What are the guidelines for managing bronchitis?

How to Identify and Manage Bronchitis

Critical Distinction: Adult vs. Pediatric Bronchitis

The term "bronchitis" requires immediate clarification based on patient age, as acute bronchitis in adults and bronchiolitis in infants are fundamentally different diseases requiring completely different management approaches. 1, 2

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ADULT ACUTE BRONCHITIS

Identification and Diagnosis

Acute bronchitis is a clinical diagnosis characterized by acute cough lasting up to 6 weeks due to self-limited inflammation of the large airways, typically without fever or systemic symptoms. 1, 3

Key Diagnostic Features:

• Cough (productive or non-productive) lasting 2-3 weeks on average, may extend to 6 weeks 1, 3
• Mild constitutional symptoms may be present 1
• Normal vital signs: absence of tachycardia (HR >100), tachypnea (RR >24), fever (>38°C), and abnormal chest findings rules out pneumonia in healthy adults <70 years 1

Critical Pitfall to Avoid:

• Purulent (green or yellow) sputum does NOT indicate bacterial infection - purulence is due to inflammatory cells and sloughed epithelial cells, not bacteria 1, 4
• Do not confuse acute bronchitis with pneumonia, asthma exacerbation, or chronic obstructive pulmonary disease exacerbation 3, 5

When to Perform Testing:

• No testing is indicated for uncomplicated acute bronchitis 1
• Consider chest radiography only if pneumonia is suspected (tachycardia, tachypnea, fever, abnormal lung exam) 1, 5
• Consider pertussis testing if cough persists >2 weeks with paroxysmal cough, whooping, post-tussive emesis, or known exposure 5

Management of Adult Acute Bronchitis

Clinicians should NOT prescribe antibiotics for acute bronchitis, as more than 90% of cases are viral and antibiotics provide minimal benefit (reducing cough by only 0.5 days) while exposing patients to adverse effects. 1, 3, 5

Evidence-Based Recommendations:

What NOT to Do:

• Do not prescribe antibiotics routinely - they reduce cough duration by only 0.5 days and increase adverse effects including allergic reactions, nausea, vomiting, and C. difficile infection 1, 3, 5
• Do not use antitussives, honey, antihistamines, anticholinergics, oral NSAIDs, or inhaled/oral corticosteroids - evidence does not support their use 3
• β-agonists (albuterol) have not been shown to benefit patients without asthma or COPD 1

What TO Do:

• Patient education is paramount: explain that cough typically lasts 2-3 weeks and is self-limited 1, 3, 5
• Describe the condition as a "chest cold" to reduce antibiotic expectations 3, 5
• Consider symptomatic relief with cough suppressants (dextromethorphan, codeine), expectorants (guaifenesin), first-generation antihistamines (diphenhydramine), or decongestants (phenylephrine), though data supporting these are limited 1
• The supplement pelargonium may help reduce symptom severity in adults 4

Rare Exception for Antibiotics:

• Consider antibiotics only if pertussis is suspected (to reduce transmission) or in patients at increased risk for pneumonia (age ≥65 years, significant comorbidities) 1, 4

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PEDIATRIC BRONCHIOLITIS (Infants and Children <2 Years)

Identification and Diagnosis

Bronchiolitis is diagnosed clinically based on history and physical examination in children <2 years presenting with viral upper respiratory prodrome followed by increased respiratory effort, wheezing, and tachypnea. 1, 6

Key Diagnostic Features:

• Age: typically affects infants 1-23 months 1
• Clinical presentation: rhinorrhea, cough, tachypnea, wheezing, rales, retractions (intercostal/subcostal), nasal flaring, grunting 1
• Peak season: December through March in North America (RSV predominant) 1

Risk Factors for Severe Disease:

• Age <12 weeks 1, 6
• History of prematurity (<35 weeks gestation) 1
• Hemodynamically significant congenital heart disease 1, 6
• Chronic lung disease (bronchopulmonary dysplasia) 1, 6
• Immunodeficiency 1

When NOT to Perform Testing:

• Do not obtain chest radiographs, viral testing, or laboratory studies routinely - bronchiolitis is a clinical diagnosis 1, 6, 7
• Chest radiography should be reserved only for severe respiratory distress warranting ICU admission or suspected complications (pneumothorax) 6
• Approximately 25% of hospitalized infants have radiographic findings often misinterpreted as bacterial infection 7

Management of Pediatric Bronchiolitis

The cornerstone of bronchiolitis management is supportive care alone - oxygen supplementation when SpO₂ <90%, hydration support, and gentle nasal suctioning - while avoiding ALL routine pharmacologic interventions. 2, 6, 7

Oxygen Therapy:

• Administer supplemental oxygen ONLY if SpO₂ persistently falls below 90% 1, 6, 7
• Maintain SpO₂ ≥90% with standard oxygen delivery 1, 6
• Discontinue oxygen when SpO₂ ≥90%, infant feeds well, and has minimal respiratory distress 6, 7
• Do not treat based solely on pulse oximetry without clinical correlation - transient desaturations occur in healthy infants 2, 7
• Avoid continuous pulse oximetry in stable infants as it may lead to less careful clinical monitoring 7

Hydration Management:

• Assess hydration status and ability to take fluids orally 6, 7
• Continue oral feeding if infant feeds well without respiratory compromise 7
• When respiratory rate exceeds 60-70 breaths/minute, feeding may be compromised and aspiration risk increases 2, 7
• Provide IV fluids only for infants who cannot maintain adequate oral intake 6, 7
• Use isotonic fluids if IV hydration needed - infants with bronchiolitis may develop SIADH and are at risk for hyponatremia with hypotonic fluids 7

Airway Clearance:

• Gentle nasal suctioning may provide temporary relief 6, 7
• Avoid deep suctioning - associated with longer hospital stays in infants 2-12 months 7
• Do not use chest physiotherapy - not recommended for routine management 6, 7

What NOT to Do - Pharmacologic Interventions:

Bronchodilators (Albuterol/Salbutamol):

• Do not administer routinely 1, 6, 7
• If a trial is attempted, continue only if documented positive clinical response using objective evaluation 6, 7

Corticosteroids:

• Do not use routinely - meta-analyses show no significant benefit in length of stay or clinical scores 1, 6, 7

Antibiotics:

• Use only with specific indications of bacterial coinfection (acute otitis media, documented bacterial pneumonia) 1, 6, 7
• The risk of serious bacterial infection in infants with bronchiolitis is <1% 2, 7
• Fever alone does not justify antibiotics 2, 7

Ribavirin:

• Do not use routinely 1, 6

Prevention Strategies:

Palivizumab Prophylaxis:

• Administer during the first year of life to infants with hemodynamically significant heart disease or chronic lung disease of prematurity (preterm infants <32 weeks 0 days' gestation requiring >21% oxygen for ≥28 days) 1, 6
• Give 5 monthly doses (15 mg/kg IM), usually beginning November/December 6

General Prevention:

• Hand decontamination is the most important step in preventing nosocomial RSV spread - alcohol-based rubs preferred 6
• Advise parents to avoid exposing infants to passive smoking 6
• Recommend breastfeeding - reduces hospitalization risk for respiratory diseases by 72% 7
• Limit visitor exposure during respiratory virus season 7

Expected Clinical Course:

• Symptoms (cough, congestion, wheezing) typically last 2-3 weeks - this is normal and does not indicate treatment failure 7

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CHRONIC BRONCHITIS EXACERBATIONS (Adults with COPD)

Identification

Acute exacerbation of chronic bronchitis (AECB) occurs in patients with chronic bronchitis (productive cough on most days for 3 months over 2 consecutive years with irreversible airflow reduction) who develop a period of unstable lung function with worsening airflow and symptoms. 8

Management Algorithm

Supportive care should be provided to ALL patients: removal of irritants, bronchodilators, oxygen, hydration, systemic corticosteroids, and chest physical therapy. 8

Antibiotics should be reserved for patients with at least 1 key symptom (increased dyspnea, sputum production, OR sputum purulence) AND at least 1 risk factor (age ≥65 years, FEV₁ <50% predicted, ≥4 exacerbations in 12 months, OR ≥1 comorbidity). 8

Antibiotic Selection:

• Moderate severity exacerbation: newer macrolide, extended-spectrum cephalosporin, or doxycycline 8
• Severe exacerbation: high-dose amoxicillin/clavulanate or respiratory fluoroquinolone 8, 9
• Patients with severe obstruction (FEV₁ <50%), age >65, recurrent exacerbations, or comorbidities: fluoroquinolones should be first-line due to increasing resistance among common respiratory pathogens (S. pneumoniae, H. influenzae, M. catarrhalis) 9