What are the recommended treatments for symptomatic relief of bronchitis?

Symptomatic Treatment for Bronchitis

For acute bronchitis, antitussive agents like dextromethorphan or codeine can be offered for short-term symptomatic relief of bothersome cough, while expectorants and mucolytics should not be used as they lack evidence of benefit. 1, 2

Acute Bronchitis: Symptomatic Management

Antitussive (Cough Suppressant) Therapy

• Central cough suppressants such as dextromethorphan or codeine are occasionally useful and can be offered for short-term symptomatic relief when cough is particularly bothersome 1, 2, 3
• These agents provide only modest benefit—reducing cough duration by approximately half a day in some studies 1
• The ACCP guidelines give this a Grade C recommendation (fair quality evidence, small/weak benefit) 1

Bronchodilator Therapy

• Short-acting β-agonists (like albuterol) may be beneficial in reducing cough duration and severity specifically in patients with evidence of bronchial hyperresponsiveness or wheezing 2
• Ipratropium bromide may improve cough in some patients with acute bronchitis 2
• These are not routinely indicated for all patients with acute bronchitis, only those with bronchospasm 2

What NOT to Use

• Expectorants and mucolytics (including guaifenesin) are not recommended because there is no consistent favorable effect on cough associated with acute bronchitis 1, 2
• Despite FDA labeling for guaifenesin to "help loosen phlegm," the ACCP gives this a Grade I recommendation (conflicting benefit) for acute bronchitis 1, 4
• Antibiotics should not be prescribed for uncomplicated acute bronchitis as they provide minimal benefit (reducing cough by only 0.5 days) while exposing patients to adverse effects 2, 5

Chronic Bronchitis: Symptomatic Management

First-Line Therapy

• Long-acting β-agonists combined with inhaled corticosteroids should be offered to control chronic cough (Grade A recommendation) 1, 2
• Short-acting β-agonists should be used to control bronchospasm and may reduce chronic cough 1, 2
• Ipratropium bromide should be offered to improve cough and reduce sputum volume 1, 2

Inhaled Corticosteroids

• ICS therapy should be offered for patients with chronic bronchitis and FEV1 <50% predicted or those with frequent exacerbations (Grade A recommendation) 1, 2

Antitussive Therapy

• Central cough suppressants (codeine and dextromethorphan) are recommended for short-term symptomatic relief when cough is particularly troublesome (Grade B recommendation) 1, 6
• These agents suppress cough counts by 40-60% in chronic bronchitis patients 1

What NOT to Use

• Oral corticosteroids should not be used for long-term maintenance—no evidence of benefit and high risk of serious side effects (Grade E/D recommendation) 1, 2
• Expectorants and mucolytics should not be used in stable chronic bronchitis—no evidence of effectiveness (Grade I recommendation) 1, 2
• Theophylline should not be used for acute exacerbations (Grade D recommendation) 1, 2

Acute Exacerbations of Chronic Bronchitis

Immediate Therapy

• Short-acting β-agonists or anticholinergic bronchodilators should be administered immediately during acute exacerbations 1, 2
• If no prompt response, add the other agent after maximizing the first 1

Systemic Corticosteroids

• A short course (10-15 days) of systemic corticosteroids is effective and should be given (Grade A recommendation) 1, 2
• Both IV therapy (hospitalized patients) and oral therapy (ambulatory patients) are effective 1, 2

What NOT to Use

• Expectorants are not effective during acute exacerbations and should not be used 1, 2

Common Pitfalls to Avoid

• Do not prescribe antibiotics based solely on colored sputum—purulent sputum results from inflammatory cells, not bacterial infection 2
• Do not use expectorants or mucolytics despite widespread over-the-counter availability and patient expectations—they lack evidence of benefit in any form of bronchitis 1, 2
• Do not confuse acute bronchitis with pneumonia—assess for tachycardia (>100 bpm), tachypnea (>24 breaths/min), fever (>38°C), and focal consolidation findings before ordering chest radiography 1, 2
• Consider calling it a "chest cold" rather than bronchitis to reduce patient expectations for antibiotics 2, 7

Patient Communication Strategies

• Provide realistic expectations: cough typically lasts 10-14 days after the office visit, sometimes up to 3 weeks 2, 8, 5
• Explain that patient satisfaction depends more on quality of the clinical encounter than receiving antibiotics 2
• Discuss risks of unnecessary antibiotic use, including side effects and antibiotic resistance 2, 5