Treatment for Bronchitis Cough Lasting Two Weeks
For an adult with a two-week cough from acute bronchitis, antibiotics should NOT be prescribed, and treatment should focus on inhaled ipratropium bromide as first-line therapy for symptomatic relief, along with patient education that the cough typically resolves within 2-3 weeks total. 1, 2, 3
Initial Assessment: Rule Out Serious Conditions
Before treating as simple acute bronchitis, exclude pneumonia and pertussis:
Pneumonia is unlikely if the patient lacks all of the following: heart rate >100 bpm, respiratory rate >24 breaths/min, fever >38°C, and focal consolidation findings (rales, egophony, fremitus) on chest examination. 1, 2
Chest radiography is NOT indicated at two weeks if vital signs are normal and there are no focal chest findings. 1, 4
Suspect pertussis only if the cough includes paroxysmal episodes, post-tussive vomiting, or inspiratory whooping sounds, or if there is known pertussis exposure. If suspected, obtain nasopharyngeal culture for Bordetella pertussis and initiate macrolide antibiotics. 1, 2
Evidence-Based Treatment Algorithm
First-Line Therapy: Inhaled Ipratropium Bromide
Prescribe inhaled ipratropium bromide as the primary treatment for post-infectious cough at this stage (Grade A recommendation). 2, 3, 4
This is the only inhaled anticholinergic agent with demonstrated efficacy for acute bronchitis-related cough. 4
Symptomatic Relief Measures
Analgesics (acetaminophen or ibuprofen) for chest discomfort, sore throat, or fever. 4
Pseudoephedrine if nasal congestion is present. 4
Throat lozenges for sore throat relief. 4
Adequate hydration and rest are essential. 4
What NOT to Prescribe
Do NOT prescribe antibiotics. Routine antibiotic use for acute bronchitis is not justified and provides minimal benefit (reducing cough duration by only 0.5 days) while exposing patients to adverse effects including allergic reactions, nausea, vomiting, and Clostridium difficile infection. 1, 5, 6
Do NOT prescribe expectorants or mucokinetic agents, as they show no consistent favorable effect on cough. 2
Do NOT prescribe benzonatate or other cough suppressants as first-line therapy, as they have limited efficacy in acute viral infections. 4
Do NOT prescribe inhaled bronchodilators routinely, as there is no role for bronchodilator therapy in uncomplicated acute bronchitis. 1
Patient Education and Expectations
Emphasize that the cough typically lasts 2-3 weeks total from symptom onset, with spontaneous resolution expected. 3, 5, 6
Symptoms typically peak at days 3-6 and should begin improving thereafter. 4
Transient bronchial hyperresponsiveness can persist for 2-3 weeks, occasionally up to 2 months. 1, 4
Calling the condition a "chest cold" rather than "bronchitis" helps reduce patient expectations for antibiotics. 6
When to Reassess or Escalate Care
At 3 Weeks (If Cough Persists)
Chest radiography is warranted for cough lasting ≥3 weeks in the absence of other known causes. 1, 2
Consider cough-variant asthma if cough worsens at night or with cold/exercise exposure; diagnosis requires improvement with bronchodilator therapy or positive methacholine challenge. 1
At 8 Weeks (If Cough Becomes Chronic)
Reclassify as chronic cough and initiate systematic evaluation starting with treatment for upper airway cough syndrome (first-generation antihistamine-decongestant combination). 3
If upper airway cough syndrome treatment fails, evaluate for asthma; if both fail, initiate intensive GERD therapy. 3
Critical Pitfalls to Avoid
Do not prescribe antibiotics based on purulent sputum alone. Purulence occurs from inflammatory cells and can result from viral or bacterial infection; it does not reliably differentiate between the two. 1
Do not fail to recognize the 8-week threshold where post-infectious cough becomes chronic cough requiring different evaluation. 3
Do not continue ineffective therapies. If ipratropium fails and cough persists beyond 3 weeks, reassess rather than adding multiple symptomatic agents. 2
Special Circumstance: Children with Chronic Wet Cough
If this were a child ≤14 years with chronic wet cough (>4 weeks), the approach differs entirely:
Prescribe 2 weeks of antibiotics targeted to common respiratory bacteria (Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis) based on local antibiotic sensitivities (Grade 1A). 1
If cough resolves, diagnose as protracted bacterial bronchitis. 1
If cough persists after 2 weeks, treat with an additional 2 weeks of appropriate antibiotics. 1
However, this pediatric guideline does not apply to the typical adult acute bronchitis scenario described in your question. 1