What is the treatment for bronchitis?

Treatment for Acute Bronchitis

Antibiotics should NOT be routinely prescribed for uncomplicated acute bronchitis, as they provide minimal benefit (reducing cough by only half a day) while exposing patients to adverse effects and contributing to antibiotic resistance. 1, 2, 3

Initial Assessment: Rule Out Pneumonia First

Before diagnosing uncomplicated acute bronchitis, you must exclude pneumonia by checking for:

• Tachycardia (heart rate >100 beats/min) 3
• Tachypnea (respiratory rate >24 breaths/min) 3
• Fever (oral temperature >38°C) 3
• Abnormal chest examination findings (rales, egophony, tactile fremitus, or asymmetrical lung sounds) 1, 3

Chest radiography is usually NOT indicated in healthy, nonelderly adults without vital sign abnormalities or asymmetrical lung sounds. 1, 4

First-Line Symptomatic Treatment

Bronchodilators (Preferred)

Albuterol (short-acting β-agonist) is the first-line symptomatic treatment for acute bronchitis, reducing both duration and severity of cough. 2

• Approximately 50% fewer patients report presence of cough after 7 days of albuterol treatment 2
• FDA-approved for relief of bronchospasm in patients ≥2 years with reversible obstructive airway disease 5
• Administered via nebulizer: 2.5 mg/3 mL unit-dose vial, no dilution required, treatment takes 5-15 minutes 5
• Most beneficial in patients with wheezing or evidence of bronchial hyperresponsiveness 2, 3

Alternative Symptomatic Options

• Ipratropium bromide may improve cough in some patients 2, 4
• Dextromethorphan or codeine provide modest effects on cough severity and duration, particularly for dry, bothersome cough that disturbs sleep 2, 3
• Low-cost interventions such as elimination of environmental cough triggers and vaporized air treatments are reasonable 2, 3

When Antibiotics Are NOT Indicated

Do NOT prescribe antibiotics based on:

• Duration of cough alone (cough typically lasts 10-14 days normally) 1, 2, 3
• Presence of purulent or colored sputum (occurs in 89-95% of viral cases) 3, 6
• Patient expectation for antibiotics 1, 3

Respiratory viruses cause 89-95% of acute bronchitis cases; fewer than 10% have bacterial infections. 3, 6

Exception: When Antibiotics ARE Indicated

Pertussis (Whooping Cough)

If pertussis is confirmed or suspected, prescribe a macrolide antibiotic (erythromycin or azithromycin). 3

• Isolate patients for 5 days from start of treatment 3
• Early treatment within first few weeks diminishes coughing paroxysms and prevents disease spread 3

Bacterial Superinfection

Consider antibiotics ONLY if fever >38°C persists beyond 3 days, strongly suggesting bacterial superinfection rather than viral bronchitis. 3

Patient Education (Critical for Satisfaction)

Patient satisfaction depends MORE on physician-patient communication than on receiving antibiotics. 1, 2, 3

Inform patients that:

• Cough typically lasts 10-14 days after the office visit, even with treatment 2, 3
• Most symptoms resolve within 3 weeks 3
• Antibiotics will not significantly shorten the illness and carry risks of side effects 3

Consider referring to the condition as a "chest cold" rather than "bronchitis" to reduce patient expectations for antibiotics. 3

Special Populations Requiring Different Management

These guidelines apply to otherwise healthy adults. Different approaches are needed for:

• Elderly patients (>75 years) 3
• Immunocompromised patients 3
• Patients with COPD, heart failure, or diabetes 3, 4
• Patients with chronic bronchitis experiencing acute exacerbations 4, 7

For acute exacerbations of chronic bronchitis with risk factors (age ≥65, FEV1 <50%, ≥4 exacerbations in 12 months, comorbidities), antibiotics ARE indicated using the Anthonisen criteria (increased dyspnea, sputum volume, or sputum purulence). 3, 7

Common Pitfalls to Avoid

• Prescribing antibiotics for uncomplicated acute bronchitis despite lack of evidence 2
• Assuming bacterial infection based on sputum color or purulence alone (present in 89-95% of viral cases) 3
• Failing to distinguish between acute bronchitis and pneumonia 4
• Not providing realistic expectations about natural course of illness (10-14 day cough duration) 2
• Overlooking bronchodilator therapy which has demonstrated benefit 2