Treatment of Bronchitis
The treatment approach depends critically on whether you are dealing with acute viral bronchitis (a self-limited "chest cold") or chronic bronchitis in the context of COPD—these require fundamentally different management strategies. 1
Acute Viral Bronchitis (Self-Limited "Chest Cold")
For immunocompetent adults with acute viral bronchitis, no routine pharmacologic treatment is recommended—the cornerstone is supportive care with realistic patient expectations. 1
Key Management Principles
- Avoid antibiotics entirely: They provide minimal benefit (reducing cough by only half a day) while causing adverse effects including allergic reactions, nausea, vomiting, and C. difficile infection. 1, 2
- Set appropriate expectations: Inform patients that cough typically persists for 10-14 days after the initial visit, which is normal for this illness. 1
- Use terminology strategically: Refer to the illness as a "chest cold" rather than "bronchitis" to reduce patient expectations for antibiotic prescriptions. 1
Symptomatic Relief Options
- For severe cough affecting quality of life: Dextromethorphan or codeine may be used for short-term symptomatic relief, reducing cough counts by 40-60%. 1
- Standard analgesics and antipyretics may provide symptomatic relief for associated discomfort and fever. 1
Critical Differential Diagnoses to Exclude
Up to 45% of patients diagnosed with acute bronchitis may have underlying asthma or COPD. 1 You must actively exclude:
- Asthma exacerbation: Suspect in patients with wheezing, prolonged expiration, smoking history, and allergy symptoms. Consider lung function testing in patients with ≥2 of these features. 1
- Pneumonia: Suspect in patients with tachypnea, tachycardia, dyspnea, or lung findings suggestive of pneumonia—radiography is warranted. 2
- Pertussis: Suspect when cough persists >2 weeks with paroxysmal cough, whooping cough, post-tussive emesis, or recent pertussis exposure. 2
When to Reassess
If cough persists or worsens beyond the expected timeframe, reassessment with targeted investigations should be considered, including chest x-ray, sputum culture, peak flow measurements, complete blood count, or inflammatory markers like CRP. 1
Common Pitfalls to Avoid
- Purulent sputum does NOT indicate bacterial superinfection in acute bronchitis and does not justify antibiotics. 1
- Wheezing in acute bronchitis does NOT justify bronchodilators unless underlying asthma/COPD is present. 1
- Patient satisfaction depends on physician-patient communication, not antibiotic prescription. 1, 3
Chronic Bronchitis (in Context of COPD)
For patients with chronic bronchitis—defined as cough with sputum production for at least 3 months per year during 2 consecutive years—the management approach is entirely different and focuses on bronchodilator therapy and smoking cessation. 4
First-Line Therapy for Stable Chronic Bronchitis
Ipratropium bromide is the first-line therapy to improve cough in stable COPD patients with chronic bronchitis (Grade A recommendation). 5
- Standard dosing: Ipratropium bromide 36 μg (2 inhalations) four times daily. 5
- Short-acting β-agonists (like albuterol) should be used to control bronchospasm and relieve dyspnea; they may also reduce chronic cough in some patients. 5
Treatment Based on Disease Severity
- For patients with low symptom burden and low exacerbation risk: Start with a bronchodilator to reduce breathlessness. 5
- For patients with severe airflow obstruction (FEV1 <50%) or frequent exacerbations: Consider adding an inhaled corticosteroid with a long-acting β-agonist. 5
- Theophylline may be considered to control chronic cough in stable patients with chronic bronchitis, but careful monitoring for complications is necessary. 5
Most Effective Intervention: Smoking Cessation
Smoking cessation is the most effective means to improve or eliminate the cough of chronic bronchitis, with 90% of patients reporting resolution of cough after smoking cessation. 5 Cough disappears or markedly decreases in 94-100% of patients after smoking cessation, with approximately half experiencing improvement within 1 month. 4
Treatments with Limited or No Evidence of Benefit
For adult patients with chronic cough due to stable chronic bronchitis, there is insufficient evidence to recommend the routine use of any pharmacologic treatments (antibiotics, mucolytics) as a means of relieving cough per se. 4
- Long-term prophylactic antibiotics are NOT recommended for stable patients with chronic bronchitis (Grade I recommendation). 5
- Currently available expectorants have NOT been proven effective for cough in chronic bronchitis and should not be used. 5, 6
- Long-term oral corticosteroids should be avoided due to lack of evidence of benefit and high risk of serious side effects. 6
Acute Exacerbations of Chronic Bronchitis
Stable patients with chronic bronchitis who have a sudden deterioration with increased cough, sputum production, sputum purulence, and/or shortness of breath should be considered to have an acute exacerbation of chronic bronchitis. 4
Treatment of Acute Exacerbations
During acute exacerbations, both short-acting β-agonists and anticholinergic bronchodilators should be administered. 5
Antibiotics are recommended for acute exacerbations of chronic bronchitis, particularly for patients with severe exacerbations and those with more severe airflow obstruction at baseline (Grade A recommendation). 5
A short course (10-15 days) of systemic corticosteroid therapy is recommended for acute exacerbations: IV therapy for hospitalized patients and oral therapy for ambulatory patients. 5
Treatments NOT Recommended for Acute Exacerbations
- Expectorants, postural drainage, chest physiotherapy, and theophylline are not recommended for acute exacerbations. 4