What is the treatment for a patient with acute bronchitis, considering potential underlying respiratory conditions such as asthma or chronic obstructive pulmonary disease (COPD)?

Treatment of Acute Bronchitis

Antibiotics should NOT be prescribed for acute bronchitis in otherwise healthy adults, as they provide minimal benefit (reducing cough by only 0.5 days) while exposing patients to adverse effects and contributing to antibiotic resistance. 1, 2, 3

Diagnostic Considerations Before Treatment

Before diagnosing acute bronchitis, you must rule out pneumonia by checking for these vital sign abnormalities: 4, 1

• Heart rate >100 beats/min
• Respiratory rate >24 breaths/min
• Oral temperature >38°C
• Focal consolidation, egophony, or fremitus on chest examination

If any of these findings are present, obtain chest radiography to evaluate for pneumonia rather than treating as simple bronchitis. 4, 1

Approximately one-third of patients diagnosed with acute bronchitis actually have undiagnosed asthma or COPD exacerbation, so consider these alternative diagnoses, especially with recurrent episodes or wheezing. 1

Primary Treatment: Patient Education and Symptomatic Management

Patient Education (Most Important)

• Inform patients that cough typically lasts 10-14 days after the visit, even without antibiotics, and may persist up to 3 weeks. 1, 2, 3
• Refer to the condition as a "chest cold" rather than bronchitis to reduce patient expectations for antibiotics. 1, 5
• Explain that patient satisfaction depends more on physician-patient communication than whether an antibiotic is prescribed. 1, 6

Symptomatic Treatment Options

Antitussives (for bothersome dry cough, especially disturbing sleep): 1, 2

• Codeine or dextromethorphan may provide modest effects on cough severity and duration
• These are the only symptomatic treatments with evidence of benefit

Bronchodilators (β2-agonists like albuterol): 1, 2, 7

• Should NOT be routinely used for most patients with acute bronchitis
• May be useful ONLY in select adult patients with accompanying wheezing
• Standard dosing: 2.5 mg by nebulization 3-4 times daily if indicated 7

What NOT to prescribe (no proven benefit): 1, 2

• Expectorants or mucolytics
• Antihistamines
• Inhaled or oral corticosteroids
• NSAIDs at anti-inflammatory doses

Exception: Pertussis (Whooping Cough)

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

• 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
• Suspect pertussis if: cough with severe paroxysms, typical whooping sound, post-tussive vomiting, or known pertussis exposure 4

When to Reassess

Instruct patients to return if: 1

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

Special Populations: Underlying COPD or Chronic Bronchitis

These patients are NOT included in standard acute bronchitis recommendations and require different management. 1, 8

For Acute Exacerbation of Chronic Bronchitis (AECB):

Consider antibiotics ONLY if the patient has ≥1 key symptom (Anthonisen criteria) AND ≥1 risk factor: 1, 2, 9

Key symptoms (need at least 1):

• Increased dyspnea
• Increased sputum volume
• Increased sputum purulence

Risk factors (need at least 1):

• Age ≥65 years
• FEV1 <50% predicted
• ≥4 exacerbations in 12 months
• Comorbidities (cardiac failure, insulin-dependent diabetes, serious neurological disorders)

Antibiotic Selection for AECB:

Moderate severity exacerbations: 1, 2

• Doxycycline 100 mg twice daily for 7-10 days (first-line)
• Clarithromycin extended-release 1000 mg once daily for 5-7 days
• Clarithromycin immediate-release 500 mg twice daily for 7-14 days

Severe exacerbations: 1, 2

• Amoxicillin/clavulanate 625 mg three times daily for 14 days
• Respiratory fluoroquinolone (e.g., levofloxacin)

Bronchodilator Therapy for COPD with Chronic Bronchitis:

Ipratropium bromide is first-line therapy to improve cough in stable COPD patients with chronic bronchitis: 8, 2

• Dosing: 36 μg (2 inhalations) four times daily
• Reduces cough frequency, severity, and sputum volume

Short-acting β-agonists should be used to control bronchospasm and relieve dyspnea. 8, 2

For acute exacerbations of chronic bronchitis: 8, 2

• Administer short-acting β-agonists or anticholinergic bronchodilators
• If no prompt response, add the other agent at maximal dose
• Systemic corticosteroids for 10-15 days

Critical Pitfalls to Avoid

• Purulent sputum occurs in 89-95% of VIRAL bronchitis cases and does NOT indicate bacterial infection. 1
• Cough duration alone does not indicate bacterial infection, as viral bronchitis cough normally lasts 10-14 days. 1, 3
• Do not assume bacterial infection before the 3-day fever threshold, as most cases are viral. 1
• Up to 25% of H. influenzae and 50-70% of M. catarrhalis produce β-lactamase, making simple aminopenicillins ineffective in COPD exacerbations. 1