Is prednisone (corticosteroid) indicated for treatment of acute bronchitis in patients with or without underlying respiratory conditions such as asthma (chronic obstructive airway disease) or COPD (chronic obstructive pulmonary disease)?

Prednisone Should NOT Be Given for Acute Bronchitis in Otherwise Healthy Adults

Do not prescribe prednisone or any oral corticosteroids for acute bronchitis in immunocompetent adults without underlying chronic lung disease, as they provide no clinical benefit while exposing patients to unnecessary harm. 1, 2

Critical Distinction: Acute Bronchitis vs. Chronic Bronchitis Exacerbation

The answer depends entirely on whether you're treating acute bronchitis (a self-limited viral infection) or an acute exacerbation of chronic bronchitis/COPD (a different disease entity):

For Acute Bronchitis (No Underlying Lung Disease)

• Oral corticosteroids are explicitly NOT recommended by the CHEST Expert Panel for immunocompetent adult outpatients with acute bronchitis 1

• The French guidelines state that systemic corticosteroids are not justified in acute bronchitis in healthy adults, as the clinical course is spontaneously favorable after about 10 days 2

• Acute bronchitis is caused by respiratory viruses in 89-95% of cases, making anti-inflammatory therapy ineffective for shortening illness duration 3, 2

• Purulent sputum does NOT indicate bacterial superinfection or justify steroid treatment - it occurs in 89-95% of viral cases 3, 2

For Acute Exacerbations of Chronic Bronchitis/COPD

• Prednisone 40 mg daily for 5-7 days IS recommended for patients with established COPD or chronic bronchitis experiencing an acute exacerbation 2

• This improves lung function (FEV1), oxygenation, shortens recovery time and hospitalization duration 2, 4

• The American Thoracic Society recommends a short course (10-15 days) of systemic corticosteroid therapy for acute exacerbations of chronic bronchitis 2

Clinical Algorithm for Decision-Making

Step 1: Establish the correct diagnosis

• Check vital signs: heart rate >100 bpm, respiratory rate >24 breaths/min, or oral temperature >38°C suggests pneumonia, not bronchitis 3

• Obtain chest radiography if any vital sign abnormalities or focal lung findings are present 3

• Rule out asthma exacerbation - approximately one-third of patients diagnosed with "recurrent acute bronchitis" actually have undiagnosed asthma 3

Step 2: Determine if patient has underlying chronic lung disease

• No underlying COPD/chronic bronchitis → This is acute bronchitis → NO steroids 1, 2

• Known COPD/chronic bronchitis with acute worsening → This is an exacerbation → YES to steroids (prednisone 40 mg daily for 5-7 days) 2

Step 3: If acute exacerbation of chronic bronchitis, confirm indication

• Patient should have sudden deterioration with increased cough, sputum production, sputum purulence, and/or dyspnea 2

• Often preceded by upper respiratory tract infection symptoms 2

Common Pitfalls to Avoid

• Mistaking acute bronchitis for asthma exacerbation - asthma benefits from steroid therapy, but true acute bronchitis does not 2

• Prescribing steroids based on wheezing or purulent sputum - these are not indications for steroid therapy in acute bronchitis 2

• Using steroids to shorten illness duration - evidence shows no benefit for this purpose in acute bronchitis 2

• Assuming all "bronchitis" is the same - acute bronchitis and chronic bronchitis exacerbations are completely different conditions requiring different management 3, 2

What TO Do for Acute Bronchitis Instead

• Inform patients that cough typically lasts 10-14 days after the visit, even without treatment, and may persist up to 3 weeks 3, 2

• Consider antitussives (codeine or dextromethorphan) for bothersome dry cough that disturbs sleep 3, 2

• Consider β2-agonist bronchodilators only in select patients with accompanying wheezing 3, 2

• Reassess if fever persists >3 days (suggests bacterial superinfection or pneumonia) or cough persists >3 weeks (consider other diagnoses) 3, 2

Risks of Inappropriate Steroid Use

• Short-term corticosteroid risks include hyperglycemia, weight gain, insomnia, and immunosuppression 2

• In viral respiratory infections, corticosteroids may prolong viral shedding and suppress the immune response needed to clear the infection 2

• Prescribing steroids for true acute bronchitis exposes patients to unnecessary harm without any clinical benefit 2