What are the treatment options for bronchitis?

Bronchitis Treatment

Acute Bronchitis

Antibiotics should NOT be prescribed for acute bronchitis, as viruses cause over 90% of cases and antibiotics provide minimal benefit (reducing cough by only half a day) while causing significant adverse effects. 1, 2, 3, 4

Symptomatic Management

• Short-acting β-agonists (albuterol) may reduce cough duration and severity in patients with evidence of bronchial hyperresponsiveness 1, 2
• Ipratropium bromide may improve cough in some patients 1, 2
• Dextromethorphan or codeine are recommended for short-term symptomatic relief of bothersome cough 1, 2

When to Consider Antibiotics (Rare Exceptions)

• Patients aged ≥75 years with fever 5
• Patients with cardiac failure 5
• When pertussis is suspected to reduce transmission 1, 3

Critical Diagnostic Step

• Rule out pneumonia by assessing for tachycardia, tachypnea, fever, and abnormal chest examination findings before diagnosing uncomplicated bronchitis 2, 5, 4
• Chest radiography is usually not indicated in healthy, nonelderly adults without vital sign abnormalities or asymmetrical lung sounds 2

Chronic Bronchitis (Stable)

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

First-Line Bronchodilator Therapy

• Short-acting β-agonists should be used to control bronchospasm and relieve dyspnea; may also reduce chronic cough 6, 1
• Ipratropium bromide should be offered to improve cough 6, 1
• Theophylline should be considered to control chronic cough, but requires careful monitoring for complications 6

Advanced Therapy for Persistent Symptoms

• Long-acting β-agonists combined with inhaled corticosteroids should be offered to control chronic cough 6, 1
• Inhaled corticosteroids alone should be offered to patients with FEV1 <50% predicted or those with frequent exacerbations 6, 1, 5

Treatments NOT Recommended

• Expectorants lack evidence of effectiveness and should not be used 6, 1
• Postural drainage and chest percussion have not proven beneficial 6
• Long-term prophylactic antibiotics are not recommended 1

Acute Exacerbations of Chronic Bronchitis (AECB)

Short-acting β-agonists or anticholinergic bronchodilators should be administered immediately; if no prompt response, add the other agent after maximizing the first. 6, 1

Systemic Corticosteroids

• A short course (10-15 days) of systemic corticosteroids is effective for acute exacerbations 6, 1
• IV therapy for hospitalized patients and oral therapy for ambulatory patients are both effective 6
• A 2-week course is equivalent to an 8-week course with fewer side effects 6

Antibiotic Therapy

• Antibiotics are recommended for acute exacerbations, particularly for patients with severe exacerbations and those with more severe airflow obstruction at baseline 1, 2
• Reserve antibiotics for patients with at least 2 of 3 cardinal symptoms: increased dyspnea, increased sputum production, increased sputum purulence 7, 8
• Risk factors warranting antibiotics: age ≥65 years, FEV1 <50% predicted, ≥4 exacerbations in 12 months, or comorbidities 7

Antibiotic Selection

• Moderate severity: newer macrolide (azithromycin), extended-spectrum cephalosporin, or doxycycline 7
• Severe exacerbation: high-dose amoxicillin/clavulanate or respiratory fluoroquinolone 9, 7
• Azithromycin 500 mg once daily for 3 days showed 85% clinical cure rate at Day 21-24 for AECB 10

Treatments NOT Recommended During Exacerbations

• Theophylline should NOT be used for acute exacerbations 6, 1, 5
• Expectorants are not effective and should not be used 6, 1
• Mucokinetic agents are not useful during acute exacerbations 6

Common Pitfalls to Avoid

• Do not prescribe antibiotics based solely on colored sputum - purulent sputum results from inflammatory cells, not necessarily bacterial infection 2, 5, 3
• Do not fail to distinguish acute bronchitis from pneumonia - check vital signs and lung examination carefully 2, 5
• Do not use theophylline for acute exacerbations despite its benefit in stable chronic bronchitis 6, 5
• Do not underestimate airflow obstruction - routine pulmonary function testing is important as physical exam alone underestimates severity 8

Patient Communication Strategies

• Set realistic expectations: cough typically lasts 10-14 days after the office visit 5, 4
• Consider calling the illness a "chest cold" rather than bronchitis to reduce antibiotic expectations 5, 4
• Explain that patient satisfaction depends more on quality of clinical encounter than receiving antibiotics 5
• Discuss risks of unnecessary antibiotic use including side effects and antibiotic resistance 5