What is the appropriate treatment plan for a patient with acute bronchitis whose symptoms worsen at night?

Treatment Plan for Acute Bronchitis with Nocturnal Symptom Worsening

For a 2-week duration of acute bronchitis with nighttime worsening, consider cough-variant asthma and treat with a short-acting bronchodilator like albuterol, while avoiding antibiotics. 1, 2

Key Diagnostic Consideration

The nighttime worsening pattern is a critical red flag that should prompt you to consider cough-variant asthma rather than simple acute bronchitis. 1 Cough-variant asthma is characterized by:

• Persistent cough that worsens at night or after exposure to cold or exercise 1
• Lack of wheezing 1
• Usually normal pulmonary function tests 1
• Improvement with bronchodilator treatment 1

While guidelines typically reserve the diagnosis of cough-variant asthma for cough lasting >2-3 weeks, the nocturnal worsening pattern at 2 weeks warrants empiric bronchodilator therapy. 1

Recommended Treatment Approach

First-Line Therapy: Bronchodilators

Prescribe albuterol (short-acting β-agonist) for symptomatic relief, as it reduces cough duration and severity in patients with bronchial hyperresponsiveness. 2, 3, 4 This is FDA-approved for relief of bronchospasm in patients with reversible obstructive airway disease and acute attacks of bronchospasm. 4

• Evidence shows albuterol is more effective than antibiotics, with only 41% of patients still coughing after 7 days versus 88% with erythromycin (P<0.05). 5
• Albuterol may also be beneficial as it addresses the underlying bronchial hyperresponsiveness that commonly occurs in acute bronchitis. 2, 3

Symptomatic Relief Options

Consider antitussives containing dextromethorphan or codeine for short-term relief of bothersome nighttime cough. 2, 3 These provide symptomatic relief without addressing the underlying pathophysiology but can improve sleep quality.

What NOT to Do

Do NOT prescribe antibiotics. 1, 2, 3 Routine antibiotic treatment of uncomplicated acute bronchitis is not recommended regardless of cough duration. 1, 2 Antibiotics only reduce cough by approximately half a day while causing adverse effects including allergic reactions, nausea, vomiting, and Clostridium difficile infection. 6, 7

Rule Out Pneumonia First

Before finalizing the diagnosis of acute bronchitis, ensure pneumonia is excluded by checking for: 1, 3, 8

• Heart rate >100 beats/min 1, 8
• Respiratory rate >24 breaths/min 1, 8
• Oral temperature >38°C 1, 8
• Focal chest examination findings (rales, egophony, fremitus) 1, 8

If all four are absent, chest radiography is not needed. 1, 3, 8

Common Pitfalls to Avoid

• Do not assume purulent sputum indicates bacterial infection requiring antibiotics—purulence reflects inflammatory cells from either viral or bacterial causes. 1, 3
• Do not ignore the nighttime worsening pattern—this suggests bronchial hyperresponsiveness that responds to bronchodilators, not antibiotics. 1
• Do not wait until 3 weeks to consider cough-variant asthma when the clinical pattern strongly suggests it at 2 weeks. 1

Patient Communication Strategy

Patient satisfaction depends more on physician-patient communication than on antibiotic prescription. 1, 2 Explain that:

• The cough typically lasts 2-3 weeks 6
• The nighttime worsening suggests airway hyperresponsiveness that responds to bronchodilators 1
• Antibiotics provide minimal benefit (only half a day improvement) with real risks 6, 7