Management of Acute Bronchitis
For immunocompetent adult outpatients with acute bronchitis, do not prescribe antibiotics, do not order routine investigations, and focus on symptomatic management with patient education about the expected 2-3 week duration of cough. 1, 2
Initial Diagnostic Assessment
Rule out pneumonia first by checking for these four findings—if all are absent, no chest X-ray is needed: 1, 2
- Heart rate >100 beats/min
- Respiratory rate >24 breaths/min
- Oral temperature >38°C (100.4°F)
- Chest examination findings of focal consolidation, egophony, or fremitus
Do not order routine investigations including chest X-ray, spirometry, sputum culture, viral PCR, C-reactive protein, or procalcitonin at initial presentation. 1
Consider pertussis if cough persists >2 weeks with paroxysmal cough, whooping sound, post-tussive vomiting, or known exposure. 1, 2
Antibiotic Management
Do not prescribe antibiotics routinely—they reduce cough duration by only half a day while causing adverse effects including allergic reactions, nausea, and Clostridium difficile infection. 1, 2
Critical pitfall to avoid: Purulent or colored sputum occurs in 89-95% of viral cases and does NOT indicate bacterial infection or need for antibiotics. 2, 3
Exception—When to Prescribe Antibiotics:
Prescribe a macrolide (erythromycin or azithromycin) only if pertussis is confirmed or strongly suspected, and isolate the patient for 5 days from treatment start. 2
Consider antibiotics only if the condition significantly worsens after initial presentation, suggesting bacterial superinfection, particularly if: 1, 2
- Fever >38°C persists beyond 3 days
- Patient is high-risk (age ≥75 years with fever, cardiac failure, insulin-dependent diabetes, immunocompromised)
Symptomatic Treatment
β2-agonist bronchodilators should NOT be routinely prescribed for most patients with acute bronchitis. 1, 2
Exception: Consider β2-agonists only in select patients with wheezing accompanying the cough. 2, 4
For bothersome dry cough, consider codeine or dextromethorphan for modest symptomatic relief, especially when sleep is disturbed. 2, 4
- Expectorants or mucolytics
- Antihistamines
- Inhaled corticosteroids
- Oral corticosteroids
- NSAIDs at anti-inflammatory doses
Low-risk supportive measures that may be reasonable include elimination of environmental cough triggers (tobacco smoke, irritants) and humidified air. 2
Patient Communication Strategy
Set realistic expectations: Inform patients that cough typically lasts 10-14 days after the visit, and may persist up to 3 weeks. 2, 3, 5
Reframe the diagnosis: Consider calling it a "chest cold" rather than "bronchitis" to reduce antibiotic expectations. 2, 4
Explain the decision not to prescribe antibiotics by discussing: 1, 2
- Minimal benefit (only half-day reduction in cough)
- Risk of adverse effects to the individual
- Contribution to antibiotic resistance in the community
Emphasize that patient satisfaction depends more on physician-patient communication quality than whether an antibiotic is prescribed. 2, 4
Reassessment Criteria
Advise patients to return for reassessment if: 1, 2
- Cough persists or worsens after initial visit
- Fever develops or persists beyond 3 days
- New symptoms develop suggesting pneumonia
At reassessment, consider targeted investigations such as chest X-ray, sputum culture, peak flow measurement, or inflammatory markers if the condition has not improved. 1
Common pitfall: Do not assume bacterial infection based on cough duration alone, as viral bronchitis cough normally lasts 10-14 days. 2