What is the management plan for a patient with bronchitis?

SOAP Note for Bronchitis

Subjective

Chief Complaint:

• Cough (duration, character, productivity)
• Sputum production (color, amount)
• Dyspnea or shortness of breath
• Fever or constitutional symptoms
• Duration of symptoms (acute <3 weeks vs. chronic >3 months for 2 consecutive years) 1

Key History Points:

• Smoking history and pack-years 1
• Occupational/environmental exposures 1
• Previous episodes and frequency of exacerbations 2
• Baseline lung function if known (FEV1) 2
• Comorbidities (cardiac, pulmonary) 2
• Recent upper respiratory infection 1
• Pertussis exposure if cough >2 weeks 3

Objective

Vital Signs:

• Temperature, respiratory rate, heart rate, oxygen saturation 3
• Tachypnea, tachycardia, or hypoxia suggest pneumonia rather than bronchitis 3

Physical Examination:

• Lung auscultation: wheezing, rhonchi, or clear breath sounds 3
• Absence of focal consolidation findings (rules out pneumonia) 3
• Signs of respiratory distress 3

Diagnostic Considerations:

• Chest X-ray NOT routinely indicated unless pneumonia suspected (tachypnea, tachycardia, dyspnea, focal findings) 3
• Sputum color does NOT differentiate bacterial from viral infection 4

Assessment

Acute Bronchitis (Uncomplicated)

For patients WITHOUT chronic lung disease, the diagnosis is acute bronchitis when cough is present without pneumonia findings. 3, 4

• Viral etiology in >90% of cases 4
• Expected cough duration: 2-3 weeks 1, 3, 4
• Antibiotics are NOT indicated 1, 3, 5, 4

Acute Exacerbation of Chronic Bronchitis (AECB)

For patients with chronic bronchitis (productive cough most days for ≥3 months over 2 consecutive years), AECB is diagnosed when there is sudden deterioration with increased cough, sputum production, sputum purulence, and/or dyspnea. 1

Antibiotic Criteria for AECB: Antibiotics are indicated ONLY if patient has ≥1 key symptom (increased dyspnea, sputum production, or purulence) AND ≥1 risk factor: 2

• Age ≥65 years
• FEV1 <50% predicted
• ≥4 exacerbations in 12 months
• Comorbidities present

Plan

Acute Bronchitis (Uncomplicated)

Patient Education (CRITICAL):

• Refer to illness as "chest cold" rather than "bronchitis" to reduce antibiotic expectations 1
• Cough will last 10-14 days after visit 1
• Antibiotics provide minimal benefit (reduce cough by only half a day) with significant risks (allergic reactions, nausea, C. difficile) 3

Symptomatic Treatment:

• Albuterol inhaler 2 puffs every 4-6 hours as needed for cough/wheezing (50% reduction in cough at 7 days) 1
• Dextromethorphan or codeine for short-term cough suppression 1
• Avoid expectorants (no proven benefit) 1
• Environmental trigger avoidance (dust, dander) 1
• Humidified air 1

What NOT to Do:

• Do NOT prescribe antibiotics 1, 3, 5, 4
• Do NOT use NSAIDs at anti-inflammatory doses 6
• Do NOT use chest percussion/postural drainage 1

Acute Exacerbation of Chronic Bronchitis (AECB)

Bronchodilator Therapy:

• Start with short-acting β-agonist (albuterol) OR ipratropium bromide 250-500 μg nebulized every 4-6 hours 1
• If inadequate response to first agent at maximal dose, add the other agent 1
• Do NOT use theophylline for acute exacerbations 1

Corticosteroid Therapy:

• Prednisone 40 mg daily (0.5 mg/kg/day) for 5-7 days for acute exacerbations 6
• Improves lung function, oxygenation, and shortens recovery time 6
• IV therapy for hospitalized patients, oral for outpatients 1

Antibiotic Therapy (if criteria met above):

• Moderate severity: Azithromycin 500 mg daily x3 days, extended-spectrum cephalosporin, or doxycycline 7, 2
• Severe exacerbation (FEV1 <50%, age >65, comorbidities): Respiratory fluoroquinolone or high-dose amoxicillin-clavulanate 8, 2
• Azithromycin clinical cure rate 85% at Day 21-24 for AECB 7

Stable Chronic Bronchitis (Maintenance)

Smoking Cessation (MOST EFFECTIVE):

• 90% of patients achieve cough resolution after smoking cessation 1
• This is the single most effective intervention 1

Maintenance Bronchodilators:

• Short-acting β-agonists for bronchospasm and dyspnea 1
• Ipratropium bromide to improve cough 1
• Long-acting β-agonist + inhaled corticosteroid for chronic cough control 1

Inhaled Corticosteroids:

• Offer ICS if FEV1 <50% predicted OR frequent exacerbations 1

What NOT to Do:

• Do NOT use long-term prophylactic antibiotics 1
• Do NOT use long-term oral corticosteroids (prednisone) 1
• Do NOT use expectorants 1

Common Pitfalls to Avoid

• Prescribing antibiotics for acute bronchitis based on green sputum (color does not indicate bacterial infection) 4
• Mistaking acute bronchitis for pneumonia (check vital signs, lung exam) 3
• Using antibiotics for AECB without meeting criteria (must have key symptom + risk factor) 2
• Failing to emphasize expected cough duration (leads to unnecessary follow-up and antibiotic requests) 1, 3
• Using albuterol in patients on β-blockers (use ipratropium instead) 9