Initial Management of Acute Bronchitis
For immunocompetent adult outpatients with acute bronchitis, provide supportive care only—no routine investigations, no antibiotics, no bronchodilators, and no other medications should be prescribed at initial presentation. 1
Clinical Diagnosis and Differential Exclusion
The diagnosis of acute bronchitis is clinical, characterized by acute cough with or without sputum production lasting up to 3 weeks. 2, 3 Before confirming this diagnosis, you must actively exclude pneumonia and other conditions:
- Rule out pneumonia if any of the following are present: heart rate >100 beats/min, respiratory rate >24 breaths/min, oral temperature >38°C, or chest examination findings of focal consolidation, egophony, or fremitus. 1, 4, 5
- No chest radiograph is needed when these vital sign abnormalities and abnormal lung findings are absent. 1, 4
- Consider alternative diagnoses including asthma exacerbation, COPD exacerbation, pertussis (if cough >2 weeks with paroxysms), and heart failure. 1, 2
No Routine Investigations
Do not order any diagnostic tests at initial presentation for uncomplicated acute bronchitis: 1
- No chest x-ray
- No spirometry or peak flow measurement
- No sputum culture
- No viral PCR testing
- No C-reactive protein or procalcitonin
- No complete blood count
The 2020 CHEST guidelines are explicit that these investigations have not been shown to improve outcomes and should be avoided. 1
No Routine Medications
Prescribe no medications at the initial visit for uncomplicated acute bronchitis: 1, 4
- No antibiotics: They reduce cough duration by only approximately 0.5 days while causing adverse effects including allergic reactions, nausea, and Clostridium difficile infection. 5, 2, 3
- No inhaled beta-agonists: Not indicated routinely, even with wheezing, at initial presentation. 1, 4
- No inhaled anticholinergics: Not recommended for routine use. 1
- No inhaled or oral corticosteroids: No evidence of benefit. 1, 4
- No antitussives (codeine, dextromethorphan): Not recommended routinely, though may occasionally provide short-term symptomatic relief if cough is severely bothersome. 1
- No NSAIDs at anti-inflammatory doses: Ineffective for acute bronchitis. 1, 5
Patient Education: The Core Intervention
Educate patients that cough typically lasts 2-3 weeks, which is the natural course of this self-limiting viral illness. 5, 2, 3 This single intervention is critical:
- Call it a "chest cold" rather than "bronchitis" to reduce antibiotic expectations. 5, 3
- Explain that 89-95% of cases are viral, making antibiotics ineffective and potentially harmful. 5, 6
- Emphasize that patient satisfaction depends on communication quality, not antibiotic prescribing. 5, 7
- Discuss antibiotic risks: adverse effects and contribution to resistance. 5, 3
When to Reassess
Advise patients to return if symptoms persist beyond 2-3 weeks or worsen, at which point targeted investigations should be considered: 1
- Chest x-ray
- Sputum culture
- Peak flow measurements
- Complete blood count and inflammatory markers (CRP)
If acute bronchitis worsens and bacterial superinfection is suspected, only then consider antibiotic therapy. 1, 4
Critical Exception: Pertussis
If pertussis is confirmed or highly suspected (cough >2 weeks with paroxysms, whooping, post-tussive emesis, or known exposure): 1, 5
- Prescribe a macrolide antibiotic (erythromycin)
- Isolate patient for 5 days from treatment start
- Early treatment (within first few weeks) diminishes paroxysms and prevents spread
Common Pitfalls to Avoid
- Do not prescribe antibiotics based on purulent or colored sputum—this does not indicate bacterial infection. 5, 3
- Do not confuse acute bronchitis with pneumonia—vital signs and lung examination distinguish these. 1, 4, 2
- Do not use expectorants or mucolytics—no evidence supports their use. 1, 4
- Recognize that 65% of recurrent "acute bronchitis" episodes may actually be mild asthma—consider this in patients with multiple episodes. 1