What is the initial approach to managing bronchitis?

Initial Management of Bronchitis

Distinguish Between Acute and Chronic Bronchitis First

The initial approach depends critically on whether you are managing acute bronchitis or chronic bronchitis with acute exacerbation—these require fundamentally different strategies.

For Acute Bronchitis (Most Common Presentation)

Do not prescribe antibiotics routinely for acute bronchitis, as they provide minimal benefit (reducing cough by only 0.5 days) while exposing patients to adverse effects. 1, 2, 3

Initial Assessment

• Diagnose clinically based on history and physical examination alone—routine laboratory tests and chest radiography are not indicated 1, 4
• Rule out pneumonia by checking for: heart rate >100 beats/min, respiratory rate >24 breaths/min, oral temperature >38°C, or focal chest examination findings (rales, egophony, tactile fremitus) 1, 4
• If these vital sign abnormalities or asymmetric lung sounds are present, obtain chest radiography to exclude pneumonia 5, 4
• The presence of purulent or colored sputum does NOT indicate bacterial infection and is NOT an indication for antibiotics 1, 2, 3

Treatment Approach

• Provide symptomatic management and patient education only 1, 3
• Inform patients that cough typically lasts 10-14 days after the visit, and may persist up to 3 weeks 1, 5, 2
• Refer to the condition as a "chest cold" rather than bronchitis to reduce patient expectations for antibiotics 1, 6
• Explain that patient satisfaction depends more on physician-patient communication than whether an antibiotic is prescribed 1

Symptomatic Treatment Options

• β2-agonist bronchodilators should NOT be routinely used, but may be considered in select patients with wheezing accompanying the cough 1, 4
• Codeine or dextromethorphan may provide modest short-term relief of bothersome cough 1, 5
• Low-cost interventions like elimination of environmental cough triggers and humidified air may be reasonable 1

Exception: Pertussis

• If pertussis is confirmed or suspected, prescribe a macrolide antibiotic (such as erythromycin or azithromycin) 1
• Isolate patients for 5 days from the start of treatment 1
• Early treatment within the first few weeks diminishes coughing paroxysms and prevents disease spread 1

For Chronic Bronchitis with Acute Exacerbation

Antibiotics ARE indicated for acute exacerbations of chronic bronchitis, particularly in patients with severe exacerbations and more severe baseline airflow obstruction. 5, 7

Diagnostic Criteria

• Chronic bronchitis is defined as cough with sputum production on most days for at least 3 months per year for at least 2 consecutive years 8, 5
• Acute exacerbation is characterized by unstable lung function with worsening airflow and symptoms 7

When to Prescribe Antibiotics

Reserve antibacterial treatment for patients with at least 1 key symptom AND at least 1 risk factor: 7

Key symptoms (need ≥1):

• Increased dyspnea
• Increased sputum production
• Increased sputum purulence 7

Risk factors (need ≥1):

• Age ≥65 years
• FEV1 <50% of predicted value
• ≥4 exacerbations in 12 months
• One or more comorbidities 7

Antibiotic Selection

• For moderate severity exacerbations: newer macrolide (azithromycin), extended-spectrum cephalosporin, or doxycycline 7
• For severe exacerbations: high-dose amoxicillin/clavulanate or a respiratory fluoroquinolone 7
• Common bacterial pathogens include S. pneumoniae, H. influenzae, and M. catarrhalis 8, 9, 7

Additional Management for Acute Exacerbations

• Administer short-acting β-agonists or anticholinergic bronchodilators 5
• Prescribe a short course (10-15 days) of systemic corticosteroids 5
• Provide supportive care including removal of irritants, oxygen if needed, hydration, and chest physical therapy as appropriate 7

Common Pitfalls to Avoid

• Do not prescribe antibiotics based solely on colored sputum in acute bronchitis 1, 5
• Do not fail to distinguish between acute bronchitis and pneumonia—check vital signs and perform thorough chest examination 5, 4
• Do not use expectorants and mucolytics—they lack evidence of benefit 5, 4
• Do not overlook underlying conditions (asthma, COPD, cardiac failure, diabetes) that may be exacerbated 5
• Do not use theophylline for acute exacerbations of chronic bronchitis 5