What is the recommended management for acute bronchitis?

Management of Acute Bronchitis

Do not prescribe antibiotics for acute bronchitis in otherwise healthy adults—they provide no meaningful clinical benefit, shortening cough by only half a day while causing significant adverse effects and promoting antibiotic resistance. 1, 2, 3

Initial Diagnostic Assessment

Before labeling a patient with acute bronchitis, you must actively exclude pneumonia by checking these four vital parameters 1, 2:

• Heart rate >100 beats/min 1
• Respiratory rate >24 breaths/min 1
• Oral temperature >38°C (100.4°F) 1
• Abnormal chest examination (rales, egophony, tactile fremitus) 1

If any one of these is present, obtain a chest radiograph to rule out pneumonia before treating as bronchitis. 1, 2 In adults under 70 years without comorbidities, if all four are absent, pneumonia is sufficiently unlikely that chest X-ray is not required. 1, 2

Consider Alternative Diagnoses

Approximately one-third of patients diagnosed with "recurrent acute bronchitis" actually have undiagnosed asthma or COPD. 2, 4 If the patient has recurrent episodes, perform spirometry or peak-flow testing, especially in smokers. 2 Look for ≥12% and ≥200 mL FEV₁ improvement after bronchodilator (or ≥20% peak-flow improvement) to diagnose asthma. 2

The Evidence Against Antibiotics

The case against antibiotics is overwhelming 1, 2, 3:

• Respiratory viruses cause 89-95% of acute bronchitis cases—antibiotics cannot treat viral infections 2, 3, 5
• Antibiotics reduce cough duration by only 0.5 days (approximately 12 hours) 1, 2, 6
• Antibiotics increase adverse events (risk ratio 1.20; 95% CI 1.05-1.36), including diarrhea, rash, yeast infections, and allergic reactions 1, 2, 7
• The FDA removed uncomplicated acute bronchitis from approved antibiotic indications in 1998 2

Common Misconceptions That Lead to Inappropriate Prescribing

Purulent (green or yellow) sputum does NOT indicate bacterial infection. 1, 2, 3 This occurs in 89-95% of viral bronchitis cases because purulence reflects inflammatory cells and sloughed epithelial cells, not bacteria. 1, 2

Cough duration does NOT indicate bacterial infection. 2, 3 Viral bronchitis cough typically lasts 10-14 days and may persist up to 3 weeks—this is the normal course. 2, 3, 6, 7

Recommended Management: Symptomatic Treatment Only

Patient Education (Most Important Intervention)

Inform patients that cough typically lasts 10-14 days after the visit and may persist up to 3 weeks, even without antibiotics. 2, 3, 6, 7 This single intervention is critical because patient satisfaction depends more on physician-patient communication than whether an antibiotic is prescribed. 2, 3, 8

Communication strategies that reduce antibiotic expectations 2, 3, 7:

• Refer to the illness as a "chest cold" rather than "bronchitis" 2, 3, 7
• Explain that antibiotics expose patients to adverse effects without meaningful benefit 2, 3
• Personalize the risk of antibiotic resistance from prior use 2

Symptomatic Relief Options

For bothersome dry cough (especially nocturnal): 2, 3, 4

• Codeine or dextromethorphan provide modest relief 2, 3, 4
• These are the only cough suppressants with evidence of benefit 2, 3

For patients with wheezing accompanying the cough: 2, 3, 4

• Short-acting β₂-agonists (e.g., albuterol) may be useful in select patients with documented wheezing 2, 3, 4
• Do NOT use β₂-agonists routinely in patients without wheezing 2, 3

Environmental measures (low-risk, low-cost): 2

• Remove environmental cough triggers (dust, dander, irritants) 2
• Use humidified air, especially in low-humidity settings 2

What NOT to Prescribe

The following have no proven benefit and should NOT be used 1, 2, 4:

• Expectorants or mucolytics 1, 2, 4
• Antihistamines 2, 3
• Inhaled or oral corticosteroids 1, 2
• Oral NSAIDs at anti-inflammatory doses 1, 2
• Inhaled anticholinergics (in acute bronchitis without COPD) 2

The One Exception: Pertussis (Whooping Cough)

If pertussis is confirmed or strongly suspected, prescribe a macrolide antibiotic (azithromycin or erythromycin) immediately. 2, 3 Clinical clues include 7, 9:

• Cough persisting >2 weeks 7, 9
• Paroxysmal cough 2
• Post-tussive vomiting 2
• Inspiratory "whoop" 2
• Recent pertussis exposure 7

Isolate the patient for 5 days from the start of treatment to prevent disease spread. 2, 3 Early treatment (within the first few weeks) diminishes coughing paroxysms and limits transmission. 2, 3

When to Reassess (Red Flags)

Instruct patients to return if 2, 3:

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

Special Populations: High-Risk Patients

These recommendations apply ONLY to otherwise healthy adults. 1, 2, 3 The following high-risk groups may require antibiotics and are outside the scope of uncomplicated bronchitis management 1, 2, 3:

• COPD or chronic bronchitis patients with acute exacerbations 1, 2, 3
• Age ≥75 years with significant comorbidities (cardiac failure, insulin-dependent diabetes, serious neurological disorders) 2, 3
• Immunocompromised patients 1, 2, 3
• Heart failure patients 2, 3

For COPD exacerbations specifically, the American College of Physicians recommends limiting antibiotic treatment to 5 days when managing patients with clinical signs of bacterial infection (increased sputum purulence plus increased dyspnea and/or increased sputum volume). 1

Critical Pitfalls to Avoid

• Do NOT prescribe antibiotics based on purulent sputum color—this occurs in 89-95% of viral cases 1, 2, 3
• Do NOT rely on cough duration alone to justify antibiotics—viral cough normally lasts 10-14 days 2, 3
• Do NOT assume early fever (first 1-3 days) indicates bacterial infection—only fever persisting >3 days suggests possible bacterial superinfection 2, 3
• Do NOT fail to distinguish between acute bronchitis and pneumonia—always check vital signs and lung examination 1, 2, 4
• Do NOT prescribe antibiotics to meet patient expectations—focus on communication instead 2, 8