Wheezy Bronchitis: Diagnosis and Treatment
Diagnosis
Wheezy bronchitis is diagnosed clinically when a patient presents with acute cough and wheeze, but only after excluding pneumonia, asthma exacerbation, COPD exacerbation, and the common cold. 1
Essential Diagnostic Steps
Check vital signs immediately to rule out pneumonia: heart rate >100 bpm, respiratory rate >24 breaths/min, or oral temperature >38°C all suggest pneumonia rather than bronchitis and warrant chest radiography 1, 2
Examine the chest for focal findings such as asymmetrical lung sounds, rales, egophony, or tactile fremitus—any of these indicate pneumonia, not bronchitis 1
Consider undiagnosed asthma in approximately one-third of patients labeled with "acute bronchitis," especially if there are recurrent episodes or if wheezing is prominent 1
Evaluate for pertussis if cough includes paroxysmal episodes, post-tussive vomiting, inspiratory whooping sounds, or known pertussis exposure—obtain nasopharyngeal culture and initiate macrolide antibiotics immediately if suspected 1, 2
What Chest X-ray Does NOT Indicate
Chest radiography is not routinely indicated in healthy adults with normal vital signs and no focal chest findings 1
Order chest X-ray only if cough persists ≥3 weeks without other known causes, or if vital sign abnormalities or focal findings are present 1, 2
Treatment
For adults with wheezy bronchitis, prescribe inhaled bronchodilators (β2-agonists) for symptomatic relief of wheeze, but do NOT prescribe antibiotics. 1, 3
Evidence-Based Treatment Algorithm
First-Line Treatment for Wheeze
Prescribe inhaled β2-agonist bronchodilators (such as albuterol) specifically for patients with accompanying wheeze—this is the only medication with evidence supporting use in wheezy bronchitis 1, 3
Do NOT use bronchodilators routinely in patients without wheeze, as they provide no benefit 1, 3
Symptomatic Management
Prescribe codeine or dextromethorphan for bothersome dry cough that disturbs sleep—these provide modest effects on cough severity and duration 1, 3, 2
Recommend analgesics (acetaminophen or ibuprofen) for chest discomfort, sore throat, or fever 2
Suggest low-risk measures including elimination of environmental cough triggers, vaporized air treatments, adequate hydration, and rest 1, 2
What NOT to Prescribe
Do NOT prescribe antibiotics for wheezy bronchitis—they reduce cough by only 0.5 days (12 hours) while significantly increasing adverse events (RR 1.20; 95% CI 1.05-1.36) 1, 3, 4
Antibiotics are NOT indicated regardless of cough duration, purulent sputum color, or patient expectations—respiratory viruses cause 89-95% of cases 1, 3
Do NOT prescribe expectorants, mucokinetic agents, inhaled corticosteroids, oral corticosteroids, or NSAIDs at anti-inflammatory doses—these show no consistent benefit 1, 3, 2
The ONLY Exception: Pertussis
If pertussis is confirmed or suspected, prescribe a macrolide antibiotic (azithromycin or erythromycin) immediately and isolate the patient for 5 days from treatment start 1, 3, 2
Early treatment within the first few weeks diminishes coughing paroxysms and prevents disease spread 1, 3
Patient Education and Follow-Up
Set Realistic Expectations
Inform patients that cough typically lasts 10-14 days after the visit, even without antibiotics, and may persist up to 3 weeks total 1, 3, 4
Explain that the condition is self-limiting and resolves spontaneously within 3 weeks in most cases 1, 3
Emphasize that patient satisfaction depends more on physician-patient communication than whether antibiotics are prescribed 1, 3
When to Reassess
Instruct patients to return if fever persists >3 days—this suggests bacterial superinfection or pneumonia rather than simple viral bronchitis 1, 3, 2
Reevaluate if cough persists >3 weeks—consider alternative diagnoses including cough-variant asthma, COPD, pertussis, or gastroesophageal reflux 1, 3, 2
Obtain chest radiography at 3 weeks if cough persists without other known causes 1, 2
Critical Pitfalls to Avoid
Do NOT assume bacterial infection based on purulent sputum—purulence occurs in 89-95% of viral bronchitis cases and does not indicate need for antibiotics 1, 3
Do NOT miss undiagnosed asthma—approximately one-third of patients with "recurrent acute bronchitis" actually have asthma or COPD exacerbations requiring different management 1
Do NOT prescribe antibiotics to satisfy perceived patient expectations—explain the risks of unnecessary antibiotic use including adverse effects and contribution to antibiotic resistance 1, 3
Do NOT fail to check for ACE inhibitor use—if present, stop it immediately as ACE inhibitor-induced cough can mimic bronchitis 5