How should acute bronchitis be managed in an adult patient?

Management of Suspected Acute Bronchitis in Adults

Do not prescribe antibiotics for suspected acute bronchitis in otherwise healthy adults—the condition is viral in 89-95% of cases, antibiotics shorten cough by only half a day while increasing adverse effects, and your primary role is patient education about the expected 10-14 day cough duration. 1, 2, 3

Initial Diagnostic Approach: Rule Out Pneumonia First

Before labeling the illness as bronchitis, immediately check vital signs and perform a focused chest examination to exclude pneumonia. 1, 2, 3

Obtain a chest radiograph if ANY of the following are present: 1, 2, 3

• Heart rate >100 beats/min
• Respiratory rate >24 breaths/min
• Oral temperature >38°C
• Abnormal lung findings (crackles, egophony, increased tactile fremitus)

If all four criteria are absent in adults <70 years without comorbidities, pneumonia is unlikely and imaging is not required. 2

Consider Alternative Diagnoses

Approximately one-third of patients labeled with "recurrent acute bronchitis" actually have undiagnosed asthma or COPD. 1, 2

Perform spirometry or peak-flow testing if: 2

• Patient smokes or has risk factors
• Recurrent episodes occur
• Cough worsens at night or with cold/exercise exposure
• Look for ≥12% and ≥200 mL FEV₁ improvement after bronchodilator (or ≥20% peak-flow improvement)

Other differential diagnoses to consider: common cold, cough-variant asthma, COPD exacerbation, acute rhinosinusitis, pertussis. 1

Why Antibiotics Are Not Indicated

The evidence against routine antibiotics is definitive: 2, 3

• Respiratory viruses cause 89-95% of cases—antibiotics cannot treat the underlying cause 2, 4, 5
• Antibiotics reduce cough duration by only 0.5 days (approximately 12 hours) 1, 2, 6
• Antibiotics increase adverse events (RR 1.20; 95% CI 1.05-1.36) including diarrhea, rash, and yeast infections 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 2, 3, 5
• Cough duration alone does not indicate bacterial infection—viral bronchitis cough normally lasts 10-14 days and may persist up to 3 weeks 2, 3, 6

Symptomatic Management: What Actually Works

Recommended Measures

For bothersome dry cough (especially nocturnal): 1, 2, 3

• Codeine or dextromethorphan provide modest relief

For patients with wheezing accompanying the cough: 1, 2, 3

• Short-acting β₂-agonists (e.g., albuterol) may be useful
• Do NOT use bronchodilators routinely in patients without wheezing

Low-risk supportive measures: 2, 3

• Remove environmental irritants (dust, allergens, smoke)
• Use humidified air

What NOT to Prescribe

The following have no proven benefit and should NOT be routinely used: 1, 2, 3

• Expectorants or mucolytics
• Antihistamines
• Inhaled or oral corticosteroids
• Oral NSAIDs at anti-inflammatory doses
• Inhaled anticholinergics

The Critical Exception: Pertussis

If pertussis is confirmed or strongly suspected (paroxysmal cough, post-tussive vomiting, inspiratory "whoop," cough >2 weeks): 1, 2, 3

• Prescribe a macrolide antibiotic immediately (azithromycin or erythromycin)
• Isolate the patient for 5 days from treatment start
• Early treatment (within first few weeks) reduces cough paroxysms and prevents transmission

Patient Communication Strategy: The Key to Success

Patient satisfaction depends more on effective communication than on receiving antibiotics. 2, 3, 5

Essential Points to Cover

Set realistic expectations: 2, 3, 6

• "Your cough will typically last 10-14 days and may persist up to 3 weeks, even without treatment"
• "This is a chest cold caused by a virus, not a bacterial infection"

Explain why antibiotics are harmful, not helpful: 2, 3

• "Antibiotics would shorten your cough by only about 12 hours"
• "They expose you to side effects like diarrhea, rash, and yeast infections"
• "Previous antibiotic use increases your risk of carrying resistant bacteria"
• "Rare but serious reactions like anaphylaxis can occur"

Referring to the illness as a "chest cold" rather than "bronchitis" reduces patient expectations for antibiotics. 2, 3, 6

When to Reassess: Red-Flag Criteria

Instruct patients to return if: 2, 3, 7

• Fever >38°C persists beyond 3 days—suggests possible bacterial superinfection or pneumonia
• Cough persists beyond 3 weeks—consider asthma, COPD, pertussis, GERD, or upper-airway cough syndrome
• Symptoms worsen rather than gradually improve

High-Risk Populations Requiring Different Management

These recommendations apply ONLY to otherwise healthy adults. The following patients may require antibiotics and individualized management: 1, 2, 3

• Age ≥75 years with fever and comorbidities (cardiac failure, insulin-dependent diabetes, serious neurological disorders)
• Chronic lung disease (COPD, chronic bronchitis, bronchiectasis, cystic fibrosis)
• Immunosuppression
• Heart failure

For patients with COPD exacerbations, consider antibiotics when at least 2 of 3 Anthonisen criteria are met: 2

• Increased dyspnea
• Increased sputum volume
• Increased sputum purulence

Common Pitfalls to Avoid

Do NOT prescribe antibiotics based on: 2, 3

• Purulent sputum color (occurs in 89-95% of viral cases)
• Cough duration alone (viral cough normally lasts 10-14 days)
• Patient expectation or demand
• Early fever in first 1-3 days (only fever >3 days suggests bacterial superinfection)

Do NOT assume bacterial infection without meeting the criteria above. 2, 3

Do NOT order routine chest X-rays, sputum cultures, or inflammatory markers unless pneumonia or other serious conditions are suspected based on clinical findings. 1