How should I manage acute bronchitis in an otherwise healthy adult, and how should I treat chronic bronchitis in a patient with COPD?

Management of Bronchitis in Adults

Acute Bronchitis in Otherwise Healthy Adults

Do not prescribe antibiotics for acute bronchitis in otherwise healthy adults—they provide no meaningful benefit (shortening cough by only ~12 hours) while significantly increasing adverse events and antibiotic resistance. 1, 2

Diagnostic Approach

• Rule out pneumonia first by checking vital signs and performing a focused chest examination 1, 2
• Obtain chest radiography only if any of the following are present: heart rate >100 bpm, respiratory rate >24 breaths/min, oral temperature >38°C, or abnormal lung findings (crackles, egophony, increased tactile fremitus) 1, 2
• Approximately one-third of patients labeled with "recurrent acute bronchitis" actually have undiagnosed asthma or COPD—consider spirometry in smokers or those with recurrent episodes 2

Why Antibiotics Don't Work

• Respiratory viruses cause 89-95% of acute bronchitis cases, making antibiotics completely ineffective 1, 2, 3
• 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 increase adverse events (RR 1.20; 95% CI 1.05-1.36) including diarrhea, rash, and yeast infections 1, 2

The Pertussis Exception

If pertussis is confirmed or strongly suspected (paroxysmal cough, post-tussive vomiting, inspiratory "whoop," cough >2 weeks), prescribe a macrolide antibiotic (azithromycin or erythromycin) immediately and isolate the patient for 5 days from treatment start 1, 2

Symptomatic Management

• For bothersome dry cough (especially nocturnal): codeine or dextromethorphan provides modest relief 1, 2, 4
• For wheezing accompanying cough: short-acting β₂-agonist (albuterol) may be useful—but do NOT use routinely in absence of wheezing 1, 2, 4
• Environmental measures: remove irritants (dust, allergens) and use humidified air 1, 2
• Do NOT use: expectorants, mucolytics, antihistamines, inhaled/oral corticosteroids, NSAIDs at anti-inflammatory doses, or inhaled anticholinergics 1, 2

Patient Education & Communication

• Inform patients that cough typically lasts 10-14 days and may persist up to 3 weeks, even without treatment 1, 2
• Refer to the condition as a "chest cold" rather than "bronchitis" to reduce antibiotic expectations 1, 2
• Explain that antibiotics do not shorten the illness and expose patients to adverse effects while contributing to resistance 1, 2
• Patient satisfaction depends more on physician-patient communication than whether an antibiotic is prescribed 1, 2

Red-Flag Criteria for Reassessment

• Fever persisting >3 days suggests possible bacterial superinfection or pneumonia 1, 2
• Cough persisting >3 weeks warrants evaluation for asthma, COPD, pertussis, or GERD 1, 2
• Symptoms worsening rather than gradually improving 1, 2

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Chronic Bronchitis in Patients with COPD

For stable chronic bronchitis, ipratropium bromide is the first-line treatment to improve cough, reduce cough frequency and severity, and decrease sputum volume. 5, 6

First-Line Bronchodilator Therapy

• Ipratropium bromide 36 μg (2 inhalations) four times daily is the evidence-based first-line therapy (Grade A recommendation) 5, 6
• Short-acting β-agonists should be used to control bronchospasm and relieve dyspnea; may also reduce chronic cough (Grade A recommendation) 5, 6
• If inadequate response after 2 weeks of ipratropium, add a short-acting β-agonist for additional bronchodilation 5

Long-Acting Bronchodilator Selection by GOLD Group

• Group A (low symptoms, low exacerbation risk): start with a single long-acting bronchodilator; if inadequate, try alternative class 5
• Group B (high symptoms, low exacerbation risk): start with long-acting bronchodilator; for persistent breathlessness, use LABA/LAMA combination 5
• Group C (low symptoms, high exacerbation risk): start with LAMA (superior to LABA for exacerbation prevention); consider LABA/LAMA or LABA/ICS if exacerbations persist 5
• Group D (high symptoms, high exacerbation risk): initiate LABA/LAMA combination as first choice; escalate to LABA/LAMA/ICS triple therapy if exacerbations persist 5

Management of Acute Exacerbations of Chronic Bronchitis

Prescribe antibiotics for acute exacerbations when the patient has at least 2 of the 3 Anthonisen criteria (increased dyspnea, increased sputum volume, increased sputum purulence) AND has risk factors (age ≥65 years, FEV₁ <50% predicted, ≥4 exacerbations in 12 months, or comorbidities) 5, 7

Antibiotic Selection

• For moderate-severity exacerbations: newer macrolide (azithromycin, clarithromycin), doxycycline, or extended-spectrum cephalosporin 5, 7
• For severe exacerbations (FEV₁ <35% or frequent exacerbations): high-dose amoxicillin-clavulanate or respiratory fluoroquinolone (levofloxacin) 5, 7
• Standard duration: 7-10 days 5, 7
• During exacerbations: administer both short-acting β-agonists and anticholinergic bronchodilators; if no prompt response, add the other agent at maximal dose 5

Advanced Therapy Options

• For severe airflow obstruction (FEV₁ <50% predicted) or frequent exacerbations: consider adding inhaled corticosteroid (ICS) with LABA 5
• If patients on LABA/LAMA/ICS still have exacerbations: consider adding roflumilast or a macrolide 5

Critical Pitfalls to Avoid

• Long-term monotherapy with ICS is not recommended for chronic bronchitis 5
• Group D patients are at higher risk for pneumonia when receiving ICS treatment 5
• Long-term prophylactic antibiotics are not recommended for stable chronic bronchitis due to concerns about resistance and side effects (Grade I recommendation) 5, 6
• Theophylline should NOT be used during acute exacerbations (Grade D—harm outweighs benefit) 5
• Oral corticosteroids should not be used for long-term management of stable chronic bronchitis (Grade I) 5

Smoking Cessation

Smoking cessation is the most effective intervention to improve or eliminate cough in chronic bronchitis—approximately 90% of patients experience cough resolution after quitting (Grade A recommendation) 5