What is the initial treatment approach for a patient with bronchitis, considering factors such as smoking status and potential bacterial infection?

Initial Treatment of Bronchitis

For acute bronchitis in otherwise healthy adults, do NOT prescribe antibiotics—they provide minimal benefit (reducing cough by only half a day) while causing significant adverse effects and contributing to antibiotic resistance. 1

Immediate Diagnostic Priorities

Before diagnosing acute bronchitis, you must rule out pneumonia by checking these vital signs and examination findings:

• Heart rate >100 beats/min
• Respiratory rate >24 breaths/min
• Oral temperature >38°C
• Abnormal chest examination (rales, egophony, tactile fremitus, or focal consolidation) 1

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

Smoking Status: The Most Critical Factor

Smoking cessation is the single most effective intervention for chronic bronchitis—90% of patients experience complete cough resolution after quitting. 2, 3

• For patients with chronic exposure to tobacco or other respiratory irritants, avoidance should always be recommended first. 2
• In the Lung Health Study, 90% of patients who had chronic cough at baseline and stopped smoking reported no cough by the end of the 5-year study period. 2
• Benefits occur within the first month in approximately half of patients. 2

Treatment Algorithm Based on Clinical Presentation

For Acute Bronchitis (Cough <3 Weeks, No Chronic Lung Disease)

Step 1: Patient Education

• Inform patients that cough typically lasts 10-14 days after the visit, even without antibiotics, and may persist up to 3 weeks. 1
• Refer to the condition as a "chest cold" rather than bronchitis to reduce antibiotic expectations. 1
• Explain that 89-95% of cases are viral, making antibiotics completely ineffective. 1

Step 2: Symptomatic Treatment Only

• For bothersome dry cough: Codeine or dextromethorphan may provide modest relief, especially when sleep is disturbed. 1, 3
• For wheezing: β2-agonist bronchodilators only in select patients with accompanying wheezing—do NOT use routinely. 1
• Avoid: Expectorants, mucolytics, antihistamines, inhaled corticosteroids, NSAIDs at anti-inflammatory doses, and systemic corticosteroids. 1

Step 3: When to Reassess

• Fever persisting >3 days: Strongly suggests bacterial superinfection or pneumonia—reassess for antibiotics. 1
• Cough persisting >3 weeks: Consider other diagnoses (asthma, COPD, pertussis, gastroesophageal reflux). 1

Exception: Pertussis

If pertussis is confirmed or strongly suspected, prescribe a macrolide antibiotic (erythromycin or azithromycin) immediately and isolate the patient for 5 days from treatment start. 1

• Early treatment within the first few weeks diminishes coughing paroxysms and prevents disease spread. 1

For Acute Exacerbation of Chronic Bronchitis (AECB)

This is a completely different entity requiring different management. 3

Antibiotic Indications for AECB:

Prescribe antibiotics if the patient has at least 2 of the 3 Anthonisen criteria:

1. Increased dyspnea
2. Increased sputum volume
3. Increased sputum purulence 1

AND has high-risk features:

• Age >65 years with moderate-to-severe COPD
• FEV1 <50% predicted
• Cardiac failure
• Insulin-dependent diabetes
• Serious neurological disorders
• Immunosuppression 1

Antibiotic Selection for AECB:

First-line for infrequent exacerbations:

• Amoxicillin 500 mg three times daily for 7-10 days 1
• Doxycycline 100 mg twice daily for 7-10 days 1
• Macrolides (azithromycin, clarithromycin) for β-lactam allergy 1

Second-line for frequent exacerbations or FEV1 <35%:

• Amoxicillin-clavulanate 625 mg three times daily for 7-14 days 1
• Respiratory fluoroquinolones (levofloxacin) 1
• Second or third-generation cephalosporins 1

Critical Pitfalls to Avoid

Do NOT assume bacterial infection based on:

• Purulent sputum or sputum color change—occurs in 89-95% of viral cases. 1
• Cough duration alone—viral bronchitis cough normally lasts 10-14 days. 1
• Patient expectation for antibiotics—satisfaction depends more on physician-patient communication than antibiotic prescription. 1

Do NOT prescribe antibiotics for:

• Uncomplicated acute bronchitis in healthy adults, regardless of cough duration or sputum appearance 2, 1
• Acute bronchitis related to smoking or environmental irritants 2
• Mild asthma exacerbations misdiagnosed as bronchitis 2

Special Consideration: Undiagnosed Asthma

Approximately one-third of patients with recurrent "acute bronchitis" episodes actually have undiagnosed asthma or will develop COPD. 3 Consider pulmonary function testing in patients with recurrent episodes or known smoking history. 3