What is the management approach for bronchitis?

Management of Bronchitis

Critical Distinction: Bronchiolitis vs. Acute Bronchitis

The management approach depends entirely on whether you are treating bronchiolitis (viral infection in infants/young children) or acute bronchitis (respiratory infection in adults)—these are fundamentally different conditions requiring opposite approaches.

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BRONCHIOLITIS (Infants 1-23 Months)

Diagnosis

• Diagnose based on history and physical examination alone—do not routinely order laboratory tests or chest radiographs 1
• Look for rhinitis and cough progressing to tachypnea, wheezing, rales, nasal flaring, and use of accessory muscles 1, 2
• Assess for risk factors: age <12 weeks, prematurity (<32 weeks gestation), chronic lung disease, hemodynamically significant heart disease, or immunodeficiency 1, 2

Core Management Principles

Supportive care is the cornerstone—most commonly used medications have been proven ineffective:

What NOT to Do:

• Do not routinely use bronchodilators 1
• Do not use corticosteroids routinely 1
• Do not use ribavirin routinely 1
• Do not use antibiotics unless there is specific evidence of bacterial co-infection 1
• Do not perform routine chest physiotherapy 1

What TO Do:

Hydration and Feeding:

• Assess hydration status and ability to take fluids orally 1
• Offer frequent small feedings, as infants tire easily with nasal congestion and tachypnea 3
• Hold infant upright during and after feedings 3

Airway Management:

• Use gentle bulb suction for visible nasal congestion affecting breathing or feeding 3
• Suction as needed (not on strict schedule), but ensure suctioning occurs at least every 4 hours if significant congestion present 3
• Avoid deep suctioning—associated with longer illness duration 3
• Keep head slightly elevated during sleep 3

Oxygen Therapy:

• Administer supplemental oxygen if SpO2 falls persistently below 90% in previously healthy infants 1
• Maintain SpO2 at or above 90% with adequate supplemental oxygen 1
• Discontinue oxygen when SpO2 ≥90%, infant feeds well, and has minimal respiratory distress 1
• Premature infants and those with hemodynamically significant heart or lung disease require close monitoring during oxygen weaning 1
• Continuous SpO2 monitoring is not routinely needed as clinical course improves 1

Prevention

Palivizumab Prophylaxis:

• Administer to infants with hemodynamically significant heart disease or chronic lung disease of prematurity (preterm <32 weeks requiring >21% oxygen for ≥28 days) 1
• Give 5 monthly doses at 15 mg/kg intramuscularly, typically beginning November/December 1

General Prevention:

• Hand decontamination before and after patient contact is the most important step in preventing nosocomial spread 1
• Use alcohol-based hand rubs (preferred) or antimicrobial soap 1
• Infants should not be exposed to passive smoking 1, 3
• Breastfeeding decreases risk of lower respiratory tract disease 1
• Keep infants away from sick contacts and avoid crowded places during RSV season 3

Expected Course

• Self-limiting illness with most children recovering within 2-3 weeks 2
• Mean time to cough resolution: 8-15 days 2, 3
• 90% of children are cough-free by day 21 2

Red Flags Requiring Immediate Evaluation

• Respiratory rate ≥70 breaths/minute 3
• Severe feeding difficulty or complete refusal to eat/drink 3
• Age <12 weeks, prematurity, chronic lung disease, heart disease, or immunodeficiency 2, 3

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ACUTE BRONCHITIS (Adults)

Diagnosis

Rule out pneumonia first—this is the critical decision point:

• In healthy, non-elderly adults, pneumonia is unlikely if ALL of the following are absent: tachycardia (>100 bpm), tachypnea (>24 breaths/min), fever (>38°C), and abnormal chest examination findings (rales, egophony, tactile fremitus) 1
• Do not order chest radiography in healthy adults without these vital sign abnormalities or asymmetric lung sounds 1
• Consider chest radiography if cough persists ≥3 weeks without other known cause 1
• Purulent or colored (green/yellow) sputum does NOT indicate bacterial infection—it reflects inflammatory cells, not bacteria 1, 4

Core Management Principle

Antibiotics are NOT indicated for uncomplicated acute bronchitis—this is the single most important management decision:

• Do not routinely prescribe antibiotics for acute uncomplicated bronchitis 1
• More than 90% of cases are viral 1, 4
• Antibiotics have not been shown to improve clinical outcomes and increase adverse events 1, 4
• Acute bronchitis leads to more inappropriate antibiotic prescribing than any other respiratory condition in adults 1

When to Consider Antibiotics (Rare Exceptions):

• Suspected pertussis infection with documented community transmission—perform diagnostic test and initiate antimicrobial therapy 1
• This is an unusual circumstance and should not drive routine management 1

Symptomatic Treatment Options

Evidence for symptomatic therapies is limited, but options include:

• Cough suppressants: dextromethorphan or codeine 1
• Expectorants: guaifenesin 1
• First-generation antihistamines: diphenhydramine 1
• Decongestants: phenylephrine 1
• β-agonists (albuterol): NOT beneficial in patients without asthma or chronic obstructive lung disease 1, 5

Important caveats:

• Symptomatic therapy has not been shown to shorten illness duration 1
• Over-the-counter medications have low incidence of minor adverse effects (nausea, vomiting, headache, drowsiness) 1
• Weigh benefits versus potential adverse effects when considering symptomatic therapy 1

Expected Course

• Cough typically lasts up to 6 weeks 1
• Symptoms typically last about 3 weeks 4
• Self-limited illness in otherwise healthy adults 1, 4

Patient Communication Strategy

• Patient satisfaction depends on physician-patient communication quality, NOT on antibiotic prescription 1, 6
• Explain viral etiology and self-limited nature 4, 6
• Discuss expected symptom duration and when to return if symptoms worsen 4
• Address antibiotic resistance concerns and lack of benefit 1, 6

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Common Pitfalls to Avoid

• Confusing bronchiolitis (pediatric) with acute bronchitis (adult)—these require completely different management approaches 1, 2
• Prescribing antibiotics for acute bronchitis based on sputum color or purulence 1, 4
• Using bronchodilators routinely in bronchiolitis without documented clinical response 1
• Ordering unnecessary chest radiographs in uncomplicated cases 1
• Deep nasal suctioning in infants with bronchiolitis 3
• Continuing oxygen therapy in bronchiolitis when SpO2 is adequate and infant is feeding well 1