What are the diagnosis and treatment options for bronchitis?

Diagnosis and Treatment of Bronchitis

Diagnosis of Acute Bronchitis

Acute bronchitis is a clinical diagnosis based on acute cough with or without sputum production lasting up to 3 weeks, and routine diagnostic testing should not be performed. 1, 2

Key Diagnostic Criteria

• Rule out pneumonia first by assessing for four critical findings: heart rate >100 beats/min, respiratory rate >24 breaths/min, oral temperature >38°C, and chest examination findings of focal consolidation, egophony, or fremitus 3, 1
• If all four findings are absent, chest radiography can be safely avoided 3, 2
• If any of these findings are present, obtain a chest radiograph to evaluate for pneumonia 2

Important Diagnostic Pitfalls

• Purulent sputum does NOT indicate bacterial infection and should not be used as a criterion for antibiotic therapy 1, 2
• The presence or color of sputum (including green sputum) does not reliably differentiate between bacterial and viral infections 4
• Respiratory viruses cause 89-95% of acute bronchitis cases; fewer than 10% are bacterial 5, 4

When to Consider Alternative Diagnoses

• Pertussis (whooping cough): Suspect when cough persists >2 weeks with paroxysmal cough, whooping, post-tussive vomiting, or recent pertussis exposure 6
• Recurrent episodes: Approximately 65% of patients with recurrent acute bronchitis may have underlying mild asthma or cough-variant asthma 1

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Treatment of Acute Bronchitis

Antibiotic Therapy: NOT Recommended

Routine antibiotic treatment should NOT be offered for acute bronchitis in immunocompetent adults. 3, 1, 5

• Antibiotics reduce cough duration by only approximately 0.5 days while exposing patients to adverse effects including allergic reactions, gastrointestinal symptoms, and Clostridium difficile infection 1, 6
• The decision not to use antibiotics should be explained to patients, as many expect antibiotics based on previous experiences 3

Exception: Pertussis

• For confirmed or probable pertussis, prescribe a macrolide antibiotic (such as azithromycin or erythromycin) 3, 5
• Patients should be isolated for 5 days from the start of treatment 3, 5
• Early treatment within the first few weeks diminishes coughing paroxysms and prevents disease spread 3, 5

Symptomatic Treatment

β2-agonist bronchodilators:

• Should NOT be routinely prescribed for cough in most patients with acute bronchitis 3, 1
• May be considered in select adult patients with wheezing accompanying the cough 3, 1

Antitussive agents:

• Codeine or dextromethorphan may provide short-term symptomatic relief and modest effects on severity and duration of cough 3, 1, 5
• Can be offered occasionally for symptomatic relief 3

NOT recommended:

• Mucokinetic agents (expectorants) have no consistent favorable effect and should not be used 3, 1

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Diagnosis of Chronic Bronchitis

Chronic bronchitis is diagnosed when a patient has chronic cough and sputum production occurring most days for at least 3 months per year for 2 consecutive years, after excluding other respiratory or cardiac causes. 3, 2

Essential History

• Obtain complete exposure history including cigarette, cigar, and pipe smoking (responsible for 85-90% of cases), passive smoke exposure, and occupational/home environmental hazards 3, 2
• Avoidance of respiratory irritants is the most effective means to improve or eliminate cough 3

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Treatment of Acute Exacerbations of Chronic Bronchitis

When to Use Antibiotics

Antibiotics ARE recommended for acute exacerbations of chronic bronchitis, particularly in patients with severe exacerbations and those with more severe airflow obstruction at baseline. 3

• Reserve antibiotics for exacerbations in patients with at least one cardinal symptom (increased dyspnea, sputum production, or purulence) AND one risk factor: age ≥65 years, FEV1 <50% predicted, or comorbidities 2, 7

Bronchodilator Therapy

For stable chronic bronchitis:

• Short-acting β-agonists should be used to control bronchospasm and relieve dyspnea; may also reduce chronic cough 3
• Ipratropium bromide should be offered to improve cough 3
• Theophylline should be considered to control chronic cough with careful monitoring for complications 3

For acute exacerbations:

• Short-acting β-agonists or anticholinergic bronchodilators should be administered 3
• If no prompt response, add the other agent after maximizing the first 3
• Theophylline should NOT be used for acute exacerbations 3

Corticosteroid Therapy

• A short course (10-15 days) of systemic corticosteroids should be given for acute exacerbations: IV for hospitalized patients, oral for ambulatory patients 3
• Long-acting β-agonists coupled with inhaled corticosteroids should be offered for stable patients to control chronic cough 3
• For stable patients with FEV1 <50% predicted or frequent exacerbations, inhaled corticosteroid therapy should be offered 3
• Long-term maintenance with oral corticosteroids (prednisone) should NOT be used due to lack of benefit and high risk of serious side effects 3

Cough Suppressants

• Central cough suppressants such as codeine and dextromethorphan are recommended for short-term symptomatic relief 3

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Patient Education Strategies

Patient satisfaction depends more on physician-patient communication than whether an antibiotic is prescribed. 3, 5

Effective Communication Points

• Inform patients that cough typically lasts 10-14 days after the office visit 3, 5
• Refer to the condition as a "chest cold" rather than bronchitis to reduce antibiotic expectations 3, 5
• Personalize the risks of unnecessary antibiotic use: previous antibiotic use increases likelihood of antibiotic-resistant bacteria, common side effects include gastrointestinal symptoms, and rare but serious adverse effects can occur 3
• Explain that antibiotics provide minimal benefit (reducing cough by only about half a day) while exposing patients to potential harm 1, 6