What is the initial approach to managing bronchitis?

Initial Management of Bronchitis

Distinguish Between Acute and Chronic Bronchitis First

The initial approach to managing bronchitis depends critically on whether you are dealing with acute bronchitis (a self-limited viral illness) or chronic bronchitis/acute exacerbation of chronic bronchitis (AECB), as these require fundamentally different management strategies. 1, 2

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Acute Bronchitis Management

Rule Out Pneumonia Before Diagnosing Acute Bronchitis

• Check for tachycardia (heart rate >100 beats/min), tachypnea (respiratory rate >24 breaths/min), fever (oral temperature >38°C), or abnormal chest examination findings (rales, egophony, tactile fremitus) 3, 1
• If any of these are present, consider chest radiography to rule out pneumonia 3, 2
• Chest radiography is usually not indicated in healthy, nonelderly adults without vital sign abnormalities or asymmetrical lung sounds 2

Do NOT Prescribe Antibiotics for Uncomplicated 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, 4, 5
• The vast majority of cases (≥90%) have a nonbacterial cause, primarily respiratory viruses 3, 1
• The presence of purulent sputum or change in sputum color does NOT signify bacterial infection and is NOT an indication for antibiotics 3, 1

Exception: Pertussis (Whooping Cough)

• For confirmed or suspected pertussis, prescribe a macrolide antibiotic (such as erythromycin) 1
• Suspect pertussis if cough persists >2 weeks with paroxysmal cough, whooping cough, post-tussive emesis, or recent pertussis exposure 5
• Patients should be isolated for 5 days from the start of treatment 1

Symptomatic Treatment Options

• β2-agonist bronchodilators should not be routinely used for cough in most patients with acute bronchitis 1, 2
• In select adult patients with wheezing accompanying the cough, β2-agonist bronchodilators may be useful 1, 2
• Codeine or dextromethorphan may provide modest effects on severity and duration of cough 1, 2
• Low-cost options like elimination of environmental cough triggers and vaporized air treatments may be reasonable 1

Patient Communication Strategy

• Inform patients that cough typically lasts 10-14 days (up to 3 weeks) after the office visit 3, 1, 4
• Refer to the condition as a "chest cold" rather than bronchitis to reduce patient expectation for antibiotics 1, 5
• Explain that patient satisfaction depends more on physician-patient communication than whether an antibiotic is prescribed 1
• Discuss the risks of unnecessary antibiotic use, including side effects and contribution to antibiotic resistance 1

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Chronic Bronchitis and Acute Exacerbations (AECB)

Define Chronic Bronchitis

• 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 3, 2

Baseline Management of Chronic Bronchitis

• Avoidance of respiratory irritants is the cornerstone of therapy, with 90% of patients experiencing resolution of cough after smoking cessation 2
• Short-acting β-agonists should be used to control bronchospasm and may reduce chronic cough 2
• Ipratropium bromide should be offered to improve cough 2
• Long-acting β-agonists combined with inhaled corticosteroids should be offered to control chronic cough 2

Identify Acute Exacerbations Requiring Antibiotic Therapy

Use antibiotics for AECB ONLY when the patient has at least 2 of the 3 cardinal symptoms (increased dyspnea, increased sputum production, increased sputum purulence) AND at least one risk factor: 6, 7

Risk factors include:

• Age ≥65 years 6
• FEV1 <50% of predicted value 6
• ≥4 exacerbations in 12 months 6
• One or more comorbidities 6

Antibiotic Selection for AECB

For moderate severity exacerbations:

• Newer macrolide, extended-spectrum cephalosporin, or doxycycline 6

For severe exacerbations:

• High-dose amoxicillin/clavulanate or a respiratory fluoroquinolone 6, 8

Additional Treatment for AECB

• Short-acting β-agonists or anticholinergic bronchodilators should be administered during acute exacerbations 2
• A short course (10-15 days) of systemic corticosteroids is effective for acute exacerbations 2, 7

Consider Roflumilast for Severe COPD with Chronic Bronchitis

• Roflumilast is indicated to reduce the risk of COPD exacerbations in patients with severe COPD associated with chronic bronchitis and a history of exacerbations 9
• This is for patients with FEV1 ≤50% predicted and recurrent exacerbations despite other therapies 3, 9
• Roflumilast is NOT a bronchodilator and is NOT indicated for relief of acute bronchospasm 9

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Common Pitfalls to Avoid

• Do not prescribe antibiotics based solely on presence of colored sputum 2
• Do not fail to distinguish between acute bronchitis and pneumonia 2
• Avoid overuse of expectorants and mucolytics which lack evidence of benefit 2
• Do not use theophylline for acute exacerbations of chronic bronchitis 2
• Do not prescribe antibiotics over the phone without examining the patient 7
• Consider congestive heart failure as a cause of worsening symptoms, especially in patients with known heart disease 7