What is the management of acute bronchitis?

Management of Acute Bronchitis

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, 2

Diagnosis and Assessment

• Acute bronchitis is an acute respiratory infection with normal chest radiograph findings, manifested by cough with or without phlegm production lasting up to 3 weeks 1
• Respiratory viruses are the most common cause (89-95% of cases), with fewer than 10% of patients having bacterial infections 1, 3
• Pneumonia should be ruled out in patients with the following findings:
  • Heart rate >100 beats/min
  • Respiratory rate >24 breaths/min
  • Oral temperature >38°C
  • Abnormal chest examination findings (rales, egophony, or tactile fremitus) 1, 2
• The presence of purulent sputum or a change in its color does not signify bacterial infection and is not an indication for antibiotics 1, 2

Treatment Approach

Antibiotic Management

• Routine antibiotic treatment of uncomplicated acute bronchitis is not recommended, regardless of the duration of cough 4, 1
• The exception is for confirmed or suspected pertussis (whooping cough), where a macrolide antibiotic should be prescribed and patients should be isolated for 5 days from the start of treatment 4, 1
• Early treatment of pertussis within the first few weeks will diminish coughing paroxysms and prevent disease spread 1
• When patients expect antibiotics, clinicians should explain the decision not to use these agents and discuss the potential harm of unnecessary antibiotic use 4, 1

Symptomatic Treatment

• β2-agonist bronchodilators should not be routinely used for cough in most patients with acute bronchitis 4, 1
• In select adult patients with wheezing accompanying the cough, β2-agonist bronchodilators may be useful 4, 1
• Antitussive agents (such as codeine or dextromethorphan) may provide modest effects on severity and duration of cough and can be offered for short-term symptomatic relief 4, 1
• Mucokinetic agents are not recommended due to lack of consistent favorable effects 4, 2
• Low-cost and low-risk actions such as elimination of environmental cough triggers and vaporized air treatments may be reasonable options 1

Patient Education

• Inform patients that cough typically lasts 10-14 days after the office visit 4, 1
• Referring to the condition as a "chest cold" rather than bronchitis may reduce patient expectation for antibiotics 4, 1
• Patient satisfaction with care depends more on physician-patient communication than whether an antibiotic is prescribed 4, 1
• Explain the risks of unnecessary antibiotic use, including side effects, allergic reactions, and contribution to antibiotic resistance 4, 1

Special Considerations

• For influenza-related bronchitis, antiviral agents may be considered if within 48 hours of symptom onset 4, 1
• These guidelines do not apply to the elderly or those with comorbid conditions such as chronic obstructive pulmonary disease, congestive heart failure, or immunosuppression 4
• If symptoms persist or worsen, consider reassessment and targeted investigations 2
• Approximately 65% of patients with recurrent episodes of acute bronchitis may have underlying mild asthma, and other potential diagnoses include cough-variant asthma, COPD, or bronchiectasis 2

Common Pitfalls to Avoid

• Prescribing antibiotics based solely on purulent sputum or patient expectation 4, 1
• Failing to distinguish acute bronchitis from pneumonia, which requires different management 1, 5
• Not providing adequate patient education about the expected duration of symptoms, leading to unnecessary return visits 1, 3
• Routinely ordering diagnostic tests for uncomplicated acute bronchitis 1, 2
• Prescribing mucokinetic agents or routine bronchodilators without evidence of benefit 4, 2