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

Treatment of Bronchitis

For acute bronchitis in otherwise healthy adults, antibiotics should NOT be prescribed regardless of cough duration or sputum color, as they provide minimal benefit (reducing cough by only half a day) while causing significant adverse effects and contributing to antibiotic resistance. 1, 2

Initial Assessment: Rule Out Other Conditions

Before diagnosing acute bronchitis, exclude pneumonia by checking for these vital sign abnormalities 1, 2:

• Heart rate >100 beats/min
• Respiratory rate >24 breaths/min
• Oral temperature >38°C
• Chest examination findings of focal consolidation, egophony, or fremitus

If any of these are present, obtain chest radiography to rule out pneumonia rather than treating as simple bronchitis. 1, 2

Approximately one-third of patients with "recurrent acute bronchitis" actually have undiagnosed asthma or COPD exacerbations. 2 Consider these diagnoses if the patient has recurrent episodes or wheezing. 2

Treatment for Uncomplicated Acute Bronchitis

What NOT to Prescribe

The American College of Chest Physicians explicitly recommends against 1, 2, 3:

• Antibiotics (including azithromycin, amoxicillin, clarithromycin) - provide no benefit in viral bronchitis
• Oral corticosteroids (including prednisone) - not effective for acute bronchitis
• Inhaled corticosteroids - no evidence of benefit
• NSAIDs at anti-inflammatory doses - not justified
• Expectorants or mucolytics (including guaifenesin) - lack consistent evidence
• Routine beta-2 agonist bronchodilators - should not be used routinely

What TO Prescribe: Symptomatic Treatment Only

Patient education is the cornerstone of management 2:

• Inform patients that cough typically lasts 10-14 days after the visit, sometimes up to 3 weeks 1, 2
• Explain that the condition is self-limiting and viral in 89-95% of cases 2
• Discuss that antibiotics expose them to adverse effects without providing benefit 2

For symptomatic relief 1, 2:

• Codeine or dextromethorphan may provide modest effects on cough severity and duration, particularly when dry cough is bothersome and disturbs sleep
• Beta-2 agonist bronchodilators (such as albuterol) may be useful ONLY in select patients with wheezing accompanying the cough
• Low-risk measures: elimination of environmental cough triggers, vaporized air treatments, nasal saline irrigation

The ONE Exception: Pertussis

For confirmed or suspected pertussis (whooping cough), prescribe a macrolide antibiotic (erythromycin or azithromycin) immediately. 1, 2 Patients should be isolated for 5 days from the start of treatment. 1, 2 Early treatment within the first few weeks diminishes coughing paroxysms and prevents disease spread. 1, 2

Treatment for Acute Exacerbations of Chronic Bronchitis (AECB)

This is a DIFFERENT condition requiring different management. 1, 4

When to Prescribe Antibiotics for AECB

Antibiotics should be prescribed if the patient has at least ONE key symptom (Anthonisen criteria) AND at least ONE risk factor 2, 4:

Key symptoms (need at least 1) 2, 4:

• Increased dyspnea
• Increased sputum volume
• Increased sputum purulence

Risk factors (need at least 1) 2, 4:

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

Antibiotic Selection for AECB

For moderate-severity exacerbations 2, 4:

• Doxycycline 100 mg twice daily for 7-10 days (first-line)
• Azithromycin 500 mg once daily for 3 days
• Clarithromycin 500 mg twice daily for 7-14 days

For severe exacerbations or high-risk patients 2:

• Amoxicillin/clavulanate 625 mg three times daily for 14 days
• Respiratory fluoroquinolones (levofloxacin) for patients with severe obstruction (FEV1 <35%)

Corticosteroids for AECB

For acute exacerbations of chronic bronchitis/COPD, prescribe prednisone 40 mg daily for 5-7 days. 3, 5 This improves lung function, oxygenation, and shortens recovery time. 3, 5 Do NOT use longer courses or maintenance therapy with oral corticosteroids. 5

When to Reassess

Instruct patients to return if 2:

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

Critical Pitfalls to Avoid

• Do not assume bacterial infection based on purulent sputum - this occurs in 89-95% of viral bronchitis cases 2
• Do not prescribe antibiotics based on cough duration alone - viral bronchitis cough normally lasts 10-14 days 2
• Do not confuse acute bronchitis with AECB - they require completely different management approaches 1, 2
• Do not prescribe steroids for acute bronchitis - they provide no benefit and expose patients to unnecessary harm 3, 5