What is the recommended management for an adult with acute bronchitis presenting with several days of cough, low‑grade fever, sputum production, and no focal lung findings?

Management of Acute Bronchitis in Adults

For an immunocompetent adult presenting with acute bronchitis (cough, low-grade fever, sputum production, no focal lung findings), no routine investigations or medications should be prescribed—this is a self-limiting viral illness requiring only patient education and symptomatic support. 1

Initial Clinical Assessment

The primary goal is to exclude pneumonia and other serious conditions before confirming acute bronchitis as the diagnosis. 1

Key vital signs and examination findings that suggest pneumonia (NOT bronchitis):

• Heart rate >100 beats/min 1
• Respiratory rate >24 breaths/min 1
• Oral temperature >38°C 1
• Focal lung findings on examination (rales, egophony, tactile fremitus) 2

If any of these are present, obtain chest radiography to evaluate for pneumonia rather than treating as simple bronchitis. 1, 2

Important differential diagnoses to consider:

• Asthma exacerbation or cough-variant asthma (approximately one-third of patients diagnosed with "acute bronchitis" actually have undiagnosed asthma) 1
• COPD exacerbation 1
• Pertussis (if cough persists >2 weeks with paroxysmal features, whooping, or post-tussive emesis) 3
• Bronchiectasis exacerbation 1

Diagnostic Testing: What NOT to Order

No routine investigations are recommended for uncomplicated acute bronchitis: 1

• No chest x-ray (unless vital signs abnormal or focal findings present) 1
• No sputum culture 1
• No viral PCR testing 1
• No C-reactive protein or procalcitonin 1
• No spirometry or peak flow at initial presentation 1

Treatment: What NOT to Prescribe

The 2020 CHEST guidelines explicitly recommend against routine prescription of: 1

• Antibiotic therapy 1
• Antiviral therapy 1
• Antitussives 1
• Inhaled beta-agonists 1
• Inhaled anticholinergics 1
• Inhaled corticosteroids 1
• Oral corticosteroids 1
• Oral NSAIDs 1

Why antibiotics don't work and cause harm:

• Respiratory viruses cause 89-95% of acute bronchitis cases 4, 3, 5
• Antibiotics reduce cough duration by only 0.5 days (approximately 12 hours) 1, 2
• Antibiotics significantly increase adverse events (RR 1.20; 95% CI 1.05-1.36) 1
• Purulent sputum occurs in 89-95% of viral cases and does NOT indicate bacterial infection 2, 3

Essential Patient Education

Inform patients about the expected natural course: 2, 3, 5

• Cough typically lasts 10-14 days after the visit 1, 2
• Symptoms may persist up to 3 weeks total 1, 2
• The condition is self-limiting and will resolve without antibiotics 1

Communication strategies to improve satisfaction: 6, 3

• Refer to the condition as a "chest cold" rather than "bronchitis" to reduce antibiotic expectations 2, 3
• Patient satisfaction depends more on physician-patient communication than whether antibiotics are prescribed 6, 7
• Explain that antibiotics expose patients to adverse effects while contributing to antibiotic resistance without providing benefit 2, 3

When to Reassess

Instruct patients to return if: 1, 8

• Fever persists beyond 3 days (suggests bacterial superinfection or pneumonia) 1, 9
• Cough persists beyond 3 weeks (consider other diagnoses: asthma, COPD, pertussis, GERD) 1, 8
• Symptoms worsen rather than gradually improve 1

At reassessment, consider targeted investigations: 1

• Chest x-ray 1
• Sputum culture 1
• Peak flow recordings 1
• Complete blood count and inflammatory markers 1

Exception: Pertussis

If pertussis is confirmed or strongly suspected: 1, 2

• Prescribe a macrolide antibiotic (erythromycin or azithromycin) immediately 1, 2
• Isolate the patient for 5 days from start of treatment 1, 2
• Early treatment within the first few weeks diminishes coughing paroxysms and prevents disease spread 1, 2

Optional Symptomatic Measures (Low-Risk)

May consider in select patients: 2

• Elimination of environmental cough triggers 2
• Vaporized air treatments 2
• Beta-2 agonist bronchodilators ONLY in patients with accompanying wheezing 2
• Codeine or dextromethorphan for bothersome dry cough that disturbs sleep 2, 8

Critical Pitfalls to Avoid

• Do not assume bacterial infection based on sputum color or purulence—this occurs in 89-95% of viral cases 2, 3
• Do not prescribe antibiotics based on cough duration alone—viral bronchitis cough normally lasts 10-14 days 2, 3
• Do not overlook undiagnosed asthma—up to 65% of patients with recurrent "acute bronchitis" episodes actually have mild asthma 1, 2
• Do not forget to check for chronic lung disease—these guidelines apply only to immunocompetent adults without COPD, asthma, or bronchiectasis 1