What is the initial treatment approach for a patient with bronchitis, possibly with a history of asthma or chronic obstructive pulmonary disease (COPD)?

Initial Treatment of Bronchitis

For uncomplicated acute bronchitis in otherwise healthy adults, do NOT prescribe antibiotics—they provide no meaningful clinical benefit (reducing cough by only half a day) while causing significant adverse effects and contributing to antibiotic resistance. 1

Immediate Assessment: Rule Out Other Diagnoses

Before treating as simple bronchitis, evaluate for conditions requiring different management:

• Check vital signs immediately: Heart rate >100 bpm, respiratory rate >24 breaths/min, or oral temperature >38°C suggests pneumonia, not bronchitis 1
• Examine the chest: Focal findings (rales, egophony, tactile fremitus) indicate pneumonia and require chest radiography 1
• Consider asthma/COPD: Approximately one-third of patients diagnosed with "recurrent acute bronchitis" actually have undiagnosed asthma or COPD exacerbations 1
• Pertussis screening: If paroxysmal cough with inspiratory whoop or post-tussive vomiting, consider pertussis 1

Treatment for Uncomplicated Acute Bronchitis (No COPD/Asthma History)

What TO Do:

• Patient education: Inform patients that cough typically lasts 10-14 days after the visit, sometimes up to 3 weeks, even without treatment 1
• Symptomatic relief options:
  • Codeine or dextromethorphan for bothersome dry cough, especially when disturbing sleep 1
  • Environmental trigger elimination and humidified air 1
• Communication strategy: Refer to the condition as a "chest cold" rather than "bronchitis" to reduce antibiotic expectations 1

What NOT To Do:

• No antibiotics: Respiratory viruses cause 89-95% of cases; antibiotics show no clinical benefit (RR 1.07; 95% CI 0.99-1.15) while significantly increasing adverse events (RR 1.20; 95% CI 1.05-1.36) 1
• No routine bronchodilators: β2-agonist bronchodilators should NOT be routinely used except in select patients with accompanying wheezing 1
• No steroids: Systemic corticosteroids are not justified for acute bronchitis in healthy adults 2
• No NSAIDs at anti-inflammatory doses 1

Critical Exception - Pertussis:

• If pertussis confirmed or suspected: Prescribe azithromycin 500 mg once daily for 5 days (or erythromycin) 1, 3
• Isolate patient for 5 days from start of treatment 1
• Early treatment (within first few weeks) diminishes coughing paroxysms and prevents disease spread 1

Treatment for Acute Exacerbation of Chronic Bronchitis (COPD/Chronic Bronchitis History)

This is a fundamentally different condition requiring different management:

Diagnostic Criteria:

Patient with known chronic bronchitis/COPD presenting with sudden deterioration characterized by:

• Increased cough
• Increased sputum production
• Increased sputum purulence
• Increased dyspnea
• Often preceded by upper respiratory infection symptoms 4

Bronchodilator Therapy (First-Line):

• Ipratropium bromide: 36 μg (2 inhalations) four times daily—first-line therapy for chronic cough in stable COPD 5
• Short-acting β2-agonists (albuterol): 2.5 mg via nebulizer three to four times daily to control bronchospasm and relieve dyspnea 5, 6
• During acute exacerbations: Administer both short-acting β-agonists AND anticholinergic bronchodilators 5

Corticosteroid Therapy:

Prednisone 40 mg daily for 5-7 days for acute exacerbations—improves lung function, oxygenation, and shortens recovery time 2, 5

Antibiotic Therapy (When Indicated):

Consider antibiotics if patient meets Anthonisen criteria (at least 2 of 3):

1. Increased dyspnea
2. Increased sputum volume
3. Increased sputum purulence 1

AND has high-risk features:

• Age >65 years with moderate-to-severe COPD
• FEV1 <50% predicted
• Cardiac failure
• Insulin-dependent diabetes
• Frequent exacerbations (≥4 per year)
• Immunosuppression 1

Antibiotic selection for high-risk patients:

• First-line for moderate exacerbations: Doxycycline 100 mg twice daily for 7-10 days 1
• For severe exacerbations: Amoxicillin/clavulanate 625 mg three times daily for 14 days 1
• Alternative: Azithromycin 500 mg once daily for 3 days (clinical cure rate 85% in AECB) 1, 3

Critical Pitfall to Avoid:

Do NOT assume bacterial infection based on:

• Purulent sputum color alone (occurs in 89-95% of viral cases) 1
• Cough duration alone 1
• Patient expectation for antibiotics 1

When to Reassess:

Instruct patients to return if:

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

Special Considerations for Asthma History:

If patient has known asthma presenting with acute cough and wheezing:

• This is likely an asthma exacerbation, not bronchitis 1
• Treat as asthma: Short-acting β2-agonists (albuterol 2.5 mg via nebulizer) 6
• Consider systemic corticosteroids if moderate-to-severe exacerbation 2
• Distinguish from true acute bronchitis, as asthma benefits from steroid therapy while simple bronchitis does not 2