What is the initial treatment for acute bronchitis?

Initial Treatment for Acute Bronchitis

Do not prescribe antibiotics or routine medications for immunocompetent adults presenting with acute bronchitis—supportive care and patient education are the cornerstones of initial management. 1, 2

Diagnostic Approach

The initial evaluation should focus on ruling out pneumonia before diagnosing uncomplicated acute bronchitis 1, 2:

• Pneumonia is unlikely if the patient lacks: heart rate >100 beats/min, respiratory rate >24 breaths/min, oral temperature >38°C, or focal chest examination findings (rales, egophony, tactile fremitus) 2, 3
• Chest radiography is not indicated in healthy, nonelderly adults without vital sign abnormalities or asymmetrical lung sounds 1, 4
• No routine investigations are recommended—avoid ordering chest x-ray, spirometry, peak flow measurement, sputum cultures, viral PCR, or inflammatory markers (CRP, procalcitonin) 1, 3

What NOT to Prescribe Initially

The CHEST Expert Panel and American Academy of Family Physicians are clear about avoiding routine medications 1, 2:

• No antibiotics: They reduce cough duration by only approximately 0.5 days while exposing patients to adverse effects including allergic reactions, nausea, vomiting, and Clostridium difficile infection 2, 5
• No β2-agonist bronchodilators routinely—most patients with acute bronchitis do not benefit 2, 3
• No inhaled anticholinergics, corticosteroids, or NSAIDs at anti-inflammatory doses 1, 2
• Purulent sputum does NOT indicate bacterial infection and is not an indication for antibiotics 2, 3

Appropriate Initial Management

Patient Education (Critical for Satisfaction)

Patient satisfaction depends more on physician-patient communication than antibiotic prescription 1, 2:

• Inform patients that cough typically lasts 10-14 days after the visit 2, 3
• Refer to the condition as a "chest cold" rather than bronchitis to reduce antibiotic expectations 2, 3
• Explain the viral etiology (89-95% of cases) and the risks of unnecessary antibiotic use 2, 6

Symptomatic Treatment Options

When symptoms warrant intervention 2, 4:

• Antitussive agents (codeine or dextromethorphan) may provide modest short-term relief for bothersome cough 2, 4
• β2-agonists may be considered only in select patients with wheezing accompanying the cough 2, 3
• Low-cost, low-risk measures: elimination of environmental cough triggers and vaporized air treatments 2

When to Reassess or Modify Treatment

Pertussis Exception

If pertussis is confirmed or suspected (cough >2 weeks with paroxysmal features, whooping, post-tussive emesis, or known exposure) 2, 5:

• Prescribe a macrolide antibiotic (such as erythromycin or azithromycin) 2
• Isolate patients for 5 days from treatment start 2
• Early treatment diminishes coughing paroxysms and prevents disease spread 2

Worsening or Persistent Symptoms

If acute bronchitis persists or worsens, advise reassessment and consider 1, 3:

• Targeted investigations: chest x-ray, sputum culture, peak flow measurements, complete blood count, inflammatory markers 1, 3
• Antibiotic therapy only if bacterial superinfection is likely 1, 3
• Consider alternative diagnoses: 65% of patients with recurrent "acute bronchitis" may have underlying mild asthma, cough-variant asthma, COPD exacerbation, or bronchiectasis 1, 3

Common Pitfalls to Avoid

• Prescribing antibiotics based on colored sputum alone—this does not indicate bacterial infection 2, 3
• Failing to educate patients about the expected duration of cough, leading to dissatisfaction and antibiotic-seeking behavior 1, 2
• Not considering underlying asthma in patients with persistent or recurrent episodes 1, 3
• Ordering unnecessary tests in uncomplicated cases, which do not change management 1, 3