What is the usual treatment for an adult patient with a chest X-ray (CXR) showing bronchitis and no severe underlying conditions?

Treatment of Bronchitis on Chest X-Ray

For an adult patient with a chest X-ray showing bronchitis, no routine medications should be prescribed—including antibiotics, bronchodilators, or corticosteroids—as these have not been shown to make cough less severe or resolve sooner, and the condition is self-limiting. 1

Critical First Step: Distinguish Acute vs. Chronic Bronchitis

The treatment approach depends entirely on whether this represents acute bronchitis or chronic bronchitis:

If This is Acute Bronchitis (cough <3 weeks duration):

No routine treatment is recommended. 1

• Antibiotics should NOT be prescribed for uncomplicated acute bronchitis, as respiratory viruses cause 89-95% of cases and antibiotics reduce cough by only approximately 0.5 days while exposing patients to adverse effects and antibiotic resistance 1, 2, 3
• Purulent sputum occurs in 89-95% of viral cases and does NOT indicate bacterial infection or need for antibiotics 2, 4
• β2-agonist bronchodilators should NOT be routinely prescribed, except in select patients with accompanying wheezing 1, 2
• Inhaled corticosteroids, oral corticosteroids, and NSAIDs are NOT recommended 1

Patient education is the cornerstone of management:

• Inform patients that cough typically lasts 10-14 days after the visit, even without treatment, and may persist up to 3 weeks 1, 2
• Patient satisfaction depends more on physician-patient communication than whether an antibiotic is prescribed 2, 5

Symptomatic relief options (optional, not routine):

• Codeine or dextromethorphan may provide modest effects on cough severity, particularly when dry cough is bothersome and disturbs sleep 2
• Elimination of environmental cough triggers and vaporized air treatments are low-risk measures 2

If This is Chronic Bronchitis (cough with sputum ≥3 months/year for 2 consecutive years):

For stable chronic bronchitis with chronic cough:

• There is insufficient evidence to recommend routine use of any pharmacologic treatments (antibiotics, bronchodilators, mucolytics) as a means of relieving cough 1
• Smoking cessation is the most effective intervention, with 90% of patients experiencing resolution of chronic cough after quitting 1, 2

For acute exacerbations of chronic bronchitis:

• Antibiotics may be indicated if the patient has at least 2 of 3 Anthonisen criteria: increased dyspnea, increased sputum volume, or increased sputum purulence 2, 6
• Consider antibiotics particularly in high-risk patients: age >65 years, FEV1 <50%, cardiac failure, insulin-dependent diabetes, or frequent exacerbations 2, 6
• First-line antibiotics include amoxicillin, doxycycline, or macrolides for 5-10 days 2, 6
• Second-line antibiotics (for severe disease or frequent exacerbations) include amoxicillin-clavulanate or respiratory fluoroquinolones 2, 6

When to Reassess and Consider Treatment

Reassess if any of the following occur:

• Fever persists >3 days (suggests bacterial superinfection or pneumonia, not simple viral bronchitis) 1, 2
• Cough persists >3 weeks (consider other diagnoses: asthma, COPD, pertussis, gastroesophageal reflux) 1, 2
• Symptoms worsen rather than gradually improve 1

Targeted investigations to consider on reassessment:

• Repeat chest x-ray, sputum for microbial culture, peak expiratory flow measurements, complete blood count, inflammatory markers (CRP) 1

Critical Exception: Pertussis

If pertussis is confirmed or suspected:

• Prescribe a macrolide antibiotic (erythromycin or azithromycin) immediately 1, 2
• Isolate patient for 5 days from start of treatment 1, 2
• Early treatment within the first few weeks diminishes coughing paroxysms and prevents disease spread 2

Common Pitfalls to Avoid

• Do NOT assume bacterial infection based on: sputum color/purulence, cough duration, or patient expectation for antibiotics 2, 4
• Do NOT prescribe antibiotics for uncomplicated acute bronchitis regardless of how long the cough has lasted (if <3 weeks) 1
• Always rule out pneumonia first by checking vital signs (heart rate >100, respiratory rate >24, temperature >38°C) and lung examination for focal findings 1, 2
• Approximately 65% of patients with recurrent "acute bronchitis" episodes actually have underlying mild asthma—consider this diagnosis with repeated episodes 1, 7