What is the initial management for a patient presenting with acute bronchitis?

Initial Management of Acute Bronchitis

For immunocompetent adult outpatients presenting with acute bronchitis, do not routinely order diagnostic tests or prescribe antibiotics, bronchodilators, or other medications—focus on patient education about the viral nature of the illness and expected 2-3 week duration of cough. 1, 2

Confirm the Diagnosis First

Before managing as acute bronchitis, actively exclude pneumonia and other conditions:

• Check vital signs systematically: If ALL of the following are absent—heart rate >100 beats/min, respiratory rate >24 breaths/min, oral temperature >38°C, and focal chest examination findings (consolidation, egophony, fremitus)—pneumonia is sufficiently unlikely that chest radiography is unnecessary 1

• Rule out asthma and COPD exacerbations: Approximately 65% of patients with recurrent "acute bronchitis" episodes actually have underlying mild asthma, making this a critical differential diagnosis not to miss 1, 3, 2

• Consider pertussis if: Cough persists >2 weeks with paroxysmal features, post-tussive vomiting, or inspiratory whooping, especially with known community transmission 1, 3, 4

What NOT to Do (Routine Management)

No routine investigations are indicated 1, 2:

• No chest x-ray (unless pneumonia cannot be clinically excluded)
• No sputum cultures or viral PCR testing
• No spirometry or peak flow measurements
• No inflammatory markers (CRP, procalcitonin)

No routine antibiotics 1, 2:

• Over 90% of acute bronchitis cases are viral 1
• Antibiotics reduce cough duration by only approximately 0.5 days while exposing patients to adverse effects including allergic reactions, nausea, vomiting, and Clostridium difficile infection 2, 5
• Purulent or colored (green/yellow) sputum does NOT indicate bacterial infection—this reflects inflammatory cells, not bacteria 1, 2
• Between 65-80% of patients inappropriately receive antibiotics despite clear evidence against their use 1

No routine bronchodilators 1:

• β2-agonist bronchodilators should not be routinely prescribed for uncomplicated acute bronchitis 1, 2
• Exception: May consider in select patients with wheezing accompanying the cough 1

No routine symptomatic medications 1, 2, 5:

• Evidence does not support antitussives, antihistamines, anticholinergics, oral NSAIDs, or corticosteroids (inhaled or oral) 1, 5
• Mucokinetic agents show no consistent favorable effect 1

What TO Do (Recommended Management)

Patient education is paramount 1:

• Explain the viral etiology and that antibiotics are ineffective and potentially harmful 1
• Set realistic expectations: cough typically lasts 2-3 weeks 4, 5
• Patient satisfaction correlates with quality of physician-patient interaction and education, NOT with antibiotic prescribing 1, 6, 7
• Consider describing the condition as a "chest cold" rather than "bronchitis" to reduce antibiotic expectations 4, 5

Symptomatic relief options (though evidence is limited) 1:

• Antitussive agents (dextromethorphan or codeine) may occasionally provide short-term symptomatic relief 1

When to Reassess or Modify Management

Consider targeted investigation and treatment if 1, 2:

• Symptoms persist beyond expected timeframe or worsen
• Targeted investigations at reassessment may include: chest x-ray, sputum culture, peak flow measurements, complete blood count, inflammatory markers 1, 2

Antibiotic therapy is indicated ONLY for 1:

• Confirmed or suspected pertussis: Use macrolide antibiotic (erythromycin) with 5-day isolation; effective only if started within first few weeks 1
• Suspected bacterial superinfection with clinical worsening 1, 2

Critical Pitfalls to Avoid

• Do not assume colored sputum requires antibiotics—this is inflammatory debris, not bacterial infection 1, 2
• Do not miss underlying asthma—one-third of patients presenting with acute cough may have asthma, and 65% of recurrent "bronchitis" cases are actually mild asthma 1, 3, 2
• Do not fail to obtain chest radiograph when pneumonia cannot be clinically excluded based on vital signs and examination 1, 8
• Do not continue to diagnose "acute bronchitis" in patients with recurrent episodes—investigate for asthma, COPD, or bronchiectasis 1, 3, 2