Treatment of Bronchitis
Critical Distinction: Acute vs. Chronic Bronchitis
The treatment of bronchitis depends entirely on whether you are dealing with acute bronchitis (viral illness lasting <3 weeks) or chronic bronchitis (productive cough for ≥3 months/year for ≥2 consecutive years), as these require fundamentally different management approaches. 1, 2
Acute Bronchitis Management
First-Line Treatment
For acute bronchitis in immunocompetent adults, use albuterol (short-acting β-agonist) as first-line therapy to reduce cough duration and severity, NOT antibiotics. 1
- Albuterol reduces cough presence by approximately 50% at 7 days and should be offered to patients with wheezing or bothersome cough 1
- Consider β2-agonist bronchodilators specifically in patients with wheezing accompanying the cough 2
What NOT to Do
Do NOT routinely prescribe antibiotics for uncomplicated acute bronchitis - they reduce cough by only 0.5 days while exposing patients to adverse effects including allergic reactions, nausea, and Clostridium difficile infection 3, 1, 2, 4, 5
- Viruses cause >90% of acute bronchitis cases 4
- Purulent sputum does NOT indicate bacterial infection and should not trigger antibiotic use 2, 4
- Antibiotics are only indicated if pertussis is suspected or if bacterial superinfection develops 3, 2, 4
Symptomatic Management
- Antitussives (dextromethorphan or codeine) provide modest short-term relief and can be offered for symptomatic control 1, 2
- Low-cost interventions like eliminating environmental triggers and vaporized air treatments are reasonable 1
- Do NOT use routine chest physiotherapy, expectorants, or mucokinetic agents - they lack proven benefit 2
Diagnostic Approach
- No routine investigations needed - do not order chest x-rays, sputum cultures, viral PCR, or inflammatory markers for uncomplicated cases 2
- Rule out pneumonia if patient has heart rate >100 bpm, respiratory rate >24 breaths/min, temperature >38°C, or focal chest findings 2
- Consider pertussis if cough persists >2 weeks with paroxysmal features, whooping, or post-tussive emesis 3, 5
Patient Education
Tell patients cough typically lasts 10-14 days after the visit - setting realistic expectations reduces unnecessary follow-up and antibiotic requests 1
Chronic Bronchitis Management
Bronchodilator Therapy (Cornerstone of Treatment)
For stable chronic bronchitis, use short-acting β-agonists to control bronchospasm and relieve dyspnea, which may also reduce chronic cough. 3, 1
Ipratropium bromide should be offered to improve cough - studies show patients cough fewer times with less severity and decreased sputum volume 3, 1
- Tiotropium bromide (long-acting anticholinergic) is FDA-approved for long-term maintenance treatment of bronchospasm in COPD including chronic bronchitis 6
- Theophylline can be considered for chronic cough control but requires careful monitoring for complications due to side effects and drug interactions 3, 1
Corticosteroids
- Do NOT use corticosteroids routinely in stable chronic bronchitis 3
- Combined long-acting β-agonist plus inhaled corticosteroid reduces exacerbation rates and cough in patients with severe airflow obstruction (FEV1 <50%) 3
What NOT to Do
- Do NOT use routine chest physiotherapy or postural drainage - clinical benefits are unproven 3
- Do NOT use prophylactic antibiotics in stable patients 3
- Do NOT use expectorants - beneficial effects have not been proven 3
Acute Exacerbation of Chronic Bronchitis
When to Treat with Antibiotics
Reserve antibiotics for patients with ≥1 key symptom (increased dyspnea, sputum production, or sputum purulence) PLUS ≥1 risk factor: 7
Risk factors:
Antibiotic Selection
For moderate exacerbations: newer macrolide, extended-spectrum cephalosporin, or doxycycline 7
For severe exacerbations: high-dose amoxicillin/clavulanate or respiratory fluoroquinolone 7, 8
Bronchodilator Therapy During Exacerbations
Use short-acting β-agonists or anticholinergic bronchodilators; if no prompt response, add the other agent after maximizing the first 3
- Do NOT use theophylline for acute exacerbations 3
Corticosteroids
Oral corticosteroids (or IV in severe cases) are useful for acute exacerbations, though effects on cough specifically have not been systematically evaluated 3
Common Pitfalls to Avoid
- Prescribing antibiotics for uncomplicated acute bronchitis despite overwhelming evidence of lack of benefit 3, 1, 2
- Failing to distinguish acute bronchitis from chronic bronchitis exacerbations - they require different approaches 1, 2
- Not providing realistic expectations about 2-3 week cough duration, leading to unnecessary follow-up 1, 4, 5
- Overlooking bronchodilator therapy which has demonstrated clear benefit in both acute and chronic bronchitis 1, 2
- Using purulent sputum as justification for antibiotics - this does not indicate bacterial infection 2, 4