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

Acute Bronchitis in 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 and contributing to antibiotic resistance. 1

Initial Assessment and Diagnosis

Before confirming acute bronchitis, you must rule out:

• Pneumonia - Check for tachycardia (HR >100), tachypnea (RR >24), fever (>38°C), or abnormal chest findings (rales, egophony, tactile fremitus) 1
• Asthma or COPD exacerbation - Approximately one-third of patients diagnosed with acute bronchitis actually have undiagnosed asthma 1
• Pertussis - Suspect if cough persists >2 weeks with paroxysmal features, whooping, or post-tussive emesis 1, 2

If any vital sign abnormalities or focal lung findings are present, obtain chest radiography to exclude pneumonia 1

Management Approach

The cornerstone of treatment is patient education and symptomatic care only. 1

• Inform patients that cough typically lasts 10-14 days after the visit, even without treatment 1
• Refer to the condition as a "chest cold" rather than "bronchitis" to reduce antibiotic expectations 1, 3
• Explain that patient satisfaction depends on physician-patient communication, not antibiotic prescription 1

Symptomatic Treatment Options

• Antitussives: Codeine or dextromethorphan may provide modest relief for severe, bothersome dry cough, especially when disturbing sleep 1, 3
• Bronchodilators: β2-agonists should NOT be routinely used, except in select patients with accompanying wheezing 1
• Avoid: Expectorants, mucolytics, antihistamines, inhaled corticosteroids, and NSAIDs at anti-inflammatory doses have no proven benefit 1

The ONE Exception: Pertussis

If pertussis is confirmed or suspected, prescribe a macrolide antibiotic (erythromycin or azithromycin) immediately and isolate the patient for 5 days from treatment start. 1

Early treatment within the first few weeks diminishes coughing paroxysms and prevents disease spread 1

When to Reassess

Instruct patients to return if:

• Fever persists >3 days (suggests bacterial superinfection or pneumonia) 1
• Cough persists >3 weeks (consider asthma, COPD, pertussis, or GERD) 1
• Symptoms worsen rather than gradually improve 1

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Acute Exacerbations of Chronic Bronchitis (COPD Patients)

For COPD patients with acute exacerbations, antibiotics ARE indicated if the patient has at least one key symptom (increased dyspnea, sputum volume, or sputum purulence) AND one risk factor. 1, 4

Risk Factors for Antibiotic Use

• Age ≥65 years 4
• FEV1 <50% predicted 4
• ≥4 exacerbations in 12 months 4
• Presence of comorbidities (cardiac failure, diabetes, immunosuppression) 1, 4

Antibiotic Selection Based on Severity

Moderate exacerbations:

• First-line: Doxycycline 100 mg twice daily for 7-10 days 1
• Alternatives: Newer macrolides or extended-spectrum cephalosporins 4

Severe exacerbations:

• Preferred: Amoxicillin/clavulanate 625 mg three times daily for 14 days 1
• Alternative: Respiratory fluoroquinolones 4, 5

Pathogen-Specific Considerations

• H. influenzae (β-lactamase negative): Amoxicillin 500 mg three times daily for 14 days 1
• H. influenzae (β-lactamase positive): Amoxicillin/clavulanate 625 mg three times daily for 14 days 1
• M. catarrhalis: Amoxicillin/clavulanate or clarithromycin 500 mg twice daily for 14 days 1
• S. pneumoniae: Amoxicillin 500 mg-1 g three times daily or doxycycline 100 mg twice daily for 14 days 1

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 Stable COPD with Chronic Bronchitis

First-line: Ipratropium bromide 36 μg (2 inhalations) four times daily to improve chronic cough 6

• Add short-acting β-agonists to control bronchospasm and relieve dyspnea 6
• For severe airflow obstruction (FEV1 <50%) or frequent exacerbations, add inhaled corticosteroid with long-acting β-agonist 6

During Acute Exacerbations

• Administer both short-acting β-agonists AND anticholinergic bronchodilators 6
• Prescribe systemic corticosteroids for 10-15 days (IV for hospitalized, oral for ambulatory patients) 6

What NOT to Do in Stable COPD

• Do NOT use long-term prophylactic antibiotics - not recommended for stable chronic bronchitis 6
• Do NOT use expectorants - no proven effectiveness for chronic cough 6

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Bronchitis with Underlying Asthma

Up to 45% of patients diagnosed with acute bronchitis may have underlying asthma or COPD. 3

Suspect asthma exacerbation if patient has:

• Wheezing 3
• Prolonged expiration 3
• Smoking history 3
• Allergy symptoms 3

For these patients, bronchodilators and systemic corticosteroids ARE appropriate, unlike in uncomplicated acute bronchitis. 3

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

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Key Clinical Pearls

• Purulent sputum occurs in 89-95% of VIRAL bronchitis cases and does NOT indicate bacterial infection 1
• Smoking cessation is the most effective means to improve chronic bronchitis cough, with 90% reporting resolution 6
• Obtain sputum cultures when possible before starting empirical antibiotics in COPD exacerbations, then adjust based on sensitivity if no improvement 1