What is the treatment for bronchitis?

Treatment of Bronchitis

Acute Bronchitis

For uncomplicated acute bronchitis in immunocompetent adults, antibiotics should NOT be routinely prescribed, and symptomatic treatment with albuterol (short-acting β-agonist) is the first-line therapy to reduce cough duration and severity. 1

Antibiotic Use - NOT Recommended

• Antibiotics provide minimal benefit in acute bronchitis, reducing cough by only approximately half a day, while carrying risks of adverse effects including allergic reactions, nausea, vomiting, and Clostridium difficile infection. 2, 3
• Viruses cause more than 90% of acute bronchitis cases, making antibiotics ineffective for most patients 2, 4
• A meta-analysis demonstrated antibiotics decreased cough and sputum production by only 0.5 days, which does not outweigh the societal cost of antibiotic resistance 2, 5
• Expectorants, mucolytics, antihistamines, and routine bronchodilators should not be prescribed in uncomplicated acute lower respiratory tract infections 2

Recommended Symptomatic Treatment

• Albuterol (short-acting β-agonist) reduces cough duration and severity, with approximately 50% fewer patients reporting cough after 7 days of treatment 1
• Antitussives containing dextromethorphan or codeine can be prescribed for dry, bothersome cough that disturbs sleep, though evidence shows only modest effects 2, 1
• Low-cost interventions including elimination of environmental cough triggers and vaporized air treatments are reasonable options 1

When to Consider Antibiotics

Consider antibiotics ONLY in these specific high-risk situations 2:

• Suspected or confirmed pneumonia (presence of tachypnea, tachycardia, dyspnea, or lung findings on examination)
• Age >75 years with fever
• Cardiac failure
• Insulin-dependent diabetes mellitus
• Serious neurological disorder
• Suspected pertussis (cough >2 weeks with paroxysmal features, whooping, post-tussive emesis) - treat with macrolide antibiotic 2

Patient Education

• Inform patients that cough typically lasts 10-14 days after the office visit, with some cases lasting up to 3 weeks 1, 4, 3
• Patient satisfaction depends more on physician-patient communication than receiving antibiotics 1

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Chronic Bronchitis (Stable)

The most effective treatment is complete avoidance of respiratory irritants, particularly cigarette smoke, passive smoke exposure, and workplace hazards. 2

First-Line Bronchodilator Therapy

• Ipratropium bromide (36 μg, 2 inhalations four times daily) should be offered to improve cough, as it reduces cough frequency, severity, and sputum volume (Grade A recommendation) 2, 6
• Short-acting β-agonists should be used to control bronchospasm and relieve dyspnea; may also reduce chronic cough (Grade A recommendation) 2
• Theophylline can be considered to control chronic cough with careful monitoring for complications (Grade A recommendation) 2

Advanced Therapy for Severe Disease

• For patients with severe airflow obstruction (FEV₁ <50%) or frequent exacerbations, add inhaled corticosteroid (ICS) combined with long-acting β-agonist (LABA) 2, 6
• For persistent exacerbations despite LABA/LAMA/ICS triple therapy, consider adding roflumilast or a macrolide 6, 7

NOT Recommended in Stable Chronic Bronchitis

• Prophylactic antibiotics (Grade I recommendation) 2, 6
• Oral corticosteroids 2
• Expectorants 2
• Postural drainage or chest physiotherapy 2

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Acute Exacerbation of Chronic Bronchitis

For acute exacerbations, treat with inhaled bronchodilators, oral antibiotics (in appropriate patients), and systemic corticosteroids. 2, 6

Bronchodilator Therapy

• Administer short-acting β-agonists OR anticholinergic bronchodilators during acute exacerbation 2
• If no prompt response, add the other agent at maximal dose 2, 6
• Theophylline should NOT be used during acute exacerbations (Grade D recommendation) 2

Antibiotic Indications

Antibiotics are indicated for patients with 2, 6, 8:

• At least ONE key symptom (increased dyspnea, increased sputum production, OR increased sputum purulence) AND
• At least ONE risk factor: age ≥65 years, FEV₁ <50% predicted, ≥4 exacerbations in 12 months, or comorbidities

Antibiotic Selection:

• Moderate severity exacerbation: newer macrolide (azithromycin), extended-spectrum cephalosporin, or doxycycline 9, 8
• Severe exacerbation: high-dose amoxicillin/clavulanate or respiratory fluoroquinolone 8

Corticosteroid Therapy

• A short course (10-15 days, with 2 weeks being optimal) of systemic corticosteroids should be given (Grade A recommendation) 2
• Use IV therapy for hospitalized patients and oral therapy for ambulatory patients 2

NOT Recommended During Exacerbations

• Expectorants (Grade I recommendation) 2
• Postural drainage or chest physiotherapy 2
• Theophylline 2

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Common Pitfalls to Avoid

• Prescribing antibiotics for uncomplicated acute bronchitis despite clear evidence of lack of benefit 1, 3
• Failing to distinguish between acute bronchitis and exacerbations of chronic bronchitis, which require different management 1
• Not providing realistic expectations about illness duration (2-3 weeks for acute bronchitis), leading to unnecessary follow-up or antibiotic requests 1, 4
• Overlooking bronchodilator therapy in acute bronchitis, which has demonstrated benefit 1
• Using long-term ICS monotherapy in chronic bronchitis, which is not recommended 6