What is the recommended treatment for a patient with bronchitis, considering potential underlying conditions such as Chronic Obstructive Pulmonary Disease (COPD) or asthma?

Treatment of Bronchitis

Distinguish Between Acute Bronchitis and Chronic Bronchitis/COPD First

The most critical first step is determining whether this is acute bronchitis in an otherwise healthy patient versus an acute exacerbation of chronic bronchitis/COPD, as treatment differs dramatically between these two conditions. 1

For Acute Bronchitis (Otherwise Healthy Patients)

Antibiotics should NOT be prescribed for uncomplicated acute bronchitis, as they provide minimal benefit (reducing cough by only half a day) while exposing patients to adverse effects including allergic reactions, nausea, and Clostridium difficile infection. 1, 2

Key Management Principles:

• Rule out pneumonia first by checking for tachycardia (heart rate >100 bpm), tachypnea (respiratory rate >24 breaths/min), fever >38°C, or abnormal chest findings (rales, egophony, tactile fremitus) 1
• Inform patients that cough typically lasts 10-14 days after the visit, with most symptoms resolving within 3 weeks 1
• Purulent sputum does NOT indicate bacterial infection and occurs in 89-95% of viral cases—this is not an indication for antibiotics 1

Symptomatic Treatment Options:

• Codeine or dextromethorphan may provide modest effects on cough severity and duration, especially when dry cough disturbs sleep 1, 3
• β2-agonist bronchodilators should NOT be routinely used except in select patients with wheezing accompanying the cough 1
• Do NOT prescribe: expectorants, mucolytics, antihistamines, inhaled corticosteroids, or NSAIDs at anti-inflammatory doses—these lack evidence of benefit 1

Critical Exception - Pertussis:

• For confirmed or suspected pertussis (whooping cough), prescribe a macrolide antibiotic (erythromycin or azithromycin) 1
• Isolate the patient for 5 days from the start of treatment 1
• Suspect pertussis if cough persists >2 weeks with paroxysmal cough, whooping, or post-tussive emesis 2

When to Reassess:

• If fever persists beyond 3 days, this strongly suggests bacterial superinfection or pneumonia rather than viral bronchitis 1
• If cough persists beyond 3 weeks, consider other diagnoses including asthma, COPD, pertussis, or gastroesophageal reflux 1, 3

For Acute Exacerbation of Chronic Bronchitis/COPD

Antibiotics ARE indicated for patients with chronic bronchitis/COPD who have at least one key symptom (increased dyspnea, increased sputum volume, or increased sputum purulence) AND at least one risk factor. 1, 4

Risk Factors That Warrant Antibiotics:

• Age ≥65 years 4
• FEV1 <50% of predicted value 4
• ≥4 exacerbations in 12 months 4
• Comorbidities (cardiac failure, insulin-dependent diabetes, immunosuppression) 1, 4

Antibiotic Selection Based on Severity:

For moderate-severity exacerbations:

• Doxycycline 100 mg twice daily for 7-10 days (first-line option) 1
• Alternative: newer macrolide (azithromycin 500 mg daily for 3 days per FDA label) 5 or extended-spectrum cephalosporin 4

For severe exacerbations (FEV1 <50%, frequent exacerbations, or significant comorbidities):

• High-dose amoxicillin/clavulanate 625 mg three times daily for 14 days 1
• Alternative: respiratory fluoroquinolone 6

Critical Pitfall to Avoid:

• Up to 25% of H. influenzae and 50-70% of M. catarrhalis produce β-lactamase, making simple aminopenicillins ineffective 1
• Avoid aminopenicillins alone, older-generation macrolides, first-generation cephalosporins, and cotrimoxazole due to increasing resistance 1

Bronchodilator Therapy for COPD Exacerbations:

• Administer short-acting β-agonists or anticholinergic bronchodilators during acute exacerbation 7
• If no prompt response, add the other agent after maximizing the first 7
• Do NOT use theophylline for acute exacerbations (Grade D recommendation) 7

Corticosteroid Therapy:

• A short course (10-15 days) of systemic corticosteroids should be given for acute exacerbations 7
• Use IV therapy for hospitalized patients and oral therapy for ambulatory patients 7
• A 2-week trial is recommended rather than 8 weeks due to significant side effect potential 7

For Stable Chronic Bronchitis (Between Exacerbations)

Ipratropium bromide 36 μg (2 inhalations) four times daily is first-line therapy to improve cough in stable COPD patients with chronic bronchitis (Grade A recommendation) 8

Additional Maintenance Options:

• Short-acting β-agonists to control bronchospasm and relieve dyspnea 8
• For severe airflow obstruction (FEV1 <50%) or frequent exacerbations, add an inhaled corticosteroid with a long-acting β-agonist 8
• Theophylline may be considered to control chronic cough, but requires careful monitoring for complications 7, 8
• Smoking cessation is the most effective intervention—90% of patients report resolution of cough after quitting 8

What NOT to Use Long-Term:

• Long-term prophylactic antibiotics are NOT recommended for stable chronic bronchitis 8
• Expectorants have not been proven effective and should not be used 7, 8

Common Pitfall: Undiagnosed Asthma

Approximately one-third of patients diagnosed with acute bronchitis actually have undiagnosed asthma. 3 Suspect asthma if the patient has:

• Wheezing with prolonged expiration 3
• Recurrent episodes of "bronchitis" 3
• Smoking history or allergy symptoms 3

Consider lung function testing in patients with ≥2 features suggestive of underlying asthma 3