Treatment of Bronchitis
Distinguish Between Acute Bronchitis and COPD/Asthma Exacerbation First
The most critical first step is to rule out pneumonia, asthma exacerbation, and COPD exacerbation before diagnosing uncomplicated acute bronchitis, as these conditions require fundamentally different treatment approaches. 1
Key Clinical Indicators to Differentiate
Pneumonia should be suspected if the patient has heart rate >100 beats/min, respiratory rate >24 breaths/min, oral temperature >38°C, or focal lung findings (rales, egophony, tactile fremitus) on examination 1
Asthma or COPD exacerbation should be considered in patients with wheezing, prolonged expiration, smoking history, or recurrent episodes—up to 45% of patients diagnosed with acute bronchitis actually have undiagnosed asthma 2
Approximately one-third of patients diagnosed with acute bronchitis have underlying undiagnosed asthma, making this a critical pitfall to avoid 1
For Uncomplicated Acute Bronchitis (No COPD/Asthma)
Antibiotic Use: The Answer is Almost Always NO
Antibiotics should NOT be prescribed for uncomplicated acute bronchitis, as they reduce cough duration by only half a day while causing significant adverse effects and contributing to antibiotic resistance. 1
Respiratory viruses cause 89-95% of acute bronchitis cases 1
Purulent sputum does NOT indicate bacterial infection—it occurs in 89-95% of viral cases and is not an indication for antibiotics 1, 2
The presence of fever alone does not justify antibiotics unless it persists beyond 3 days, which suggests bacterial superinfection or pneumonia 1
The ONE Exception: Pertussis
If pertussis is confirmed or suspected (cough >2 weeks with paroxysmal cough, whooping, post-tussive emesis), prescribe a macrolide antibiotic such as azithromycin or erythromycin 1
Isolate the patient for 5 days from the start of treatment 1
Early treatment within the first few weeks diminishes coughing paroxysms and prevents disease spread 1
Symptomatic Treatment Options
Inform patients that cough typically lasts 10-14 days after the visit, even without treatment—this is the most important patient education point 1, 2
Refer to the condition as a "chest cold" rather than "bronchitis" to reduce patient expectations for antibiotics 1, 2
For severe bothersome cough, especially when disturbing sleep, codeine or dextromethorphan may provide modest relief, reducing cough counts by 40-60% 1, 2
β2-agonist bronchodilators should NOT be routinely used for cough in acute bronchitis, except in select patients with accompanying wheezing 1
What NOT to Use
- Do NOT prescribe: expectorants, mucolytics, antihistamines, inhaled corticosteroids, systemic corticosteroids, or NSAIDs at anti-inflammatory doses—none have proven benefit 1
When to Reassess
Reevaluate if fever persists >3 days (suggests bacterial superinfection or pneumonia) 1
Reevaluate if cough persists >3 weeks (consider asthma, COPD, pertussis, gastroesophageal reflux) 1, 2
For Patients with Underlying COPD (Chronic Bronchitis)
When to Use Antibiotics in COPD Exacerbations
Antibiotics should be reserved for COPD patients with acute exacerbations who have at least one key symptom (increased dyspnea, increased sputum volume, or increased sputum purulence) AND at least one risk factor. 1, 3
Risk Factors That Warrant Antibiotics:
- Age ≥65 years 3
- FEV1 <50% of predicted value 3
- ≥4 exacerbations in 12 months 3
- One or more comorbidities (cardiac failure, insulin-dependent diabetes, immunosuppression) 1, 3
Antibiotic Selection for COPD Exacerbations
For moderate-severity exacerbations:
- Doxycycline 100 mg twice daily for 7-10 days is first-line 1
- Alternative: newer macrolide (azithromycin), extended-spectrum cephalosporin 3
For severe exacerbations (FEV1 <50%, frequent exacerbations):
- High-dose amoxicillin/clavulanate 625 mg three times daily for 14 days 1
- Alternative: respiratory fluoroquinolone 3, 4
Critical Resistance Considerations:
- 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 Stable COPD with Chronic Bronchitis
Ipratropium bromide 36 μg (2 inhalations) four times daily is first-line therapy to improve cough in stable COPD patients with chronic bronchitis 5
Short-acting β-agonists should be used to control bronchospasm and relieve dyspnea 5
For patients with severe COPD (FEV1 <50%) or frequent exacerbations, consider adding an inhaled corticosteroid with a long-acting β-agonist 5
Management of Acute COPD Exacerbations
Both short-acting β-agonists and anticholinergic bronchodilators should be administered during acute exacerbations 5
A short course (10-15 days) of systemic corticosteroids is recommended for acute exacerbations—IV for hospitalized patients, oral for ambulatory patients 5
What NOT to Use in COPD
Long-term prophylactic antibiotics are NOT recommended for stable patients with chronic bronchitis 5
Currently available expectorants have NOT been proven effective for cough in chronic bronchitis 5
For Patients with Underlying Asthma
Key Management Differences
Patients with asthma exacerbation presenting with cough and wheezing require bronchodilators and systemic corticosteroids, NOT antibiotics. 2
β2-agonist bronchodilators ARE indicated for asthma exacerbations with wheezing 1, 2
Systemic corticosteroids are appropriate for asthma exacerbations 2
Consider lung function testing (peak flow measurements) in patients with ≥2 features suggestive of underlying asthma: wheezing, prolonged expiration, smoking history, allergy symptoms 2
Critical Pitfalls to Avoid
Do NOT assume bacterial infection based on sputum color or purulence alone—this occurs in 89-95% of viral cases 1, 2
Do NOT prescribe antibiotics for cough duration alone—viral bronchitis cough normally lasts 10-14 days 1
Do NOT use bronchodilators routinely for acute bronchitis unless underlying asthma/COPD is present 1, 2
Do NOT miss underlying asthma or COPD—up to 45% of "acute bronchitis" cases are actually undiagnosed reactive airway disease 2
Patient satisfaction depends on physician-patient communication, NOT on antibiotic prescription 1, 2