What is the initial approach to managing bronchitis?

Initial Management of Bronchitis

Distinguish Between Acute and Chronic Bronchitis First

The initial approach to managing bronchitis depends critically on whether you are dealing with acute bronchitis (a self-limited viral illness) or chronic bronchitis/acute exacerbation of chronic bronchitis (AECB), as these require fundamentally different management strategies. 1, 2

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Acute Bronchitis Management

Diagnosis and Assessment

• Diagnose clinically based on acute cough (with or without sputum) lasting up to 3 weeks in a patient with normal vital signs and chest examination 1, 3
• Rule out pneumonia by checking for: heart rate >100 bpm, respiratory rate >24 breaths/min, temperature >38°C, or focal chest findings (rales, egophony, tactile fremitus) 1, 4
• Do not order chest radiography, sputum cultures, or other diagnostic tests unless pneumonia or other specific conditions are suspected 1, 4
• The presence of purulent or colored sputum does NOT indicate bacterial infection and should NOT guide antibiotic decisions 1, 4

Treatment Approach

• Do NOT prescribe antibiotics routinely—they reduce cough duration by only 0.5 days while exposing patients to adverse effects 1, 4, 5
• Inform patients that cough typically lasts 10-14 days after the visit, and may persist up to 3 weeks 1, 3
• Refer to the condition as a "chest cold" rather than "bronchitis" to reduce patient expectations for antibiotics 1, 5
• Do NOT routinely use β2-agonist bronchodilators, though they may be considered in select patients with wheezing 1, 2
• Codeine or dextromethorphan may provide modest symptomatic relief 1, 2
• Do NOT use systemic corticosteroids or NSAIDs at anti-inflammatory doses 2

Exception: Pertussis

• If pertussis is confirmed or suspected, prescribe a macrolide antibiotic (such as erythromycin) and isolate the patient for 5 days from treatment start 1, 2

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Chronic Bronchitis and Acute Exacerbations (AECB)

Initial Assessment

• Chronic bronchitis is defined as cough with sputum production on most days for at least 3 months per year for 2 consecutive years 6, 2
• Assess for acute exacerbation by identifying at least one cardinal symptom: increased dyspnea, increased sputum production, or increased sputum purulence 6, 7

Risk Stratification for AECB

Antibiotics should be reserved for patients with at least one cardinal symptom PLUS at least one risk factor: 7

• Age ≥65 years
• FEV1 <50% predicted
• ≥4 exacerbations in past 12 months
• Presence of comorbidities (cardiac disease, diabetes, immunosuppression)

Treatment of AECB

• Administer short-acting β-agonists or anticholinergic bronchodilators during acute exacerbations 2
• Prescribe a short course (10-15 days) of systemic corticosteroids 2
• For patients meeting criteria above, prescribe antibiotics targeting S. pneumoniae, H. influenzae, and M. catarrhalis 6, 7
  • Moderate severity: newer macrolide, extended-spectrum cephalosporin, or doxycycline 7
  • Severe exacerbation or high-risk patients: high-dose amoxicillin/clavulanate or respiratory fluoroquinolone 8, 7

Long-term Management of Chronic Bronchitis

• Smoking cessation is the cornerstone—90% of patients experience resolution of cough after quitting 2
• Short-acting β-agonists for bronchospasm control 2
• Ipratropium bromide to improve cough 2
• Long-acting β-agonists combined with inhaled corticosteroids for chronic cough control 2

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Critical Pitfalls to Avoid

• Do NOT prescribe antibiotics for acute bronchitis based on colored sputum alone—this does not indicate bacterial infection 1, 4
• Do NOT fail to distinguish acute bronchitis from pneumonia—check vital signs and perform thorough chest examination 1, 4
• Do NOT use antibiotics for AECB in patients without cardinal symptoms and risk factors 7
• Do NOT use expectorants or mucolytics—they lack evidence of benefit 2
• Patient satisfaction depends more on clear communication about expected illness duration than on antibiotic prescribing 1, 5