Initial Management of Acute Bronchitis
For immunocompetent adult outpatients presenting with acute bronchitis, do not prescribe antibiotics, do not order routine investigations, and focus on ruling out pneumonia, educating patients that cough typically lasts 2-3 weeks, and providing symptomatic support only. 1
Diagnostic Approach: Rule Out Serious Illness First
The primary goal at initial presentation is excluding pneumonia and other differential diagnoses, not confirming bronchitis itself. 1
Key clinical features that warrant chest radiography or further evaluation: 1
- Heart rate >100 beats/min
- Respiratory rate >24 breaths/min
- Oral temperature >38°C (100.4°F)
- Focal consolidation findings on lung exam (rales, egophony, fremitus)
If none of these features are present, chest radiography is not indicated. 1
Critical differential diagnoses to consider: 1
- Pneumonia (most important to exclude)
- Asthma or cough-variant asthma (approximately one-third of patients diagnosed with acute bronchitis actually have undiagnosed asthma) 1
- COPD exacerbation in smokers
- Pertussis (if cough >2 weeks with paroxysmal features, post-tussive vomiting, or whooping)
- Heart failure
- Acute rhinosinusitis
No Routine Investigations
Do not order the following tests at initial presentation: 1
- Chest x-ray (unless pneumonia suspected based on vital signs/exam)
- Spirometry or peak flow measurement
- Sputum culture
- Viral PCR testing
- C-reactive protein (CRP) or procalcitonin
- Complete blood count
These investigations have not been shown to improve outcomes in uncomplicated acute bronchitis and only add unnecessary cost. 1
No Routine Medications
The following medications should NOT be routinely prescribed: 1
- Antibiotics (provide only 0.5 day reduction in cough duration while causing adverse effects including allergic reactions, nausea, and Clostridium difficile infection) 1, 2, 3
- Antiviral therapy
- Antitussives (codeine or dextromethorphan)
- Inhaled beta-agonists (except in select patients with wheezing)
- Inhaled anticholinergics
- Inhaled or oral corticosteroids
- Oral NSAIDs at anti-inflammatory doses
The presence of purulent or colored sputum does NOT indicate bacterial infection and is NOT an indication for antibiotics—purulent sputum occurs in 89-95% of viral bronchitis cases. 4, 5
What TO Do: Patient Education and Symptomatic Support
Essential patient education points: 1, 4, 2
- Cough typically lasts 10-14 days after the visit, and may persist up to 3 weeks
- The condition is self-limiting and caused by viruses in 89-95% of cases
- Antibiotics will not help and expose patients to unnecessary risks
- Refer to the condition as a "chest cold" rather than "bronchitis" to reduce antibiotic expectations 4, 2
Reasonable symptomatic measures (though evidence is limited): 4
- Elimination of environmental cough triggers (smoke, irritants)
- Humidified air or vaporizer treatments
- Adequate hydration and rest
When to Reassess or Modify Management
Advise patients to return for reassessment if: 1
- Symptoms worsen rather than gradually improve
- Fever persists beyond 3 days (suggests possible bacterial superinfection or pneumonia)
- Cough persists beyond 3 weeks (consider asthma, COPD, pertussis, GERD, or other diagnoses)
At reassessment, consider targeted investigations: 1
- Chest x-ray
- Sputum culture
- Peak flow measurements
- Complete blood count and inflammatory markers (CRP)
Consider antibiotics ONLY if: 1
- Clinical worsening suggests complicating bacterial infection
- Pertussis is confirmed or strongly suspected (prescribe macrolide antibiotic and isolate patient for 5 days) 4
Critical Pitfalls to Avoid
Do not assume bacterial infection based on: 4, 5
- Sputum color or purulence (present in 89-95% of viral cases)
- Duration of cough alone
- Patient expectation for antibiotics
Do not miss underlying asthma: 1
- In retrospective studies, 65% of patients with recurrent "acute bronchitis" episodes actually had mild asthma
- Consider asthma if patient has recurrent episodes, nocturnal cough, or cough triggered by cold air or exercise
Patient satisfaction depends on physician-patient communication quality, not on whether antibiotics are prescribed. 1, 4 Effective communication about the viral nature of the illness, expected duration, and risks of unnecessary antibiotics maintains satisfaction while providing evidence-based care.