What is the treatment for acute bronchitis with a dry cough?

Treatment of Acute Bronchitis with Dry Cough

For acute bronchitis with dry cough, avoid antibiotics and bronchodilators in most cases; instead, use short-term antitussive therapy with codeine or dextromethorphan for symptomatic relief while educating patients that cough typically lasts 2-3 weeks. 1, 2

Key Diagnostic Considerations

Before treating as acute bronchitis, rule out pneumonia by checking for:

• Tachycardia (heart rate >100 beats/min) 1
• Tachypnea (respiratory rate >24 breaths/min) 1
• Fever (oral temperature >38°C) 1
• Abnormal chest examination findings (rales, egophony, or tactile fremitus) 1

If pertussis is suspected (cough >2 weeks with paroxysmal features, whooping, or post-tussive vomiting), this requires specific antibiotic treatment. 3

What NOT to Use

Antibiotics should not be prescribed for uncomplicated acute bronchitis, as they reduce cough duration by only approximately 0.5 days while exposing patients to adverse effects including allergic reactions, nausea, vomiting, and Clostridium difficile infection. 1, 2, 3 Respiratory viruses cause 89-95% of acute bronchitis cases, making antibiotics ineffective. 1, 4

β2-agonist bronchodilators should not be routinely used for dry cough in acute bronchitis, as they provide no benefit in patients without wheezing or airflow obstruction. 5, 1 The American College of Chest Physicians gives this a Grade D recommendation based on fair quality evidence showing no benefit. 5

Avoid systemic corticosteroids and NSAIDs at anti-inflammatory doses, as they are not recommended for acute bronchitis. 1

Recommended Symptomatic Treatment

For dry cough relief, use antitussive agents:

• Codeine or dextromethorphan provide modest effects on cough severity and duration 1, 6
• These central cough suppressants are recommended for short-term symptomatic relief 5, 7
• Codeine helps patients sleep when cough is disturbing rest 6, 8

Low-cost supportive measures:

• Eliminate environmental cough triggers 1
• Consider vaporized air treatments 1

The Pertussis Exception

If pertussis is confirmed or suspected, prescribe a macrolide antibiotic (such as erythromycin) immediately. 5, 1 This is the only bacterial cause requiring antibiotics in acute bronchitis. 5

• Isolate patients for 5 days from treatment start 5, 1
• Early treatment within the first few weeks diminishes coughing paroxysms and prevents disease spread 5, 1
• This carries Grade A evidence with substantial net benefit 5

Critical Patient Education

Set realistic expectations about cough duration:

• Inform patients that cough typically lasts 10-14 days after the office visit, though it may persist for 2-3 weeks 1, 2, 3
• Refer to the condition as a "chest cold" rather than "bronchitis" to reduce antibiotic expectations 1, 2, 3

Address antibiotic expectations directly:

• When patients expect antibiotics, explain why they are not indicated and discuss potential harms of unnecessary use 1
• Patient satisfaction depends more on physician-patient communication than whether antibiotics are prescribed 1

Common Pitfalls to Avoid

Do not prescribe antibiotics based on sputum color. The presence of purulent or green sputum does not signify bacterial infection and is not an indication for antibiotics. 1, 4 This is a viral inflammatory response, not bacterial.

Do not use bronchodilators unless wheezing is present. Only in select adult patients with wheezing accompanying the cough may β2-agonist bronchodilators be useful (Grade C recommendation). 5, 7

Avoid cough and cold preparations in children under 6 years. The FDA recommends against their use in this age group. 4