What is the outpatient management for an otherwise healthy adult with recurrent acute bronchitis?

Outpatient Management of Recurrent Acute Bronchitis in Healthy Adults

For otherwise healthy adults with recurrent acute bronchitis, do not prescribe antibiotics, inhaled bronchodilators, corticosteroids, or other medications routinely—focus instead on patient education about the expected 10–14 day cough duration and symptomatic relief only. 1

Critical First Step: Rule Out Misdiagnosis

Approximately one-third of patients diagnosed with "recurrent acute bronchitis" actually have undiagnosed asthma or COPD. 2, 3 Before treating as recurrent bronchitis:

• Perform spirometry or peak flow measurement to exclude asthma, looking for ≥12% and ≥200 mL improvement in FEV₁ after bronchodilator, or ≥20% improvement in peak expiratory flow 3
• Consider asthma if cough worsens at night, after cold air exposure, or with exercise—approximately 65% of patients with recurrent "bronchitis" episodes actually have mild asthma 4, 3
• Exclude COPD exacerbation in current or former smokers by checking for baseline airflow obstruction 1, 3
• Rule out upper airway cough syndrome (postnasal drip, throat clearing, rhinosinusitis symptoms) 4
• Consider gastroesophageal reflux disease if cough worsens after meals or when supine 4

Exclude Pneumonia Before Each Episode

Before diagnosing acute bronchitis, check vital signs and lung examination 1:

• Heart rate >100 beats/min suggests pneumonia, not bronchitis 1, 5
• Respiratory rate >24 breaths/min suggests pneumonia 1, 5
• Oral temperature >38°C suggests pneumonia 1, 5
• Abnormal chest findings (rales, egophony, tactile fremitus) suggest pneumonia 1

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

Evidence Against Routine Medications

Antibiotics: Not Indicated

Respiratory viruses cause 89–95% of acute bronchitis cases, making antibiotics ineffective regardless of which one you choose. 1, 2, 6

• 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, 6
• Purulent (green/yellow) sputum occurs in 89–95% of viral cases and does NOT indicate bacterial infection—it reflects inflammatory cells, not bacteria 1, 2
• Cough duration is not a marker of bacterial infection—viral bronchitis cough normally lasts 10–14 days and may persist up to 3 weeks 1, 2, 6

Other Medications: Also Not Indicated

The 2020 CHEST Expert Panel recommends against routine prescription of: 1

• Antiviral therapy (unless influenza confirmed within 48 hours of symptom onset) 1, 2
• Inhaled beta-agonists (except in select patients with wheezing) 1, 2
• Inhaled anticholinergics 1
• Inhaled or oral corticosteroids 1, 2
• Oral NSAIDs at anti-inflammatory doses 1, 2
• Expectorants or mucolytics 2

What TO Do: Symptomatic Management Only

Patient Education (Most Important)

• Inform patients that cough typically lasts 10–14 days after the visit and may persist up to 3 weeks even without treatment 1, 2, 6
• Explain that antibiotics do not shorten the illness and expose patients to adverse effects (diarrhea, rash, yeast infection) while contributing to antibiotic resistance 1, 2
• Refer to the condition as a "chest cold" rather than "bronchitis" to reduce patient expectations for antibiotics 2, 6
• Patient satisfaction depends more on physician-patient communication than whether an antibiotic is prescribed 2

Symptomatic Relief Options

• Codeine or dextromethorphan may provide modest relief for bothersome dry cough, especially when it disturbs sleep 1, 2, 5
• Short-acting β₂-agonists (albuterol) only for patients with wheezing accompanying the cough 1, 2, 5
• Environmental measures: remove cough triggers (dust, dander, irritants) and use humidified air 1, 2

Exception: Pertussis

If pertussis is confirmed or strongly suspected (paroxysmal cough, post-tussive vomiting, inspiratory whoop, cough >2 weeks): 1, 2, 4

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

When to Reassess

Instruct patients to return if: 1, 2

• Fever persists >3 days (suggests bacterial superinfection or pneumonia) 1, 2
• Cough persists >3 weeks (consider asthma, COPD, pertussis, gastroesophageal reflux, upper airway cough syndrome) 1, 4
• Symptoms worsen rather than gradually improve 1, 2

Critical Pitfalls to Avoid

• Do not prescribe antibiotics based on purulent sputum color—this occurs in 89–95% of viral cases 1, 2
• Do not assume bacterial infection before the 3-day fever threshold—most cases are viral 2
• Do not miss underlying asthma—the most commonly overlooked diagnosis in patients with recurrent "bronchitis" 4, 3
• Do not rely on cough duration alone to justify antibiotics—viral cough normally lasts 10–14 days 1, 2
• Do not assume this is still "postinfectious cough" if symptoms persist >8 weeks—systematically evaluate for upper airway cough syndrome, asthma, gastroesophageal reflux disease, and nonasthmatic eosinophilic bronchitis 4

Special Populations (Outside This Guideline)

These recommendations apply exclusively to otherwise healthy adults. Patients with the following conditions may require different management and are beyond the scope of uncomplicated acute bronchitis: 1, 2

• COPD or chronic bronchitis 1, 7
• Heart failure 1, 2
• Immunosuppression 1, 2
• Age >75 years with comorbidities (cardiac failure, insulin-dependent diabetes, serious neurological disorders) 2