What is the recommended treatment for an otherwise healthy adult with acute bronchitis and for a patient with chronic bronchitis associated with chronic obstructive pulmonary disease?

Treatment of Bronchitis

Acute Bronchitis in Otherwise Healthy Adults

For immunocompetent adults with acute bronchitis, do NOT prescribe antibiotics, antitussives, bronchodilators, inhaled corticosteroids, oral corticosteroids, or NSAIDs—these provide no clinical benefit while exposing patients to adverse effects and contributing to antibiotic resistance. 1

Why Antibiotics Don't Work

• Respiratory viruses cause 89-95% of acute bronchitis cases, making antibiotics completely ineffective 1, 2
• Antibiotics reduce cough duration by only 0.5 days (approximately 12 hours) while significantly increasing adverse events (RR 1.20; 95% CI 1.05-1.36) 1, 2
• Purulent sputum occurs in 89-95% of viral cases and does NOT indicate bacterial infection requiring antibiotics 1, 2

Appropriate Management

• Inform patients that cough typically lasts 10-14 days after the visit and may persist up to 3 weeks, even without treatment 1, 2
• Provide symptomatic relief only: consider codeine or dextromethorphan for bothersome dry cough that disturbs sleep 1, 2
• Use β2-agonist bronchodilators ONLY in select patients with accompanying wheezing 1, 2
• Recommend elimination of environmental cough triggers and vaporized air treatments 2

When to Reassess

• If fever persists >3 days: suggests bacterial superinfection or pneumonia—reassess and consider targeted investigations 1, 2
• If cough persists >3 weeks: consider other diagnoses such as asthma, COPD, pertussis, or GERD 1, 2
• If symptoms worsen rather than gradually improve: reevaluate for complications 1

Critical Exception: Pertussis

• For confirmed or suspected pertussis (whooping cough), prescribe a macrolide antibiotic (azithromycin or erythromycin) immediately 1, 2
• Isolate patients for 5 days from the start of treatment 1, 2
• Early treatment within the first few weeks diminishes coughing paroxysms and prevents disease spread 1, 2

Diagnostic Pitfalls to Avoid

• Before diagnosing acute bronchitis, exclude pneumonia by checking for heart rate >100 bpm, respiratory rate >24 breaths/min, oral temperature >38°C, or focal consolidation on lung examination 1, 2
• Approximately one-third of patients with "recurrent acute bronchitis" actually have undiagnosed asthma—consider this diagnosis if episodes recur 1, 2

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Chronic Bronchitis Associated with COPD

For patients with chronic cough due to stable chronic bronchitis, there is insufficient evidence to recommend routine use of any pharmacologic treatments (antibiotics, bronchodilators, mucolytics) as a means of relieving cough per se. 1

Most Important Intervention

• Smoking cessation is the most effective intervention—90% of patients with chronic cough who stop smoking report resolution of cough 1
• Address exposure to dusty environmental irritants and pollutants 1

Treatment for Stable Chronic Bronchitis (2006 Guidelines)

While the 2020 CHEST guidelines found insufficient evidence for routine pharmacologic treatment 1, the 2006 CHEST guidelines provide more specific recommendations for symptomatic management:

• Ipratropium bromide (36 μg, 2 inhalations four times daily) should be offered to improve cough—it reduces cough frequency, severity, and sputum volume (Grade A recommendation) 1
• Short-acting β-agonists should be used to control bronchospasm and relieve dyspnea; in some patients, may also reduce chronic cough (Grade A recommendation) 1
• Theophylline should be considered to control chronic cough, but requires careful monitoring for complications (Grade A recommendation) 1

Treatment for Acute Exacerbations of Chronic Bronchitis

Antibiotics should be prescribed for acute exacerbations ONLY when patients meet specific criteria:

Indications for Antibiotics (Anthonisen Criteria)

• Patient must have at least 2 of 3 cardinal symptoms: increased dyspnea, increased sputum volume, increased sputum purulence 3, 4, 5
• AND at least one risk factor: age ≥65 years, FEV1 <50% predicted, ≥4 exacerbations in 12 months, or comorbidities (cardiac failure, insulin-dependent diabetes) 4, 5

Antibiotic Selection Based on Severity

For moderate exacerbations (FEV1 ≥50%, <4 exacerbations/year):

• First-line: Doxycycline 100 mg twice daily for 7-10 days 2, 4
• Alternatives: Newer macrolides (azithromycin, clarithromycin) or extended-spectrum cephalosporins 4, 5

For severe exacerbations (FEV1 <50%, ≥4 exacerbations/year, or significant comorbidities):

• First-line: Amoxicillin-clavulanate 625 mg three times daily for 7-14 days 2, 4
• Alternative: Respiratory fluoroquinolones (levofloxacin, moxifloxacin) 4, 5

Bronchodilator Therapy During Exacerbations

• Short-acting β-agonists or anticholinergic bronchodilators should be administered during acute exacerbations (Grade A recommendation) 1
• If no prompt response, add the other agent after maximizing the first 1
• Do NOT use theophylline for acute exacerbations (Grade D recommendation) 1

Corticosteroid Therapy During Exacerbations

• Systemic corticosteroids (e.g., methylprednisolone 0.5 mg/kg IV every 6 hours) improve airflow and shorten duration of symptoms during acute exacerbations with respiratory insufficiency 6
• A 2-week course is recommended to minimize side effects 1
• Do NOT use oral corticosteroids for stable chronic bronchitis 1

Advanced Therapy for Severe Disease

• For patients with FEV1 <50% or frequent exacerbations, consider adding inhaled corticosteroid with a long-acting β-agonist 1
• This combination reduces exacerbation rates and may reduce cough in long-term trials 1

Common Pitfalls to Avoid

• Do NOT prescribe antibiotics for stable chronic bronchitis without evidence of acute exacerbation 1
• Do NOT assume purulent sputum alone indicates bacterial infection requiring antibiotics 1, 2
• Do NOT use mucokinetic agents during acute exacerbations—they are not useful 1
• Do NOT prescribe prophylactic antibiotics to prevent exacerbations—they do not reduce frequency but only reduce days lost from work 3