Treatment of Bronchitis with Wheezing
For patients with acute bronchitis and wheezing, β2-agonist bronchodilators should be used to provide symptomatic relief, as this subgroup demonstrates benefit from bronchodilator therapy. 1
Treatment Algorithm for Acute Bronchitis with Wheezing
First-Line Bronchodilator Therapy
β2-agonist bronchodilators (such as albuterol) are recommended specifically for patients with acute bronchitis who present with wheezing, as this subgroup shows measurable benefit despite the lack of benefit in uncomplicated acute bronchitis 1
The ACCP guidelines explicitly state that while β2-agonists should not be routinely used in most acute bronchitis cases (Grade D recommendation), they may be useful in select adult patients with wheezing accompanying the cough (Grade C recommendation) 1
Albuterol delivered by metered-dose inhaler has been shown to reduce the likelihood of persistent cough at 7 days (61% vs 91% with placebo, p=0.02), with effects independent of smoking status 2
Avoid Routine Antibiotic Use
Antibiotics should not be routinely prescribed for acute bronchitis with wheezing unless pertussis is suspected or confirmed (Grade D recommendation) 1
The decision to withhold antibiotics should be explained to patients, as many expect antibiotic treatment based on prior experiences 1
The exception is confirmed or probable pertussis infection, which requires macrolide antibiotic therapy and 5-day isolation (Grade A recommendation) 1
Adjunctive Symptomatic Treatment
Antitussive agents (codeine or dextromethorphan) can be offered for short-term symptomatic relief when cough is severely affecting quality of life (Grade C recommendation) 1
Mucokinetic agents are not recommended due to lack of consistent favorable effect on cough (Grade I recommendation) 1
Special Considerations for Chronic Bronchitis with Wheezing
If the clinical picture suggests chronic rather than acute bronchitis (symptoms on most days for ≥3 months over 2 consecutive years):
Ipratropium bromide becomes the preferred first-line agent (36 μg, 2 inhalations four times daily) with Grade A evidence for reducing cough frequency, severity, and sputum volume 3, 4, 5
Short-acting β-agonists can be added if response to ipratropium is inadequate after 2 weeks 4
For patients on beta-blockers (such as metoprolol), ipratropium bromide is the optimal choice as it avoids beta-receptor stimulation and drug interactions 5
Common Pitfalls to Avoid
Do not withhold bronchodilators in wheezing patients simply because they have "acute bronchitis" - the presence of wheezing or baseline airflow obstruction identifies a subgroup that benefits from bronchodilator therapy 1
Be aware that tremor, nervousness, and shakiness are more common with β2-agonist treatment 1
Do not prescribe antibiotics reflexively; studies show no significant benefit for cough resolution in uncomplicated acute bronchitis 1
Distinguish acute from chronic bronchitis, as treatment algorithms differ significantly - chronic bronchitis favors ipratropium bromide as first-line therapy 3, 4