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 may 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: Antibiotics ARE Indicated
Antibiotics are recommended for acute exacerbations of chronic bronchitis, particularly for patients with severe exacerbations and those with more severe airflow obstruction at baseline. 2, 6
Identifying Patients Who Need Antibiotics
Use the Anthonisen triad criteria to guide antibiotic decisions. Antibiotics should be given when at least 2 of 3 cardinal symptoms are present: 1, 7
- Increased dyspnea
- Increased sputum volume
- Increased sputum purulence
Additional risk factors that warrant antibiotic treatment include: 7
- Age ≥65 years
- FEV1 <50% predicted
- ≥4 exacerbations in 12 months
- One or more comorbidities
Antibiotic Selection Based on Severity
For moderate exacerbations (infrequent exacerbations, FEV1 ≥35%): 1
- First-line: Amoxicillin, first-generation cephalosporins
- Alternatives: Macrolides (azithromycin, clarithromycin), pristinamycin, doxycycline (especially for β-lactam allergy)
For severe exacerbations (frequent exacerbations ≥4/year, FEV1 <35%): 1
- Second-line antibiotics: Extended-spectrum cephalosporins, high-dose amoxicillin/clavulanate, or respiratory fluoroquinolones 7
The FDA label for azithromycin shows clinical cure rates of 85% at Day 21-24 for acute exacerbations of chronic bronchitis, with 91% cure for S. pneumoniae and 86% for H. influenzae 8
Additional Management 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 Diagnostic Considerations
Rule out pneumonia before diagnosing bronchitis by assessing for: 2, 3
- Tachycardia
- Tachypnea
- Fever
- Abnormal chest examination findings (asymmetric lung sounds)
Chest radiography is not routinely indicated in healthy, nonelderly adults without vital sign abnormalities or asymmetric lung sounds 2
Purulent (colored/green) sputum does NOT indicate bacterial infection—it results from inflammatory cells or sloughed epithelial cells, not bacteria 3, 4
Common Pitfalls to Avoid
Do not prescribe antibiotics based solely on colored sputum, as this does not differentiate bacterial from viral infection 3, 4
Do not use cotrimoxazole (trimethoprim-sulfamethoxazole) due to increasing resistance and poor benefit/risk ratio 1, 9
Do not overlook underlying conditions that may mimic or complicate bronchitis, including asthma, COPD exacerbations, congestive heart failure, and diabetes 3, 10
Do not rely on physical examination alone to assess airflow obstruction in chronic bronchitis—routine pulmonary function testing is important in smoking patients 10
Recognize congestive heart failure as a cause of progressive dyspnea, cough, and sputum production, especially in patients with known heart disease and cardiomegaly 10