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 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 combined with inhaled corticosteroids - Offer to control chronic cough 1

Management of Acute Exacerbations of Chronic Bronchitis (AECB)

Identify Patients Who Need Antibiotics:

Reserve antibiotics for patients with at least 2 of these 3 cardinal symptoms: 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
• One or more comorbidities

Treatment for AECB:

• Short-acting β-agonists or anticholinergic bronchodilators - Administer during acute exacerbations 1
• Systemic corticosteroids - Short course (10-15 days) is effective 1
• Antibiotics - Recommended for patients meeting above criteria 1, 10, 8

Antibiotic Selection:

For moderate severity: Newer macrolide (azithromycin 500mg daily for 3 days), extended-spectrum cephalosporin, or doxycycline 10, 8

For severe exacerbations or high-risk patients (age >65, FEV1 <50%, recurrent exacerbations): 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, sometimes 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
• 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

When to Reassess

If symptoms persist or worsen, consider: 2

• Chest x-ray
• Sputum for microbial culture
• Peak expiratory flow measurements
• Complete blood count and inflammatory markers

Note: Approximately 65% of patients with recurrent acute bronchitis may have underlying mild asthma or cough-variant asthma. 2