What is the initial approach to managing bronchitis?

Initial Management of Bronchitis

Distinguish Between Acute and Chronic Bronchitis First

The initial approach to managing bronchitis depends critically on whether you are dealing with acute bronchitis (a self-limited viral illness) or chronic bronchitis (a chronic inflammatory condition), as these require fundamentally different management strategies. 1, 2

For Acute Bronchitis (Most Common Presentation)

Diagnosis and Assessment

• Diagnose clinically based on acute cough (with or without sputum) lasting up to 3 weeks in a patient with normal vital signs and chest examination 1, 3
• Rule out pneumonia by checking for: heart rate >100 bpm, respiratory rate >24 breaths/min, temperature >38°C, or focal chest findings (rales, egophony, fremitus) 1, 3
• Do not order chest x-rays, sputum cultures, or other laboratory tests routinely - these are unnecessary in uncomplicated cases 3, 4
• The presence of green or purulent sputum does NOT indicate bacterial infection and should NOT trigger antibiotic use 1, 4

Treatment Approach

Do NOT prescribe antibiotics - they reduce cough duration by only 0.5 days while exposing patients to adverse effects and contributing to resistance 1, 3, 4, 5

Provide symptomatic management and patient education:

• Inform patients that cough typically lasts 10-14 days (sometimes up to 3 weeks) after the visit 1, 2
• Refer to the condition as a "chest cold" rather than "bronchitis" to reduce antibiotic expectations 1, 3
• Recommend elimination of environmental irritants and humidified air 1, 2
• Consider dextromethorphan or codeine for short-term relief of bothersome cough 1, 2
• Do NOT routinely prescribe β2-agonist bronchodilators unless the patient has wheezing 1, 3
• Do NOT prescribe corticosteroids, NSAIDs at anti-inflammatory doses, expectorants, mucolytics, or antihistamines - these lack evidence of benefit 1, 2

Exception - Pertussis

If pertussis is suspected or confirmed, prescribe a macrolide antibiotic (erythromycin or azithromycin) and isolate the patient for 5 days from treatment start 1, 6

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For Chronic Bronchitis (Defined as productive cough ≥3 months/year for ≥2 consecutive years)

Initial Management

• Smoking cessation is the cornerstone of therapy - 90% of patients experience resolution after quitting 2
• Eliminate other respiratory irritants 2
• Prescribe short-acting β2-agonists (albuterol) to control bronchospasm 2
• Add ipratropium bromide to improve cough 2
• Consider long-acting β2-agonists combined with inhaled corticosteroids for persistent symptoms 2

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For Acute Exacerbations of Chronic Bronchitis (AECB)

This is the ONE scenario where antibiotics ARE indicated for bronchitis. 7, 1, 2

When to Prescribe Antibiotics

Use antibiotics if the patient has at least ONE key symptom (increased dyspnea, increased sputum volume, or increased sputum purulence) PLUS at least ONE risk factor: 1, 8

• Age ≥65 years 1, 8
• FEV1 <50% predicted 1, 8
• ≥4 exacerbations in past 12 months 8
• Comorbidities (cardiac failure, diabetes, immunosuppression) 1, 8

Antibiotic Selection Based on Severity

For moderate-severity exacerbations (patients with some risk factors):

• First-line: Doxycycline 100 mg twice daily for 7-10 days 1
• Alternatives: Newer macrolide (azithromycin), extended-spectrum cephalosporin 1, 8

For severe exacerbations (multiple risk factors, FEV1 <50%, frequent exacerbations):

• First-line: High-dose amoxicillin/clavulanate 625 mg three times daily for 14 days 1
• Alternative: Respiratory fluoroquinolone 1, 9, 8

Pathogen-specific considerations (if known):

• S. pneumoniae: Amoxicillin 500 mg-1 g three times daily for 14 days OR doxycycline 100 mg twice daily 1
• H. influenzae (β-lactamase positive): Amoxicillin/clavulanate 625 mg three times daily 1
• M. catarrhalis: Amoxicillin/clavulanate OR clarithromycin 500 mg twice daily 1

Additional Management for AECB

• Administer short-acting bronchodilators or anticholinergics 2
• Prescribe systemic corticosteroids (10-15 day course) for acute exacerbations 2
• Provide oxygen if needed 2
• Ensure adequate hydration 2

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Critical Pitfalls to Avoid

• Do NOT prescribe antibiotics for acute bronchitis based on colored sputum alone - this does not indicate bacterial infection 1, 4
• Do NOT use simple aminopenicillins for AECB - up to 25% of H. influenzae and 50-70% of M. catarrhalis produce β-lactamase 1
• Do NOT fail to distinguish acute bronchitis from pneumonia - check vital signs and perform chest examination 1, 3
• Do NOT prescribe theophylline for AECB - it lacks evidence of benefit 2
• If symptoms persist beyond 3 weeks or recur frequently, consider underlying asthma, COPD, or bronchiectasis 3