What is the recommended management approach for a patient with acute bronchitis, considering their unique medical history and potential underlying respiratory conditions such as asthma or Chronic Obstructive Pulmonary Disease (COPD)?

Management of Acute Bronchitis

Antibiotics should NOT be prescribed for acute bronchitis in otherwise healthy adults, as they provide minimal benefit (reducing cough by only half a day) while exposing patients to adverse effects and contributing to antibiotic resistance. 1

Initial Assessment: Rule Out Other Diagnoses

Before confirming acute bronchitis, you must exclude pneumonia and other conditions that require specific treatment:

• Check vital signs immediately: Heart rate >100 bpm, respiratory rate >24 breaths/min, or oral temperature >38°C suggests pneumonia, not bronchitis—obtain chest radiography if any are present 1
• Examine the chest for focal findings: Rales, egophony, or tactile fremitus indicate pneumonia rather than bronchitis 1
• Consider asthma or COPD exacerbation: Approximately one-third of patients diagnosed with "acute bronchitis" actually have undiagnosed asthma, especially if there are recurrent episodes 1, 2
• Rule out pertussis: Look for paroxysmal coughing, post-tussive vomiting, or inspiratory whooping—if present with cough >2 weeks, treat as pertussis 1, 2

Primary Management: Symptomatic Treatment and Education

The cornerstone of acute bronchitis management is patient education and symptomatic relief only:

• Inform patients that cough typically lasts 10-14 days after the visit, even without antibiotics, and may persist up to 3 weeks 1
• Explain that respiratory viruses cause 89-95% of cases, making antibiotics completely ineffective 1
• Emphasize that purulent (green/yellow) sputum occurs in 89-95% of viral cases and does NOT indicate bacterial infection 1
• Consider antitussives (codeine or dextromethorphan) only for bothersome dry cough that disturbs sleep—these provide modest symptomatic relief 1
• Use β2-agonist bronchodilators (albuterol) ONLY in select patients with accompanying wheezing—do not use routinely 1
• Recommend low-risk measures: Elimination of environmental irritants, humidified air, and adequate hydration 1

What NOT to Prescribe

The following have been proven ineffective and should not be used:

• No antibiotics (unless pertussis suspected or high-risk patient with chronic bronchitis—see below) 1
• No inhaled or oral corticosteroids 1
• No NSAIDs at anti-inflammatory doses 1
• No expectorants or mucolytics 1
• No antihistamines or anticholinergics 1

The ONE Exception: Pertussis

• If pertussis is confirmed or strongly suspected, prescribe a macrolide antibiotic (azithromycin or erythromycin) immediately 1
• Isolate the patient for 5 days from the start of treatment to prevent disease spread 1
• Early treatment within the first few weeks diminishes coughing paroxysms and prevents transmission 1

Special Population: Chronic Bronchitis/COPD Exacerbations

These patients require a different approach than uncomplicated acute bronchitis:

• Consider antibiotics ONLY if the patient has at least 2 of 3 Anthonisen criteria: (1) increased dyspnea, (2) increased sputum volume, or (3) increased sputum purulence 1, 3
• AND at least one risk factor: Age ≥65 years, FEV1 <50% predicted, ≥4 exacerbations in 12 months, cardiac failure, insulin-dependent diabetes, or immunosuppression 1, 3
• First-line antibiotics for moderate exacerbations: Doxycycline 100 mg twice daily for 7-10 days, or newer macrolides (azithromycin, clarithromycin) 1, 3
• For severe exacerbations or FEV1 <35%: High-dose amoxicillin-clavulanate 625 mg three times daily for 14 days, or respiratory fluoroquinolones 1, 3
• Add bronchodilators and consider oral corticosteroids for moderate-to-severe airflow obstruction 1

When to Reassess

Instruct patients to return if:

• Fever persists >3 days (suggests bacterial superinfection or pneumonia) 1
• Cough persists >3 weeks (consider other diagnoses: asthma, COPD, pertussis, GERD, or chronic cough syndrome) 1, 2
• Symptoms worsen rather than gradually improve 1

Critical Pitfalls to Avoid

• Do not prescribe antibiotics based on sputum color alone—purulent sputum is present in 89-95% of viral cases 1
• Do not prescribe antibiotics based on cough duration alone—viral bronchitis cough normally lasts 10-14 days 1
• Do not miss underlying asthma—this is the most commonly overlooked diagnosis in patients with recurrent "bronchitis" 1, 2
• Do not assume bacterial infection before the 3-day fever threshold—most cases are viral 1
• Do not use the term "bronchitis" with patients—referring to it as a "chest cold" reduces antibiotic expectations 1

Patient Satisfaction Strategy

Patient satisfaction depends more on physician-patient communication than whether an antibiotic is prescribed 1, 4. Use these communication strategies:

• Explain why antibiotics are harmful in this case (adverse effects, resistance, no benefit) 1
• Provide a clear timeline for expected symptom resolution 1
• Offer symptomatic treatment options to demonstrate active management 1
• Consider delayed antibiotic prescription strategy (prescription to fill only if symptoms worsen after 3 days) 5