In an otherwise healthy adult with acute bronchitis, does an inhaled corticosteroid provide any benefit?

Inhaled Corticosteroids Do Not Help Acute Bronchitis

Inhaled corticosteroids should not be used for acute bronchitis in otherwise healthy adults, as they provide no proven benefit and expose patients to unnecessary medication risks. 1

The Evidence Against ICS in Acute Bronchitis

The French guidelines explicitly state that systemic corticosteroids—and by extension inhaled corticosteroids—are not justified in treating acute bronchitis in healthy adults. 1 This recommendation is based on the understanding that acute bronchitis is a self-limiting viral illness that resolves spontaneously within approximately 10 days, though cough may persist for 2-3 weeks. 1, 2

Why ICS Don't Work

• Viral etiology dominates: Respiratory viruses cause 89-95% of acute bronchitis cases, making anti-inflammatory therapy ineffective against the underlying cause. 2

• No clinical benefit demonstrated: A systematic review of randomized controlled trials in adults with acute respiratory tract infection and cough showed mixed results at best—two trials reported equivalence between ICS and placebo, while two showed marginal benefits that were not clinically meaningful. 3

• Purulent sputum is misleading: The presence of purulent sputum occurs in 89-95% of viral cases and does not indicate bacterial superinfection or justify any form of corticosteroid treatment. 1, 2

Critical Distinction: Acute Bronchitis vs. Chronic Bronchitis Exacerbations

This is where clinical judgment becomes essential. You must distinguish between acute bronchitis in a healthy adult and an acute exacerbation of chronic bronchitis/COPD, as these are entirely different conditions requiring different management. 1

When Corticosteroids ARE Indicated

For patients with established chronic bronchitis or COPD experiencing an acute exacerbation, systemic corticosteroids (not inhaled) are recommended:

• Prednisone 40 mg daily for 5-7 days improves lung function, oxygenation, and shortens recovery time and hospitalization duration. 1

• This applies specifically to patients with chronic respiratory insufficiency (FEV1 <50% predicted) or those meeting Anthonisen criteria (increased dyspnea, increased sputum volume, or increased sputum purulence). 1

• Inhaled corticosteroids are reserved for long-term maintenance therapy in stable chronic bronchitis patients with FEV1 <50% predicted or frequent exacerbations, typically combined with long-acting bronchodilators. 1, 4

What TO Do for Acute Bronchitis

Instead of prescribing ICS, focus on:

• Patient education: Inform patients that cough typically lasts 10-14 days after the visit, even without treatment, and may persist up to 3 weeks. 1, 2

• Symptomatic relief only: Consider codeine or dextromethorphan for bothersome dry cough that disturbs sleep. 1, 2

• Selective bronchodilator use: β2-agonist bronchodilators may help in select patients with accompanying wheezing, but should not be used routinely. 1, 2

Common Pitfalls to Avoid

• Don't mistake acute bronchitis for asthma exacerbation: Approximately one-third of patients diagnosed with "recurrent acute bronchitis" actually have undiagnosed asthma, which DOES benefit from ICS therapy. 1

• Don't prescribe based on wheezing alone: Wheezing in acute bronchitis is due to airway inflammation from the viral infection, not bronchospasm requiring corticosteroids. 1

• Don't use ICS hoping to shorten illness duration: There is no evidence supporting this approach in acute bronchitis. 1, 3

When to Reassess

Instruct patients to return if:

• Fever persists beyond 3 days (suggests bacterial superinfection or pneumonia). 1, 2
• Cough persists beyond 3 weeks (consider alternative diagnoses: asthma, COPD, pertussis, GERD). 1, 2
• Symptoms worsen rather than gradually improve. 2