What is the treatment (Tx) for a patient with bronchitis (inflammation of the bronchial tubes)?

Treatment of Bronchitis

Acute Bronchitis: Antibiotics Are NOT Recommended

For immunocompetent adults with acute bronchitis, do not prescribe antibiotics, as they provide minimal benefit (reducing cough by only 0.5 days) while causing adverse effects and promoting antibiotic resistance. 1, 2

Key Management Principles

• No routine investigations are needed—do not order chest x-rays, spirometry, sputum cultures, or inflammatory markers at initial presentation 1
• Patient education is critical: Inform patients that cough typically lasts 10-14 days after the visit, with complete resolution within 3 weeks 2
• Symptomatic treatment only:
  • Antitussives (codeine or dextromethorphan) provide modest relief for bothersome dry cough, especially when disturbing sleep 2
  • Bronchodilators should NOT be routinely used, except in select patients with accompanying wheezing 2
  • Do NOT use: expectorants, mucolytics, antihistamines, inhaled corticosteroids, oral corticosteroids, or NSAIDs—none have proven benefit 1, 2

When to Reassess

• If cough persists or worsens, advise the patient to return for reassessment and consider targeted investigations (chest x-ray, sputum culture, peak flow, CBC, CRP) 1
• Consider complicating bacterial infection only if the condition deteriorates significantly 1

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Chronic Bronchitis: Bronchodilators Are First-Line

For stable chronic bronchitis, ipratropium bromide is the first-line therapy to improve cough, with short-acting β-agonists as adjunctive therapy for bronchospasm. 3, 2

Stable Chronic Bronchitis Management

Primary therapy:

• Ipratropium bromide 36 μg (2 inhalations) four times daily—reduces cough frequency, severity, and sputum volume (Grade A recommendation) 1, 3
• Short-acting β-agonists to control bronchospasm and relieve dyspnea; may also reduce chronic cough 1, 2

If inadequate response after 2 weeks:

• Add a short-acting β-agonist to ipratropium for additional bronchodilation 3
• Consider theophylline for chronic cough control, but requires careful monitoring for complications 1, 2

For severe disease (FEV1 <50% or frequent exacerbations):

• Add inhaled corticosteroid (ICS) with long-acting β-agonist (LABA) 1, 3, 2
• For Group D patients (high symptoms, high exacerbation risk), initiate LABA/LAMA combination as first choice 3

Critical Interventions

• Smoking cessation is the most effective treatment: 90% of patients will have resolution of cough after quitting smoking 1
• Do NOT use long-term prophylactic antibiotics in stable patients—no benefit and promotes resistance (Grade I recommendation) 1, 3
• Do NOT use expectorants—no evidence of effectiveness 1
• Do NOT use chest physiotherapy or postural drainage—no proven benefit 1

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Acute Exacerbation of Chronic Bronchitis: Antibiotics ARE Indicated

For acute exacerbations of chronic bronchitis, use antibiotics ONLY in patients with at least one key symptom (increased dyspnea, sputum volume, or sputum purulence) AND at least one risk factor (age ≥65 years, FEV1 <50%, ≥4 exacerbations in 12 months, or comorbidities). 2, 4

Acute Exacerbation Management Algorithm

Bronchodilator therapy (all patients):

• Administer short-acting β-agonists OR anticholinergic bronchodilators 1, 2
• If no prompt response, add the other agent at maximal dose 1, 2
• Do NOT use theophylline during acute exacerbations (Grade D recommendation) 1

Corticosteroid therapy:

• Systemic corticosteroids are recommended for acute exacerbations, with a 10-15 day course 2

Antibiotic selection based on severity:

For moderate severity exacerbations:

• Doxycycline, clarithromycin extended-release, or clarithromycin immediate-release 2, 4
• Alternative: newer macrolide or extended-spectrum cephalosporin 4

For severe exacerbations:

• Amoxicillin/clavulanate or respiratory fluoroquinolone 2, 4
• Azithromycin 500 mg once daily for 3 days is effective (85% clinical cure rate at Day 21-24) 5

Common Pitfalls

• Do NOT prescribe antibiotics for simple acute bronchitis—this is the most common error in practice 1, 2, 6
• Do NOT use chest physiotherapy during acute exacerbations—no proven benefit 1
• Patients with severe exacerbations and more severe baseline airflow obstruction benefit most from antibiotics 1
• Consider differential diagnoses: asthma exacerbation, COPD exacerbation, pneumonia, or bronchiectasis 1