What is the first line treatment for acute bronchitis?

First-Line Treatment for Acute Bronchitis

The first-line treatment for acute bronchitis is symptomatic management without antibiotics, focusing on patient education about the expected 2-3 week duration of cough and consideration of short-acting β-agonists or antitussives for symptom relief. 1, 2

Antibiotics Should NOT Be Used

• Antibiotics are not recommended for uncomplicated acute bronchitis and should not be routinely prescribed. 1, 2, 3
• Antibiotics provide minimal benefit, reducing cough duration by only approximately half a day while exposing patients to adverse effects including allergic reactions, nausea, vomiting, and Clostridium difficile infection. 2, 4
• The presence of purulent or colored sputum does NOT indicate bacterial infection and is NOT an indication for antibiotics—this results from inflammatory cells or sloughed mucosal epithelial cells, not bacteria. 1, 2
• Viral infections account for 89-95% of acute bronchitis cases, making antibiotics ineffective. 2, 5
• The French guidelines explicitly state that antibiotic therapy has not been confirmed to benefit clinical course or prevent complications in healthy adults with acute bronchitis. 6

Symptomatic Treatment Options

β-Agonist Bronchodilators

• Short-acting β-agonists like albuterol may be beneficial in reducing cough duration and severity specifically in patients with evidence of bronchial hyperresponsiveness such as wheezing or bothersome cough. 6, 1, 3
• Approximately 50% fewer patients report presence of cough after 7 days of albuterol treatment compared to placebo. 6
• β2-agonist bronchodilators should not be routinely used in most patients, but may be useful in select adult patients with wheezing accompanying the cough. 2

Anticholinergic Agents

• Ipratropium bromide may improve cough in some patients with acute bronchitis. 1, 3

Antitussive Agents

• Dextromethorphan or codeine are recommended for short-term symptomatic relief of bothersome cough and probably have a modest effect on severity and duration. 6, 1, 2, 3
• These agents appear more effective for chronic cough (>3 weeks duration) than early acute cough, but still provide modest benefit in acute bronchitis where average cough duration is 2-3 weeks. 6

Non-Pharmacologic Measures

• Elimination of environmental cough triggers (dust, dander) and vaporized air treatments, particularly in low-humidity environments, are reasonable low-cost, low-risk options. 6, 2

Exception: Pertussis (Whooping Cough)

• For confirmed or suspected pertussis, a macrolide antibiotic such as erythromycin should be prescribed. 2
• Patients with pertussis should be isolated for 5 days from the start of treatment. 2
• Early treatment within the first few weeks will diminish coughing paroxysms and prevent disease spread. 2

Exception: Influenza-Related Bronchitis

• Consider antiviral agents (neuraminidase inhibitors or rimantadine) if influenza is suspected and treatment can be initiated within 48 hours (preferably <30 hours) of symptom onset during documented influenza outbreaks. 6

Critical Patient Communication

• Inform patients that cough typically lasts 10-14 days after the office visit, with total duration of 2-3 weeks being normal. 1, 2, 3
• Consider referring to the illness as a "chest cold" rather than "bronchitis" to reduce patient expectation for antibiotics. 1, 2, 3
• Explain that patient satisfaction depends more on the quality of physician-patient communication than whether an antibiotic is prescribed. 6, 1, 2
• Discuss the risks of unnecessary antibiotic use, including side effects and contribution to antibiotic resistance. 1, 2

Rule Out Pneumonia First

• Before diagnosing uncomplicated acute bronchitis, rule out pneumonia by assessing for tachycardia (heart rate >100 beats/min), tachypnea (respiratory rate >24 breaths/min), fever (oral temperature >38°C), or abnormal chest examination findings (rales, egophony, tactile fremitus). 1, 2
• Chest radiography is usually not indicated in healthy, nonelderly adults without vital sign abnormalities or asymmetrical lung sounds. 3

Common Pitfalls to Avoid

• Prescribing antibiotics based solely on presence of colored sputum. 1, 3
• Failing to distinguish between acute bronchitis and pneumonia. 1, 3
• Overuse of expectorants, mucolytics, and antihistamines which lack evidence of benefit. 1, 3
• Using NSAIDs at anti-inflammatory doses or systemic corticosteroids, which are not justified in acute bronchitis. 6
• Not considering underlying conditions that may be exacerbated by bronchitis (asthma, COPD, cardiac failure, diabetes). 1, 3

High-Risk Populations Requiring Different Consideration

• The American College of Physicians suggests antibiotics may be considered only in specific high-risk populations, such as patients aged ≥75 years with fever. 1
• The European Respiratory Society suggests antibiotics may be considered for patients with cardiac failure. 1
• Patients with comorbidities like COPD, immunosuppression, or severe underlying disease may require different management approaches. 2