What is the appropriate treatment approach for an adult patient, possibly a smoker, presenting with acute bronchitis characterized by rhonchi?

Treatment of Acute Bronchitis with Rhonchi

For an adult patient presenting with acute bronchitis characterized by rhonchi, do not prescribe antibiotics or routine medications—provide symptomatic management only and educate the patient that cough typically lasts 10-14 days. 1, 2, 3

Initial Assessment: Rule Out Pneumonia First

Before diagnosing acute bronchitis, you must exclude pneumonia by checking for these specific findings 1, 2, 3:

• Heart rate >100 beats/min (tachycardia) 2
• Respiratory rate >24 breaths/min (tachypnea) 2
• Oral temperature >38°C (fever) 2
• Abnormal chest examination findings including rales, egophony, or tactile fremitus 2

If any of these are present, obtain chest radiography to rule out pneumonia rather than treating as simple bronchitis. 2, 3

Critical pitfall: Approximately one-third of patients with "recurrent acute bronchitis" actually have undiagnosed asthma or COPD exacerbations—consider these diagnoses especially if the patient has had multiple similar episodes. 1, 2

Primary Treatment: Symptomatic Management Only

What NOT to Prescribe

The 2020 CHEST Expert Panel explicitly recommends against routine prescription of: 1

• Antibiotics (provide no benefit, only 0.5 days reduction in cough duration while increasing adverse events) 1, 2
• Antiviral therapy 1
• Inhaled beta-agonists (in most patients) 1
• Inhaled anticholinergics 1
• Inhaled corticosteroids 1, 2
• Oral corticosteroids 1, 2
• Oral NSAIDs at anti-inflammatory doses 1, 2
• Expectorants or mucolytics 2, 3

Why antibiotics don't work: Respiratory viruses cause 89-95% of acute bronchitis cases. 2, 3 Purulent sputum does NOT indicate bacterial infection—it occurs in 89-95% of viral cases. 2, 3

What TO Consider for Symptomatic Relief

For bothersome dry cough (especially disturbing sleep): 1, 2

• Codeine or dextromethorphan may provide modest effects on cough severity and duration 1, 2, 3
• These are reasonable options when cough is particularly bothersome 2

For patients with wheezing accompanying the cough: 1, 4

• β2-agonist bronchodilators (albuterol/salbutamol) may be useful in this select subgroup 1, 2, 4
• Dosing: 2-4 inhalations (200-400 μg) every 4 hours 4
• Important: Do NOT use bronchodilators routinely in patients without wheezing—they provide no benefit and cause adverse effects (tremor, nervousness, shakiness) 1, 4

Low-risk supportive measures: 2

• Elimination of environmental cough triggers 2
• Vaporized air treatments/humidification 2

The ONE Exception: Pertussis (Whooping Cough)

If pertussis is confirmed or suspected, immediately prescribe: 1, 2, 3

• Macrolide antibiotic (erythromycin or azithromycin) 1, 2, 3
• Isolate patient for 5 days from start of treatment 1, 2, 3
• Early treatment within first few weeks diminishes coughing paroxysms and prevents disease spread 1, 2

Patient Education: The Key to Satisfaction

Essential information to communicate: 2, 3

• Cough typically lasts 10-14 days after the visit, even without antibiotics 2, 3
• The condition is self-limiting and resolves within 3 weeks 2
• Patient satisfaction depends more on physician-patient communication than whether an antibiotic is prescribed 2, 3
• Refer to the condition as a "chest cold" rather than "bronchitis" to reduce antibiotic expectations 2, 3

Discuss risks of unnecessary antibiotics: 2, 3

• Adverse effects (diarrhea, nausea, rash) 2
• Contribution to antibiotic resistance 2, 3

When to Reassess

Instruct patient to return if: 1, 2

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

At reassessment, consider targeted investigations including chest x-ray, sputum culture, peak flow measurements, or inflammatory markers. 1

Special Populations: High-Risk Patients

Consider antibiotics more readily in patients with: 2, 3

• Age ≥75 years with fever 2, 3
• Cardiac failure 2, 3
• Insulin-dependent diabetes 2, 3
• Immunosuppression 2, 3
• Serious neurological disorders 2

For these high-risk patients with suspected bacterial infection, first-line treatment: 2, 3

• Doxycycline 100 mg twice daily for 7-10 days 2, 3
• Alternative: Amoxicillin 500 mg three times daily for 5-8 days 2

Critical caveat: These recommendations apply to otherwise healthy adults with uncomplicated acute bronchitis. Patients with COPD exacerbations or asthma exacerbations require different management approaches. 1, 2