What is the recommended treatment for acute viral bronchitis?

Treatment of Acute Viral Bronchitis

Antibiotics should not be prescribed for acute viral bronchitis, as they provide minimal benefit (reducing cough by only half a day) while exposing patients to unnecessary side effects and promoting antibiotic resistance. 1

Initial Assessment and Diagnosis

Before diagnosing uncomplicated acute bronchitis, rule out pneumonia by checking for:

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

The presence of purulent or colored sputum does NOT indicate bacterial infection and is NOT an indication for antibiotics, as it occurs in 89-95% of viral cases due to inflammatory cells and sloughed epithelial cells. 1, 2

Primary Treatment Approach: Symptomatic Management

What TO Use:

For bothersome dry cough:

• Dextromethorphan or codeine may provide modest relief of cough severity and duration 1, 3
• These agents are most helpful for nighttime cough that disturbs sleep 1

For cough with wheezing:

• β2-agonist bronchodilators (such as albuterol) may be useful in select adult patients with wheezing accompanying the cough 1
• Do NOT routinely use bronchodilators in patients without wheezing 1

Low-risk supportive measures:

• Elimination of environmental cough triggers 1
• Vaporized air treatments/humidification 1
• Analgesics and antipyretics for symptom relief 4

What NOT to Use:

The following have no proven benefit and should be avoided:

• Expectorants (including guaifenesin) 1, 2
• Mucolytics 1, 2
• Antihistamines 1
• Inhaled corticosteroids 1
• Systemic corticosteroids 1
• NSAIDs at anti-inflammatory doses 1

Exception: Pertussis (Whooping Cough)

If pertussis is confirmed or strongly suspected, prescribe a macrolide antibiotic (erythromycin or azithromycin). 1

• Isolate patients for 5 days from the start of treatment 1
• Early treatment within the first few weeks diminishes coughing paroxysms and prevents disease spread 1
• Limit suspicion and treatment to patients with high probability of exposure, usually during an outbreak 4

Patient Education and Communication

Critical counseling points to improve satisfaction without antibiotics:

• Inform patients that cough typically lasts 10-14 days after the office visit, even with treatment 4, 1
• Refer to the condition as a "chest cold" rather than bronchitis to reduce antibiotic expectations 4, 1
• Explain that patient satisfaction depends more on physician-patient communication than whether antibiotics are prescribed 4, 1
• Discuss risks of unnecessary antibiotic use: side effects, increased carriage of antibiotic-resistant bacteria, and rare serious reactions like anaphylaxis 4

Special Populations Requiring Different Management

These guidelines do NOT apply to:

• Elderly patients (>75 years) with fever 1
• Patients with COPD, congestive heart failure, or immunosuppression 4, 1
• Patients with cardiac failure or insulin-dependent diabetes 1

These high-risk patients may require antibiotics and should be managed differently. 1

Common Pitfalls to Avoid

• Do NOT prescribe antibiotics based on purulent sputum color or presence - this occurs in 89-95% of viral cases 1
• Do NOT prescribe antibiotics based on cough duration alone - viral bronchitis cough normally lasts 10-14 days 1
• Do NOT assume bacterial infection unless fever persists beyond 3 days, which suggests bacterial superinfection 1
• Do NOT use routine chest X-rays - diagnosis is clinical unless pneumonia is suspected 1