What is the recommended treatment for acute bronchitis, including supportive care, use of bronchodilators, steroids, and indications for antibiotics?

Treatment of Acute Bronchitis

Antibiotics should NOT be prescribed for acute uncomplicated bronchitis in otherwise healthy adults, regardless of cough duration, sputum color, or patient expectations. 1, 2

Why Antibiotics Don't Work

• Respiratory viruses cause 89-95% of acute bronchitis cases, making antibiotics completely ineffective against the underlying pathogen 1, 3
• Antibiotics reduce cough duration by only 0.5 days (approximately 12 hours) while significantly increasing adverse events (risk ratio 1.20; 95% CI 1.05-1.36) 1, 4
• Purulent (green/yellow) sputum occurs in 89-95% of viral cases and does NOT indicate bacterial infection—it reflects inflammatory cells, not bacteria 1
• The FDA removed uncomplicated acute bronchitis from approved antibiotic indications in 1998 due to lack of efficacy 1

Exclude Pneumonia First

Before diagnosing acute bronchitis, check for these red flags that suggest pneumonia instead 1, 2:

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

If ANY of these are present, obtain chest radiography to rule out pneumonia rather than treating as simple bronchitis. 1

Symptomatic Management

Recommended Treatments

• Antitussives (dextromethorphan or codeine) provide modest relief for bothersome dry cough, especially when it disrupts sleep 1, 2, 5
• Short-acting β₂-agonists (albuterol) should be used ONLY in patients with documented wheezing accompanying the cough 1, 2, 5
• Environmental measures: remove irritants (dust, dander, smoke) and use humidified air 1

NOT Recommended

The American College of Chest Physicians recommends against routine use of 1:

• Expectorants or mucolytics
• Antihistamines
• Inhaled or oral corticosteroids
• NSAIDs at anti-inflammatory doses
• Routine bronchodilators (without wheezing)

The Pertussis Exception

If pertussis (whooping cough) is confirmed or strongly suspected, prescribe a macrolide antibiotic (azithromycin or erythromycin) immediately. 1

• Isolate the patient for 5 days from treatment start 1
• Early treatment reduces coughing paroxysms and prevents disease spread 1
• Suspect pertussis if: paroxysmal cough, post-tussive vomiting, inspiratory "whoop," or cough >2 weeks 1

Patient Education & Communication

Patient satisfaction depends more on physician-patient communication than whether an antibiotic is prescribed. 1, 2

Key Counseling Points

• Cough typically lasts 10-14 days and may persist up to 3 weeks even without antibiotics 1, 2
• Antibiotics expose patients to adverse effects (diarrhea, rash, yeast infections) without meaningful benefit 1
• Referring to the illness as a "chest cold" rather than "bronchitis" reduces patient expectations for antibiotics 1
• Emphasize that antibiotics contribute to antimicrobial resistance 1

When to Reassess

Advise patients to return if 1:

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

Common Pitfalls to Avoid

• Do NOT prescribe antibiotics based on purulent sputum color—this occurs in 89-95% of viral cases 1
• Do NOT use cough duration alone to justify antibiotics—viral cough normally lasts 10-14 days 1
• Do NOT assume early fever (first 1-3 days) indicates bacterial infection—only fever persisting >3 days suggests possible bacterial superinfection 1
• Do NOT diagnose "recurrent acute bronchitis" without ruling out asthma or COPD—approximately one-third of these patients have undiagnosed reactive airway disease 1

Special Populations (Different Management)

These recommendations apply ONLY to otherwise healthy adults. The following populations require individualized approaches and are outside the scope of uncomplicated bronchitis management 1, 2:

• Patients with COPD or chronic bronchitis
• Immunocompromised patients
• Heart failure patients
• Age >75 years with significant comorbidities
• Insulin-dependent diabetes

For acute exacerbations of chronic bronchitis in high-risk patients, antibiotics may be indicated if at least 2 of the 3 Anthonisen criteria are present (increased dyspnea, increased sputum volume, increased sputum purulence) 6. First-line options include doxycycline 100 mg twice daily for 7-10 days or amoxicillin/clavulanate for severe cases 1, 6.