What is the treatment for a patient with bronchitis (inflammation of the bronchial tubes)?

Treatment of Bronchitis

Distinguish Acute vs. Chronic Bronchitis First

For acute bronchitis in otherwise healthy adults, do NOT prescribe antibiotics—they provide minimal benefit (reducing cough by only half a day) while causing significant adverse effects and contributing to antibiotic resistance. 1, 2, 3, 4

Before treating any bronchitis, you must rule out pneumonia by checking for:

• Heart rate >100 beats/min 1, 2
• Respiratory rate >24 breaths/min 1, 2
• Oral temperature >38°C 1, 2
• Focal lung findings (rales, egophony, tactile fremitus) 1, 2

If any of these are present, obtain chest radiography—this is pneumonia, not simple bronchitis. 1, 2

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Acute Bronchitis Management

Primary Treatment: Education and Symptomatic Care Only

Inform patients that cough typically lasts 10-14 days after the visit, sometimes up to 3 weeks, even without antibiotics. 2, 3, 4 Calling it a "chest cold" rather than "bronchitis" reduces patient expectations for antibiotics. 2, 4

Symptomatic treatment options:

• Antitussives (codeine or dextromethorphan) provide modest relief for bothersome dry cough, especially when sleep is disturbed 1, 2, 5
• β2-agonist bronchodilators (albuterol) should be used ONLY in select patients with accompanying wheezing—not routinely 1, 2, 5
• Low-risk measures include elimination of environmental cough triggers and vaporized air treatments 2

Critical Exception: Pertussis

If pertussis is suspected or confirmed (cough >2 weeks with paroxysmal cough, whooping, post-tussive emesis), prescribe a macrolide antibiotic (erythromycin or azithromycin) immediately and isolate the patient for 5 days from treatment start. 1, 2, 4

When to Reassess

Instruct patients to return if:

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

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Chronic Bronchitis Management

Stable Chronic Bronchitis

The most effective treatment is avoidance of respiratory irritants, particularly smoking cessation—90% of patients experience resolution of chronic cough after quitting. 1

Pharmacologic therapy for stable patients:

• Short-acting β-agonists to control bronchospasm and relieve dyspnea; may reduce chronic cough 1, 5
• Ipratropium bromide should be offered to improve cough 1, 5
• Theophylline can be considered to control chronic cough, but requires careful monitoring for complications 1
• Long-acting β-agonist + inhaled corticosteroid combination should be offered to control chronic cough 1
• Inhaled corticosteroids should be offered for patients with FEV1 <50% predicted or frequent exacerbations 1, 5

Do NOT use:

• Long-term prophylactic antibiotics (no benefit) 1
• Expectorants or mucolytics (no evidence of effectiveness) 1
• Postural drainage and chest percussion (benefits not proven) 1

Acute Exacerbations of Chronic Bronchitis (AECB)

Antibiotics are recommended for acute exacerbations, particularly in patients with severe exacerbations and those with more severe baseline airflow obstruction. 1, 5

Criteria for antibiotic use in AECB:

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

• Increased dyspnea 2, 6
• Increased sputum volume 2, 6
• Increased sputum purulence 2, 6

AND at least 1 risk factor:

• Age ≥65 years 2, 6
• FEV1 <50% predicted 2, 6
• ≥4 exacerbations in 12 months 6
• Comorbidities (cardiac failure, insulin-dependent diabetes, immunosuppression) 2, 6

Antibiotic selection for AECB:

For moderate severity exacerbations (infrequent exacerbations, FEV1 >50%):

• Newer macrolide (azithromycin, clarithromycin) 2, 6
• Extended-spectrum cephalosporin 6
• Doxycycline 2, 6

For severe exacerbations (frequent exacerbations, FEV1 <35%, age >75 with comorbidities):

• High-dose amoxicillin/clavulanate 625 mg three times daily for 14 days 2, 6
• Respiratory fluoroquinolone (levofloxacin) 2, 7, 6

Duration: 7-10 days standard; may extend to 14 days for documented bacterial pathogens 2

Bronchodilator therapy during exacerbations:

• Short-acting β-agonists or anticholinergic bronchodilators should be administered 1
• If no prompt response, add the other agent after maximizing the first 1
• Do NOT use theophylline for acute exacerbations 1

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Critical Pitfalls to Avoid

• Purulent sputum does NOT indicate bacterial infection—it occurs in 89-95% of viral bronchitis cases 2, 3
• Cough duration does NOT indicate bacterial infection—viral bronchitis cough typically lasts 10-14 days 2, 3
• Up to 25% of H. influenzae and 50-70% of M. catarrhalis produce β-lactamase, making simple aminopenicillins ineffective 2
• Approximately one-third of patients with "recurrent acute bronchitis" actually have undiagnosed asthma or COPD 2

Patient satisfaction depends more on physician-patient communication than whether an antibiotic is prescribed. 1, 2, 8