What is the initial approach to managing bronchitis?

Initial Management of Bronchitis

For acute bronchitis in otherwise healthy adults, do not prescribe antibiotics—they provide minimal benefit (reducing cough by only 0.5 days) while exposing patients to unnecessary adverse effects. 1, 2, 3

Distinguish Between Acute and Chronic Bronchitis

Acute bronchitis is self-limited inflammation of large airways with cough lasting up to 3-6 weeks, often with mild constitutional symptoms. 1, 4 Most cases (89-95%) are viral in origin. 3

Chronic bronchitis is defined as cough with sputum production on most days for at least 3 months per year over 2 consecutive years. 4, 1

Initial Assessment: Rule Out Other Conditions

Before diagnosing uncomplicated acute bronchitis, assess for:

• Heart rate >100 beats/min 2, 3
• Respiratory rate >24 breaths/min 2, 3
• Oral temperature >38°C 2, 3
• Focal chest examination findings (rales, egophony, tactile fremitus) 2, 3

If these findings are absent, pneumonia is unlikely and chest radiography is not needed. 2, 3 Do not order routine laboratory tests, sputum cultures, viral PCR, or inflammatory markers for uncomplicated acute bronchitis. 2

Critical Pitfall to Avoid

The presence of purulent or colored sputum does NOT indicate bacterial infection and is NOT an indication for antibiotics. 2, 3, 5 This is one of the most common errors in bronchitis management.

Management of Acute Bronchitis

What NOT to Do

• Do not routinely prescribe antibiotics 1, 2, 3
• Do not routinely use β2-agonist bronchodilators 2, 3
• Do not use NSAIDs at anti-inflammatory doses 3
• Do not use systemic corticosteroids 3
• Do not use expectorants or mucolytics (lack evidence of benefit) 1

What TO Do

Symptomatic management:

• Dextromethorphan or codeine may provide short-term relief of bothersome cough 1, 3
• Consider β2-agonist bronchodilators (like albuterol) only in select patients with wheezing accompanying the cough 1, 2, 3
• Ipratropium bromide may improve cough in some patients 1
• Eliminate environmental cough triggers and consider vaporized air treatments 3

The Pertussis Exception

If pertussis is confirmed or suspected, prescribe a macrolide antibiotic (such as erythromycin) and isolate the patient for 5 days from treatment start. 3 Early treatment within the first few weeks diminishes coughing paroxysms and prevents disease spread. 3

Patient Education Strategy

• Inform patients that cough typically lasts 10-14 days after the office visit 3
• Refer to the condition as a "chest cold" rather than bronchitis to reduce antibiotic expectations 3, 6
• Explain that patient satisfaction depends more on physician-patient communication than whether an antibiotic is prescribed 3
• Discuss risks of unnecessary antibiotic use, including side effects and contribution to antibiotic resistance 3

Management of Chronic Bronchitis

Smoking cessation is the cornerstone of therapy—90% of patients experience resolution of cough after quitting. 1

Maintenance Therapy

• Short-acting β-agonists should be used to control bronchospasm and may reduce chronic cough 1
• Ipratropium bromide should be offered to improve cough 1
• Long-acting β-agonists combined with inhaled corticosteroids should be offered to control chronic cough 1

Immunizations

Institute appropriate immunizations against influenza and pneumococcus. 7

Management of Acute Exacerbations of Chronic Bronchitis (AECB)

When to Treat with Antibiotics

Reserve antibiotics for patients with at least 2 of the 3 cardinal symptoms:

1. Increased dyspnea
2. Increased sputum production
3. Increased sputum purulence 7

AND at least one risk factor:

• Age ≥65 years 8
• FEV1 <50% predicted 8
• ≥4 exacerbations in 12 months 8
• One or more comorbidities 8

Treatment Regimen for AECB

Bronchodilators:

• Short-acting β-agonists or anticholinergic bronchodilators should be administered during acute exacerbations 1

Corticosteroids:

• A short course (10-15 days) of systemic corticosteroids is effective for acute exacerbations 1
• When airflow obstruction is moderately severe or more pronounced, AECB should usually be treated with oral steroids 7

Antibiotics (when indicated):

• For moderate severity exacerbations: newer macrolide, extended-spectrum cephalosporin, or doxycycline 8
• For severe exacerbations: high-dose amoxicillin/clavulanate or a respiratory fluoroquinolone 8
• Azithromycin (500 mg once daily for 3 days) has demonstrated 85% clinical cure rate at Day 21-24 for AECB 9

Common Pathogens in AECB

The most common bacterial pathogens include Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. 4, 10, 8 Pseudomonas aeruginosa is becoming more prevalent in patients with severe underlying disease. 10

Special Considerations

If symptoms persist or worsen, consider reassessment with targeted investigations such as chest x-ray, sputum culture, peak expiratory flow measurements, complete blood count, and inflammatory markers. 2

Approximately 65% of patients with recurrent acute bronchitis may have underlying mild asthma. 2 Other potential diagnoses include cough-variant asthma, COPD, or bronchiectasis. 2

Consider antiviral agents for influenza-related bronchitis if within 48 hours of symptom onset. 3

Patients with comorbidities like COPD, heart failure, or immunosuppression may require different management approaches. 3 Recognize that in some patients, progressive shortness of breath, cough, and increasing sputum production may be due to congestive heart failure rather than infection. 7