What is the treatment approach for bronchitis?

Treatment of Bronchitis

The treatment approach for bronchitis depends critically on whether it is acute or chronic, with antibiotics playing NO role in uncomplicated acute bronchitis but being reserved for specific high-risk patients with acute exacerbations of chronic bronchitis. 1, 2

Acute Bronchitis Management

Do NOT Prescribe Antibiotics

• Antibiotics should not be prescribed for uncomplicated acute bronchitis regardless of cough duration or sputum color. 1, 2, 3
• Viruses cause more than 90% of acute bronchitis cases. 4
• Purulent sputum does NOT indicate bacterial infection—it results from inflammatory cells or sloughed epithelial cells. 1
• Antibiotics may reduce cough duration by only 0.5 days while exposing patients to adverse effects. 3
• The only exception: antibiotics may be considered for patients aged ≥75 years with fever or those with cardiac failure. 1

Symptomatic Treatment That Works

• Short-acting β-agonists (albuterol) reduce cough duration and severity by approximately 50% at 7 days in patients with bronchial hyperresponsiveness (wheezing or bothersome cough). 5, 1
• Ipratropium bromide may improve cough in some patients. 1, 2, 4
• Codeine or dextromethorphan provide short-term symptomatic relief of bothersome cough, with modest effect on cough lasting 2-3 weeks. 5, 1

Treatments to AVOID

• Expectorants have no proven benefit. 5, 1, 2
• Antitussives, honey, antihistamines, anticholinergics, oral NSAIDs, and inhaled or oral corticosteroids lack evidence of benefit. 3

Patient Communication Strategy

• Set realistic expectations: cough typically lasts 10-14 days after the visit, sometimes 2-3 weeks. 1, 3
• Refer to the illness as a "chest cold" rather than "bronchitis" to reduce antibiotic expectations. 1, 2, 3
• Explain that satisfaction depends on quality of communication, not antibiotic prescribing. 5, 1
• Discuss risks of unnecessary antibiotics including side effects and resistance. 1

Chronic Bronchitis Management

First-Line: Remove Respiratory Irritants

• Smoking cessation is the most effective intervention, with 90% of patients experiencing cough resolution after quitting. 1, 4
• Remove passive smoke exposure and workplace/environmental irritants. 5, 1

Bronchodilator Therapy

• Short-acting β-agonists should be used to control bronchospasm, relieve dyspnea, and may reduce chronic cough. 5, 1, 2
• Ipratropium bromide should be offered to improve cough and reduce sputum volume. 5, 1, 2
• Theophylline may be considered but requires careful monitoring for complications. 5

Inhaled Corticosteroid Therapy

• Long-acting β-agonists combined with inhaled corticosteroids should be offered to control chronic cough. 5, 1
• Inhaled corticosteroids should be offered to patients with FEV1 <50% predicted or those with frequent exacerbations. 5, 1

Treatments NOT Recommended

• Long-term oral corticosteroids have no evidence of benefit and high risk of side effects. 5, 1
• Expectorants and mucolytics lack evidence of benefit. 5, 1
• Prophylactic antibiotics are not recommended. 5, 4

Acute Exacerbations of Chronic Bronchitis

Immediate Bronchodilator Therapy

• Administer short-acting β-agonists or anticholinergic bronchodilators immediately; if no prompt response, add the other agent after maximizing the first. 5, 1, 2

Systemic Corticosteroids

• A short course (10-15 days) of systemic corticosteroids is effective for acute exacerbations; use IV therapy for hospitalized patients and oral therapy for ambulatory patients. 5, 1
• A 2-week trial is equivalent to an 8-week trial with fewer side effects. 5

Antibiotic Therapy

• Antibiotics are recommended for patients with severe exacerbations, particularly those with baseline FEV1 <50% or more severe airflow obstruction. 2, 4, 6
• Target pathogens include Haemophilus influenzae, Moraxella catarrhalis, and Streptococcus pneumoniae. 6, 7
• Azithromycin (500 mg once daily for 3 days) shows 85% clinical cure rate at Day 21-24. 8
• For patients with risk factors (age ≥65, FEV1 <50%, ≥4 exacerbations/year, comorbidities), use fluoroquinolones, newer macrolides, or high-dose amoxicillin/clavulanate. 6, 7

Treatments to AVOID During Exacerbations

• Theophylline should NOT be used for acute exacerbations. 5, 2, 4
• Expectorants have no evidence of effectiveness. 5, 1

Common Pitfalls to Avoid

• Do not prescribe antibiotics based solely on colored sputum—this is NOT an indicator of bacterial infection. 1, 2
• Rule out pneumonia by assessing for tachycardia, tachypnea, fever >100.4°F, and abnormal chest examination findings before diagnosing uncomplicated bronchitis. 1, 2
• Do not overlook underlying conditions (asthma, COPD, cardiac failure, diabetes) that may be exacerbated by bronchitis. 1, 2
• Avoid overuse of expectorants, mucolytics, and antihistamines which lack evidence. 1, 2