What is the treatment for bronchitis in Chronic Obstructive Pulmonary Disease (COPD)?

Treatment of Bronchitis in COPD

For patients with bronchitis in COPD, the first-line treatment should include bronchodilators, with ipratropium bromide being the most effective option for improving cough and reducing sputum production. 1, 2

First-Line Bronchodilator Therapy

• Ipratropium bromide should be offered as first-line therapy to improve cough in stable COPD patients with chronic bronchitis (Grade A recommendation) 3, 2
• Standard dosing is ipratropium bromide 36 μg (2 inhalations) four times daily 1, 4
• Short-acting β-agonists should be used to control bronchospasm and relieve dyspnea; they may also reduce chronic cough in some patients (Grade A recommendation) 3
• If response to ipratropium bromide is inadequate after 2 weeks, consider adding a short-acting β-agonist for additional bronchodilation and potential cough relief 4, 2

Treatment Based on Disease Severity

• For patients with low symptom burden and low exacerbation risk, start with a bronchodilator to reduce breathlessness 1
• For patients with high symptom burden, initial therapy should be a long-acting bronchodilator 1
• For persistent breathlessness on monotherapy, use two bronchodilators (LABA/LAMA combination) 1, 5
• For patients with severe airflow obstruction (FEV1 <50%) or frequent exacerbations, consider adding an inhaled corticosteroid with a long-acting β-agonist 3

Management of Acute Exacerbations

• Antibiotics are recommended for acute exacerbations of chronic bronchitis, particularly for patients with severe exacerbations and those with more severe airflow obstruction at baseline (Grade A recommendation) 3
• During acute exacerbations, both short-acting β-agonists and anticholinergic bronchodilators should be administered 3
• If the patient does not show a prompt response to one agent, add the other agent at maximal dose 3
• A short course (10-15 days) of systemic corticosteroid therapy is recommended for acute exacerbations; IV therapy for hospitalized patients and oral therapy for ambulatory patients 3
• Theophylline should NOT be used during acute exacerbations (Grade D recommendation) 3

Additional Treatment Options

• Theophylline may be considered to control chronic cough in stable patients with chronic bronchitis, but careful monitoring for complications is necessary (Grade A recommendation) 3
• Combined therapy with a long-acting β-agonist and an inhaled corticosteroid has been shown to reduce exacerbation rate and cough in long-term trials 3, 6
• For patients with severe COPD with characteristics of chronic bronchitis and a history of exacerbations, roflumilast may be considered 3
• Macrolides could be used as alternative treatment for stable disease in patients still experiencing exacerbations despite optimal treatment 3, 7

Treatments with Limited or No Evidence of Benefit

• Long-term prophylactic therapy with antibiotics is not recommended for stable patients with chronic bronchitis (Grade I recommendation) 3
• Postural drainage and chest percussion have not been proven beneficial and are not recommended for stable patients or during acute exacerbations (Grade I recommendation) 3
• Currently available expectorants have not been proven effective for cough in chronic bronchitis and should not be used 3
• N-acetylcysteine has shown some benefit in reducing exacerbations but is not approved for use in the United States 3

Important Considerations

• Smoking cessation is the most effective means to improve or eliminate the cough of chronic bronchitis, with 90% of patients reporting resolution of cough after smoking cessation 3
• Proper inhaler technique is essential for optimal medication delivery and efficacy 2
• For troublesome cough that requires temporary suppression, codeine and dextromethorphan can be effective, reducing cough counts by 40-60% 3, 2
• When prescribing antibiotics for acute exacerbations, consider local resistance patterns and patient risk factors 8, 9
• Fluoroquinolones may be appropriate first-line treatment for AECB in patients with co-morbid illness, severe obstruction, advanced age, or recurrent exacerbations 8, 9