What is the recommended management for bronchitis?

Management of Bronchitis

Acute Bronchitis: Antibiotics Are Not Recommended

For uncomplicated acute bronchitis, do not prescribe antibiotics—they provide minimal benefit (reducing cough by only half a day) while exposing patients to adverse effects and contributing to antibiotic resistance. 1, 2, 3

Diagnosis and Initial Assessment

• Diagnose acute bronchitis clinically based on cough lasting up to 6 weeks with or without sputum production, often following an upper respiratory infection 1, 2
• Rule out pneumonia first by checking for tachycardia (>100 bpm), tachypnea (>24 breaths/min), fever (>38°C), or abnormal chest findings (rales, egophony, tactile fremitus) 1, 2
• Chest radiography is not indicated in healthy adults without vital sign abnormalities or asymmetrical lung sounds 1
• Purulent or colored sputum does NOT indicate bacterial infection—it results from inflammatory cells and sloughed epithelial cells, not bacteria 4, 2

Symptomatic Management for Acute Bronchitis

• Short-acting β-agonists (albuterol) may reduce cough duration and severity in patients with wheezing or bronchial hyperresponsiveness 1, 4, 2
• Ipratropium bromide may improve cough in select patients 1, 4
• Dextromethorphan or codeine can provide short-term symptomatic relief for bothersome cough 1, 4, 2
• Avoid routine use of expectorants, mucolytics, antihistamines, NSAIDs at anti-inflammatory doses, or systemic corticosteroids—they lack evidence of benefit 1, 4, 2

Exception: Pertussis

• For confirmed or suspected pertussis, prescribe a macrolide antibiotic (erythromycin) and isolate the patient for 5 days from treatment start 2

Patient Communication Strategy

• Set realistic expectations: cough typically lasts 10-14 days after the office visit 1, 4, 2
• Refer to the condition as a "chest cold" rather than "bronchitis" to reduce antibiotic expectations 4, 2
• Explain that patient satisfaction depends more on quality communication than receiving antibiotics 4, 2
• Discuss risks of unnecessary antibiotics including side effects and antibiotic resistance 4, 2

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Chronic Bronchitis: Bronchodilators and Smoking Cessation

For stable chronic bronchitis, use short-acting β-agonists to control bronchospasm and offer ipratropium bromide to improve cough—but the single most effective intervention is smoking cessation, which resolves cough in 90% of patients. 5, 1

Definition and Risk Factor Modification

• Chronic bronchitis is defined as cough with sputum production on most days for at least 3 months per year for 2 consecutive years 5, 1, 4
• Avoidance of respiratory irritants (tobacco smoke, passive smoke, workplace hazards) is the cornerstone of therapy 5, 1
• 90% of patients experience resolution of cough after smoking cessation 5, 1

Pharmacologic Management for Stable Chronic Bronchitis

• Short-acting β-agonists should be used to control bronchospasm and relieve dyspnea; may also reduce chronic cough 5, 1
• Ipratropium bromide should be offered to improve cough 5, 1
• Long-acting β-agonists combined with inhaled corticosteroids should be offered to control chronic cough 5, 1, 4
• Theophylline may be considered to control chronic cough but requires careful monitoring for complications 5
• Inhaled corticosteroids should be offered for patients with FEV1 <50% predicted or those with frequent exacerbations 5, 4

What NOT to Use in Stable Chronic Bronchitis

• No role for long-term prophylactic antibiotics 5
• Expectorants are not effective and should not be used 5
• Postural drainage and chest percussion have not proven beneficial and are not recommended 5

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Acute Exacerbations of Chronic Bronchitis: Bronchodilators, Antibiotics, and Steroids

For acute exacerbations of chronic bronchitis (increased dyspnea, sputum production, or sputum purulence), administer short-acting β-agonists or anticholinergic bronchodilators first, then add antibiotics for patients with severe exacerbations or baseline airflow obstruction. 5, 1

Diagnosis of Acute Exacerbation

• Suspect acute exacerbation when stable patients experience sudden deterioration with increased cough, sputum production, sputum purulence, and/or dyspnea, often preceded by upper respiratory infection symptoms 5

Bronchodilator Therapy

• Short-acting β-agonists or anticholinergic bronchodilators should be administered during acute exacerbations 5, 1, 4
• If no prompt response, add the other agent after maximizing the first 5
• Do NOT use theophylline for acute exacerbations—it provides no benefit 5, 4

Antibiotic Therapy

• Antibiotics are recommended for acute exacerbations, particularly for patients with severe exacerbations and those with more severe baseline airflow obstruction 5, 1, 6, 7
• Patients most likely to benefit have at least one cardinal symptom (increased dyspnea, sputum production, or purulence) plus risk factors (age ≥65 years, FEV1 <50% predicted, ≥4 exacerbations in 12 months, or comorbidities) 7

Corticosteroid Therapy

• A short course (10-15 days) of systemic corticosteroids is effective for acute exacerbations 1, 4

What NOT to Use in Acute Exacerbations

• Postural drainage and chest percussion have not proven beneficial 5
• Theophylline should not be used 5, 4

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Common Pitfalls to Avoid

• Do not prescribe antibiotics based solely on colored sputum—this does not indicate bacterial infection 1, 4, 2
• Do not fail to distinguish acute bronchitis from pneumonia—check vital signs and lung examination 1, 2
• Do not overuse expectorants and mucolytics—they lack evidence of benefit 1, 4
• Do not ignore underlying conditions (asthma, COPD, cardiac failure, diabetes) that may be exacerbated by bronchitis 1, 4
• Do not use theophylline for acute exacerbations of chronic bronchitis 5, 4