Management of Bronchitis

Distinguish Between Acute and Chronic Bronchitis First

The cornerstone of bronchitis management depends entirely on whether you are treating acute bronchitis (which almost never requires antibiotics) or chronic bronchitis with acute exacerbations (which often does require antibiotics). 1, 2, 3

Acute Bronchitis

Defined as self-limited inflammation of large airways with cough lasting up to 6 weeks, often with mild constitutional symptoms 1, 3
Caused by viruses in 89-95% of cases 2
Rule out pneumonia before diagnosing acute bronchitis by checking for tachycardia (>100 bpm), tachypnea (>24 breaths/min), fever (>38°C oral), or abnormal chest findings (rales, egophony, tactile fremitus) 1, 2, 3
Chest radiography is not indicated in healthy, nonelderly adults without vital sign abnormalities or asymmetrical lung sounds 1

Chronic Bronchitis

Defined as cough with sputum production on most days for at least 3 months per year for at least 2 consecutive years 4, 1
Must rule out other respiratory or cardiac causes of chronic productive cough 4
Evaluate for exposures to respiratory irritants including tobacco smoke and workplace hazards 4

Management of Acute Bronchitis

Antibiotic Therapy: Almost Never Indicated

Antibiotics should NOT be prescribed for uncomplicated acute bronchitis, regardless of cough duration or sputum color. 1, 2, 3

Antibiotics reduce cough duration by only approximately 0.5 days while significantly increasing adverse effects 2, 5
Purulent or colored sputum does NOT indicate bacterial infection and is not an indication for antibiotics 2, 3
The presence of green sputum results from inflammatory cells or sloughed mucosal epithelial cells, not bacteria 3, 6

Exception for pertussis: If pertussis is confirmed or suspected, prescribe a macrolide antibiotic (such as erythromycin) and isolate the patient for 5 days from treatment start 2

Symptomatic Management

For cough relief:

Dextromethorphan or codeine may provide modest short-term symptomatic relief 4, 1, 2
Antitussive agents are occasionally useful and can be offered for short-term relief 4

For bronchospasm:

Short-acting β-agonists (like albuterol) may be beneficial in select patients with wheezing or evidence of bronchial hyperresponsiveness 1, 2, 3
β2-agonist bronchodilators should NOT be routinely used for cough in most patients with acute bronchitis 2

Avoid these ineffective therapies:

Mucokinetic agents and expectorants are not recommended due to lack of consistent benefit 4
NSAIDs at anti-inflammatory doses are not recommended 2
Systemic corticosteroids are not recommended 2

Patient Communication Strategy

Set realistic expectations: Inform patients that cough typically lasts 10-14 days after the office visit, and may persist for 2-3 weeks total 1, 2, 3, 5

Reduce antibiotic expectations: Consider referring to the condition as a "chest cold" rather than bronchitis 2, 3, 5

Explain the evidence: Discuss that antibiotics provide minimal benefit while exposing patients to adverse effects and contributing to antibiotic resistance 2, 3

Emphasize communication quality: Patient satisfaction depends more on the quality of the clinical encounter than on receiving antibiotics 2, 3

Management of Chronic Bronchitis (Stable)

Smoking Cessation: The Most Effective Intervention

Avoidance of respiratory irritants should always be recommended as the most effective means to improve or eliminate chronic bronchitis cough. 4, 1

Ninety percent of patients will have resolution of their cough after smoking cessation 4
Address personal tobacco use, passive smoke exposure, and workplace hazards 4

Bronchodilator Therapy

First-line pharmacologic management:

Short-acting β-agonists should be used to control bronchospasm and relieve dyspnea; may also reduce chronic cough 4, 1
Ipratropium bromide should be offered to improve cough 4, 1
Theophylline should be considered to control chronic cough, but requires careful monitoring for complications 4

For more severe disease:

Long-acting β-agonists combined with inhaled corticosteroids (ICS) should be offered to control chronic cough 4, 1, 3
ICS therapy should be offered for patients with FEV1 <50% predicted or those with frequent exacerbations 4, 1, 3

What NOT to Do in Stable Chronic Bronchitis

Avoid these interventions:

No role for long-term prophylactic antibiotics 4
Postural drainage and chest percussion are not recommended (no proven benefit) 4
Long-term maintenance therapy with oral corticosteroids (like prednisone) should NOT be used due to lack of benefit and high risk of serious side effects 4
Currently available expectorants are not effective and should not be used 4

Management of Acute Exacerbations of Chronic Bronchitis (AECB)

Diagnosis of Acute Exacerbation

Recognize AECB when stable patients with chronic bronchitis have sudden deterioration with:

Increased cough 4
Increased sputum production 4
Increased sputum purulence 4
Increased shortness of breath 4
Often preceded by upper respiratory tract infection symptoms 4

Bronchodilator Therapy for Exacerbations

Immediate bronchodilator management:

Short-acting β-agonists OR anticholinergic bronchodilators should be administered during acute exacerbations 4, 1
If no prompt response, add the other agent after the first is administered at maximal dose 4
Do NOT use theophylline for acute exacerbations 4, 3

Antibiotic Therapy for Exacerbations

Antibiotics ARE recommended for acute exacerbations of chronic bronchitis. 4, 1

Patients with severe exacerbations and those with more severe airflow obstruction at baseline are most likely to benefit 4
Antibiotics should be reserved for patients with at least 1 key symptom (increased dyspnea, sputum production, or sputum purulence) AND at least 1 risk factor 7

Risk factors for antibiotic use:

Age ≥65 years 7
FEV1 <50% of predicted 7
≥4 exacerbations in 12 months 7
One or more comorbidities 7

Antibiotic selection based on severity:

Moderate exacerbations: Newer macrolide, extended-spectrum cephalosporin, or doxycycline 7
Severe exacerbations: High-dose amoxicillin/clavulanate or respiratory fluoroquinolone 7
Complicated chronic bronchitis (with comorbid illness, severe obstruction FEV1 <50%, age >65 years, or recurrent exacerbations): Fluoroquinolones should be first-line treatment 8

Corticosteroid Therapy for Exacerbations

A short course (10-15 days) of systemic corticosteroids should be given for acute exacerbations. 4, 1, 3

IV therapy for hospitalized patients and oral therapy for ambulatory patients are both effective 4

What NOT to Do in Acute Exacerbations