What is the appropriate treatment plan for a patient diagnosed with bronchitis, considering potential bacterial infection, chronic condition, and lifestyle factors such as smoking?

Treatment of Bronchitis

For acute bronchitis in otherwise healthy adults, antibiotics should NOT be prescribed regardless of cough duration or sputum color, as they provide minimal benefit (reducing cough by only half a day) while causing significant adverse effects and contributing to antibiotic resistance. 1, 2, 3

Distinguishing Acute vs. Chronic Bronchitis

Acute Bronchitis:

• Cough lasting less than 3 weeks with or without sputum production 1, 3
• Typically viral etiology (89-95% of cases) 1, 2
• Self-limiting condition with expected cough duration of 10-14 days, sometimes up to 3 weeks 1, 3, 4

Chronic Bronchitis:

• Daily expectoration for at least 3 consecutive months during at least 2 consecutive years 5
• Often associated with smoking and may have reversible airway disease 6

Rule Out Pneumonia First

Before diagnosing acute bronchitis, exclude pneumonia by checking for: 1, 2, 3

• Heart rate >100 beats/min
• Respiratory rate >24 breaths/min
• Oral temperature >38°C
• Focal consolidation on lung examination

If any of these are present, obtain chest radiography rather than treating as simple bronchitis. 1, 3

Acute Bronchitis Management

What NOT to Do:

• Do not prescribe antibiotics routinely - they are ineffective for viral bronchitis and expose patients to adverse effects including allergic reactions, nausea, vomiting, and Clostridium difficile infection 1, 2, 3, 4
• Purulent or green sputum does NOT indicate bacterial infection (occurs in 89-95% of viral cases) and is NOT an indication for antibiotics 1, 2
• Do not use inhaled corticosteroids, oral corticosteroids, NSAIDs at anti-inflammatory doses, expectorants, mucolytics, or antihistamines - no evidence of benefit 1, 4

Symptomatic Treatment Options:

• β2-agonist bronchodilators (albuterol) may be useful in select patients with accompanying wheezing 1, 7, 3
• Codeine or dextromethorphan may provide modest relief for bothersome dry cough, especially when sleep is disturbed 1, 5
• Elimination of environmental irritants and humidified air 1

Exception - Pertussis:

If pertussis is suspected or confirmed (cough >2 weeks with paroxysmal cough, whooping, post-tussive emesis), prescribe a macrolide antibiotic (azithromycin or erythromycin) immediately and isolate patient for 5 days from start of treatment. 1, 3

Patient Education:

• Inform patients that cough typically lasts 10-14 days after the visit, even without antibiotics 1, 3, 4
• Refer to the condition as a "chest cold" rather than bronchitis to reduce antibiotic expectations 1, 3, 4
• Explain that patient satisfaction depends more on physician-patient communication than antibiotic prescription 1, 8

When to Reassess:

• Fever persisting >3 days (suggests bacterial superinfection or pneumonia) 1
• Cough persisting >3 weeks (consider asthma, COPD, pertussis, GERD) 1, 5
• Symptoms worsening rather than gradually improving 1

Chronic Bronchitis Management

For Patients with Reversible Airway Disease:

First-Line Bronchodilator Therapy:

• Short-acting β-agonists (albuterol) for symptom relief and bronchospasm control 6, 5
• Ipratropium bromide as first-line therapy to improve cough in stable chronic bronchitis 5

Smoking Cessation - MANDATORY:

Avoidance of all respiratory irritants, especially smoking cessation, is the single most effective intervention - 90% of patients with chronic bronchitis experience cough resolution after quitting. 6, 5

Step-Up Therapy if Symptoms Persist:

• Consider combination short-acting β-agonist plus anticholinergic 6
• For patients with significant airway reversibility or asthmatic features, consider inhaled corticosteroids 6
• Theophylline may be considered but requires careful monitoring 5

What NOT to Use:

• Long-term prophylactic antibiotics are NOT indicated for stable chronic bronchitis 6
• Long-term oral corticosteroids are NOT recommended due to lack of benefit and significant side effects 5

Acute Exacerbations of Chronic Bronchitis:

Consider antibiotics ONLY if patient has: 1

• Chronic respiratory insufficiency (dyspnea at rest, FEV1 <35%, hypoxemia with PaO2 <60 mmHg)
• At least 2 of 3 Anthonisen criteria: increased dyspnea, increased sputum volume, increased sputum purulence
• Fever >38°C persisting >3 days

Antibiotic Selection for Exacerbations:

• First-line (infrequent exacerbations): amoxicillin, first-generation cephalosporins, macrolides (azithromycin), or doxycycline 1
• Second-line (frequent exacerbations or FEV1 <35%): amoxicillin-clavulanate, second/third-generation cephalosporins, respiratory fluoroquinolones 1
• Standard duration: 7-10 days 1

For acute exacerbations, a short course of systemic corticosteroids may be beneficial. 6

Critical Pitfalls to Avoid

• Do not assume bacterial infection based on sputum color alone - purulent sputum occurs in 89-95% of viral cases 1, 2
• Do not prescribe antibiotics for cough duration alone - viral bronchitis cough normally lasts 10-14 days 1
• Do not ignore recurrent "acute bronchitis" episodes - 65% actually have underlying mild asthma or will develop COPD 5
• Do not use expectorants - currently available expectorants have not been proven effective 5