What are the diagnostic and treatment approaches for a patient presenting with bronchitis?

Bronchitis: Diagnosis and Treatment

Diagnostic Approach

For acute bronchitis, diagnosis is clinical and requires ruling out pneumonia first—if heart rate >100 bpm, respiratory rate >24 breaths/min, temperature >38°C, or focal chest findings are absent, pneumonia is unlikely and chest radiography is unnecessary. 1

Initial Clinical Assessment

• Differentiate acute bronchitis from common cold: Acute bronchitis presents with cough as the predominant symptom lasting up to 3 weeks, whereas common cold features nasal stuffiness, discharge, and sneezing as primary complaints 2
• Rule out pneumonia systematically: Check vital signs and perform chest examination; absence of tachycardia, tachypnea, fever, and focal findings (consolidation, egophony, fremitus) effectively excludes pneumonia 1, 2
• No routine investigations needed: Chest x-ray, spirometry, sputum cultures, viral PCR, and inflammatory markers are not recommended for uncomplicated acute bronchitis 1

Key Diagnostic Pitfalls

• Purulent sputum does NOT indicate bacterial infection: Sputum color is unreliable for distinguishing viral from bacterial etiology and should not guide antibiotic decisions 1, 3
• Consider masked asthma: Up to 45% of patients with cough lasting >2 weeks may have undiagnosed asthma or COPD; consider lung function testing if wheezing, prolonged expiration, smoking history, or allergy symptoms are present 2
• Recurrent "bronchitis" suggests asthma: Approximately 65% of patients with recurrent acute bronchitis episodes actually have underlying mild asthma with exacerbations 1

When to Investigate Further

If symptoms persist or worsen beyond 3 weeks, obtain: 1

• Chest radiograph
• Sputum culture
• Peak expiratory flow measurements
• Complete blood count and inflammatory markers

Treatment of Acute Bronchitis

Antibiotics should NOT be prescribed for acute bronchitis in immunocompetent adults—they reduce cough duration by only 0.5 days while exposing patients to adverse effects including allergic reactions, gastrointestinal symptoms, and C. difficile infection. 1, 4, 5

Recommended Management

• Patient education is paramount: Inform patients that cough typically lasts 2-3 weeks and that antibiotics provide minimal benefit 4, 5
• Call it a "chest cold": Using this terminology instead of "bronchitis" reduces patient expectations for antibiotics 5, 3
• Symptomatic treatment options: 6
  • Albuterol inhaler for cough suppression (only if wheezing present)
  • Dextromethorphan or codeine for cough (though evidence of benefit is limited)
  • Avoid antitussives, honey, antihistamines, anticholinergics, NSAIDs, and corticosteroids—none are effective 4

β2-Agonist Use

• Do not routinely prescribe bronchodilators: They should not be given for cough in acute bronchitis 1
• Exception: May consider in select patients with wheezing accompanying the cough 1

Antibiotic Considerations (Rare Exceptions)

Antibiotics may be considered only in: 1

• Significant worsening of symptoms suggesting bacterial superinfection
• High-risk patients (age ≥65 years)
• Suspected pertussis (to reduce transmission)

Common pitfall: Avoid diagnosing "acute bronchitis" when the patient actually has a common cold, as this increases inappropriate antibiotic prescribing 7

Treatment of Acute Exacerbation of Chronic Bronchitis (AECB)

For AECB, bronchodilator therapy with short-acting β-agonist or ipratropium bromide is the cornerstone of treatment, with antibiotics reserved only for patients meeting specific criteria. 6

Indications for Antibiotic Therapy in AECB

Antibiotics should be used only when patients have: 8

• At least one key symptom: Increased dyspnea, increased sputum production, OR increased sputum purulence
• AND at least one risk factor: Age ≥65 years, FEV1 <50% predicted, ≥4 exacerbations in 12 months, OR comorbidities

AECB Treatment Algorithm

Bronchodilator therapy (all patients): 6

• Short-acting β-agonist OR ipratropium bromide

Corticosteroid therapy (moderate to severe exacerbations): 6

• Prednisone 40 mg daily for 5-7 days

Antibiotic selection (when criteria met): 8

• Moderate severity: Newer macrolide (azithromycin 500 mg daily for 3 days 9), extended-spectrum cephalosporin, or doxycycline
• Severe exacerbation: High-dose amoxicillin/clavulanate or respiratory fluoroquinolone

Common Pathogens in AECB

The three most prevalent bacteria are: 8, 10

• Streptococcus pneumoniae
• Haemophilus influenzae
• Moraxella catarrhalis

Note: Pseudomonas aeruginosa is increasingly prevalent in patients with severe underlying disease and nosocomial infections 10

Chronic Bronchitis Maintenance Therapy

Smoking cessation is the single most effective intervention for chronic bronchitis and should be emphasized at every visit. 6

Maintenance Medications

• Bronchodilators: Short-acting β-agonists and ipratropium bromide for bronchospasm and dyspnea 6
• Inhaled corticosteroids: Consider for patients with FEV1 <50% predicted or frequent exacerbations 6
• Long-acting bronchodilators: Tiotropium-based combinations (e.g., tiotropium/olodaterol) are indicated for long-term maintenance treatment of COPD including chronic bronchitis 11

Critical Assessment Points

• Evaluate smoking history: Document pack-years at every visit 6
• Monitor for exacerbations: Assess for sudden deterioration with increased cough, sputum production, purulence, or dyspnea 6