What are the treatment options for a patient presenting with bronchitis symptoms, including cough, sputum production, and chest discomfort?

Treatment of Bronchitis Symptoms

Acute Bronchitis: Do NOT Use Antibiotics

For patients presenting with acute bronchitis symptoms (cough, sputum production, chest discomfort lasting less than 3 weeks), antibiotics should NOT be prescribed routinely, as they provide minimal benefit (reducing cough by only half a day) while exposing patients to adverse effects and contributing to antibiotic resistance. 1

Diagnosis and Initial Assessment

Before diagnosing acute bronchitis, you must rule out pneumonia by checking for these four findings 1:

• Heart rate >100 beats/min
• Respiratory rate >24 breaths/min
• Oral body temperature >38°C
• Chest examination findings of focal consolidation, egophony, or fremitus

If ANY of these are present, obtain a chest radiograph to rule out pneumonia rather than treating as simple bronchitis. 1

Also exclude 1:

• Common cold (predominantly upper respiratory symptoms)
• Acute asthma (wheezing, history of asthma)
• COPD exacerbation (known COPD with baseline airflow obstruction)

Treatment Approach for Acute Bronchitis

The cornerstone of management is patient education and symptomatic relief only. 1, 2

What TO Do:

• Inform patients that cough typically lasts 10-14 days after the visit, sometimes up to 3 weeks, even without treatment. 1, 2, 3, 4

• For bothersome dry cough, especially disturbing sleep, antitussive agents (codeine or dextromethorphan) can be offered for short-term symptomatic relief. 1, 2

• For select adult patients with wheezing accompanying the cough, β2-agonist bronchodilators may be useful. 1, 2

What NOT To Do:

• Do NOT routinely prescribe β2-agonist bronchodilators in most patients without wheezing. 1

• Do NOT prescribe mucokinetic agents (expectorants, mucolytics) as they show no consistent favorable effect on cough. 1

• Do NOT prescribe antibiotics, antivirals, inhaled anticholinergics, inhaled corticosteroids, oral corticosteroids, or oral NSAIDs routinely. 1, 2

Critical Exception: Pertussis

If pertussis (whooping cough) is confirmed or suspected (severe paroxysms, whooping sound, post-tussive vomiting), prescribe a macrolide antibiotic immediately and isolate the patient for 5 days from treatment start. 1, 2

When to Reassess

Advise patients to return if 1, 2:

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

Important Pitfall to Avoid

Purulent or green sputum does NOT indicate bacterial infection—it occurs in 89-95% of viral bronchitis cases and is NOT an indication for antibiotics. 2, 3, 4

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Chronic Bronchitis: Stepwise Treatment Approach

For patients with chronic cough and sputum production occurring on most days for at least 3 months per year for 2 consecutive years (after excluding other causes), use this treatment algorithm 1:

Step 1: Eliminate Respiratory Irritants (MOST EFFECTIVE)

Smoking cessation is the single most effective intervention—90% of patients will have resolution of their cough after stopping smoking. 1

Also address 1:

• Passive smoke exposure
• Workplace hazards
• Environmental pollutants

Step 2: Pharmacologic Management for Stable Chronic Bronchitis

First-line: Ipratropium bromide (36 μg, 2 inhalations four times daily) should be offered to improve cough, as it decreases cough frequency and severity while reducing sputum volume. 1, 5

Second-line: Short-acting β-agonists should be used to control bronchospasm and relieve dyspnea; in some patients, it may also reduce chronic cough. 1

Third-line: Oral theophylline can be considered to control chronic cough, but requires careful monitoring for complications due to narrow therapeutic index and drug interactions, especially in elderly patients. 1, 5

For severe cases: Consider adding a long-acting β-agonist combined with an inhaled corticosteroid for patients with severe airflow obstruction or frequent exacerbations. 5, 6

For symptomatic relief: Central cough suppressants (codeine or dextromethorphan) can provide short-term relief, reducing cough counts by 40-60%. 1, 5

Step 3: Treatment of Acute Exacerbations

An acute exacerbation is characterized by sudden deterioration with increased cough, sputum volume, sputum purulence, and/or worsening dyspnea 1:

Bronchodilators: Administer short-acting β-agonists or anticholinergic bronchodilators; if no prompt response, add the other agent after maximizing the first. 1

Antibiotics: Use antibiotics for exacerbations; patients with severe exacerbations and those with more severe baseline airflow obstruction benefit most. 1

Corticosteroids: Oral corticosteroids (or IV for severe cases) are useful during acute exacerbations. 1

What NOT To Do for Chronic Bronchitis:

• Do NOT use long-term prophylactic antibiotics in stable patients. 1

• Do NOT use postural drainage or chest percussion—clinical benefits have not been proven. 1

• Do NOT use theophylline during acute exacerbations. 1

Monitoring and Follow-up

• Assess improvement in cough frequency and severity after starting ipratropium bromide. 5
• Monitor for changes in sputum color or volume indicating acute exacerbation. 5
• If cough persists beyond 8 weeks despite appropriate therapy or character changes, consider additional evaluation for other causes (asthma, GERD, malignancy). 5