Treatment of Bronchitis

For acute viral bronchitis in otherwise healthy adults, antibiotics should NOT be prescribed—they provide no meaningful benefit (shortening cough by only ~12 hours) while causing significant adverse effects and promoting resistance. 1, 2

Acute Viral Bronchitis (Uncomplicated)

Diagnosis and Exclusion of Pneumonia

Before labeling the illness as acute bronchitis, rule out pneumonia by checking vital signs and lung examination. If any of the following are present, obtain a chest radiograph rather than treating as simple bronchitis: 1, 2

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

Why Antibiotics Don't Work

Respiratory viruses cause 89–95% of acute bronchitis cases, making antibiotics completely ineffective regardless of which agent you choose. 1, 2
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 typically lasts 10–14 days and may persist up to 3 weeks. 1, 2
Antibiotics reduce cough by only ~~0.5 days (~~12 hours) while increasing adverse events (RR 1.20; 95% CI 1.05–1.36). 1, 2

Recommended Management

Patient Education (Most Critical): 1, 2

Inform patients that cough typically lasts 10–14 days after the visit and may persist up to 3 weeks even without antibiotics.
Explain that physician-patient communication drives satisfaction more than antibiotic prescriptions.
Refer to the condition as a "chest cold" rather than "bronchitis" to reduce antibiotic expectations.
Discuss risks of unnecessary antibiotics: diarrhea, rash, yeast infections, anaphylaxis, and contribution to resistance.

Symptomatic Treatment: 1, 2

Antitussives (codeine or dextromethorphan): Provide modest relief for bothersome dry cough, especially when it disrupts sleep.
Short-acting β₂-agonists (e.g., albuterol): Use only in patients with documented wheezing accompanying the cough—not routinely.
Environmental measures: Remove cough triggers (dust, dander) and use humidified air.

What NOT to Use: 1, 2

Do NOT prescribe expectorants, mucolytics, antihistamines, inhaled corticosteroids, oral corticosteroids, or NSAIDs at anti-inflammatory doses—no consistent benefit demonstrated.

Exception: Pertussis (Whooping Cough)

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

Prescribe a macrolide antibiotic (azithromycin or erythromycin) immediately.
Isolate the patient for 5 days from treatment start.
Early treatment reduces cough paroxysms and limits transmission.

When to Reassess (Red Flags)

Advise patients to return if: 1, 2

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

Acute Exacerbation of Chronic Bronchitis (COPD)

When to Prescribe Antibiotics

Antibiotics are indicated for acute exacerbations of chronic bronchitis when patients meet at least 2 of 3 Anthonisen criteria (suggesting bacterial origin): 1, 2

Increased dyspnea
Increased sputum volume
Increased sputum purulence

AND have high-risk features: 1, 2

Age >65 years with moderate-to-severe COPD (FEV₁ <50%)
Cardiac failure
Insulin-dependent diabetes
Serious neurological disorders
Immunosuppression
Chronic respiratory insufficiency (dyspnea at rest, FEV₁ <35%, PaO₂ <60 mmHg)

Antibiotic Selection and Duration

First-line antibiotics (for infrequent exacerbations, FEV₁ >50%): 2

Amoxicillin 500 mg three times daily for 7–10 days
Doxycycline 100 mg twice daily for 7–10 days
Azithromycin or clarithromycin (macrolides)

Second-line antibiotics (for frequent exacerbations, FEV₁ <50%, or risk of resistant pathogens): 2

Amoxicillin-clavulanate 625 mg three times daily for 7–14 days
Respiratory fluoroquinolones (levofloxacin, moxifloxacin)
Second- or third-generation cephalosporins

Critical Pitfall: Up to 25% of H. influenzae and 50–70% of M. catarrhalis produce β-lactamase, making simple aminopenicillins ineffective. 2

Bronchodilator Therapy

During acute exacerbations: 1

Administer short-acting β-agonists (e.g., albuterol) or anticholinergic bronchodilators (e.g., ipratropium bromide).
If no prompt response, add the other agent after maximizing the first.
Do NOT use theophylline during acute exacerbations—no benefit and significant side effects.

Corticosteroid Therapy

Systemic corticosteroids (oral for outpatients, IV for hospitalized patients) are recommended during acute exacerbations: 1

Duration: 10–15 days (2-week course equivalent to 8-week course with fewer side effects)
Shortens duration of illness and improves lung function
Effects on cough specifically have not been systematically evaluated

Chronic Stable Bronchitis (COPD)

First-Line Bronchodilator Therapy

Ipratropium bromide is the preferred initial treatment for cough in stable COPD patients with chronic bronchitis: 1, 3

Dosing: 36 μg (2 inhalations) four times daily
Evidence: Reduces cough frequency, cough severity, and sputum volume (Grade A recommendation)

Short-acting β-agonists should be used to control bronchospasm and may also reduce chronic cough (Grade A recommendation). 1, 3

Theophylline may be considered for persistent cough but requires careful monitoring for complications due to narrow therapeutic index (Grade A recommendation). 1

Combined Long-Acting Therapy

For patients with FEV₁ <50% or frequent exacerbations, combined therapy with a long-acting β-agonist plus inhaled corticosteroid reduces exacerbation rate and may improve cough. 1

Cough Suppressants (Short-Term Symptomatic Relief)

Codeine (~30 mg three times daily) or dextromethorphan reduce cough counts by 40–60% in chronic bronchitis: 1, 3

Use only for short-term relief when cough severely impairs quality of life despite optimal bronchodilator therapy (Grade B recommendation).
These are adjuncts, not replacements, for bronchodilator therapy.

What NOT to Use

Expectorants (e.g., guaifenesin): No proven benefit (Grade I—insufficient evidence). 1, 3
Long-term prophylactic antibiotics: Not recommended—lack benefit and promote resistance. 1
Oral corticosteroids (chronic use): No benefit in stable patients; significant side effects preclude long-term use. 1
Postural drainage or chest physiotherapy: No proven benefit. 1

Most Effective Intervention: Smoking Cessation

Smoking cessation is the single most effective intervention for COPD-related cough: 1, 3

90% of patients experience cough resolution within one month after quitting.
Avoidance of all respiratory irritants (occupational exposures, second-hand smoke) is first-line therapy (Grade A recommendation).

Chemical Bronchitis

Immediate Management

The single most critical intervention is immediate cessation of exposure to the chemical irritant—this is the cornerstone of therapy: 4

90% of patients experience resolution of cough after removing the exposure.
For acute chemical exposures, patients may experience increased cough, sputum production, and dyspnea similar to infectious exacerbations.

Pharmacologic Considerations

Short-acting β-agonists or anticholinergic bronchodilators should be administered if bronchospasm is present. 4
Antibiotics are NOT indicated unless there is evidence of secondary bacterial infection (fever >38°C persisting >3 days, purulent sputum with systemic symptoms). 4
Inhaled corticosteroids may be considered for severe airflow obstruction or persistent symptoms; a short course of systemic corticosteroids may be effective for significant acute inflammation. 4

Monitoring and Follow-Up

Monitor for improvement in cough frequency and severity after starting therapy; reassess if symptoms persist or worsen. 4
Watch for development of secondary bacterial infection, which would warrant antibiotic therapy. 4

Common Pitfalls to Avoid

Do NOT prescribe antibiotics based on purulent sputum color—this occurs in 89–95% of viral cases. 1, 2
Do NOT rely on cough duration alone to justify antibiotics—viral cough normally lasts 10–14 days. 1, 2
Do NOT assume early fever (first 1–3 days) indicates bacterial infection—only fever persisting >3 days suggests possible bacterial superinfection. 1, 2
Do NOT use benzonatate as monotherapy without addressing underlying bronchospasm with bronchodilators in COPD. 3
Do NOT assume bacterial infection in acute bronchitis before the 3-day fever threshold—most cases are viral. 1, 2

What is the recommended treatment for a patient presenting with bronchitis, including management of acute viral bronchitis and chronic bronchitis associated with COPD?

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