What is the treatment for a patient with bronchitis?

Treatment for Bronchitis

Distinguish Between Acute and Chronic Bronchitis First

For acute bronchitis in otherwise healthy adults, do NOT prescribe antibiotics—they provide no meaningful benefit (reducing cough by only half a day) while causing significant adverse effects and contributing to antibiotic resistance. 1, 2

Acute Bronchitis Management

Rule out pneumonia before diagnosing acute bronchitis by checking for:

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

If any of these are present, obtain chest radiography and consider pneumonia rather than simple bronchitis. 1

Primary Treatment Approach

• Symptomatic therapy is the cornerstone of management 1, 2
• Albuterol (short-acting β-agonist) is first-line treatment for patients with wheezing or bothersome cough, reducing cough duration and severity by approximately 50% after 7 days 2
• Antitussives (codeine or dextromethorphan) provide modest relief for dry, bothersome cough, especially when sleep is disturbed 1, 2
• Low-cost interventions such as elimination of environmental cough triggers and vaporized air treatments are reasonable options 1, 2

Patient Education Critical Points

• Inform patients that cough typically lasts 10-14 days after the visit, even without antibiotics 1, 2
• Refer to the condition as a "chest cold" rather than bronchitis to reduce antibiotic expectations 1
• Patient satisfaction depends more on physician-patient communication than whether an antibiotic is prescribed 1, 2

The ONE Exception: Pertussis

For confirmed or suspected pertussis (whooping cough), prescribe a macrolide antibiotic immediately (azithromycin or erythromycin) 1, 3

• Isolate the patient for 5 days from the start of treatment 1
• Early treatment within the first few weeks diminishes coughing paroxysms and prevents disease spread 1

When to Reassess

Instruct patients to return if:

• Fever persists >3 days (suggests bacterial superinfection or pneumonia) 1
• Cough persists >3 weeks (consider asthma, COPD, pertussis, or GERD) 1
• Symptoms worsen rather than gradually improve 1

Chronic Bronchitis (COPD) Management

For stable chronic bronchitis, the treatment hierarchy is:

1. Ipratropium bromide 36 μg (2 inhalations) four times daily is the preferred initial treatment for improving cough, reducing cough frequency, severity, and sputum volume 4

2. Short-acting β-agonists to control bronchospasm and relieve dyspnea, which may also reduce chronic cough 2, 4

3. Smoking cessation is the most effective intervention—94-100% of patients experience cough resolution or marked decrease, with approximately half improving within 1 month 5

Acute Exacerbations of Chronic Bronchitis (AECB)

Prescribe antibiotics ONLY if the patient has:

• At least 2 of 3 Anthonisen criteria: increased dyspnea, increased sputum volume, or increased sputum purulence 1, 6
• PLUS at least one risk factor: age ≥65 years, FEV₁ <50% predicted, ≥4 exacerbations in 12 months, or significant comorbidities (cardiac failure, insulin-dependent diabetes, immunosuppression) 1, 6

Antibiotic Selection Algorithm:

For moderate-severity exacerbations (infrequent, FEV₁ >50%):

• Doxycycline 100 mg twice daily for 7-10 days (first-line) 1
• Alternatives: Azithromycin 500 mg daily for 5 days 3, or amoxicillin 500 mg three times daily for 7-10 days 1

For severe exacerbations (frequent, FEV₁ <50%, or high-risk patients):

• Amoxicillin/clavulanate 625 mg three times daily for 7-14 days 1
• Respiratory fluoroquinolones (levofloxacin or moxifloxacin) for 7-10 days 1, 7
• Clarithromycin extended-release 1000 mg once daily for 5-7 days achieves 90-97% clinical cure rates 1

Critical Pitfalls to Avoid

• Do NOT assume bacterial infection based on purulent sputum alone—it occurs in 89-95% of viral cases 1
• Do NOT prescribe antibiotics for acute bronchitis based on cough duration alone—viral bronchitis cough normally lasts 10-14 days 1
• Up to 25% of H. influenzae and 50-70% of M. catarrhalis produce β-lactamase, making simple aminopenicillins ineffective 1
• Avoid aminopenicillins alone, older-generation macrolides, first-generation cephalosporins, and cotrimoxazole due to increasing resistance 1, 8

Adjunctive Therapy for Chronic Bronchitis

• Oral corticosteroids should be used when airflow obstruction is moderately severe or more pronounced during exacerbations 9
• Benzonatate may be used for short-term symptomatic relief when cough severely affects quality of life 4
• Long-term prophylactic antibiotics are NOT recommended for stable chronic bronchitis 4