Treatment of Bronchitis
For acute bronchitis, avoid antibiotics and focus on symptomatic management, as viruses cause over 90% of cases; for chronic bronchitis, use short-acting β-agonists and ipratropium bromide as first-line therapy, with inhaled corticosteroids reserved for severe airflow obstruction or frequent exacerbations. 1, 2
Acute Bronchitis Management
Primary Treatment Approach
Do not prescribe antibiotics for uncomplicated acute bronchitis, regardless of cough duration or sputum color. 1, 2, 3 Antibiotics reduce cough by only 0.5 days while exposing patients to adverse effects including allergic reactions, nausea, and Clostridium difficile infection. 4, 5
Purulent or colored sputum does NOT indicate bacterial infection—it results from inflammatory cells and sloughed epithelial cells, not bacteria. 3 This is a critical pitfall to avoid.
Symptomatic Relief Options
Short-acting β-agonists (albuterol) may reduce cough duration and severity in patients with bronchial hyperresponsiveness or wheezing. 1, 2, 3
Ipratropium bromide may improve cough in some patients with acute bronchitis. 1, 2
Dextromethorphan or codeine can provide short-term symptomatic relief for bothersome cough. 1, 2, 3
Treatments NOT Recommended
- Expectorants, mucolytics, antihistamines, oral NSAIDs, and corticosteroids lack evidence of benefit. 2, 3, 4
Rare Exceptions for Antibiotics
- Consider antibiotics only for patients ≥75 years with fever, or those with cardiac failure. 3 Otherwise, antibiotics should be avoided entirely.
Chronic Bronchitis Management
First-Line Bronchodilator Therapy
Short-acting β-agonists should be used to control bronchospasm, relieve dyspnea, and may reduce chronic cough. 6, 1, 2 This is Grade A recommendation with substantial net benefit. 6
Ipratropium bromide should be offered to improve cough—it reduces cough frequency, severity, and sputum volume. 6, 1, 2 This is also Grade A recommendation. 6
Advanced Therapy for Persistent Symptoms
Long-acting β-agonists combined with inhaled corticosteroids should be offered to control chronic cough and reduce exacerbation rates. 1, 2, 3
Inhaled corticosteroids are specifically recommended when FEV1 <50% predicted or with frequent exacerbations. 1, 3
Cornerstone Non-Pharmacologic Therapy
- Avoidance of respiratory irritants, particularly smoking cessation, is the cornerstone of therapy—90% of patients experience cough resolution after quitting smoking. 1, 2
Treatments NOT Recommended
Theophylline may improve cough but requires careful monitoring for complications and drug interactions, particularly in elderly patients. 6 It should be considered only after other options.
Long-term prophylactic antibiotics are not recommended for stable chronic bronchitis. 1
Expectorants lack proven benefit for chronic bronchitis cough. 6, 2
Acute Exacerbations of Chronic Bronchitis
Bronchodilator Management
- Administer short-acting β-agonists or anticholinergic bronchodilators during acute exacerbations. 6, 1, 2, 3 If no prompt response occurs, add the other agent after maximizing the first. 6
Corticosteroid Therapy
- A short course (10-15 days) of systemic corticosteroids is effective for acute exacerbations. 1, 3 An 8-week course shows no advantage over 2 weeks. 6
Antibiotic Therapy
Antibiotics are recommended for acute exacerbations, particularly for patients with severe exacerbations or baseline FEV1 <50%. 1, 2 This contrasts sharply with acute bronchitis where antibiotics are contraindicated.
Appropriate choices include newer macrolides, extended-spectrum cephalosporins, or doxycycline for moderate severity; high-dose amoxicillin/clavulanate or respiratory fluoroquinolones for severe exacerbations. 7
Treatments NOT Recommended
Theophylline should NOT be used for acute exacerbations (Grade D recommendation). 6, 1, 2, 3
Mucokinetic agents are not useful during acute exacerbations. 6
Critical Pitfalls to Avoid
Never prescribe antibiotics based solely on colored sputum in acute bronchitis. 2, 3
Always rule out pneumonia before diagnosing bronchitis by assessing for tachycardia, tachypnea, fever >100.4°F, and abnormal lung findings. 2, 3, 5
Set realistic expectations: acute bronchitis cough typically lasts 2-3 weeks. 3, 4, 5 Patient satisfaction depends more on communication quality than receiving antibiotics. 3
Consider calling acute bronchitis a "chest cold" to reduce patient expectations for antibiotics. 3, 5