Bronchitis Treatment
For acute bronchitis, antibiotics should NOT be prescribed as viruses cause over 90% of cases; treatment focuses on symptomatic relief with short-acting β-agonists for patients with bronchial hyperresponsiveness and cough suppressants for bothersome cough. 1, 2, 3
Acute Bronchitis Management
First-Line Approach
- Avoid antibiotics in uncomplicated cases regardless of cough duration or sputum color, as purulent sputum does not indicate bacterial infection 1, 2, 4
- Antibiotics may be considered only in specific high-risk populations: patients ≥75 years with fever or those with cardiac failure 4
- Set realistic expectations: cough typically lasts 10-14 days after the visit, sometimes up to 3 weeks 4, 3
Symptomatic Treatment Options
- Short-acting β-agonists (albuterol) reduce cough duration and severity in patients with bronchial hyperresponsiveness 1, 2, 4
- Ipratropium bromide may improve cough in some patients 1, 2, 4
- Dextromethorphan or codeine for short-term relief of bothersome cough 1, 2, 4
Treatments NOT Recommended
- Expectorants and mucolytics lack evidence of benefit 1, 2, 4
- Antihistamines, oral NSAIDs, and corticosteroids are ineffective 5
Chronic Bronchitis Management
Cornerstone Therapy
- Smoking cessation is paramount: 90% of patients experience cough resolution after quitting 1, 2
- Remove all respiratory irritants from the environment 1, 2
Stable Chronic Bronchitis
- Short-acting β-agonists control bronchospasm and may reduce chronic cough 6, 1, 2
- Ipratropium bromide should be offered to improve cough (reduces cough frequency, severity, and sputum volume) 6, 1, 2
- Long-acting β-agonists combined with inhaled corticosteroids control chronic cough and reduce exacerbation rates 1, 2, 4
- Inhaled corticosteroids for patients with FEV1 <50% predicted or frequent exacerbations 1, 4
- Theophylline may be considered for cough control but requires careful monitoring for complications 6
Treatments NOT Recommended for Stable Disease
- Long-term prophylactic antibiotics 1
- Oral corticosteroids (no proven benefit, significant side effects) 6
- Expectorants 1, 2
Acute Exacerbations of Chronic Bronchitis
Identifying Patients Who Need Antibiotics
Antibiotics are indicated when patients have at least 2 of these 3 cardinal symptoms PLUS at least 1 risk factor: 7
Cardinal Symptoms:
- Increased dyspnea
- Increased sputum production
- Increased sputum purulence
Risk Factors:
- Age ≥65 years
- FEV1 <50% predicted
- ≥4 exacerbations in 12 months
- One or more comorbidities
Treatment Algorithm for Exacerbations
Bronchodilator Therapy (All Patients):
- Short-acting β-agonists or anticholinergic bronchodilators should be administered first 6, 1, 2
- If no prompt response, add the other agent after maximizing the first 6
Corticosteroid Therapy:
- Systemic corticosteroids for 10-15 days are effective for acute exacerbations 1, 2, 4
- An 8-week course is equivalent to a 2-week course 6
Antibiotic Selection (When Indicated):
- Moderate severity exacerbations: newer macrolide, extended-spectrum cephalosporin, or doxycycline 7
- Severe exacerbations: high-dose amoxicillin/clavulanate or respiratory fluoroquinolone 7
Do NOT Use:
Critical Pitfalls to Avoid
- Do not prescribe antibiotics based solely on colored sputum 2, 4
- Rule out pneumonia by assessing for tachycardia, tachypnea, fever, and abnormal chest examination before diagnosing bronchitis 2, 4
- Consider underlying conditions (asthma, COPD, heart failure) that may mimic or complicate bronchitis 2, 4
- Avoid overusing expectorants and mucolytics which lack evidence 2, 4
- Do not use theophylline for acute exacerbations despite its benefit in stable disease 6, 1, 2
Patient Communication Strategies
- Refer to acute bronchitis as a "chest cold" to reduce antibiotic expectations 4
- Explain that patient satisfaction depends on encounter quality, not antibiotic prescribing 4
- Discuss antibiotic risks: side effects and resistance development 4
- Consider delayed antibiotic prescriptions as a strategy to reduce unnecessary use 5