What is the management for a patient with bronchitis?

Management of Bronchitis

Distinguish Between Acute and Chronic Bronchitis First

The most critical initial step is determining whether you are managing acute bronchitis (self-limited viral illness) or chronic bronchitis (chronic inflammatory condition), as their management differs fundamentally. 1, 2

Acute Bronchitis

• Defined as acute cough lasting up to 6 weeks due to self-limited inflammation of large airways, typically without fever or significant systemic symptoms 2, 3
• More than 90% of cases are viral; antibiotics provide minimal benefit (reducing cough by only 0.5 days) while exposing patients to adverse effects 2, 4, 3
• Do NOT prescribe antibiotics for uncomplicated acute bronchitis 1, 2, 3

Chronic Bronchitis

• Defined as cough with sputum production on most days for at least 3 months per year for 2 consecutive years 5, 1
• Requires long-term management focused on bronchodilation, smoking cessation, and preventing exacerbations 5, 1

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Management of Acute Bronchitis

Rule Out Pneumonia First

Before diagnosing uncomplicated acute bronchitis, assess for tachycardia, tachypnea, fever, and abnormal chest examination findings to rule out pneumonia. 1, 6 Normal vital signs in healthy adults under 70 years effectively rules out pneumonia 2.

Antibiotic Use: Almost Never Indicated

• Antibiotics should NOT be prescribed for acute bronchitis 1, 2, 3
• Consider antibiotics ONLY in these specific high-risk situations:
  • Patients aged ≥75 years with fever 1
  • Patients with cardiac failure 1
  • Suspected pertussis (to reduce transmission) 4, 6

Symptomatic Management

• Short-acting β-agonists (albuterol) may reduce cough duration and severity in patients with evidence of bronchial hyperresponsiveness 1
• Ipratropium bromide may improve cough in some patients 1
• Dextromethorphan or codeine for short-term symptomatic relief of bothersome cough 1
• Do NOT use antitussives, honey, antihistamines, oral NSAIDs, or inhaled/oral corticosteroids—evidence does not support their use 3

Patient Communication Strategy

The quality of your clinical encounter matters more than prescribing antibiotics for patient satisfaction. 1

• Set realistic expectations: cough typically lasts 10-14 days after the visit, sometimes up to 3 weeks 1, 3, 6
• Call it a "chest cold" rather than "bronchitis" to reduce patient expectation for antibiotics 1, 3, 6
• Explain that colored (green/yellow) sputum does NOT indicate bacterial infection—it results from inflammatory cells or sloughed epithelial cells 1, 4
• Discuss risks of unnecessary antibiotics: side effects, allergic reactions, Clostridium difficile infection, and antibiotic resistance 1, 6

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Management of Chronic Bronchitis

Smoking Cessation: The Most Effective Intervention

Smoking cessation is the single most effective intervention for chronic bronchitis, with 90% of patients experiencing cough resolution after quitting. 5, 1 Remove all respiratory irritants including passive smoke exposure and workplace/environmental hazards 5, 1.

Stable Chronic Bronchitis: Bronchodilator Therapy

Short-acting β-agonists should be used to control bronchospasm, relieve dyspnea, and may reduce chronic cough. 5, 1

• Ipratropium bromide should be offered to improve cough and reduce sputum volume 5, 1
• Theophylline may be considered to control chronic cough, but requires careful monitoring for complications 5

Advanced Therapy for Severe Disease

• Long-acting β-agonists combined with inhaled corticosteroids should be offered to control chronic cough and reduce exacerbation rates 1
• Inhaled corticosteroids are recommended when FEV1 <50% predicted or with frequent exacerbations 5, 1

What NOT to Use

• Do NOT use long-term prophylactic antibiotics in stable chronic bronchitis 5
• Do NOT use long-term oral corticosteroids—no evidence of benefit and high risk of side effects 5, 1
• Do NOT use expectorants or mucolytics—no evidence of benefit 5, 1
• Do NOT use postural drainage or chest percussion—not proven effective 5

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Management of Acute Exacerbations of Chronic Bronchitis

Immediate Bronchodilator Therapy

Administer short-acting β-agonists or anticholinergic bronchodilators immediately during acute exacerbations. 5, 1 If no prompt response, add the other agent after maximizing the first 5.

Antibiotic Use in Exacerbations

Antibiotics are recommended for acute exacerbations, especially in patients with severe exacerbations and baseline FEV1 <50%. 5, 1 Patients most likely to benefit include those with:

• Severe airflow obstruction at baseline 5
• Increased cough, sputum production, and sputum purulence 5
• Shortness of breath preceded by upper respiratory infection symptoms 5

Systemic Corticosteroids

A short course (10-15 days) of systemic corticosteroids should be given for acute exacerbations—both IV therapy for hospitalized patients and oral therapy for ambulatory patients are effective. 5, 1

What NOT to Use During Exacerbations

• Do NOT use theophylline for acute exacerbations 5, 1
• Do NOT use expectorants or mucolytics during exacerbations 5, 1
• Do NOT use postural drainage or chest percussion 5

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Common Pitfalls to Avoid

• Do NOT prescribe antibiotics based solely on colored sputum—purulence does not indicate bacterial infection 1, 4
• Do NOT fail to distinguish acute bronchitis from pneumonia—check vital signs and lung examination 1, 6
• Do NOT overuse expectorants, mucolytics, and antihistamines—they lack evidence of benefit 1, 3
• Do NOT ignore underlying conditions (asthma, COPD, cardiac failure, diabetes) that may be exacerbated by bronchitis 1
• Consider delayed antibiotic prescriptions as a strategy to reduce inappropriate prescribing while maintaining patient satisfaction 3, 6