What is the recommended treatment for a patient with chronic asthma experiencing bronchitis?

Treatment of Chronic Asthma with Acute Bronchitis

For a patient with chronic asthma experiencing an acute exacerbation (bronchitis), initiate short-acting bronchodilators (β-agonists or anticholinergic agents) immediately, add a short course of systemic corticosteroids (10-15 days), and consider antibiotics only if there is evidence of bacterial infection with purulent sputum and severe symptoms. 1

Immediate Bronchodilator Management

• Administer short-acting β-agonists or anticholinergic bronchodilators as first-line therapy during the acute exacerbation. 1
• If the patient does not show a prompt response to the first bronchodilator at maximal dose, add the other agent (i.e., if starting with β-agonist, add anticholinergic, or vice versa). 1
• For adults and children ≥2 years weighing at least 15 kg, albuterol 2.5 mg administered three to four times daily by nebulization is the standard dosing. 2

Systemic Corticosteroid Therapy

• A short course (10-15 days) of systemic corticosteroids should be given for acute exacerbations. 1
• IV therapy is effective for hospitalized patients, while oral therapy works well for ambulatory patients. 1
• This recommendation carries a Grade A evidence level with substantial net benefit. 1
• Research supports that methylprednisolone significantly improves airflow in patients with chronic bronchitis and acute respiratory insufficiency compared to placebo (P < 0.001). 3

Antibiotic Considerations

• Antibiotics are recommended for acute exacerbations when there is evidence of bacterial infection, particularly in patients with severe exacerbations and more severe baseline airflow obstruction. 1
• The indication for antibiotics is strongest when at least two of the three Anthonisen criteria are present: increased sputum volume, increased sputum purulence, and increased dyspnea. 1
• Patients with severe exacerbations are most likely to benefit from antibiotic therapy. 1
• Do not use prophylactic antibiotics in stable chronic bronchitis or asthma. 1

Critical Distinction: Asthma vs. Chronic Bronchitis

• The French guidelines specifically note that early chronic asthma has no indication for antibiotic therapy, but late-stage chronic asthma with considerable similarities to obstructive chronic bronchitis may warrant antibiotics during exacerbations. 1
• For patients with chronic asthma experiencing what appears to be bronchitis, prioritize the asthma exacerbation protocol (bronchodilators + systemic corticosteroids) first. 1

Therapies to Avoid During Acute Exacerbations

• Theophylline should not be used for treatment of acute exacerbations (Grade D recommendation). 1
• Currently available expectorants have no proven effectiveness and should not be used during acute exacerbations. 1
• Postural drainage and chest percussion have not proven clinical benefits and are not recommended. 1

Common Pitfalls and Caveats

• Do not mistake an asthma exacerbation for simple acute bronchitis—patients with underlying chronic asthma require more aggressive treatment with systemic corticosteroids, not just symptomatic care. 1
• Fever does not reliably distinguish viral from bacterial causes; however, fever persisting beyond 3 days suggests bacterial infection (bronchial superinfection or pneumonia). 1
• The presence of upper respiratory tract signs (rhinorrhea, nasal obstruction) suggests viral infection, which would not require antibiotics. 1
• If a previously effective dosage regimen fails to provide usual relief, this is often a sign of seriously worsening asthma requiring immediate reassessment of therapy. 2