What is the recommended management approach for a patient presenting with acute bronchitis, considering their medical history and potential pre-existing respiratory conditions?

Management of Acute Bronchitis

Immediate Clinical Assessment

Acute bronchitis is a viral illness in 89-95% of cases that requires symptomatic treatment only—antibiotics should NOT be prescribed for otherwise healthy patients, 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, 3

Before diagnosing acute bronchitis, you must exclude pneumonia by evaluating for these specific findings 1, 2, 3:

• 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 are present, obtain chest radiography to rule out pneumonia rather than treating as simple bronchitis. 1, 3

Also exclude 2, 3:

• Asthma exacerbation (approximately one-third of patients diagnosed with acute bronchitis actually have undiagnosed asthma) 2
• COPD exacerbation in known COPD patients
• Heart failure (can mimic bronchitis with cough and dyspnea) 1

Primary Management: Patient Education and Symptomatic Treatment

Patient Education (Most Critical Component)

Inform patients that 1, 2, 3, 4:

• Cough typically lasts 10-14 days after the visit, sometimes extending to 3 weeks
• The condition is self-limiting and caused by viruses in 89-95% of cases
• Antibiotics will NOT help and expose them to adverse effects while contributing to antibiotic resistance

Patient satisfaction depends on physician-patient communication quality, NOT on whether an antibiotic is prescribed. 1, 2, 5, 6 Consider referring to the condition as a "chest cold" rather than "bronchitis" to reduce antibiotic expectations. 2, 4

Symptomatic Treatment Options

For bothersome dry cough, especially disturbing sleep 1, 2, 3:

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

For wheezing accompanying cough 1, 2, 3:

• β2-agonist bronchodilators (e.g., albuterol) may be useful in SELECT adult patients with wheezing
• Do NOT use routinely in all patients—only when wheezing is present

Low-risk supportive measures 2:

• Elimination of environmental cough triggers
• Vaporized air treatments/humidification
• Nasal saline irrigation

Critical Exception: Pertussis (Whooping Cough)

For confirmed or suspected pertussis, prescribe a macrolide antibiotic (erythromycin or azithromycin) immediately and isolate the patient for 5 days from treatment start. 1, 2, 3

Early treatment within the first few weeks diminishes coughing paroxysms and prevents disease spread. 1, 2

High-Risk Patients Requiring Different Approach

Consider antibiotics ONLY in high-risk patients with significant comorbidities 2, 3, 7:

• Age ≥75 years with fever
• Cardiac failure
• Insulin-dependent diabetes
• Immunosuppression
• Serious neurological disorders
• COPD with FEV₁ <50%

For these high-risk patients, prescribe antibiotics ONLY if they have at least 2 of the 3 Anthonisen criteria 2:

1. Increased dyspnea
2. Increased sputum volume
3. Increased sputum purulence

Antibiotic Selection for High-Risk Patients (When Indicated)

First-line options 2:

• Doxycycline 100 mg twice daily for 7-10 days
• Amoxicillin 500 mg three times daily for 5-8 days

For severe exacerbations or β-lactamase producing organisms 2:

• Amoxicillin-clavulanate 625 mg three times daily for 7-14 days
• Clarithromycin 500 mg twice daily for 7-14 days

Common Pitfalls to Avoid

Do NOT assume bacterial infection based on 1, 2, 3, 7:

• Purulent sputum color or presence—this occurs in 89-95% of VIRAL cases and does NOT indicate bacterial infection
• Cough duration alone—viral bronchitis cough normally lasts 10-14 days
• Patient expectation for antibiotics—satisfaction depends on communication, not prescriptions

Do NOT prescribe immediately for fever 2:

• Wait to see if fever persists beyond 3 days before considering bacterial superinfection or pneumonia
• Fever persisting >3 days strongly suggests bacterial superinfection and warrants reassessment

When to Reassess

Instruct patients to return if 2, 3:

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

What NOT to Use

The following have NO proven benefit and should NOT be prescribed 1, 2:

• Routine antibiotics (for uncomplicated cases)
• Expectorants or mucolytics
• Antihistamines
• Inhaled corticosteroids
• Oral corticosteroids
• NSAIDs at anti-inflammatory doses
• Montelukast

Special Consideration: Acute Exacerbations of Chronic Bronchitis

This is a DIFFERENT entity from acute bronchitis. For patients with established chronic bronchitis/COPD presenting with acute worsening 1:

Definition: Sudden deterioration with increased cough, sputum production, sputum purulence, and/or dyspnea, often preceded by upper respiratory infection symptoms, with other causes (pneumonia, PE, heart failure) excluded. 1

Treatment approach 1, 2:

• Antibiotics ARE indicated for moderate-to-severe exacerbations with ≥2 Anthonisen criteria
• Short-acting β-agonists improve pulmonary function and breathlessness
• Ipratropium bromide reduces cough frequency and sputum volume
• Consider oral corticosteroids for moderately severe or worse obstruction
• Smoking cessation remains the most effective intervention—90% experience cough resolution after quitting 1, 2