What is the best treatment approach for a patient with acute bronchitis, considering symptom management and potential underlying respiratory conditions such as Chronic Obstructive Pulmonary Disease (COPD)?

Treatment of Acute Bronchitis

Antibiotics should NOT be prescribed for acute bronchitis in otherwise healthy adults, as they reduce cough duration by only half a day while significantly increasing adverse events, and the condition is viral in 89-95% of cases. 1

Initial Assessment: Rule Out Pneumonia First

Before diagnosing acute bronchitis, you must exclude pneumonia by checking these specific vital signs and examination findings: 1

• Heart rate >100 beats/min 1
• Respiratory rate >24 breaths/min 1
• Oral temperature >38°C 1
• Abnormal chest findings (rales, egophony, tactile fremitus) 1

If ANY of these are present, obtain chest radiography and consider pneumonia rather than simple bronchitis. 1

Consider Underlying Conditions

Approximately one-third of patients diagnosed with "recurrent acute bronchitis" actually have undiagnosed asthma or COPD. 1 Before confirming acute bronchitis, rule out: 1, 2

• Asthma exacerbation (look for wheezing, prolonged expiration, allergy symptoms) 2
• COPD exacerbation (in patients with known disease or smoking history) 1, 3
• Pertussis (if cough is paroxysmal or prolonged beyond 3 weeks) 1

Primary Treatment: Symptomatic Management Only

The cornerstone of treatment is patient education and supportive care: 1, 2

Patient Education

• Inform patients that cough typically lasts 10-14 days after the visit, even without treatment, and may persist up to 3 weeks 1, 2
• Refer to the condition as a "chest cold" rather than "bronchitis" to reduce antibiotic expectations 1, 2
• Explain that patient satisfaction depends on communication quality, not antibiotic prescription 1, 2

Symptomatic Relief Options

For bothersome dry cough (especially disturbing sleep): 1, 3

• Dextromethorphan or codeine may provide modest short-term relief, reducing cough counts by 40-60% 1, 2, 3

For wheezing (select patients only): 1, 4

• β2-agonist bronchodilators (such as albuterol) should ONLY be used in patients with accompanying wheezing 1, 4
• Do NOT use bronchodilators routinely for cough without wheezing 1

Low-risk supportive measures: 1

• Elimination of environmental cough triggers 1
• Vaporized air treatments/humidification 1
• Standard analgesics and antipyretics for discomfort and fever 2

What NOT to Prescribe

The following have NO proven benefit in acute bronchitis and should NOT be used: 1

• Antibiotics (except for pertussis—see below) 1, 5, 6
• Inhaled corticosteroids 1
• Oral corticosteroids 1
• NSAIDs at anti-inflammatory doses 1
• Expectorants or mucolytics 1
• Antihistamines (unless associated with common cold symptoms) 1

The ONE Exception: Pertussis

If pertussis is confirmed or strongly suspected: 1

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

When to Reassess

Instruct patients to return if: 1

• Fever persists >3 days (suggests bacterial superinfection or pneumonia) 1
• Cough persists >3 weeks (consider asthma, COPD, pertussis, GERD) 1, 2
• Symptoms worsen rather than gradually improve 1

Special Population: COPD/Chronic Bronchitis Exacerbations

These patients require DIFFERENT management and are NOT included in standard acute bronchitis recommendations. 1, 3

When to Prescribe Antibiotics in COPD Exacerbations

Consider antibiotics if the patient has at least 2 of 3 Anthonisen criteria: 1

• Increased dyspnea 1
• Increased sputum volume 1
• Increased sputum purulence 1

AND has high-risk features: 1

• Age >65 years with moderate-to-severe COPD 1
• Cardiac failure 1
• Insulin-dependent diabetes 1
• Serious neurological disorders 1
• Chronic respiratory insufficiency (FEV1 <35%, hypoxemia with PaO2 <60 mmHg) 1

Recommended Antibiotics for COPD Exacerbations

First-line options: 1

• Doxycycline 100 mg twice daily for 7-10 days 1
• Amoxicillin-clavulanate 625 mg three times daily for 7-14 days 1
• Clarithromycin 500 mg twice daily for 7-14 days (or extended-release 1000 mg once daily for 5-7 days) 1

For severe exacerbations or frequent relapses: 1

• Respiratory fluoroquinolones (such as levofloxacin) 1

Additional COPD Exacerbation Management

• Short-acting β-agonists improve pulmonary function, breathlessness, and exercise tolerance 1, 3
• Ipratropium bromide reduces cough frequency, severity, and sputum volume 1, 3
• Inhaled corticosteroids combined with long-acting β-agonists for patients with severe airflow obstruction or frequent exacerbations 3
• Smoking cessation is the single most effective intervention, with 90% of patients experiencing cough resolution after quitting 1, 3

Critical Pitfalls to Avoid

Do NOT assume bacterial infection based on: 1

• Purulent sputum or sputum color change (occurs in 89-95% of viral cases) 1
• Cough duration alone (viral bronchitis cough normally lasts 10-14 days) 1
• Patient expectation for antibiotics 1

Remember: 1

• Antibiotics increase adverse events (RR 1.20; 95% CI 1.05-1.36) while providing minimal benefit 1
• Overuse contributes to antibiotic resistance 1, 5, 6
• Up to 25% of H. influenzae and 50-70% of M. catarrhalis produce β-lactamase, making simple aminopenicillins ineffective in true bacterial infections 1