What is the recommended treatment plan for a patient with acute bronchitis, considering potential underlying respiratory conditions such as chronic obstructive pulmonary disease (COPD) or asthma?

Acute Bronchitis Treatment Plan

Do not prescribe antibiotics for uncomplicated acute bronchitis—they reduce cough by only half a day while causing adverse effects and promoting antibiotic resistance. 1, 2

Initial Assessment and Diagnosis

Rule out pneumonia first by checking for these red flags 1:

• Heart rate >100 beats/min
• Respiratory rate >24 breaths/min
• Oral temperature >38°C
• Focal consolidation findings on lung exam (rales, egophony, tactile fremitus)

If any of these are present, obtain chest radiography to exclude pneumonia before diagnosing acute bronchitis. 1

Consider alternative diagnoses 1, 2:

• Approximately one-third of patients diagnosed with acute bronchitis actually have undiagnosed asthma
• Rule out COPD exacerbation in patients with known chronic lung disease
• Consider pertussis if paroxysmal cough with inspiratory whoop is present

Treatment for Uncomplicated Acute Bronchitis

Patient Education (Most Important)

Inform patients that cough typically lasts 10-14 days after the visit, with complete resolution within 3 weeks. 1, 2 This single intervention improves satisfaction more than prescribing antibiotics. 1

Use the term "chest cold" rather than "bronchitis" to reduce patient expectations for antibiotics. 1

Symptomatic Treatment

For bothersome dry cough, especially disturbing sleep 1, 2:

• Codeine or dextromethorphan provide modest symptom relief (40-60% reduction in cough counts)
• These are the only pharmacologic agents with proven benefit

For patients with wheezing 1, 2:

• β2-agonist bronchodilators may be used in select patients with accompanying wheezing
• Do NOT use routinely in patients without wheezing

Do NOT prescribe 1, 2:

• Expectorants or mucolytics (no proven benefit)
• Antihistamines (no proven benefit)
• Inhaled corticosteroids (no proven benefit)
• Oral corticosteroids (no proven benefit)
• NSAIDs at anti-inflammatory doses (no proven benefit)

Non-Pharmacologic Measures

Recommend low-risk interventions 1:

• Elimination of environmental cough triggers (smoke, irritants)
• Humidified air treatments

Special Situations Requiring Antibiotics

Pertussis (Whooping Cough)

If pertussis is confirmed or strongly suspected, prescribe a macrolide antibiotic immediately 1:

• Erythromycin or azithromycin
• Isolate patient for 5 days from start of treatment
• Early treatment (within first few weeks) diminishes coughing paroxysms and prevents disease spread

Patients with COPD or Chronic Bronchitis

These patients are NOT included in standard acute bronchitis recommendations. 1, 2 For acute exacerbations of chronic bronchitis, use the Anthonisen criteria 1, 3:

Prescribe antibiotics if patient has ≥1 key symptom AND ≥1 risk factor 1, 3:

Key symptoms (need at least 1):

• Increased dyspnea
• Increased sputum volume
• Increased sputum purulence

Risk factors (need at least 1):

• Age ≥65 years
• FEV1 <50% predicted
• ≥4 exacerbations in past 12 months
• Comorbidities (cardiac failure, insulin-dependent diabetes, serious neurological disorders)

Antibiotic regimens for COPD exacerbations 1, 2:

• Moderate severity: Doxycycline 100 mg twice daily for 7-10 days, OR clarithromycin extended-release 1000 mg once daily for 5-7 days
• Severe exacerbations: Amoxicillin/clavulanate 625 mg three times daily for 14 days, OR respiratory fluoroquinolone

Also provide during COPD exacerbations 2, 4:

• Short-acting β-agonists or anticholinergic bronchodilators; if no prompt response, add the other agent at maximal dose
• Systemic corticosteroids for 10-15 days

When to Reevaluate

Instruct patients to return if 1:

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

Critical Pitfalls to Avoid

Do NOT assume bacterial infection based on 1:

• Purulent sputum or sputum color change (present in 89-95% of viral cases)
• Duration of cough alone
• Patient expectation for antibiotics

Do NOT prescribe antibiotics for uncomplicated cases even if fever is present initially—wait to see if fever persists beyond 3 days. 1

Remember that 89-95% of acute bronchitis cases are viral, making antibiotics ineffective and potentially harmful. 1, 5