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 for 2 consecutive years. 1, 4 This is typically caused by prolonged exposure to cigarette smoke and other pulmonary irritants. 4

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

Management of Acute Bronchitis

Antibiotics: When NOT to Use Them

• Do not prescribe antibiotics routinely for acute bronchitis in immunocompetent adults 1, 2, 3
• Purulent or colored sputum does NOT indicate bacterial infection and is not an indication for antibiotics 2, 3, 5
• Antibiotics may be considered only if symptoms significantly worsen suggesting bacterial superinfection, or in high-risk patients (age ≥65 years, immunocompromised) 2, 3

Exception: Pertussis

For confirmed or suspected pertussis, 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

Symptomatic Treatment

• β2-agonist bronchodilators (like albuterol) should not be routinely prescribed, but may be considered in select patients with wheezing accompanying the cough 1, 2, 3
• Antitussive agents (dextromethorphan or codeine) may provide short-term symptomatic relief for bothersome cough 1, 3
• Ipratropium bromide may improve cough in some patients 1
• Do NOT use: NSAIDs at anti-inflammatory doses, systemic corticosteroids, expectorants, or mucolytics—these lack evidence of benefit 1, 3

Patient Education

• 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

Prevention and Non-Pharmacologic Management

• Smoking cessation is the cornerstone of therapy—90% of patients experience resolution of cough after quitting 1
• Avoidance of respiratory irritants is essential 1
• Provide appropriate immunizations against influenza and pneumococcus 7

Pharmacologic Management

• 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

Management of Acute Exacerbations of Chronic Bronchitis (AECB)

When to Treat with Antibiotics

Antibiotics are recommended for AECB when patients have at least TWO of the following three cardinal symptoms: 7

• Increased dyspnea
• Increased sputum production
• Increased sputum purulence

AND at least ONE risk factor: 8

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

Antibiotic Selection

For moderate severity exacerbations: newer macrolide (azithromycin), extended-spectrum cephalosporin, or doxycycline 8

For severe exacerbations: high-dose amoxicillin/clavulanate or a respiratory fluoroquinolone 8

The most common bacterial pathogens are Haemophilus influenzae, Moraxella catarrhalis, and Streptococcus pneumoniae. 4, 9

Additional Therapies for AECB

• Short-acting β-agonists or anticholinergic bronchodilators should be administered during acute exacerbations 1
• A short course (10-15 days) of systemic corticosteroids is effective for acute exacerbations 1
• Provide supportive care including removal of irritants, oxygen if needed, hydration, and chest physical therapy 8

Common Pitfalls to Avoid

• Do not prescribe antibiotics based solely on colored sputum 1, 2, 3
• Do not fail to distinguish between acute bronchitis and pneumonia—check vital signs and perform chest examination 1, 2
• Do not overuse expectorants and mucolytics which lack evidence of benefit 1
• Do not use theophylline for acute exacerbations of chronic bronchitis 1
• Do not underestimate the degree of airflow obstruction in smoking patients—routine pulmonary function testing is important 7
• Consider congestive heart failure as a cause of worsening symptoms, especially in patients with known heart disease 7