What is the treatment for bronchitis?

Treatment for Bronchitis

Acute Bronchitis: Avoid Antibiotics

For acute bronchitis in otherwise healthy adults, antibiotics should NOT be prescribed, as viruses cause more than 90% of cases and antibiotics provide minimal benefit (reducing cough by only half a day) while causing adverse effects. 1, 2, 3, 4

Symptomatic Management for Acute Bronchitis

• Set realistic expectations: Inform patients their cough will typically last 10-14 days after the visit, with total duration of 2-3 weeks 5, 4

• Use the term "chest cold" rather than "bronchitis" when discussing the illness, as this terminology reduces patient expectations for antibiotics 5, 2

• Consider short-acting β-agonists (albuterol) for patients with evidence of bronchial hyperresponsiveness or wheezing, which may reduce cough duration and severity 1, 2

• Ipratropium bromide may improve cough in some patients with acute bronchitis 1, 2

• Dextromethorphan or codeine can provide short-term symptomatic relief for bothersome cough, though evidence shows modest effect 5, 1, 2

• Environmental modifications: Remove irritants (dust, dander) and consider vaporized air treatments, particularly in low-humidity environments 5

When to Consider Antibiotics in Acute Bronchitis

• Only if pertussis is suspected to reduce transmission 3
• Only for patients at increased risk of pneumonia (age ≥65 years) 3
• Rule out pneumonia first by assessing for tachycardia, tachypnea, fever, and abnormal chest examination findings 2

Chronic Bronchitis: Stepwise Bronchodilator Approach

Smoking cessation is the cornerstone of therapy, with 90% of patients experiencing resolution of cough after quitting. 1, 2

Stable Chronic Bronchitis Treatment Algorithm

1. First-line: Short-acting β-agonists to control bronchospasm and reduce chronic cough (Grade A recommendation) 5, 1, 2

2. Add ipratropium bromide to improve cough if β-agonists alone are insufficient (Grade A recommendation) 5, 1, 2

3. Consider theophylline for chronic cough control in stable patients, though careful monitoring for complications is necessary (Grade A recommendation) 5

4. For severe airflow obstruction (FEV₁ <50%) or frequent exacerbations: Add long-acting β-agonist combined with inhaled corticosteroid 5, 1, 2

Treatments NOT Recommended for Stable Chronic Bronchitis

• Expectorants and mucolytics lack evidence of benefit 1, 2
• Long-term prophylactic antibiotics are not recommended 1, 2
• Oral corticosteroids have no proven benefit in stable patients and carry significant side effects 5

Acute Exacerbations of Chronic Bronchitis: Antibiotics ARE Indicated

For acute exacerbations, prescribe antibiotics for patients with at least 2 of 3 cardinal symptoms (increased dyspnea, increased sputum production, increased sputum purulence) AND at least one risk factor. 6

Risk Factors Requiring Antibiotic Treatment

• Age ≥65 years 6
• FEV₁ <50% of predicted value 6
• ≥4 exacerbations in 12 months 6
• One or more comorbidities 6

Antibiotic Selection for Acute Exacerbations

For moderate severity exacerbations: Newer macrolide (azithromycin), extended-spectrum cephalosporin, or doxycycline 6

For severe exacerbations or high-risk patients (age >65, severe obstruction, recurrent exacerbations): High-dose amoxicillin/clavulanate or respiratory fluoroquinolone 7, 6

• Azithromycin 500 mg once daily for 3 days showed 85% clinical cure rate at Day 21-24 for acute exacerbations 8

Additional Management for Acute Exacerbations

• Bronchodilators: Administer short-acting β-agonists or anticholinergic bronchodilators; if no prompt response, add the other agent after maximizing the first (Grade A recommendation) 5, 1, 2

• Systemic corticosteroids: A short course (10-15 days) is effective for acute exacerbations 1, 2

• DO NOT use theophylline for acute exacerbations (Grade D recommendation) 5, 1, 2

Common Pitfalls to Avoid

• Do not prescribe antibiotics based solely on colored sputum, as this does not reliably differentiate bacterial from viral infection 2, 3

• Do not confuse acute bronchitis with pneumonia—always assess vital signs and lung examination before diagnosing uncomplicated bronchitis 2

• Do not use expectorants or mucolytics, which lack evidence of benefit for either acute or chronic bronchitis 1, 2

• Avoid prophylactic antibiotics in stable chronic bronchitis patients 1, 2

• Communicate effectively about the natural course of illness and lack of antibiotic benefit to maintain patient satisfaction without inappropriate prescribing 5, 4