What is the initial approach to managing bronchitis?

Initial Management of Acute Bronchitis

Do not prescribe antibiotics for uncomplicated acute bronchitis—this is a viral illness in 89-95% of cases, and antibiotics provide minimal benefit (reducing cough by only half a day) while exposing patients to unnecessary adverse effects. 1, 2, 3

Diagnosis and Initial Assessment

Rule Out Pneumonia First

• Check vital signs for tachycardia (>100 bpm), tachypnea (>24 breaths/min), or fever (>38°C) 1, 4
• Perform chest examination looking for focal findings such as rales, egophony, or tactile fremitus 1
• If any of these are present, consider chest radiography to rule out pneumonia 4, 2
• In healthy, nonelderly adults without vital sign abnormalities or asymmetrical lung sounds, chest radiography is not indicated 4

Confirm the Diagnosis

• Acute bronchitis is characterized by cough with or without phlegm production lasting up to 3 weeks 1
• The presence of upper respiratory symptoms (rhinorrhea, nasal obstruction) supports a viral etiology 1
• Critical pitfall: Purulent sputum occurs in 89-95% of viral cases and does NOT indicate bacterial infection 1, 4

Initial Treatment Approach

Patient Education (Most Important)

• Inform patients that cough typically lasts 10-14 days after the office visit, with most symptoms resolving within 3 weeks 1, 4, 3
• Refer to the condition as a "chest cold" rather than "bronchitis" to reduce patient expectations for antibiotics 1, 4
• Explain that patient satisfaction depends more on physician-patient communication than whether an antibiotic is prescribed 1
• Discuss the risks of unnecessary antibiotic use, including side effects and contribution to antibiotic resistance 1

Symptomatic Treatment Options

For Cough Relief:

• Codeine or dextromethorphan may provide modest effects on severity and duration of cough 1, 4
• These agents can be prescribed for patients with dry and bothersome cough, especially when nights are disturbed 1

For Wheezing (If Present):

• Short-acting β2-agonists (like albuterol) may be useful in select adult patients with wheezing accompanying the cough 1, 4
• β2-agonist bronchodilators should NOT be routinely used for cough in most patients without wheezing 1

Environmental Measures:

• Elimination of environmental cough triggers and vaporized air treatments are reasonable low-cost, low-risk options 1

What NOT to Use

• Do not prescribe expectorants, mucolytics, antihistamines, inhaled corticosteroids, or NSAIDs at anti-inflammatory doses—these lack consistent evidence for benefit 1, 4
• Do not prescribe systemic corticosteroids for uncomplicated acute bronchitis 4

When to Consider Antibiotics (Rare Exceptions)

Pertussis (Whooping Cough)

• If pertussis is confirmed or suspected, prescribe a macrolide antibiotic such as erythromycin or azithromycin 1
• Patients with pertussis should be isolated for 5 days from the start of treatment 1
• Early treatment within the first few weeks diminishes coughing paroxysms and prevents disease spread 1
• Suspect pertussis if cough persists >2 weeks with paroxysmal cough, whooping cough, post-tussive emesis, or recent pertussis exposure 2

Bacterial Superinfection

• Consider antibiotics only if fever >38°C persists beyond 3 days, which strongly suggests bacterial superinfection rather than viral bronchitis 1
• If antibiotics are warranted, use amoxicillin 500 mg three times daily for 5-8 days 1

High-Risk Patients

• Consider antibiotics in patients aged >75 years with fever, cardiac failure, insulin-dependent diabetes, or serious neurological disorders 1
• Consider antibiotics in elderly or immunocompromised patients at high risk for complications 1

Critical Pitfalls to Avoid

• Do not prescribe antibiotics based solely on purulent sputum color or presence—this occurs in 89-95% of viral cases 1, 4
• Do not prescribe antibiotics based on cough duration alone—viral bronchitis cough normally lasts 10-14 days 1
• Do not assume bacterial infection before the 3-day fever threshold—most cases are viral 1
• Failing to distinguish between acute bronchitis and pneumonia can lead to undertreating pneumonia 4

Follow-Up Strategy

• Reassess patients who do not improve or worsen after 2-3 days 1
• Reevaluate for other diagnoses (pneumonia, pertussis, asthma, COPD exacerbation) if symptoms persist beyond 10-14 days 1, 2
• Consider delayed antibiotic prescriptions as a strategy to reduce immediate antibiotic use while providing reassurance 3