What is the best management approach for an adult outpatient with acute bronchitis and no underlying health conditions?

Best Management for Outpatient Acute Bronchitis

For immunocompetent adult outpatients with acute bronchitis, do not prescribe antibiotics, antitussives, beta-agonists, inhaled corticosteroids, oral corticosteroids, or NSAIDs routinely—instead, provide symptomatic management and educate patients that cough typically lasts 10-14 days. 1, 2

Initial Assessment: Rule Out Alternative Diagnoses

Before diagnosing acute bronchitis, evaluate for conditions requiring specific treatment 1, 2:

• Check vital signs and chest examination to exclude pneumonia: heart rate >100 beats/min, respiratory rate >24 breaths/min, oral temperature >38°C, or focal chest findings (rales, egophony, tactile fremitus) suggest pneumonia rather than bronchitis 2, 3
• Consider pertussis if paroxysmal cough with inspiratory whoop is present 2, 3
• Evaluate for asthma or COPD exacerbation in patients with wheezing or known underlying lung disease 1
• No routine investigations (chest x-ray, sputum culture, viral PCR, inflammatory markers) are indicated for uncomplicated cases 1, 4

Primary Management: Symptomatic Care and Patient Education

The cornerstone of management is reassurance and setting appropriate expectations 2, 3:

• Inform patients that cough typically lasts 10-14 days after the visit, even without treatment, and may persist up to 3 weeks 2, 3, 5
• Refer to the condition as a "chest cold" rather than "bronchitis" to reduce antibiotic expectations 2, 3
• Explain that patient satisfaction depends more on physician-patient communication than whether antibiotics are prescribed 2, 3
• Discuss risks of unnecessary antibiotic use, including adverse effects and antibiotic resistance 2, 3

What NOT to Prescribe

Avoid routine prescription of the following therapies, as they lack evidence of benefit 1, 2:

• Antibiotics: Reduce cough duration by only 0.5 days while exposing patients to adverse effects (tremor, GI symptoms, allergic reactions) 2, 3, 5
• Beta-agonist bronchodilators: Not effective for cough in most patients without wheezing 1, 2, 6
• Inhaled or oral corticosteroids: No evidence of benefit 1, 2
• NSAIDs at anti-inflammatory doses: Ineffective for acute bronchitis 1, 3
• Antitussives, expectorants, mucolytics, antihistamines: Lack consistent evidence of favorable effects 1, 3

Limited Symptomatic Treatment Options

Consider these only for select patients with specific symptoms 2, 3:

• Codeine or dextromethorphan may provide modest effects on cough severity and duration, particularly for dry, bothersome cough disturbing sleep 2, 3
• Beta-agonist bronchodilators may be useful in select adult patients with wheezing accompanying the cough 2, 3

Critical Exception: Pertussis (Whooping Cough)

If pertussis is confirmed or suspected, prescribe a macrolide antibiotic immediately 2, 3:

• Erythromycin or azithromycin is the treatment of choice 2, 3
• Isolate patients for 5 days from the start of treatment 2, 3
• Early treatment within the first few weeks diminishes coughing paroxysms and prevents disease spread 2, 3

When to Reassess and Consider Antibiotics

Reassess patients if symptoms persist or worsen 1, 3:

• If acute bronchitis worsens, consider antibiotic therapy if a complicating bacterial infection is thought likely 1
• Consider antibiotics in high-risk patients with significant comorbidities: age ≥75 years with fever, cardiac failure, insulin-dependent diabetes, immunosuppression, or serious neurological disorders 2, 3
• If fever persists beyond 3 days, this strongly suggests bacterial superinfection rather than viral bronchitis 3
• Targeted investigations at reassessment may include chest x-ray, sputum culture, peak flow measurements, complete blood count, and inflammatory markers 1, 4

Common Pitfalls to Avoid

• Do not use purulent sputum as an indication for antibiotics: Purulent sputum occurs in 89-95% of viral bronchitis cases and does not indicate bacterial infection 2, 3
• Do not assume bacterial infection based on cough duration alone: Viral bronchitis cough normally lasts 10-14 days 2, 3
• Recognize that 65% of patients with recurrent "acute bronchitis" may have underlying mild asthma: Consider alternative diagnoses in patients with multiple episodes 1, 4