What is the treatment for bronchitis?

Treatment for Acute Bronchitis

Antibiotics should NOT be prescribed for uncomplicated acute bronchitis, regardless of cough duration or sputum color, as they provide minimal benefit (reducing cough by only half a day) while causing adverse effects and promoting resistance. 1, 2

Initial Assessment: Rule Out Pneumonia First

Before diagnosing acute bronchitis, evaluate for pneumonia by checking:

• Heart rate >100 beats/min (tachycardia) 2
• Respiratory rate >24 breaths/min (tachypnea) 2
• Oral temperature >38°C (fever) 2
• Abnormal chest examination findings (rales, egophony, tactile fremitus) 2

If any of these are present, consider pneumonia and obtain chest radiography. 2 In healthy, nonelderly adults without these findings, chest X-ray is not indicated. 3, 4

First-Line Symptomatic Treatment

Albuterol (short-acting β-agonist) is the recommended first-line treatment for reducing cough duration and severity in acute bronchitis. 1

• Approximately 50% fewer patients report cough after 7 days of albuterol treatment 1
• FDA-approved for relief of bronchospasm in patients ≥2 years with reversible obstructive airway disease 5
• Administer via nebulizer: 2.5 mg/3 mL unit-dose vial, no dilution required, nebulize over 5-15 minutes 5
• Most beneficial in patients with wheezing or evidence of bronchial hyperresponsiveness 1, 2

Additional Symptomatic Options

For bothersome dry cough (especially disturbing sleep):

• Dextromethorphan or codeine provide modest effects on cough severity and duration 1, 2, 4
• These are reasonable for short-term symptomatic relief 4

Low-cost supportive measures:

• Eliminate environmental cough triggers 1, 2
• Vaporized air treatments/humidification 1, 2

What NOT to Use

Avoid the following as they lack evidence of benefit:

• Expectorants 4
• Mucolytics 4
• Antihistamines 2
• Inhaled corticosteroids 2
• NSAIDs at anti-inflammatory doses 2, 4
• Systemic corticosteroids 2

The Antibiotic Question: When to Withhold

Do NOT prescribe antibiotics based on:

• Purulent or colored sputum (occurs in 89-95% of viral cases) 2, 6
• Duration of cough alone 3, 2
• Patient expectation for antibiotics 3, 2

The presence of purulent sputum does NOT signify bacterial infection and is NOT an indication for antibiotics. 2

The ONE Exception: Pertussis

If pertussis (whooping cough) is suspected or confirmed:

• Prescribe a macrolide antibiotic (erythromycin or azithromycin) 2
• Isolate patient for 5 days from start of treatment 2
• Early treatment within first few weeks diminishes coughing paroxysms and prevents spread 2

When to Consider Antibiotics (Rare Situations)

Only consider antibiotics if:

• Fever >38°C persists beyond 3 days, strongly suggesting bacterial superinfection 2
• Patient has significant comorbidities (COPD, heart failure, insulin-dependent diabetes, age >75 years, immunosuppression) AND meets criteria for acute exacerbation of chronic bronchitis 2, 7

For high-risk patients with acute exacerbation of chronic bronchitis (NOT simple acute bronchitis):

• Must have ≥1 key symptom: increased dyspnea, increased sputum volume, or increased sputum purulence 7
• First-line: Doxycycline 100 mg twice daily for 7-10 days 2
• Severe cases: High-dose amoxicillin/clavulanate 625 mg three times daily for 14 days 2

Critical Patient Education

Set realistic expectations:

• Cough typically lasts 10-14 days after the office visit, even with treatment 1, 2, 4
• Refer to the condition as a "chest cold" rather than "bronchitis" to reduce antibiotic expectations 2
• Patient satisfaction depends more on physician-patient communication than whether antibiotics are prescribed 3, 1, 2

Explain the harms of unnecessary antibiotics:

• Side effects and adverse events (20% increase in adverse events) 2
• Contribution to antibiotic resistance 2
• No meaningful clinical benefit in uncomplicated cases 1, 2

Common Pitfalls to Avoid

• Prescribing antibiotics for uncomplicated acute bronchitis despite clear evidence of lack of benefit 1, 2
• Assuming bacterial infection based on sputum color or purulence 2
• Failing to distinguish between acute bronchitis and pneumonia 4
• Not providing realistic expectations about natural course, leading to unnecessary follow-up or antibiotic requests 1
• Overlooking bronchodilator therapy which has demonstrated benefit 1