Diagnosis and Treatment of Bronchitis
Diagnosis
Bronchitis diagnosis depends critically on distinguishing acute from chronic forms and ruling out pneumonia through clinical assessment rather than routine imaging.
Acute Bronchitis
- Acute bronchitis is defined as self-limited inflammation of the large airways with cough lasting up to 6 weeks, often with mild constitutional symptoms 1, 2.
- Rule out pneumonia before diagnosing acute bronchitis by assessing for tachycardia (>100 bpm), tachypnea (>24 breaths/min), fever (>38°C oral), or abnormal chest examination findings including rales, egophony, or tactile fremitus 1, 3.
- Chest radiography is not indicated in healthy, nonelderly adults without vital sign abnormalities or asymmetrical lung sounds 2.
- Purulent or colored sputum does NOT indicate bacterial infection—it results from inflammatory cells or sloughed epithelial cells and is not an indication for antibiotics 1, 3.
Chronic Bronchitis
- Chronic bronchitis is diagnosed when cough with sputum production occurs on most days for at least 3 months per year for at least 2 consecutive years 1, 2.
- Spirometry should be performed to assess for airflow obstruction (FEV1) to guide treatment decisions 4.
Non-Eosinophilic Bronchitis (NAEB)
- Consider NAEB in patients with chronic cough who have normal chest radiograph, normal spirometry, and no evidence of variable airflow obstruction or airway hyperresponsiveness 4.
- Diagnosis is confirmed by airway eosinophilia on sputum induction or bronchial wash and improvement with corticosteroid therapy 4.
Treatment of Acute Bronchitis
Antibiotics should NOT be prescribed for uncomplicated acute bronchitis—they reduce cough by only half a day while causing adverse effects and promoting resistance.
Antibiotic Use
- Do not routinely prescribe antibiotics for acute bronchitis regardless of cough duration or sputum color 1, 3, 2.
- Antibiotics provide minimal benefit (reducing cough by approximately 0.5 days) while exposing patients to adverse effects and contributing to antibiotic resistance 3, 5, 6.
- The only exception is confirmed or suspected pertussis, which requires macrolide antibiotics (erythromycin) with 5 days of isolation 3.
Symptomatic Treatment
- Short-acting β-agonists (albuterol) may reduce cough duration and severity in patients with evidence of bronchial hyperresponsiveness or wheezing 1, 3, 2.
- Ipratropium bromide may improve cough in some patients 1, 2.
- Dextromethorphan or codeine are recommended for short-term symptomatic relief of bothersome cough 1, 3, 2.
- Avoid routine use of expectorants, mucolytics, antihistamines, NSAIDs at anti-inflammatory doses, or systemic corticosteroids—they lack evidence of benefit 1, 3, 2.
Patient Communication Strategy
- Inform patients that cough typically lasts 10-14 days after the office visit 1, 3, 2.
- Refer to the condition as a "chest cold" rather than bronchitis to reduce patient expectations for antibiotics 1, 3, 2.
- Explain that patient satisfaction depends more on quality of communication than receiving antibiotics 1, 3.
- Discuss risks of unnecessary antibiotic use including side effects and antibiotic resistance 1, 3.
Treatment of Chronic Bronchitis (Stable)
For stable chronic bronchitis, inhaled bronchodilators form the foundation of therapy, with inhaled corticosteroids added for severe disease.
Bronchodilator Therapy
- Short-acting β-agonists should be used to control bronchospasm, relieve dyspnea, and may reduce chronic cough 4, 2.
- Ipratropium bromide should be offered to improve cough 4, 2.
- Long-acting β-agonists combined with inhaled corticosteroids (ICS) should be offered to control chronic cough 4, 2.
- Theophylline may be considered to control chronic cough but requires careful monitoring for complications 4.
Corticosteroid Therapy
- Inhaled corticosteroids should be offered to patients with FEV1 <50% predicted or those with frequent exacerbations 4, 2.
- Do not use long-term oral corticosteroids (prednisone)—there is no evidence of benefit for cough and sputum production, and risks of serious side effects are high 4.
Lifestyle Modifications
- Avoidance of respiratory irritants is the cornerstone of therapy, with 90% of patients experiencing resolution of cough after smoking cessation 2.
Medications to Avoid
- Do not use expectorants—there is no evidence they are effective 4.
- Postural drainage and chest percussion have not proven beneficial 4.
Treatment of Acute Exacerbations of Chronic Bronchitis
Acute exacerbations require bronchodilators, systemic corticosteroids, and antibiotics in appropriate patients.
Bronchodilator Therapy
- Administer short-acting β-agonists OR anticholinergic bronchodilators during acute exacerbations 4, 2.
- If no prompt response, add the other agent after maximizing the first 4.
- Do not use theophylline for acute exacerbations—it provides no benefit 4.
Corticosteroid Therapy
- Administer a short course (10-15 days) of systemic corticosteroids—both IV therapy for hospitalized patients and oral therapy for ambulatory patients are effective 4, 2.
Antibiotic Therapy
- Antibiotics are recommended for acute exacerbations, particularly in patients with severe exacerbations and those with more severe baseline airflow obstruction 4, 2.
- Appropriate antibiotics include newer macrolides (clarithromycin), extended-spectrum cephalosporins, or doxycycline for moderate severity 7, 8.
- For severe exacerbations, use high-dose amoxicillin/clavulanate or respiratory fluoroquinolones 8, 9.
- Target pathogens include Haemophilus influenzae, Moraxella catarrhalis, and Streptococcus pneumoniae 7, 8, 9.
Medications to Avoid
- Do not use expectorants—no evidence of effectiveness 4.
- Postural drainage and chest percussion are not recommended 4.
Common Pitfalls to Avoid
- Do not prescribe antibiotics based solely on colored or purulent sputum in acute bronchitis 1, 2.
- Do not fail to distinguish between acute bronchitis and pneumonia—check vital signs and perform chest examination 1, 2.
- Do not overuse expectorants, mucolytics, and antihistamines which lack evidence of benefit 1, 2.
- Do not ignore underlying conditions (asthma, COPD, cardiac failure, diabetes) that may be exacerbated by bronchitis 1, 2.
- Do not use theophylline for acute exacerbations of chronic bronchitis 4, 2.