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 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, typically viral in origin (89-95% of cases). 1, 3, 4
Chronic bronchitis is defined as cough with sputum production on most days for at least 3 months per year for 2 consecutive years, primarily caused by cigarette smoke exposure. 5, 1
Rule Out Pneumonia First
Before diagnosing uncomplicated bronchitis, assess for pneumonia by checking for: 1, 2, 3
- Heart rate >100 beats/min
- Respiratory rate >24 breaths/min
- Oral temperature >38°C
- Abnormal chest examination findings (rales, egophony, tactile fremitus)
If these findings are absent, pneumonia is unlikely and chest radiography is not needed. 2, 3
Management of Acute Bronchitis
Do NOT Use Routinely:
- Antibiotics - Not indicated regardless of cough duration or sputum color/purulence 1, 2, 3, 6, 7
- β2-agonist bronchodilators - Should not be routinely prescribed 2, 3
- Corticosteroids - Not recommended for uncomplicated cases 3, 7
- Expectorants and mucolytics - Lack evidence of benefit 1
Consider Using:
- Short-acting β-agonists (albuterol) - Only in select patients with wheezing or evidence of bronchial hyperresponsiveness 1, 2, 3
- Ipratropium bromide - May improve cough in some patients 1
- Dextromethorphan or codeine - For short-term symptomatic relief of bothersome cough 1, 3
Exception for Pertussis:
If pertussis is confirmed or suspected, prescribe a macrolide antibiotic (erythromycin) and isolate the patient for 5 days from treatment start. 3
Management of Chronic Bronchitis
First-Line Approach:
Smoking cessation is the cornerstone of therapy—90% of patients experience resolution of cough after quitting. 1
Pharmacologic Management:
- Short-acting β-agonists - Use to control bronchospasm and reduce chronic cough 1
- Ipratropium bromide - Offer to improve cough 1
- Long-acting β-agonists + inhaled corticosteroids - Offer combination therapy to control chronic cough 1
Management of Acute Exacerbations of Chronic Bronchitis (AECB)
Identify Patients Who Need Antibiotics:
Prescribe antibiotics only for patients with at least 2 of these 3 cardinal symptoms: 4, 8, 9
- Increased dyspnea
- Increased sputum production
- Increased sputum purulence
AND at least 1 risk factor: 8
- Age ≥65 years
- FEV1 <50% predicted
- ≥4 exacerbations in 12 months
- Comorbidities present
Treatment for AECB:
- Short-acting β-agonists or anticholinergic bronchodilators - Administer during acute exacerbations 1
- Systemic corticosteroids - Give short course (10-15 days) for acute exacerbations 1
- Antibiotics - Recommended for patients meeting above criteria, particularly those with severe exacerbations and baseline airflow obstruction 1, 10, 4, 8
Antibiotic Selection:
- Moderate severity: Newer macrolide (azithromycin), extended-spectrum cephalosporin, or doxycycline 8
- Severe exacerbation: High-dose amoxicillin/clavulanate or respiratory fluoroquinolone 4, 8
Patient Communication Strategies
Refer to acute bronchitis as a "chest cold" rather than bronchitis to reduce antibiotic expectations. 3, 7
Inform patients that cough typically lasts 10-14 days after the visit, and may persist up to 3 weeks. 3, 7
Explain that patient satisfaction depends more on physician-patient communication than whether an antibiotic is prescribed. 3
Common Pitfalls to Avoid
- Do not prescribe antibiotics based solely on colored or purulent sputum - This does not indicate bacterial infection 1, 2, 3, 6
- Do not use theophylline for acute exacerbations of chronic bronchitis 1
- Do not fail to consider underlying conditions that may be exacerbated (asthma, COPD, heart failure, diabetes) 1
- Do not order routine chest x-rays, sputum cultures, or inflammatory markers for uncomplicated acute bronchitis 2