What is the recommended inpatient management for an adult admitted with acute bronchitis?

Inpatient Management of Acute Bronchitis

The Critical First Question: Should This Patient Be Hospitalized?

Acute bronchitis is an outpatient disease—if a patient requires hospitalization for respiratory symptoms initially attributed to "bronchitis," the diagnosis is almost certainly wrong. 1, 2 The presence of any vital sign abnormality (heart rate >100 bpm, respiratory rate >24 breaths/min, temperature >38°C) or abnormal lung findings (crackles, egophony, increased tactile fremitus) suggests pneumonia, not bronchitis, and warrants chest radiography. 1, 2

Diagnostic Reassessment Algorithm

When a patient is admitted with presumed "acute bronchitis," immediately reassess for:

• Pneumonia: Check vital signs and perform focused chest examination; obtain chest X-ray if any abnormality is present 1, 2
• Undiagnosed asthma or COPD: Approximately one-third of patients labeled with "recurrent acute bronchitis" actually have reactive airway disease 1, 2
• Acute exacerbation of chronic bronchitis/COPD: These patients may require antibiotics and systemic corticosteroids, unlike simple acute bronchitis 1, 2, 3
• Pertussis: Consider in patients with cough >2 weeks, paroxysmal cough, post-tussive vomiting, or inspiratory "whoop" 1, 2, 4
• Heart failure: Especially in elderly patients with dyspnea 5

Management If True Acute Bronchitis Is Confirmed

What NOT to Do (Strong Evidence Against)

Do not prescribe antibiotics. Respiratory viruses cause 89-95% of acute bronchitis cases; antibiotics reduce cough duration by only ~0.5 days (approximately 12 hours) while significantly increasing adverse events (RR 1.20; 95% CI 1.05-1.36). 1, 2, 4, 5

Do not prescribe systemic corticosteroids. These are not indicated for uncomplicated acute bronchitis and provide no clinical benefit. 1, 2, 3

Do not prescribe:

• Inhaled corticosteroids 1, 2
• Oral NSAIDs at anti-inflammatory doses 1, 2
• Expectorants or mucolytics 1, 2
• Antihistamines 2, 5
• Routine antiviral therapy (unless influenza confirmed within 48 hours) 1, 2

Appropriate Symptomatic Management

For bothersome dry cough (especially nocturnal):

• Codeine or dextromethorphan provide modest symptomatic relief 1, 2, 5

For wheezing accompanying cough:

• Short-acting β₂-agonists (e.g., albuterol) may be useful only in select patients with documented wheezing 1, 2, 6
• Do not use bronchodilators routinely in the absence of wheezing 1

Environmental measures:

• Remove irritants (dust, allergens) and provide humidified air 2, 6

Patient Education (Essential Component)

• Cough typically lasts 10-14 days and may persist up to 3 weeks even without treatment 1, 2, 4, 5
• The illness is self-limiting and viral in origin 1, 2, 4
• Purulent (green/yellow) sputum occurs in 89-95% of viral cases and does not indicate bacterial infection 1, 2, 4

Exception: Pertussis

If pertussis is confirmed or strongly suspected, prescribe a macrolide antibiotic (azithromycin or erythromycin) immediately and isolate the patient for 5 days from treatment start. 1, 2, 4 Early treatment within the first few weeks reduces cough paroxysms and prevents disease spread. 1, 2

Management of Acute Exacerbation of Chronic Bronchitis/COPD (Different Disease)

If the patient has underlying COPD or chronic bronchitis and meets at least two of the three Anthonisen criteria (increased dyspnea, increased sputum volume, increased sputum purulence):

Systemic corticosteroids ARE indicated:

• Prednisone 40 mg daily for 5-7 days improves lung function, oxygenation, and shortens recovery time 1, 2, 3

Antibiotics ARE indicated in this population:

• First-line: Amoxicillin-clavulanate, doxycycline, or respiratory fluoroquinolone 2, 7
• Duration: 5-10 days 2, 7

Bronchodilators:

• Short-acting β₂-agonists and/or anticholinergics (ipratropium) 1, 2, 3

Critical Pitfalls to Avoid

• Do not assume bacterial infection based on purulent sputum—this occurs in 89-95% of viral cases 1, 2, 4
• Do not use cough duration alone to justify antibiotics—viral cough normally lasts 10-14 days 1, 2, 4
• Do not prescribe antibiotics for patient satisfaction—communication is more important than prescribing 1, 2, 4
• Do not miss undiagnosed asthma—approximately one-third of "recurrent bronchitis" is actually reactive airway disease 1, 2, 6

Discharge Planning and Follow-Up

Advise the patient to return if:

• Fever persists >3 days (suggests bacterial superinfection or pneumonia) 1, 2, 7
• Cough persists >3 weeks (consider asthma, COPD, pertussis, GERD) 1, 2, 4
• Symptoms worsen rather than gradually improve 1, 2

The bottom line: If a patient is sick enough to require hospitalization, they almost certainly do not have simple acute bronchitis—reassess the diagnosis immediately and manage the actual underlying condition (pneumonia, COPD exacerbation, heart failure, etc.). 1, 2, 5