What is the recommended treatment plan for bronchitis?

Treatment Plan for Bronchitis

Distinguish Between Acute and Chronic Bronchitis First

The treatment approach differs fundamentally based on whether the patient has acute bronchitis (self-limited viral infection) or chronic bronchitis (chronic productive cough ≥3 months for 2 consecutive years), so accurate classification is essential before initiating therapy. 1, 2

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Acute Bronchitis Management

Rule Out Pneumonia and Other Diagnoses

• Assess vital signs: tachycardia (>100 bpm), tachypnea (>24 breaths/min), fever (>38°C), or abnormal lung findings (rales, egophony, fremitus) suggest pneumonia requiring chest radiography 1, 3
• Consider pertussis if cough persists >2 weeks with paroxysmal features, whooping, or post-tussive vomiting 1, 4
• Evaluate for asthma, COPD exacerbation, heart failure, or COVID-19/influenza if clinically indicated 5

Do NOT Prescribe Antibiotics

• Antibiotics should not be prescribed for uncomplicated acute bronchitis regardless of cough duration, sputum color, or patient expectations 1, 2, 3
• Purulent sputum occurs in 89-95% of viral cases and does not indicate bacterial infection 1, 3
• Antibiotics reduce cough by only 0.5 days while causing adverse effects (allergic reactions, GI symptoms, C. difficile risk) 1, 5, 4
• Exception: Prescribe macrolide antibiotics (azithromycin or erythromycin) only for confirmed or suspected pertussis, with 5-day isolation from treatment start 1, 3

Symptomatic Treatment Options

• Short-acting β-agonists (albuterol) may reduce cough duration and severity in patients with wheezing or bronchial hyperresponsiveness 1, 2, 3
• Codeine or dextromethorphan provide modest short-term relief for bothersome dry cough, especially when sleep is disturbed 1, 2, 3
• Ipratropium bromide may improve cough in select patients 1, 2
• Avoid expectorants, mucolytics, antihistamines, inhaled corticosteroids, and NSAIDs at anti-inflammatory doses—no evidence of benefit 1, 3

Patient Education

• Inform patients that cough typically lasts 10-14 days after the visit, with most symptoms resolving within 3 weeks 1, 3, 5
• Refer to the condition as a "chest cold" rather than "bronchitis" to reduce antibiotic expectations 1, 3
• Explain that satisfaction depends on communication quality, not antibiotic prescribing 1, 3
• Discuss risks of unnecessary antibiotics: side effects and antibiotic resistance 1, 3

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Chronic Bronchitis Management (Stable Disease)

Eliminate Respiratory Irritants

• Smoking cessation is the most effective intervention—90% of patients experience cough resolution after quitting 6, 2
• Remove passive smoke exposure and workplace/environmental irritants 6, 2

Bronchodilator Therapy

• Short-acting β-agonists should be used to control bronchospasm, relieve dyspnea, and may reduce chronic cough 6, 2
• Ipratropium bromide should be offered to improve cough and reduce sputum volume 6, 2
• Theophylline may be considered for chronic cough control but requires careful monitoring for complications 6

Inhaled Corticosteroid Therapy

• Long-acting β-agonist combined with inhaled corticosteroid should be offered to control chronic cough 6, 1, 2
• Inhaled corticosteroids alone should be offered for patients with FEV1 <50% predicted or frequent exacerbations 6, 1, 2
• Do NOT use long-term oral corticosteroids (prednisone)—no evidence of benefit and high risk of serious side effects 6

What NOT to Use

• No role for prophylactic antibiotics in stable chronic bronchitis due to resistance concerns and side effects 6, 2
• Expectorants are not effective and should not be used 6
• Postural drainage and chest percussion have not proven beneficial 6, 2

Antitussive Agents

• Codeine or dextromethorphan are recommended for short-term symptomatic relief when cough is troublesome (suppress cough by 40-60%) 6

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Acute Exacerbation of Chronic Bronchitis

Diagnostic Criteria

• Sudden deterioration with increased cough, sputum production, sputum purulence, and/or dyspnea, often preceded by upper respiratory infection 6, 2
• Rule out other conditions (pneumonia, heart failure) 6

Bronchodilator Therapy

• Administer short-acting β-agonists or anticholinergic bronchodilators immediately 6, 1, 2
• If no prompt response, add the other agent after maximizing the first 6
• Do NOT use theophylline for acute exacerbations 6

Antibiotic Therapy

• Antibiotics are recommended, especially for patients with severe exacerbations (all three cardinal symptoms: increased dyspnea, sputum volume, and purulence) and those with baseline FEV1 <50% 6, 2, 7
• First-line options for moderate severity: doxycycline 100 mg twice daily for 7-10 days 3
• For severe exacerbations: high-dose amoxicillin/clavulanate 625 mg three times daily for 14 days 3
• Alternative: newer macrolides or extended-spectrum cephalosporins 7
• Avoid simple aminopenicillins alone due to β-lactamase resistance (25% H. influenzae, 50-70% M. catarrhalis) 3

Systemic Corticosteroid Therapy

• A short course (10-15 days) of systemic corticosteroids should be given: IV for hospitalized patients, oral for ambulatory patients 6, 1, 2
• Use 2-week course rather than 8-week course to minimize side effects 6

What NOT to Use

• Expectorants are not effective during acute exacerbations 6
• Mucokinetic agents are not useful 6
• Postural drainage and chest percussion have not proven beneficial 6, 2

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Critical Pitfalls to Avoid

• Do NOT prescribe antibiotics for acute bronchitis based on sputum color alone—purulent sputum is present in 89-95% of viral cases 1, 3
• Do NOT assume bacterial infection in acute bronchitis unless fever persists >3 days 3
• Do NOT use long-term oral corticosteroids for stable chronic bronchitis 6
• Do NOT overlook smoking cessation counseling—it is the single most effective intervention for chronic bronchitis 6, 2
• Do NOT use expectorants or mucolytics—no evidence of benefit in any form of bronchitis 6, 1
• Do NOT forget to assess for underlying conditions (asthma, COPD, heart failure, diabetes) that may complicate bronchitis 1, 2