What is the treatment for an adult patient with bronchitis, with or without chronic obstructive pulmonary disease (COPD)?

Treatment for Bronchitis

For acute bronchitis in otherwise healthy adults, antibiotics should NOT be prescribed, as they provide minimal benefit (reducing cough by only half a day) while exposing patients to adverse effects and contributing to antibiotic resistance. 1, 2

Distinguishing Acute vs. Chronic Bronchitis

Acute Bronchitis (Viral)

• Defined as cough with or without phlegm lasting up to 3 weeks, with normal chest radiograph 1
• Viruses cause 89-95% of cases; bacterial infection accounts for fewer than 10% 1, 3
• Purulent or green sputum does NOT indicate bacterial infection and is NOT an indication for antibiotics 1, 2

Chronic Bronchitis

• Defined as cough with sputum production for at least 3 months per year during 2 consecutive years 4
• Part of the COPD spectrum; requires different management approach 4, 5

Rule Out Pneumonia First

Before diagnosing acute bronchitis, exclude pneumonia by checking for: 1, 2

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

If any of these are present, obtain chest radiograph to rule out pneumonia 1, 2

Treatment for Acute Bronchitis

What NOT to Do

• Do NOT routinely prescribe antibiotics 1, 3, 2
• Do NOT prescribe β2-agonist bronchodilators routinely 1
• Do NOT prescribe inhaled corticosteroids, oral corticosteroids, or NSAIDs at anti-inflammatory doses 1
• Do NOT prescribe expectorants, mucolytics, or antihistamines 1

What TO Do

Patient Education (Most Important):

• Inform patients that cough typically lasts 10-14 days after the visit, with most symptoms resolving within 3 weeks 1, 3, 2
• Refer to the condition as a "chest cold" rather than "bronchitis" to reduce antibiotic expectations 1, 2
• Explain that patient satisfaction depends on physician-patient communication, not antibiotic prescription 1, 6

Symptomatic Treatment Options:

• Codeine or dextromethorphan may provide modest effects on cough severity and duration, especially when dry cough disturbs sleep 1, 7
• Consider β2-agonist bronchodilators ONLY in select patients with wheezing accompanying the cough 1
• Low-cost measures: eliminate environmental cough triggers and use humidified air 1

Exception: Pertussis (Whooping Cough)

For confirmed or suspected pertussis:

• Prescribe a macrolide antibiotic (erythromycin or azithromycin) 1
• Isolate patient for 5 days from start of treatment 1
• Early treatment within first few weeks diminishes coughing paroxysms and prevents disease spread 1

Suspect pertussis if: 2

• Cough persisting >2 weeks
• Paroxysmal cough, whooping cough, or post-tussive emesis
• Recent pertussis exposure

When to Reassess

Reevaluate if: 1, 7

• Fever persists >3 days (suggests bacterial superinfection or pneumonia)
• Cough persists >3 weeks (consider asthma, COPD, pertussis, or GERD)
• Symptoms worsen rather than gradually improve

Treatment for Chronic Bronchitis (Stable)

For chronic bronchitis without acute exacerbation:

Primary Management

• Smoking cessation is essential 4
• There is insufficient evidence to recommend routine use of antibiotics, bronchodilators, or mucolytics for relieving cough in stable chronic bronchitis 4

If COPD is Present

For chronic bronchitis with COPD:

• Ipratropium bromide is the preferred initial treatment, dosed at 36 μg (2 inhalations) four times daily 8
• Short-acting β-agonists should be used to control bronchospasm 8
• Consider long-acting bronchodilators (tiotropium/olodaterol combination) for long-term maintenance, dosed as 2 inhalations once daily 9

Airway Clearance Techniques

• Individuals should be assessed and taught airway clearance techniques by a respiratory physiotherapist 4
• Consider humidification with sterile water or normal saline to facilitate airway clearance 4
• Review airway clearance technique within 3 months of initial assessment 4

Common Pitfalls to Avoid

• Do NOT assume bacterial infection based on sputum color, purulence, or cough duration alone 1, 2
• Do NOT prescribe antibiotics before the 3-day fever threshold, as most cases are viral 1
• Do NOT use benzonatate as monotherapy without addressing underlying bronchospasm with bronchodilators in COPD patients 8
• Do NOT confuse acute bronchitis with asthma exacerbation—up to 45% of patients diagnosed with acute bronchitis may have underlying asthma or COPD 7