Treatment of Bronchitis
Acute Bronchitis: Antibiotics Are Not Indicated
Antibiotics should not be prescribed for uncomplicated acute bronchitis, as viruses cause more than 90% of cases and antibiotics provide no meaningful clinical benefit. 1, 2, 3, 4, 5
Symptomatic Management for Acute Bronchitis
Short-acting β-agonists (albuterol) should be offered to patients with evidence of bronchial hyperresponsiveness such as wheezing or bothersome cough, as they may reduce cough duration and severity 2, 3, 6
Ipratropium bromide may improve cough in some patients with acute bronchitis 2, 3, 6
Dextromethorphan or codeine are recommended for short-term symptomatic relief of bothersome cough, though evidence shows they work better for chronic cough (>3 weeks) than early acute cough 1, 2, 3, 6
Expectorants, mucolytics, antihistamines, and corticosteroids should not be used as they lack evidence of benefit 3, 5
Patient Communication Strategy
Inform patients that cough typically lasts 10-14 days after the office visit, setting realistic expectations 1, 3
Refer to the illness as a "chest cold" rather than bronchitis, as this terminology reduces patient expectations for antibiotics 1, 3
Explain that unnecessary antibiotic use increases risk of antibiotic-resistant infections, causes side effects (gastrointestinal symptoms, rash), and rare serious reactions like anaphylaxis 1, 3
Patient satisfaction depends on quality of communication and time spent explaining the illness, not on receiving antibiotics 1, 3
Rare Exceptions for Antibiotic Use in Acute Bronchitis
Consider antibiotics only for patients aged ≥75 years with fever or patients with cardiac failure 3
Antibiotics are indicated if pertussis is suspected to reduce transmission 4
Chronic Bronchitis: Avoidance of Irritants is Cornerstone
Smoking cessation and avoidance of all respiratory irritants is the most effective treatment, with 90% of patients experiencing resolution of cough after quitting smoking. 1, 2, 6
Pharmacologic Management for Stable Chronic Bronchitis
Short-acting β-agonists should be used to control bronchospasm and may reduce chronic cough 1, 2, 3, 6
Ipratropium bromide should be offered to improve cough 1, 2, 3, 6
Long-acting β-agonists combined with inhaled corticosteroids should be offered to control chronic cough 1, 2, 3, 6
Theophylline should be considered to control chronic cough, though careful monitoring for complications is necessary 1
Inhaled corticosteroids should be offered to patients with FEV1 <50% predicted or those with frequent exacerbations 1, 3, 6
Treatments NOT Recommended for Stable Chronic Bronchitis
Oral corticosteroids are not indicated for stable disease 1
Postural drainage and chest physiotherapy have not been proven beneficial 1
Acute Exacerbations of Chronic Bronchitis: Identify High-Risk Patients
When to Treat with Antibiotics
Antibiotics should be reserved for patients with at least 2 of the 3 Anthonisen criteria (increased dyspnea, increased sputum volume, increased sputum purulence) AND at least one risk factor. 1, 7
Risk factors include: 7
- Age ≥65 years
- FEV1 <50% predicted
- ≥4 exacerbations in 12 months
- One or more comorbidities
Treatment Algorithm by Severity
For patients with FEV1 <35% and hypoxemia at rest (chronic respiratory insufficiency): Immediate antibiotic therapy is recommended 1
For patients with FEV1 35-80% (obstructive chronic bronchitis): Immediate antibiotic therapy only if at least 2 of 3 Anthonisen criteria are present 1
For simple chronic bronchitis (FEV1 >80%): Immediate antibiotics are not recommended even with fever; reassess at 2-3 days and prescribe antibiotics only if fever >38°C persists beyond 3 days 1
Antibiotic Selection
First-line antibiotics (for infrequent exacerbations <3/year, FEV1 ≥35%): 1
- Amoxicillin (reference standard)
- First-generation cephalosporins
- Macrolides (particularly for β-lactam allergy)
Second-line antibiotics (for frequent exacerbations ≥4/year or baseline FEV1 <35%): 1
- Amoxicillin/clavulanate
- Extended-spectrum cephalosporins
- Respiratory fluoroquinolones
- Newer macrolides (azithromycin 500mg daily for 3 days showed 85% clinical cure rate) 8, 7
Additional Therapies for Acute Exacerbations
Short-acting β-agonists or anticholinergic bronchodilators should be administered; if no prompt response, add the other agent after maximizing the first 1, 2, 3, 6
Systemic corticosteroids (10-15 day course) are effective for acute exacerbations 2, 6
Theophylline should NOT be used for acute exacerbations 1, 3, 6
Expectorants, postural drainage, and chest physiotherapy are not recommended 1
Critical Pitfalls to Avoid
Do not prescribe antibiotics based solely on colored/purulent sputum, as this results from inflammatory cells and sloughed epithelial cells, not bacterial infection 3, 4
Rule out pneumonia before diagnosing bronchitis by assessing for tachycardia, tachypnea, fever, and asymmetric lung findings 2, 3
Do not use chest radiography routinely in healthy, nonelderly adults without vital sign abnormalities or asymmetric lung sounds 2
Recognize that increasing dyspnea alone is insufficient to diagnose infectious exacerbation, as COPD patients have many days of increased breathlessness without infection 9
Consider congestive heart failure as a cause of worsening symptoms, especially in patients with known heart disease and cardiomegaly 9