations

• Antibiotics are not recommended for uncomplicated acute bronchitis, regardless of duration of cough 3, 1
• Antibiotics may be considered only in specific high-risk populations, such as patients aged ≥75 years with fever 1
• If pertussis infection is suspected, diagnostic testing should be performed and antimicrobial therapy initiated 3
• Short-acting β-agonists like albuterol may be beneficial in reducing cough duration and severity in patients with evidence of bronchial hyperresponsiveness 1, 4
• Ipratropium bromide may improve cough in some patients 1, 4
• Dextromethorphan or codeine are recommended for short-term symptomatic relief of bothersome cough 1, 4

Patient Communication

• Provide realistic expectations for cough duration (typically 2-3 weeks) 1, 5
• 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 physician-patient communication than on antibiotic treatment 3

Management of Chronic Bronchitis

First-line Interventions

• Avoidance of respiratory irritants is the cornerstone of therapy, with 90% of patients experiencing resolution of cough after smoking cessation 1, 4
• Short-acting β-agonists should be used to control bronchospasm and may reduce chronic cough 3, 1, 4
• Ipratropium bromide should be offered to improve cough 3, 1, 4

Additional Therapies

• Long-acting β-agonists combined with inhaled corticosteroids should be offered to control chronic cough 3, 1, 4
• Inhaled corticosteroids should be offered to patients with chronic bronchitis and FEV1 <50% predicted or those with frequent exacerbations 3, 1, 4
• Long-term prophylactic antibiotic therapy is not recommended in stable chronic bronchitis patients 3, 4
• Theophylline should be considered to control chronic cough, but careful monitoring for complications is necessary 3

Management of Acute Exacerbations of Chronic Bronchitis

• Short-acting β-agonists or anticholinergic bronchodilators should be administered during acute exacerbations 3, 1, 4
• If the patient does not show a prompt response to one bronchodilator, the other agent should be added after the first is administered at the maximal dose 3
• Antibiotics are recommended for acute exacerbations of chronic bronchitis, particularly for patients with severe exacerbations and those with more severe airflow obstruction at baseline 3, 4, 2
• Antibiotics should be reserved for patients with 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) 2
• A short course (10-15 days) of systemic corticosteroids is effective for acute exacerbations 1, 4
• Theophylline should not be used for treatment of acute exacerbations 3

Common Pitfalls to Avoid

• Prescribing antibiotics based solely on presence of colored sputum (purulent sputum does not indicate bacterial infection; it results from inflammatory cells or sloughed mucosal epithelial cells) 1
• Failing to distinguish between acute bronchitis and pneumonia 1
• Overuse of expectorants and mucolytics 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 3, 4