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 (self-limited viral infection) or chronic bronchitis (chronic inflammatory condition), as these require fundamentally different management strategies. 1, 2

For Acute Bronchitis

Diagnosis and Assessment

• Diagnose clinically based on history and physical examination alone—do not routinely order laboratory tests or chest radiography. 1, 3
• Rule out pneumonia by checking for vital sign abnormalities: heart rate >100 bpm, respiratory rate >24 breaths/min, oral temperature >38°C, or focal chest examination findings (rales, egophony, tactile fremitus). 1, 3
• If these findings are absent, pneumonia is unlikely and chest x-ray is not needed. 3, 4
• Consider pertussis if cough persists beyond 2-3 weeks with paroxysmal features, whooping, or post-tussive vomiting. 1, 4

Treatment Approach

• Do NOT prescribe antibiotics routinely—they reduce cough duration by only 0.5 days while exposing patients to adverse effects including allergic reactions, gastrointestinal symptoms, and C. difficile infection. 1, 5, 6
• The presence of purulent or colored sputum does NOT indicate bacterial infection and is NOT an indication for antibiotics. 1, 3
• Exception: Prescribe a macrolide antibiotic (erythromycin) if pertussis is confirmed or suspected, and isolate the patient for 5 days from treatment start. 1

Symptomatic Management

• Do NOT routinely prescribe β2-agonist bronchodilators for most patients. 1, 3
• Consider a trial of β2-agonists only in select patients with wheezing accompanying the cough. 1, 3
• Antitussive agents (codeine or dextromethorphan) may provide modest short-term relief for bothersome cough. 1, 2
• Do NOT use systemic corticosteroids, NSAIDs at anti-inflammatory doses, or chest physiotherapy. 1, 2

Patient Education

• Inform patients that cough typically lasts 10-14 days after the visit, even up to 2-3 weeks—this is the most important intervention. 1, 6, 4
• Refer to the condition as a "chest cold" rather than "bronchitis" to reduce antibiotic expectations. 1, 4
• Explain that patient satisfaction depends more on physician-patient communication than whether antibiotics are prescribed. 1

For Chronic Bronchitis (Stable)

Definition and Assessment

• Chronic bronchitis is defined as cough with sputum production on most days for at least 3 months per year for 2 consecutive years. 2, 7
• Assess for risk factors including smoking history, environmental irritants, and severity of airflow obstruction. 2

Management Approach

• Smoking cessation is the cornerstone of therapy—90% of patients experience resolution of cough after quitting. 2
• Prescribe short-acting β-agonists (albuterol) to control bronchospasm and reduce chronic cough. 2
• Offer ipratropium bromide to improve cough symptoms. 2
• Prescribe long-acting β-agonists combined with inhaled corticosteroids for persistent symptoms. 2

For Acute Exacerbations of Chronic Bronchitis (AECB)

When to Treat with Antibiotics

• Reserve antibiotics for patients with at least one cardinal symptom (increased dyspnea, increased sputum production, or increased sputum purulence) AND at least one risk factor. 2, 7
• Risk factors include: age ≥65 years, FEV₁ <50% predicted, ≥4 exacerbations in 12 months, or comorbidities. 7
• Patients with severe COPD associated with chronic bronchitis benefit most from antibiotic therapy. 8, 9

Treatment for AECB

• Administer short-acting β-agonists or anticholinergic bronchodilators during acute exacerbations. 2
• Prescribe antibiotics for moderate severity: newer macrolides, extended-spectrum cephalosporins, or doxycycline. 7
• For severe exacerbations: high-dose amoxicillin/clavulanate or respiratory fluoroquinolones. 10, 7
• Administer a short course (10-15 days) of systemic corticosteroids for acute exacerbations. 2

Common Pitfalls to Avoid

• Do NOT prescribe antibiotics based solely on colored sputum—this does not indicate bacterial infection. 1, 3
• Do NOT fail to distinguish between acute bronchitis and pneumonia—check vital signs and perform chest examination. 2, 3
• Do NOT use expectorants or mucolytics—they lack evidence of benefit. 2, 3
• Do NOT overlook underlying conditions (asthma, COPD, heart failure) that may be exacerbated. 2
• Do NOT use theophylline for acute exacerbations of chronic bronchitis. 2