What is the standard dose of prednisone (corticosteroid) for an adult patient with acute bronchitis and no significant underlying respiratory conditions?

Prednisone Should NOT Be Used for Acute Bronchitis

For an adult patient with acute bronchitis and no underlying respiratory conditions, prednisone is not recommended and should not be prescribed. The evidence is clear that corticosteroids provide no benefit in this setting and expose patients to unnecessary harm 1, 2.

Key Distinction: Acute Bronchitis vs. Chronic Bronchitis Exacerbation

The critical clinical decision point is distinguishing between:

• Acute bronchitis in a healthy adult: No steroids indicated 1, 2
• Acute exacerbation of chronic bronchitis/COPD: Steroids ARE indicated 1, 2, 3, 4

Evidence Against Steroids in Acute Bronchitis

The 2020 CHEST Expert Panel explicitly recommends against routine prescription of oral corticosteroids for immunocompetent adult outpatients with acute bronchitis 1. This recommendation is supported by:

• A high-quality 2017 randomized controlled trial in JAMA (n=398) showing prednisolone 40 mg daily for 5 days provided no reduction in cough duration (median 5 days in both groups, HR 1.11,95% CI 0.89-1.39, P=0.36) or symptom severity compared to placebo 5
• Acute bronchitis resolves spontaneously after approximately 10 days without corticosteroid therapy 2, 4
• Purulent sputum does NOT indicate bacterial superinfection requiring steroid treatment 2, 4

When Steroids ARE Indicated: Chronic Bronchitis Exacerbations

If your patient has established COPD or chronic bronchitis experiencing an acute exacerbation, the recommendation changes completely:

Standard dose: Prednisone 40 mg daily for 5 days 1, 2, 3, 4

Alternative dosing supported by guidelines:

• 30-40 mg daily for 5-7 days 1, 3
• 0.5 mg/kg/day (typically 40 mg for most adults) for 5-7 days 2, 4

This regimen:

• Improves lung function (mean FEV1 increase of 53.30 ml vs placebo) 3
• Shortens recovery time and hospitalization duration 2, 4
• Reduces treatment failure rates (OR 0.01 vs placebo) 3
• Prevents hospitalization within 30 days (HR 0.78) 3

Clinical Algorithm for Decision-Making

Step 1: Establish the diagnosis

• Does the patient have pre-existing COPD or chronic bronchitis? 2, 4
• Are they experiencing an acute exacerbation with at least 2 of 3 Anthonisen criteria: increased dyspnea, increased sputum volume, increased sputum purulence? 4

Step 2: If YES to both above → Prescribe prednisone 40 mg daily for 5 days 1, 3, 4

Step 3: If NO (healthy adult with acute bronchitis) → Do NOT prescribe steroids 1, 2

Common Pitfalls to Avoid

• Mistaking acute bronchitis for asthma exacerbation: Asthma DOES benefit from steroids; obtain history of prior asthma diagnosis or bronchodilator use 2
• Prescribing steroids based on wheezing alone: Wheezing in acute bronchitis does not justify steroid use 2
• Prescribing steroids based on purulent sputum: This is NOT an indication for steroids in acute bronchitis 2, 4
• Using steroids to "shorten illness duration": Evidence shows no benefit for this purpose in acute bronchitis 2, 5

Risks of Inappropriate Steroid Use

Even short courses (5 days) carry risks 2, 3:

• Hyperglycemia (OR 2.79), especially problematic in diabetics 3
• Weight gain 2
• Insomnia 2
• Immunosuppression 2

What TO Prescribe for Acute Bronchitis

For symptomatic relief in acute bronchitis 1:

• Codeine or dextromethorphan for troublesome cough (short-term use only)
• Consider β2-agonist bronchodilators for select patients with significant wheezing

Antibiotics are also NOT routinely indicated for acute bronchitis in healthy adults 1.