What is the treatment approach for bronchitis?

Treatment of Bronchitis

Acute Bronchitis: Antibiotics Are Not Indicated

Antibiotics should not be prescribed for uncomplicated acute bronchitis, regardless of cough duration or sputum color. 1, 2, 3 Viruses cause more than 90% of acute bronchitis cases, and antibiotics provide minimal benefit—reducing cough by only half a day while causing adverse effects including allergic reactions, gastrointestinal symptoms, and promoting antibiotic resistance. 4, 5

Key Diagnostic Considerations

• Rule out pneumonia before diagnosing acute bronchitis by assessing for tachycardia (>100 bpm), tachypnea (>24 breaths/min), fever (>38°C), and asymmetric lung findings on examination. 2, 5
• Chest radiography is not indicated in healthy, nonelderly adults without vital sign abnormalities or asymmetric lung sounds. 2
• Purulent (green or yellow) sputum does not indicate bacterial infection—it results from inflammatory cells and sloughed epithelial cells, not bacteria. 3, 4

Symptomatic Treatment for Acute Bronchitis

• Short-acting β-agonists (albuterol) should be offered to patients with wheezing or evidence of bronchial hyperresponsiveness to reduce cough duration and severity. 1, 2, 6
• Ipratropium bromide may improve cough in some patients. 2, 3, 6
• Dextromethorphan or codeine are recommended for short-term symptomatic relief of bothersome cough. 1, 2, 3
• Expectorants and mucolytics lack evidence of benefit and should not be used. 2, 3

Patient Communication Strategy

• Set realistic expectations: cough typically lasts 10-14 days after the visit, sometimes up to 3 weeks. 1, 3, 5
• Refer to the illness as a "chest cold" rather than "bronchitis"—this terminology reduces patient expectation for antibiotics. 1, 3
• Explain that antibiotics increase risk of antibiotic-resistant infections, cause side effects (diarrhea, nausea, rash), and rare serious reactions like anaphylaxis. 1
• Emphasize that patient satisfaction depends on quality communication and time spent, not antibiotic prescribing. 1, 3

Chronic Bronchitis: Avoidance and Bronchodilators

Avoidance of respiratory irritants is the cornerstone of therapy, with 90% of patients experiencing cough resolution after smoking cessation. 1, 2, 6 This is defined as cough with sputum production on most days for at least 3 months per year for 2 consecutive years. 1, 3

Maintenance Treatment for Stable Chronic Bronchitis

• Short-acting β-agonists should be used to control bronchospasm and may reduce chronic cough. 1, 2, 6
• Ipratropium bromide should be offered to improve cough. 1, 2, 6
• Long-acting β-agonists combined with inhaled corticosteroids should be offered to control chronic cough. 1, 2, 6
• Inhaled corticosteroids should be offered to patients with FEV1 <50% predicted or those with frequent exacerbations (≥4 per year). 1, 3, 6
• Theophylline may be considered to control chronic cough but requires careful monitoring for complications. 1

What NOT to Use in Stable Chronic Bronchitis

• Prophylactic antibiotics are not recommended. 1, 6
• Expectorants lack evidence of effectiveness. 1, 2
• Postural drainage and chest physiotherapy have not proven beneficial. 1

Acute Exacerbations of Chronic Bronchitis: When Antibiotics ARE Indicated

Antibiotics are recommended for acute exacerbations of chronic bronchitis, particularly in patients with severe exacerbations and baseline airflow obstruction. 2, 6, 7 The French guidelines specify antibiotics when at least 2 of 3 Anthonisen criteria are present: increased dyspnea, increased sputum volume, and increased sputum purulence. 1

Risk Stratification for Antibiotic Use

Immediate antibiotics are indicated for:

• Patients with chronic obstructive bronchitis AND chronic respiratory insufficiency (dyspnea at rest and/or FEV1 <35% and hypoxemia at rest). 1
• Patients with at least 2 of 3 Anthonisen criteria (increased dyspnea, sputum volume, sputum purulence) AND risk factors: age ≥65 years, FEV1 <50% predicted, ≥4 exacerbations in 12 months, or comorbidities. 8

Antibiotics may be considered for:

• Patients aged ≥75 years with fever. 3
• Patients with cardiac failure. 3

Antibiotics NOT immediately indicated for:

• Simple chronic bronchitis exacerbations (no obstruction, FEV1 >80%) unless fever >38°C persists beyond 3 days. 1

Antibiotic Selection

For moderate exacerbations (infrequent, FEV1 ≥35%):

• First-line: Amoxicillin, newer macrolides (azithromycin), extended-spectrum cephalosporins, or doxycycline. 1, 8
• Azithromycin 500 mg daily for 3 days showed 85% clinical cure rate at Day 21-24. 7

For severe exacerbations (frequent exacerbations ≥4/year, FEV1 <35%, or significant comorbidities):

• High-dose amoxicillin/clavulanate or respiratory fluoroquinolones. 9, 8
• Fluoroquinolones should be first-line in patients with severe obstruction, age >65 years, or recurrent exacerbations due to increasing resistance and Pseudomonas risk. 9

Additional Treatment for Acute Exacerbations

• Short-acting β-agonists or anticholinergic bronchodilators should be administered; if no prompt response, add the other agent. 1, 2, 6
• Systemic corticosteroids (10-15 day course) are effective for acute exacerbations, particularly when airflow obstruction is moderately severe or worse. 2, 6, 10
• Theophylline should NOT be used for acute exacerbations. 1, 3, 6

Critical Pitfalls to Avoid

• Do not prescribe antibiotics based solely on colored sputum—this does not indicate bacterial infection. 2, 3, 4
• Do not confuse acute bronchitis with pneumonia—check vital signs and lung examination findings systematically. 2, 5
• Do not use expectorants, mucolytics, or antihistamines—they lack evidence of benefit. 2, 3
• Do not overlook underlying conditions that may be exacerbated (asthma, COPD, heart failure, diabetes). 2, 3
• Do not use antibiotics for acute bronchitis over the phone—examination is essential to rule out pneumonia. 10
• Do not underestimate obstruction severity based on physical exam alone—pulmonary function testing is important in smoking patients. 10