Prescribe symptomatic therapy for an otherwise healthy adult with uncomplicated acute bronchitis.

Symptomatic Therapy Prescription for Uncomplicated Acute Bronchitis

Do not prescribe antibiotics for uncomplicated acute bronchitis—they provide no meaningful benefit (shortening cough by only ~12 hours) while causing significant adverse effects and promoting resistance. 1

First: Rule Out Pneumonia Before Treating as Simple Bronchitis

Before writing any prescription, verify the patient does NOT have:

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

If ANY of these are present, obtain chest radiography to rule out pneumonia—this is NOT simple bronchitis. 1, 3

Prescription for Symptomatic Relief

For Bothersome Dry Cough (Especially Nocturnal)

Option 1 (Preferred):

• Dextromethorphan 10-20 mg PO every 4-6 hours as needed
• Maximum 120 mg/24 hours
• Provides modest relief for dry, bothersome cough 1, 3

Option 2 (Alternative):

• Codeine 10-20 mg PO every 4-6 hours as needed
• Maximum 120 mg/24 hours
• Use when dextromethorphan is insufficient 1, 3

For Cough with Wheezing ONLY

Only if wheezing is present on examination:

• Albuterol inhaler 2 puffs (90 mcg/puff) every 4-6 hours as needed
• Maximum 12 puffs/24 hours
• Do NOT prescribe if no wheezing is documented 1, 3, 2

Critical Patient Education (Document This Conversation)

Explain to the patient:

1. Expected duration: Cough will last 10-14 days and may persist up to 3 weeks even with treatment 1, 3

2. Why no antibiotics: This is a viral infection (89-95% of cases), and antibiotics:

   • Do not work against viruses 1, 4
   • Shorten cough by only ~12 hours 1
   • Cause side effects (diarrhea, rash, yeast infections) 1
   • Promote antibiotic resistance 1

3. Green/yellow sputum is NORMAL: Purulent sputum occurs in 89-95% of viral bronchitis and does NOT indicate bacterial infection 1, 5

4. Non-prescription measures:

   • Remove environmental irritants (dust, smoke, strong odors) 1
   • Use humidified air 1
   • Stay hydrated 1

When to Return for Reassessment

Instruct the patient to return if:

• Fever persists >3 days (suggests bacterial superinfection or pneumonia) 1
• Cough persists >3 weeks (consider asthma, COPD, pertussis, GERD) 1
• Symptoms worsen rather than gradually improve 1

What NOT to Prescribe

Avoid these medications—they have no proven benefit in acute bronchitis:

• Antibiotics (amoxicillin, azithromycin, doxycycline, etc.) 1, 6
• Expectorants or mucolytics 1, 3
• Antihistamines 1
• Inhaled or oral corticosteroids 1, 3
• NSAIDs at anti-inflammatory doses 1, 3

Exception: Suspected Pertussis

If pertussis is suspected (paroxysmal cough, post-tussive vomiting, inspiratory "whoop," cough >2 weeks):

• Azithromycin 500 mg PO day 1, then 250 mg PO daily × 4 days
• Isolate patient for 5 days from treatment start 1
• This is the ONLY indication for antibiotics in acute bronchitis 1, 6

Common Pitfalls to Avoid

• Do NOT prescribe antibiotics based on sputum color—occurs in 89-95% of viral cases 1, 5
• Do NOT prescribe antibiotics based on cough duration—viral cough normally lasts 10-14 days 1
• Do NOT prescribe bronchodilators without documented wheezing 1, 3
• Do NOT assume early fever (days 1-3) indicates bacterial infection—only fever >3 days warrants reassessment 1

Documentation Template

"Patient counseled that acute bronchitis is viral (89-95% of cases), antibiotics provide no benefit and cause harm. Expected cough duration 10-14 days, up to 3 weeks. Return precautions given for fever >3 days, cough >3 weeks, or worsening symptoms. Patient verbalized understanding and agreement with symptomatic management plan."