What is the best treatment approach for bronchitis?

Treatment of Bronchitis

Critical Distinction: Acute vs. Chronic Bronchitis

The treatment approach for bronchitis fundamentally depends on whether you are managing acute bronchitis in a healthy adult or chronic bronchitis with or without acute exacerbations—these are entirely different clinical entities requiring opposite management strategies.

Acute Bronchitis in Healthy Adults

Do NOT prescribe antibiotics for uncomplicated acute bronchitis, regardless of cough duration or sputum color. 1, 2, 3, 4

Diagnosis and Initial Assessment

• Rule out pneumonia first by checking for vital sign abnormalities: heart rate >100 bpm, respiratory rate >24 breaths/min, temperature >38°C, or focal chest findings (rales, egophony, fremitus) 1, 3, 4
• If these are absent, chest radiography is not needed 1, 3
• Purulent or green sputum does NOT indicate bacterial infection and is NOT an indication for antibiotics 3, 4, 5
• Viruses cause >90% of acute bronchitis cases 4, 6

Evidence-Based Treatment

• Antibiotics reduce cough by only 0.5 days while exposing patients to adverse effects (allergic reactions, GI symptoms, C. difficile infection) 3, 4, 5, 7
• Inform patients cough typically lasts 10-14 days (up to 3 weeks) after the visit 1, 4, 7
• Call it a "chest cold" rather than "bronchitis" to reduce antibiotic expectations 1, 4

Symptomatic Management

• Short-acting β-agonists (albuterol) may reduce cough duration and severity in patients with wheezing or bronchial hyperresponsiveness 1, 2, 3
• Dextromethorphan or codeine may provide modest symptomatic relief for bothersome cough 1, 2, 4
• Do NOT routinely use: antitussives, honey, antihistamines, anticholinergics, NSAIDs, or corticosteroids 3, 7

Exception: Pertussis

• If pertussis is suspected (cough >2 weeks with paroxysms, whooping, post-tussive emesis), prescribe a macrolide (erythromycin) and isolate patient for 5 days 4, 5

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Chronic Bronchitis (Stable)

Smoking cessation is the cornerstone—90% of patients experience resolution of cough after quitting. 2

Bronchodilator Therapy

• Short-acting β-agonists should be used to control bronchospasm and may reduce chronic cough 1, 2
• Ipratropium bromide should be offered to improve cough—it reduces cough frequency, severity, and sputum volume 1, 2
• Long-acting β-agonists combined with inhaled corticosteroids should be offered for chronic cough control, especially when FEV1 <50% 1, 2
• Theophylline may be considered but requires careful monitoring for complications 1

What NOT to Use

• Chest physiotherapy and postural drainage are not recommended—no proven benefit 1
• Expectorants and mucolytics lack evidence of benefit 1, 2

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Acute Exacerbations of Chronic Bronchitis (AECB)

Unlike acute bronchitis in healthy adults, antibiotics ARE recommended for AECB, particularly in high-risk patients. 2, 8, 9

When to Prescribe Antibiotics

Antibiotics are indicated when patients have at least 1 key symptom PLUS at least 1 risk factor: 9

Key symptoms:

• Increased dyspnea
• Increased sputum production
• Increased sputum purulence

Risk factors:

• Age ≥65 years
• FEV1 <50% predicted
• ≥4 exacerbations in 12 months
• Comorbidities (cardiac disease, diabetes, immunosuppression)

Antibiotic Selection

• Moderate severity exacerbation: newer macrolide, extended-spectrum cephalosporin, or doxycycline 9
• Severe exacerbation or high-risk patients: high-dose amoxicillin/clavulanate or respiratory fluoroquinolone 8, 9
• Consider Pseudomonas coverage in patients with severe obstruction, recurrent exacerbations, or recent hospitalization 8

Bronchodilator and Corticosteroid Therapy

• Short-acting β-agonists or anticholinergic bronchodilators should be administered immediately 1, 2
• If no prompt response, add the other bronchodilator class at maximal dose 1
• Short course (10-15 days) of systemic corticosteroids is effective for acute exacerbations 2
• Do NOT use theophylline for acute exacerbations 1, 2

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Common Pitfalls to Avoid

• Prescribing antibiotics for acute bronchitis based on colored sputum 2, 3, 4
• Failing to distinguish acute bronchitis from pneumonia—check vital signs and chest exam 1, 3
• Overusing expectorants and mucolytics which lack evidence 1, 2
• Using theophylline for acute exacerbations of chronic bronchitis 1, 2
• Not assessing for underlying conditions (asthma, COPD, heart failure) that may complicate bronchitis 2, 3