What is the recommended management for acute bronchitis and chronic bronchitis (including COPD), covering supportive measures, antitussives, NSAIDs, bronchodilators, corticosteroids, and indications for antibiotics?

Bronchitis Treatment

Acute Bronchitis Management

Antibiotics should NOT be prescribed for acute bronchitis in otherwise healthy adults—they reduce cough by only 0.5 days while significantly increasing adverse effects and antibiotic resistance. 1

Diagnosis and Exclusion of Pneumonia

• Check vital signs immediately: heart rate >100 bpm, respiratory rate >24 breaths/min, or oral temperature >38°C suggests pneumonia, not bronchitis 1
• Perform focused chest examination for rales, egophony, or tactile fremitus—any of these findings warrant chest radiography before treating as bronchitis 1
• Respiratory viruses cause 89-95% of acute bronchitis cases, making antibiotics completely ineffective regardless of which agent you choose 1, 2
• Critical pitfall: Purulent (green/yellow) sputum occurs in 89-95% of viral cases and does NOT indicate bacterial infection—it reflects inflammatory cells, not bacteria 1

Symptomatic Treatment

• Antitussives: Codeine or dextromethorphan provide modest relief for bothersome dry cough, especially when it disturbs sleep 1
• Bronchodilators: Short-acting β₂-agonists (e.g., albuterol) should be used ONLY in patients with documented wheezing accompanying the cough 1
• Environmental measures: Remove irritants (dust, dander) and use humidified air 1
• NOT recommended: Expectorants, mucolytics, antihistamines, inhaled or oral corticosteroids, or NSAIDs at anti-inflammatory doses—no consistent benefit demonstrated 1

Patient Education

• Inform patients that cough typically lasts 10-14 days and may persist up to 3 weeks even without antibiotics 1, 2
• Explain that antibiotics expose patients to adverse effects (diarrhea, rash, yeast infection) while contributing to resistance without meaningful benefit 1
• Referring to the illness as a "chest cold" rather than "bronchitis" reduces patient expectations for antibiotics 1
• Patient satisfaction depends more on physician-patient communication than whether an antibiotic is prescribed 1

Exception: Pertussis

• When pertussis is confirmed or strongly suspected (paroxysmal cough, post-tussive vomiting, inspiratory "whoop"), prescribe a macrolide antibiotic (azithromycin or erythromycin) immediately 1
• Isolate the patient for 5 days from treatment start; early therapy reduces coughing paroxysms and prevents disease spread 1

When to Reassess

• Fever persisting >3 days suggests bacterial superinfection or pneumonia—reevaluate 1
• Cough persisting >3 weeks warrants evaluation for asthma, COPD, pertussis, or gastroesophageal reflux 1
• Symptoms worsening rather than gradually improving require reassessment 1

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Chronic Bronchitis/COPD Exacerbation Management

For acute exacerbations of chronic bronchitis, prescribe antibiotics if the patient has at least 2 of 3 Anthonisen criteria (increased dyspnea, increased sputum volume, increased sputum purulence) AND risk factors. 3, 4

Bronchodilator Therapy

• First-line: Add or increase beta-agonists and/or anticholinergic drugs (ipratropium bromide) 3
• Inhaled route is preferable; ensure the patient can use the device effectively 3
• Nebulizers are usually not required for outpatient management 3
• For stable chronic bronchitis with persistent cough, ipratropium bromide 36 μg (2 inhalations) four times daily reduces cough frequency, severity, and sputum volume 5

Antibiotic Indications

Prescribe antibiotics if the patient meets BOTH criteria:

1. At least 2 of 3 Anthonisen criteria:

   • Increased dyspnea 3
   • Increased sputum volume 3
   • Development of purulent sputum 3

2. At least 1 risk factor:

   • Age ≥65 years 4
   • FEV₁ <50% predicted 4
   • ≥4 exacerbations in 12 months 4
   • Comorbidities (cardiac failure, insulin-dependent diabetes, immunosuppression) 4

Antibiotic Selection

For moderate-severity exacerbations:

• Doxycycline 100 mg twice daily for 7-10 days 1
• Newer macrolide (azithromycin or clarithromycin) 4
• Extended-spectrum cephalosporin 4

For severe exacerbations (FEV₁ <35%, frequent exacerbations, significant comorbidities):

• High-dose amoxicillin/clavulanate 625 mg three times daily for 14 days 1
• Respiratory fluoroquinolone (levofloxacin, moxifloxacin) 4, 6

Critical pitfall: Up to 25% of H. influenzae and 50-70% of M. catarrhalis produce β-lactamase, making simple aminopenicillins ineffective 1

Corticosteroid Use

Oral corticosteroids should NOT be used routinely for acute exacerbations in the community unless: 3

• Patient is already on oral corticosteroids 3
• Previously documented response to oral corticosteroids 3
• Airflow obstruction fails to respond to increased bronchodilator dose 3
• First presentation of airflow obstruction 3

Dosing when indicated: Prednisolone 30 mg daily for one week; do not continue long-term 3

Stable Chronic Bronchitis Management

• Smoking cessation is the most effective intervention: 90% of patients experience resolution of chronic cough after quitting 3, 5
• Ipratropium bromide: Preferred first-line treatment for chronic cough in stable COPD patients 5
• Short-acting β-agonists: Improve pulmonary function, breathlessness, and exercise tolerance 3
• Antitussives: Codeine or dextromethorphan reduce cough counts by 40-60% in chronic bronchitis for short-term symptomatic relief 5
• NOT recommended: Long-term prophylactic antibiotics—no role in stable patients due to concerns about resistance and side effects 3
• NOT recommended: Postural drainage and chest percussion—clinical benefits not proven 3

Follow-up After Acute Exacerbation

• Review patient if fails to respond fully to treatment—consider chest radiograph and possible hospital referral 3
• Use follow-up visit to reinforce smoking cessation, review lifestyle and activity levels, and optimize medication 3