Characteristic Breath Sounds and Treatment of Bronchitis
In acute bronchitis, breath sounds typically include wheezes and crackles (rales) on auscultation, but antibiotics should NOT be prescribed as this is predominantly a viral illness that resolves spontaneously in 2-3 weeks. 1, 2
Distinguishing Bronchitis from Pneumonia
Before diagnosing acute bronchitis, you must rule out pneumonia by assessing these four clinical criteria 1:
- Heart rate >100 beats/min
- Respiratory rate >24 breaths/min
- Oral temperature >38°C
- Chest examination findings of focal consolidation, egophony, or fremitus
The absence of ALL four findings reduces the likelihood of pneumonia sufficiently to eliminate the need for chest radiography. 1 Purulent or green sputum does NOT indicate bacterial infection and should not guide antibiotic decisions 1.
Physical Examination Findings in Bronchitis
Acute Bronchitis
Characteristic findings include 1, 2, 3:
- Wheezes and crackles (rales) on lung auscultation
- Cough (productive or nonproductive)
- Rhinorrhea and mild constitutional symptoms
- Normal vital signs (if abnormal, consider pneumonia)
Chronic Bronchitis
Breath sounds may reveal 4:
- Abnormally loud inspiratory sounds heard at the mouth, reflecting turbulent airflow from narrowed central airways
- Wheezes indicating bronchial narrowing
- The intensity of inspiratory sounds inversely correlates with FEV1 and peak expiratory flow
Treatment of Acute Bronchitis
What NOT to Do
Antibiotics are NOT indicated for uncomplicated acute bronchitis and should not be offered. 1, 2 They provide minimal benefit (reducing cough by only half a day) while causing adverse effects including allergic reactions, nausea, vomiting, and Clostridium difficile infection 1, 3.
Recommended Symptomatic Treatment
Short-acting β-agonists (albuterol) may reduce cough duration and severity in patients with evidence of bronchial hyperresponsiveness or wheezing 1, 2. However, they do not benefit patients without underlying asthma or chronic lung disease 1.
Dextromethorphan or codeine are recommended for short-term symptomatic relief of bothersome cough 1, 2.
Ipratropium bromide may improve cough in some patients 2.
Patient Communication Strategy
Set aside time to explain why antibiotics are not needed, emphasizing 1:
- The cough typically lasts 2-3 weeks regardless of treatment
- Over 90% of cases are viral
- Antibiotics cause harm without benefit
Treatment of Chronic Bronchitis
Primary Intervention
Avoidance of respiratory irritants (especially smoking cessation) is the cornerstone of therapy, with 90% of patients experiencing resolution of cough after quitting smoking. 1, 2
Pharmacologic Management for Stable Disease
Short-acting β-agonists should be used to control bronchospasm and may reduce chronic cough 1, 2.
Ipratropium bromide should be offered to improve cough 1, 2.
Long-acting β-agonists combined with inhaled corticosteroids should be offered to control chronic cough in patients with persistent symptoms 1, 2.
Treatment of Acute Exacerbations
Short-acting β-agonists or anticholinergic bronchodilators should be administered during acute exacerbations 2.
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, 5. Azithromycin (500 mg once daily for 3 days) demonstrates clinical cure rates of 85% at Day 21-24 5.
A short course (10-15 days) of systemic corticosteroids is effective for acute exacerbations 2.
Common Pitfalls to Avoid
- Do not prescribe antibiotics based solely on colored (green or yellow) sputum 1
- Do not use expectorants or mucolytics - they lack evidence of benefit 1, 2
- Do not use theophylline for acute exacerbations of chronic bronchitis 1, 2
- Do not overlook underlying conditions (asthma, COPD, cardiac failure) that may be exacerbated 2
- Do not assume silent inspiration with severe expiratory obstruction is bronchitis - this suggests primary emphysema 4