What is the best approach to manage cough in an adult patient with acute bronchitis?

Management of Cough in Acute Bronchitis

For immunocompetent adults with acute bronchitis, no routine medications should be prescribed—including antibiotics, antitussives, bronchodilators, or anti-inflammatory agents—as the evidence shows these provide minimal benefit while exposing patients to adverse effects. 1

Initial Diagnostic Approach

Before treating cough as acute bronchitis, you must rule out more serious conditions:

• Exclude pneumonia by checking for tachycardia (heart rate >100 beats/min), tachypnea (respiratory rate >24 breaths/min), fever (oral temperature >38°C), or abnormal chest examination findings (rales, egophony, tactile fremitus). 2, 3
• Rule out asthma or COPD exacerbation, as approximately one-third of patients diagnosed with acute bronchitis actually have undiagnosed asthma. 2, 4
• Consider pertussis if cough persists beyond 2 weeks with paroxysmal features, whooping, or post-tussive emesis. 5, 6
• Purulent or green sputum does NOT indicate bacterial infection—it occurs in 89-95% of viral cases and should not trigger antibiotic use. 2, 3, 7

Primary Management Strategy: Patient Education

The cornerstone of treatment is setting appropriate expectations, not prescribing medications. 3, 4

• Inform patients that cough typically lasts 10-14 days after the office visit, even without treatment, and may persist up to 3 weeks. 2, 3, 6
• Refer to the condition as a "chest cold" rather than "bronchitis" to reduce patient expectations for antibiotics. 2, 3
• Explain that patient satisfaction depends more on physician-patient communication than whether medications are prescribed. 2, 3

What NOT to Prescribe

The most recent 2020 CHEST guidelines are explicit about avoiding routine medications:

• No antibiotics: They reduce cough by only 0.5 days while causing adverse effects including allergic reactions, nausea, and C. difficile infection. 1, 5
• No antitussives (codeine, dextromethorphan): Despite older 2006-2007 guidelines suggesting modest benefit 1, the 2020 CHEST expert panel found insufficient evidence to recommend routine use. 1
• No inhaled beta-agonists or anticholinergics: These should not be routinely prescribed unless wheezing is present. 1, 3
• No inhaled or oral corticosteroids: No evidence supports their use in uncomplicated acute bronchitis. 1
• No NSAIDs at anti-inflammatory doses: These lack consistent evidence of benefit. 1, 2
• No expectorants or mucolytics: Despite guaifenesin being FDA-approved to "loosen phlegm" 8, clinical guidelines do not recommend these agents due to lack of efficacy evidence. 2, 4

Important Nuance on Antitussives

There is a divergence between older and newer guidelines. The 2006-2007 recommendations suggested dextromethorphan (60 mg doses) or first-generation antihistamines for symptomatic relief 1, and some research supports modest benefit 7, 9. However, the 2020 CHEST guidelines—the most recent and highest quality evidence—explicitly recommend against routine prescription of antitussives until proven safe and effective. 1 In real-world practice, if patients have severe, sleep-disrupting dry cough, dextromethorphan 10 may provide short-term symptomatic relief, but this should not be routine. 2

Selective Use of Bronchodilators

Beta-2 agonist bronchodilators may be considered ONLY in select adult patients with wheezing accompanying the cough, not for cough alone. 2, 3, 4 This represents a subset of patients who may have underlying reactive airways.

Critical Exception: Pertussis

If pertussis is confirmed or strongly suspected, immediately prescribe a macrolide antibiotic (erythromycin or azithromycin) and isolate the patient for 5 days from treatment start. 2, 3 Early treatment within the first few weeks diminishes coughing paroxysms and prevents disease spread. 2

When to Consider Antibiotics

Antibiotics should be considered ONLY in specific high-risk scenarios:

• If acute bronchitis significantly worsens, suggesting bacterial superinfection (fever persisting >3 days). 1, 2
• High-risk patients (age ≥75 years with fever, cardiac failure, insulin-dependent diabetes, immunosuppression, or serious neurological disorders) who meet Anthonisen criteria (increased dyspnea, sputum volume, or purulence). 2, 3, 4
• For these high-risk patients, doxycycline 100 mg twice daily for 7-10 days is first-line. 2, 3

Common Pitfall to Avoid

Do not prescribe antibiotics based on cough duration, sputum color, or patient expectation alone. 2, 3 The presence of purulent sputum occurs in 89-95% of viral cases and does not indicate bacterial infection. 2, 3, 7

Follow-up and Reassessment

Instruct patients to return if:

• Fever persists beyond 3 days (consider bacterial superinfection or pneumonia). 2, 3, 4
• Cough persists beyond 3 weeks (consider asthma, COPD, pertussis, or GERD). 2, 3, 4
• Symptoms worsen rather than gradually improve. 2, 3

Practical Algorithm

1. Rule out pneumonia (check vital signs and lung exam). 2, 3, 4
2. Rule out asthma/COPD (especially if recurrent episodes). 2, 4
3. If uncomplicated acute bronchitis confirmed: Provide education on expected 2-3 week duration and avoid routine medications. 1, 3
4. Consider beta-2 agonist ONLY if wheezing present. 2, 3, 4
5. Prescribe macrolide immediately if pertussis suspected. 2, 3
6. Reassess if fever >3 days or cough >3 weeks. 2, 3, 4