What are the signs, symptoms, and medical management for an adult or child with acute bronchitis, possibly with a history of respiratory infections or exposure to irritants?

Acute Bronchitis: Signs, Symptoms, and Medical Management

Clinical Presentation

Acute bronchitis presents as an acute cough lasting up to 3 weeks, typically following a viral upper respiratory prodrome, with or without sputum production. 1, 2

Key Signs and Symptoms

• Cough is the hallmark symptom, typically lasting 10-14 days but may persist up to 3 weeks 1, 2, 3
• Viral upper respiratory prodrome including rhinorrhea, nasal congestion, and sore throat precedes lower respiratory symptoms 1
• Sputum production occurs in most cases, and purulent (green or yellow) sputum is present in 89-95% of viral cases—this does NOT indicate bacterial infection 2, 4, 3
• Wheezing or chest tightness may accompany cough in some patients 1
• Low-grade fever may be present initially but typically resolves within 3 days in viral bronchitis 1, 4
• Increased respiratory effort with dyspnea can occur but should prompt evaluation for pneumonia 1

Critical Differential Diagnoses to Exclude

Before diagnosing acute bronchitis, you must rule out conditions requiring specific therapy:

• Pneumonia: Check for heart rate >100 beats/min, respiratory rate >24 breaths/min, oral temperature >38°C, or focal consolidation findings (rales, egophony, tactile fremitus) 1, 2, 4
• Asthma exacerbation: Consider in patients with recurrent episodes or known asthma history; 34-65% of patients with recurrent "bronchitis" actually have undiagnosed asthma 1, 2
• COPD exacerbation: Evaluate in smokers or those with known chronic lung disease 1
• Pertussis: Suspect with paroxysmal cough, post-tussive emesis, or inspiratory whoop 1, 2

Diagnostic Approach

Diagnosis is clinical based on history and physical examination; routine laboratory tests and chest radiography are NOT indicated. 1, 2

When to Order Chest Radiography

• Heart rate >100 beats/min, respiratory rate >24 breaths/min, or oral temperature >38°C 1, 4
• Abnormal focal chest examination findings 1, 2
• Cough persisting ≥3 weeks without improvement 1, 2

Risk Factors for Severe Disease Requiring Closer Monitoring

• Age >75 years 2, 5
• Underlying cardiopulmonary disease (COPD, heart failure, bronchiectasis) 1, 2, 5
• Immunocompromised state 1, 2, 4
• Insulin-dependent diabetes mellitus 2, 5

Medical Management

Primary Treatment: Symptomatic Management and Patient Education

Antibiotics should NOT be prescribed for acute uncomplicated bronchitis in otherwise healthy adults, as 89-95% of cases are viral and antibiotics provide minimal benefit (reducing cough by only half a day) while causing significant adverse effects and promoting antibiotic resistance. 1, 2, 4, 3

Patient Education (Essential for Satisfaction)

• 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
• Explain that patient satisfaction depends on physician-patient communication, not antibiotic prescription 2, 6, 7
• Refer to the condition as a "chest cold" rather than "bronchitis" to reduce antibiotic expectations 2
• Discuss risks of unnecessary antibiotic use: adverse effects, antibiotic resistance, and no clinical benefit 2, 4

Symptomatic Relief Options

• Antitussives (codeine or dextromethorphan): May provide modest short-term relief for bothersome dry cough, especially when sleep is disturbed 1, 2
• β2-agonist bronchodilators (albuterol): Use ONLY in select patients with accompanying wheezing; do NOT use routinely 1, 2
• Environmental measures: Eliminate cough triggers, use humidified air, consider nasal saline irrigation 1, 2

What NOT to Use

• Mucokinetic agents/expectorants: Not recommended due to lack of consistent benefit 1, 2
• Inhaled corticosteroids: No evidence of benefit in acute bronchitis 2
• NSAIDs at anti-inflammatory doses: Not recommended 2
• Antihistamines: No proven benefit 2

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, 4

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

When to Consider Antibiotics: High-Risk Patients Only

Antibiotics may be considered in high-risk patients with significant comorbidities IF fever persists >3 days, suggesting bacterial superinfection: 2, 4, 5

• Age >75 years with cardiac failure, insulin-dependent diabetes, or serious neurological disorders 2, 5
• Immunocompromised patients 2, 4
• Patients with COPD meeting Anthonisen criteria (increased dyspnea, sputum volume, or sputum purulence) 2

Recommended antibiotic regimens for high-risk patients:

• Amoxicillin 500 mg three times daily for 5-8 days 2, 4
• Doxycycline 100 mg twice daily for 5-8 days 2, 4

Reassessment Criteria

Instruct patients to return if: 1, 2, 4

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

Common Pitfalls to Avoid

• Do NOT prescribe antibiotics based on purulent sputum color alone—this occurs in 89-95% of viral cases 2, 4, 3
• Do NOT prescribe antibiotics based on cough duration alone—viral bronchitis cough normally lasts 10-14 days 2, 4
• Do NOT assume bacterial infection before the 3-day fever threshold—most cases are viral 2, 4
• Do NOT routinely use β2-agonists in all patients—reserve for those with wheezing 1, 2
• Do NOT forget to exclude pneumonia before diagnosing acute bronchitis—check vital signs and perform thorough lung examination 1, 2, 4