What is the best treatment approach for a patient with bronchitis, considering their symptoms and potential underlying respiratory conditions such as Chronic Obstructive Pulmonary Disease (COPD)?

Treatment of Bronchitis

Distinguish Between Acute Bronchitis and Chronic Bronchitis/COPD First

The treatment approach differs fundamentally based on whether you're dealing with acute bronchitis in an otherwise healthy patient versus chronic bronchitis or an acute exacerbation of COPD.

For Acute Bronchitis (Otherwise Healthy Patients)

Do not prescribe antibiotics for acute bronchitis in healthy adults—the condition is viral in 89-95% of cases and antibiotics provide minimal benefit (reducing cough by only half a day) while causing unnecessary harm. 1, 2

• Acute bronchitis is characterized by cough due to acute inflammation of the trachea and large airways without evidence of pneumonia 1
• The cough typically lasts 2-3 weeks, and patients must be educated about this natural course 1
• Symptomatic treatment only: Use antitussives (codeine or dextromethorphan) for short-term cough suppression 3, 4
• Consider beta-2-agonist bronchodilators only for select patients with wheezing 4
• Do not use systemic corticosteroids for acute bronchitis in healthy adults—they are not justified and provide no benefit 4

Common pitfall: Prescribing antibiotics or steroids based on purulent sputum or wheezing—these are not indications for treatment in acute bronchitis 4

For Chronic Bronchitis (Stable COPD Patients)

The most effective treatment is complete avoidance of respiratory irritants, particularly smoking cessation—90% of patients will have resolution of chronic cough after quitting. 3, 5, 6

First-Line Pharmacologic Therapy for Stable Disease:

• Start with ipratropium bromide 36 μg (2 inhalations) four times daily as first-line bronchodilator therapy 5, 6
• Add a short-acting β-agonist to control bronchospasm and relieve dyspnea 5, 6
• Theophylline may be considered for chronic cough control, but requires careful monitoring for complications 5

For Patients with Severe Disease (FEV1 <50% or Frequent Exacerbations):

• Add an inhaled corticosteroid combined with a long-acting β-agonist 5, 6, 4
• Consider roflumilast for patients with severe COPD, chronic bronchitis characteristics, and history of exacerbations 5

What NOT to do in stable chronic bronchitis:

• Do not use long-term prophylactic antibiotics 3, 5
• Do not use long-term oral corticosteroids (prednisone)—no evidence of benefit and high risk of serious side effects 3, 4
• Do not use expectorants—they have not been proven effective 3, 5
• Do not use postural drainage or chest physiotherapy—no proven benefit 3

For Acute Exacerbations of Chronic Bronchitis (AECB)

An acute exacerbation is defined by sudden deterioration with at least 2 of 3 cardinal symptoms: increased dyspnea, increased sputum volume, or increased sputum purulence. 6, 7

Immediate Treatment Algorithm:

1. Bronchodilators (start immediately):

   • Administer both ipratropium bromide and short-acting β-agonist together 6
   • If no prompt response, maximize the dose of the second agent 6

2. Antibiotics (for patients meeting criteria):

   • Prescribe antibiotics empirically for 7-10 days if the patient has at least 2 of the 3 Anthonisen criteria (increased dyspnea, increased sputum volume, increased sputum purulence) 6, 7
   • First-line options: amoxicillin 500 mg three times daily for 7-10 days, doxycycline 100 mg twice daily for 7-10 days, or azithromycin 500 mg once daily for 3 days 6
   • Antibiotics are most effective in patients with purulent sputum and those with more severe airflow obstruction 3

3. Systemic Corticosteroids:

   • Administer prednisone 40 mg daily for 5-7 days (or 30-40 mg for 10-15 days) for all acute exacerbations 6, 4
   • Use IV methylprednisolone for hospitalized patients; oral prednisone for outpatients 6, 4
   • Corticosteroids improve lung function, oxygenation, shorten recovery time and hospitalization duration, and reduce recurrent exacerbations in the first 30 days 4

Monitoring:

• Reassess 2-3 days after starting antibiotics to evaluate treatment response 6
• If fever persists beyond 3 days, consider bacterial superinfection or pneumonia 6
• If cough persists beyond 3 weeks, consider alternative diagnoses (asthma, pertussis, GERD) 6

Critical distinction: Rule out pneumonia before diagnosing acute exacerbation—suspect pneumonia if tachypnea, tachycardia, dyspnea, or lung findings suggestive of pneumonia are present, and obtain chest radiography 1

Short-term corticosteroid risks to discuss with patients: hyperglycemia, weight gain, insomnia, and immunosuppression 4