What is the recommended treatment for a patient with bronchitis, considering factors such as age, other medical conditions, and presence of complications like Chronic Obstructive Pulmonary Disease (COPD)?

Treatment for Bronchitis

Distinguish Between Acute and Chronic Bronchitis First

For acute bronchitis in otherwise healthy adults, do NOT prescribe antibiotics—they reduce cough by only half a day while causing significant adverse effects and contributing to antibiotic resistance. 1, 2, 3

Acute Bronchitis Management

Rule out pneumonia before diagnosing acute bronchitis by checking for heart rate >100 bpm, respiratory rate >24 breaths/min, fever >38°C, or focal lung findings (rales, egophony, fremitus)—if any are present, obtain chest radiography. 2, 4

Core Treatment Approach:

• Patient education is the cornerstone: Inform patients that cough typically lasts 10-14 days after the visit, with complete resolution within 3 weeks. 1, 2, 3
• Refer to the condition as a "chest cold" rather than bronchitis to reduce antibiotic expectations. 1, 2
• Symptomatic treatment only:
  • Codeine or dextromethorphan for bothersome dry cough, especially when disturbing sleep (reduces cough by 40-60%). 5, 2, 3
  • β2-agonist bronchodilators ONLY in select patients with accompanying wheezing—not routinely. 2, 3, 6
  • Avoid expectorants, mucolytics, antihistamines, inhaled corticosteroids, oral corticosteroids, and NSAIDs—no proven benefit. 2, 3

The ONE Exception—Pertussis:

• If pertussis is suspected or confirmed (cough >2 weeks with paroxysms, whooping, post-tussive emesis, or known exposure), prescribe a macrolide antibiotic (erythromycin or azithromycin) immediately. 2, 4
• Isolate patient for 5 days from treatment start. 2
• Early treatment within first few weeks diminishes coughing paroxysms and prevents disease spread. 2

When to Reevaluate:

• Fever persisting >3 days suggests bacterial superinfection or pneumonia. 2
• Cough persisting >3 weeks warrants consideration of asthma, COPD, pertussis, or gastroesophageal reflux. 2

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Chronic Bronchitis (Stable COPD with Chronic Bronchitis)

Ipratropium bromide is the first-line therapy to improve cough in stable COPD patients with chronic bronchitis—dose 36 μg (2 inhalations) four times daily. 5, 3

Additional Stable Management:

• Short-acting β-agonists to control bronchospasm, relieve dyspnea, and may reduce chronic cough in some patients. 5, 3
• Theophylline may be considered for chronic cough control, but requires careful monitoring for complications. 5, 3
• For severe airflow obstruction (FEV1 <50%) or frequent exacerbations, add inhaled corticosteroid with long-acting β-agonist. 5, 3
• Smoking cessation is the most effective intervention—90% of patients report cough resolution after quitting. 1, 5

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Acute Exacerbation of Chronic Bronchitis (AECB)

Reserve antibiotics for patients with ≥1 key symptom (increased dyspnea, sputum volume, or sputum purulence) AND ≥1 risk factor (age ≥65 years, FEV1 <50%, ≥4 exacerbations in 12 months, or comorbidities like heart failure or diabetes). 2, 3, 7

Bronchodilator Therapy During Exacerbations:

• Administer short-acting β-agonists or anticholinergic bronchodilators; if no prompt response, add the other agent at maximal dose. 5, 3

Systemic Corticosteroids:

• Prescribe a 10-15 day course of systemic corticosteroids for acute exacerbations—IV for hospitalized patients, oral for ambulatory patients. 5, 3

Antibiotic Selection (When Indicated):

• For moderate severity exacerbations: Doxycycline 100 mg twice daily for 7-10 days, OR clarithromycin extended-release 1000 mg once daily for 5-7 days, OR clarithromycin immediate-release 500 mg twice daily for 7-14 days. 2, 3, 7
• For severe exacerbations: High-dose amoxicillin/clavulanate 625 mg three times daily for 14 days, OR respiratory fluoroquinolone (levofloxacin). 2, 3, 7

Critical Pitfalls to Avoid:

• Do NOT use purulent sputum color alone as indication for antibiotics—it occurs in 89-95% of viral cases. 2, 8
• Do NOT prescribe antibiotics for acute bronchitis in patients with COPD unless they meet AECB criteria (key symptoms + risk factors). 2, 3
• Up to 25% of H. influenzae and 50-70% of M. catarrhalis produce β-lactamase, making simple aminopenicillins ineffective—use amoxicillin/clavulanate instead. 2

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Special Populations Requiring Different Approach

These guidelines do NOT apply to elderly patients or those with comorbidities (COPD, congestive heart failure, immunosuppression)—these patients have lower threshold for antibiotic use with longer duration (7-10 days). 1, 2

For high-risk patients with acute bronchitis (age >75 with fever, cardiac failure, insulin-dependent diabetes, or serious neurological disorders), consider antibiotics even without chronic bronchitis diagnosis. 2