What is the recommended treatment approach for a patient with bronchitis, considering factors such as underlying respiratory conditions like chronic obstructive pulmonary disease (COPD) or asthma, and potential complications?

Treatment of Bronchitis

Distinguish Acute vs. Chronic Bronchitis First

The cornerstone of bronchitis management is determining whether you are treating acute bronchitis (which is viral in >90% of cases and does NOT require antibiotics) or an acute exacerbation of chronic bronchitis/COPD (which may require antibiotics in specific high-risk situations). 1, 2

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Acute Bronchitis Management

Rule Out Pneumonia Before Diagnosing Acute Bronchitis

Before confirming acute bronchitis, assess for:

• Heart rate >100 bpm
• Respiratory rate >24 breaths/min
• Temperature >38°C (100.4°F)
• Focal consolidation on chest exam (rales, egophony, tactile fremitus)

If ANY of these are present, obtain chest radiography to rule out pneumonia rather than treating as simple bronchitis. 1, 2

Antibiotic Use: The Default Answer is NO

Antibiotics should NOT be prescribed for uncomplicated acute bronchitis in otherwise healthy adults, regardless of cough duration, sputum color, or purulence. 1, 2

Key evidence:

• Antibiotics reduce cough duration by only half a day while causing significant adverse effects (allergic reactions, nausea, vomiting, C. difficile infection) 2, 3, 4
• 89-95% of acute bronchitis cases are viral, making antibiotics completely ineffective 2
• Purulent sputum occurs in 89-95% of viral cases and does NOT indicate bacterial infection 1, 2

The ONE Exception: Pertussis

For confirmed or suspected pertussis (whooping cough), prescribe a macrolide antibiotic (erythromycin or azithromycin) immediately. 2

• Isolate patients for 5 days from start of treatment 2
• Early treatment within the first few weeks diminishes coughing paroxysms and prevents disease spread 2

Symptomatic Treatment Options

For dry, bothersome cough (especially disturbing sleep):

• Dextromethorphan or codeine may provide modest relief 1, 2

For wheezing accompanying cough:

• β2-agonist bronchodilators (albuterol) may be useful in select patients with wheezing 2
• Do NOT routinely use bronchodilators in patients without wheezing 2

What NOT to use:

• Expectorants, mucolytics, antihistamines, inhaled corticosteroids, NSAIDs at anti-inflammatory doses, or systemic corticosteroids have no proven benefit 2

Patient Education is Critical

• Inform patients that cough typically lasts 10-14 days after the visit, sometimes up to 3 weeks 1, 2, 3
• Refer to the condition as a "chest cold" rather than bronchitis to reduce antibiotic expectations 2
• Explain that patient satisfaction depends more on physician-patient communication than whether an antibiotic is prescribed 2

When to Reassess

Instruct patients to return if:

• Fever persists >3 days (suggests bacterial superinfection or pneumonia) 1, 2
• Cough persists >3 weeks (consider asthma, COPD, pertussis, GERD) 1, 2
• Symptoms worsen rather than gradually improve 2

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Chronic Bronchitis/COPD Management

Stable Chronic Bronchitis

First-line bronchodilator therapy:

• Ipratropium bromide 36 μg (2 inhalations) four times daily is first-line therapy to improve cough 5
• Short-acting β-agonists (albuterol) to control bronchospasm and reduce dyspnea 5

For severe airflow obstruction (FEV1 <50%) or frequent exacerbations:

• Add inhaled corticosteroids combined with long-acting β-agonists 1, 5

Additional options:

• Theophylline may control chronic cough but requires careful monitoring for complications 1, 5
• Roflumilast may be considered for severe COPD with chronic bronchitis characteristics and history of exacerbations 5

Most important intervention:

• Smoking cessation leads to cough resolution in 90% of patients with chronic bronchitis 1, 5

Acute Exacerbation of Chronic Bronchitis (AECB)

Antibiotics ARE indicated for AECB in high-risk patients with:

At least 2 of 3 Anthonisen criteria:

• Increased dyspnea
• Increased sputum volume
• Increased sputum purulence 1, 6

PLUS at least 1 risk factor:

• Age ≥65 years
• FEV1 <50% predicted
• ≥4 exacerbations in 12 months
• Comorbidities (cardiac failure, insulin-dependent diabetes, immunosuppression) 1, 2, 6

Antibiotic Selection for AECB

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

• Doxycycline 100 mg twice daily for 7-10 days 2, 6
• Azithromycin 500 mg once daily for 3 days 7
• Clarithromycin extended-release 1000 mg once daily for 5-7 days 1

For severe exacerbations (FEV1 <35%, frequent exacerbations, severe comorbidities):

• High-dose amoxicillin/clavulanate 625 mg three times daily for 14 days 2
• Respiratory fluoroquinolones (levofloxacin) 6

Pathogen-specific considerations:

• H. influenzae: Amoxicillin/clavulanate (25% produce β-lactamase) 2
• M. catarrhalis: Amoxicillin/clavulanate or clarithromycin (50-70% produce β-lactamase) 2
• S. pneumoniae: Amoxicillin 500 mg to 1 g three times daily or doxycycline 2

Supportive Care for AECB

• Short-acting β-agonists and anticholinergic bronchodilators during exacerbations 5
• Systemic corticosteroids for 10-15 days (oral for outpatients, IV for hospitalized patients) 5
• Oxygen, hydration, chest physical therapy as needed 6

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Common Pitfalls to Avoid

• Do NOT prescribe antibiotics for acute bronchitis based on purulent sputum alone – this occurs in 89-95% of viral cases 1, 2
• Do NOT use long-term prophylactic antibiotics in stable chronic bronchitis – no proven benefit 5
• Do NOT use expectorants – no evidence of effectiveness 1, 5
• Do NOT assume bacterial infection before 3 days of fever – most cases are viral 1, 2
• Avoid simple aminopenicillins alone for AECB due to high β-lactamase production rates 2