What is the best management approach for a patient with acute bronchitis, considering symptomatic relief, potential antibiotic therapy, and underlying conditions such as chronic obstructive pulmonary disease (COPD) or asthma?

Management of Acute Bronchitis

Antibiotics should NOT be prescribed for uncomplicated acute bronchitis in otherwise healthy adults, as they provide minimal benefit (reducing cough by only half a day) while exposing patients to adverse effects and contributing to antibiotic resistance. 1, 2

Initial Assessment: Rule Out Other Diagnoses

Before confirming acute bronchitis, exclude pneumonia by evaluating 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 to rule out pneumonia rather than treating as simple bronchitis. 1, 2

Also consider:

• Asthma exacerbation (approximately one-third of patients diagnosed with acute bronchitis actually have undiagnosed asthma) 1
• COPD exacerbation in patients with known chronic lung disease 1
• Pertussis if cough persists >2 weeks with paroxysmal features, whooping, post-tussive emesis, or recent exposure 3

Primary Treatment: Symptomatic Management and Patient Education

Patient Education (Critical for Satisfaction)

Inform patients that cough typically lasts 10-14 days after the visit, even without antibiotics, and may persist up to 3 weeks. 4, 1, 2

Key communication strategies:

• Refer to the condition as a "chest cold" rather than bronchitis (reduces antibiotic expectations) 4, 1
• Explain that patient satisfaction depends more on physician-patient communication than whether an antibiotic is prescribed 4, 1
• Personalize the risks of unnecessary antibiotic use: previous antibiotic use increases carriage of resistant bacteria, common side effects (GI symptoms), and rare but serious adverse events 4

Symptomatic Relief Options

β2-agonist bronchodilators (albuterol):

• Should NOT be routinely used for cough in most patients 1, 2
• May be useful ONLY in select adult patients with wheezing accompanying the cough 4, 1, 2
• Evidence shows approximately 50% fewer patients report cough after 7 days when bronchodilators are used in patients with bronchial hyperresponsiveness 4

Antitussives:

• Codeine or dextromethorphan may provide modest effects on severity and duration of cough, particularly when dry cough is bothersome and disturbs sleep 4, 1, 2
• These agents appear more effective for chronic cough or cough associated with underlying lung disease than for early viral upper respiratory infections 4

Other low-risk measures:

• Elimination of environmental cough triggers (dust, dander) 4
• Vaporized air treatments, particularly in low-humidity environments 4

What NOT to use:

• Expectorants, mucolytics, antihistamines (lack evidence of benefit) 1, 2
• Inhaled or oral corticosteroids 1
• NSAIDs at anti-inflammatory doses 1

Exception: Pertussis (Whooping Cough)

For confirmed or suspected pertussis, prescribe a macrolide antibiotic (erythromycin or azithromycin) immediately. 1, 2

• Isolate patients for 5 days from the start of treatment 1, 2
• Early treatment within the first few weeks diminishes coughing paroxysms and prevents disease spread 1

Special Populations: High-Risk Patients

Consider antibiotics ONLY in high-risk patients with significant comorbidities:

• Age ≥75 years with fever 1, 2
• Cardiac failure 1, 2
• Insulin-dependent diabetes 1, 2
• Immunosuppression 1, 2
• Serious neurological disorders 1

For these high-risk patients, prescribe doxycycline 100 mg twice daily for 7-10 days as first-line treatment if bacterial infection is suspected. 1, 2

Management of Acute Exacerbations of Chronic Bronchitis (NOT Acute Bronchitis)

This is a distinct condition from acute bronchitis and requires different management:

Antibiotics ARE recommended for acute exacerbations of chronic bronchitis, particularly in:

• Patients with severe exacerbations 4
• Those with more severe airflow obstruction at baseline 4
• Patients with purulent sputum and cardinal symptoms (increased cough, increased sputum volume, increased dyspnea) 4

Bronchodilators:

• Short-acting β-agonists improve pulmonary function, breathlessness, and exercise tolerance 4, 5
• Ipratropium bromide reduces cough frequency and severity, and decreases sputum volume 4, 5

Smoking cessation:

• 90% of patients with chronic cough will have resolution after smoking cessation 4, 5
• This is the most effective intervention for chronic bronchitis 4, 5

When to Reassess

Instruct patients to return if:

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

Common Pitfalls to Avoid

• Do NOT prescribe antibiotics based on purulent sputum color alone (occurs in 89-95% of viral cases) 1, 2
• Do NOT assume bacterial infection based on cough duration alone (viral bronchitis cough typically lasts 10-14 days) 1
• Do NOT prescribe antibiotics to meet perceived patient expectations (satisfaction depends on communication, not antibiotics) 4, 1
• Do NOT fail to distinguish acute bronchitis from pneumonia (check vital signs and lung examination) 1, 2