What is the best management approach for a patient with viral bronchitis, particularly those with a history of respiratory issues such as asthma or Chronic Obstructive Pulmonary Disease (COPD)?

Management of Viral Bronchitis

Primary Management: Supportive Care Only

For immunocompetent adults with acute viral bronchitis, no routine pharmacologic treatment is recommended—the cornerstone is supportive care with realistic patient expectations. 1 This includes avoiding antibiotics, antivirals, bronchodilators, corticosteroids, and antitussives in otherwise healthy patients. 1

Key Patient Education Points

• Inform patients that cough typically persists for 10-14 days after the initial visit, which is the normal duration of illness. 1
• Refer to the condition as a "chest cold" rather than "bronchitis" to reduce expectations for antibiotic prescriptions. 1
• Emphasize that antibiotics provide minimal benefit (reducing cough by only half a day) while causing adverse effects including allergic reactions, nausea, vomiting, and Clostridium difficile infection. 2

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 Assessment for Underlying Lung Disease

Up to 45% of patients diagnosed with acute bronchitis actually have underlying asthma or COPD, making this a critical differential diagnosis. 3, 1

When to Suspect Underlying Asthma/COPD

Perform lung function testing in patients with ≥2 of the following features: 3, 1

• Wheezing
• Prolonged expiration
• History of smoking
• Symptoms of allergy

Red Flags Requiring Reassessment

If cough persists or worsens beyond the expected 2-3 week timeframe, reassess with targeted investigations including: 1, 2

• Chest x-ray
• Sputum culture
• Peak flow measurements
• Complete blood count
• Inflammatory markers (CRP)

Management for Patients with Underlying Lung Disease

Patients with underlying COPD or asthma require fundamentally different management approaches. 1

For COPD Exacerbations

• Short-acting β-agonists or anticholinergic bronchodilators should be administered during acute exacerbations. 4
• A short course (10-15 days) of systemic corticosteroids is effective for acute exacerbations. 4
• Antibiotics are indicated for COPD exacerbations, particularly in elderly patients with risk factors (age ≥65 years, FEV1 <50% predicted, ≥4 exacerbations in 12 months, or comorbidities). 5, 4, 6

For Asthma Exacerbations

• β-agonists and steroids have been shown to be beneficial in asthma exacerbations presenting with respiratory symptoms. 3

Common Pitfalls to Avoid

Pitfall #1: Misinterpreting Purulent Sputum

Purulent sputum does NOT indicate bacterial superinfection in acute viral bronchitis and does not justify antibiotics. 1 This is a viral inflammatory response, not bacterial infection.

Pitfall #2: Prescribing Bronchodilators Without Underlying Disease

Wheezing in acute bronchitis does not justify bronchodilators unless underlying asthma/COPD is present. 1 First confirm chronic lung disease before initiating bronchodilator therapy.

Pitfall #3: Inappropriate Antibiotic Use

Viruses are responsible for >90% of acute bronchitis cases. 5, 2 Antibiotics should NOT be prescribed routinely, as they contribute to antibiotic resistance without meaningful clinical benefit. 5

Pitfall #4: Missing Pertussis

Suspect pertussis in patients with cough persisting >2 weeks accompanied by paroxysmal cough, whooping cough, post-tussive emesis, or recent pertussis exposure. 2 This is one of the few scenarios where specific antimicrobial therapy is indicated.

Preventive Measures

• Influenza vaccination is recommended yearly for those at increased risk for complications, including patients aged ≥65 years and those with chronic pulmonary diseases. 3
• Smoking cessation counseling is mandatory, as 90% of patients with chronic bronchitis experience cough resolution after quitting. 5, 4