Initial Management of Acute Tracheobronchitis
The primary management of acute tracheobronchitis is symptomatic treatment without antibiotics, as viruses cause over 90% of cases, but you must first rule out pneumonia, asthma exacerbation, and COPD exacerbation before making this diagnosis. 1, 2
Diagnostic Exclusion Algorithm
Before diagnosing acute tracheobronchitis, systematically exclude:
Pneumonia: Check vital signs and perform lung auscultation. In healthy, non-elderly adults, pneumonia is uncommon without vital sign abnormalities or asymmetrical lung sounds—chest radiography is usually not indicated unless these are present. 1
Asthma or COPD exacerbation: Consider lung function testing if the patient has at least two of the following: wheezing, prolonged expiration, smoking history, or symptoms of allergy. 1 Studies show that up to 45% of patients with acute cough lasting more than 2 weeks actually have asthma or COPD, and approximately one-third of patients diagnosed with acute bronchitis are misdiagnosed asthma cases. 1
Common cold vs. acute bronchitis: Clinical distinction is often impossible as both share symptoms (cough, sputum, constitutional symptoms), and the common cold causes cough in 83% of cases within the first 2 days. 1
Symptomatic Management (Primary Treatment)
Antibiotics are NOT indicated for uncomplicated acute tracheobronchitis regardless of cough duration or sputum color, as bacterial infections account for only 5-11% of cases. 1, 3, 2 The presence of green or purulent sputum does not reliably differentiate bacterial from viral infection. 2
Supportive Care Measures:
Bronchodilators: Consider beta-2 agonists only if there is evidence of bronchospasm or wheezing, as these may indicate underlying reactive airway disease rather than simple bronchitis. 1
Cough management: Most typical antitussive therapies have been shown ineffective. The FDA recommends against cough and cold preparations in children under 6 years. 2 The herbal supplement pelargonium may reduce symptom severity in adults. 2
Hydration and removal of irritants: Standard supportive measures. 4
When to Consider Antibiotics (Rare Exceptions)
Antibiotics should only be prescribed if:
Pertussis is suspected: Perform diagnostic testing and initiate antimicrobial therapy to reduce transmission. 1
High-risk patients: Age ≥65 years with increased risk of pneumonia progression. 1
Management in Patients with Underlying COPD
If the patient has known COPD and presents with acute tracheobronchitis symptoms, treat as a COPD exacerbation rather than simple bronchitis:
Bronchodilators: Increase or add beta-agonists (salbutamol 2.5-5 mg) and/or anticholinergics (ipratropium 0.25-0.5 mg) via nebulizer or inhaler. 1
Systemic corticosteroids: Prednisolone 30 mg/day for 7-14 days if the patient has at least two of: increased dyspnea, increased sputum volume, or purulent sputum. 1, 5
Antibiotics: Only if two or more cardinal symptoms are present (increased dyspnea, increased sputum volume, purulent sputum), as antibiotic therapy reduces short-term mortality by 77% and treatment failure by 53% in COPD exacerbations. 5
Management in Patients with Underlying Asthma
If asthma is suspected or known:
Inhaled bronchodilators: Beta-2 agonists are first-line therapy. 1
Systemic corticosteroids: Consider if there is evidence of significant airflow obstruction or poor response to bronchodilators. 1
Lung function testing: Perform spirometry or peak flow measurements to assess severity and guide treatment intensity. 1
Follow-Up Considerations
Cough persisting >3 weeks: Consider alternative diagnoses including postinfectious cough, upper airway cough syndrome, asthma, or gastroesophageal reflux disease. 1
Recurrent episodes: If a patient has had at least two similar episodes in the past 5 years, 65% can be identified as having mild asthma requiring long-term management. 1
Critical Pitfalls to Avoid
Do not prescribe antibiotics based solely on sputum color or duration of cough—this contributes to antimicrobial resistance without improving outcomes. 1, 2
Do not miss underlying asthma or COPD: These require specific therapies (bronchodilators, corticosteroids) that are beneficial, unlike antibiotics in simple bronchitis. 1
Do not order chest radiography routinely in healthy adults without vital sign abnormalities or asymmetrical lung findings. 1