What is the recommended management for an adult patient presenting with bronchitis, including acute self‑limited episodes and chronic obstructive airway disease exacerbations?

Management of Bronchitis in Adults

For acute bronchitis in otherwise healthy adults, do not prescribe antibiotics—they provide no meaningful benefit and cause harm; for acute exacerbations of chronic bronchitis in patients with COPD, prescribe antibiotics when at least two of three cardinal symptoms are present (increased dyspnea, sputum volume, or sputum purulence).

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Acute Bronchitis (Self-Limited Episodes)

Diagnosis and Initial Assessment

• Rule out pneumonia first by checking vital signs: heart rate >100 bpm, respiratory rate >24 breaths/min, or temperature >38°C warrant chest radiography rather than a bronchitis diagnosis 1.
• Exclude asthma or COPD in patients with recurrent episodes, wheezing, or risk factors (smoking history); approximately one-third of patients labeled with "recurrent acute bronchitis" have undiagnosed reactive airway disease 1, 2, 3.
• Respiratory viruses cause 89–95% of acute bronchitis cases; bacterial pathogens account for only 5–10% 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, 3.

Treatment Approach

What NOT to Prescribe (Strong Evidence Against)

• Antibiotics are not recommended for uncomplicated acute bronchitis—they shorten cough by only ~0.5 day (12 hours) while increasing adverse events (RR 1.20; 95% CI 1.05–1.36) 1, 2.
• Inhaled corticosteroids, oral corticosteroids, oral NSAIDs at anti-inflammatory doses, expectorants, and mucolytics have no proven benefit 1, 2.
• Routine bronchodilators should not be used unless wheezing is present 1, 3.

Symptomatic Management

• Inform patients that cough typically lasts 10–14 days and may persist up to 3 weeks—this is normal for viral bronchitis 1, 2.
• For bothersome dry cough (especially nocturnal), offer codeine or dextromethorphan for modest symptomatic relief 1, 3.
• If wheezing is present, a short-acting β₂-agonist (albuterol) may be useful 1, 4.
• Environmental measures: remove irritants (dust, smoke) and use humidified air 1.

Pertussis Exception

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

Red-Flag Criteria for Reassessment

• Fever persisting >3 days suggests bacterial superinfection or pneumonia 1, 2.
• Cough lasting >3 weeks warrants evaluation for asthma, COPD, pertussis, or GERD 1, 2.
• Worsening symptoms rather than gradual improvement require diagnostic reconsideration 1, 2.

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Acute Exacerbations of Chronic Bronchitis (COPD)

Diagnostic Criteria

• Diagnose acute exacerbation when a stable COPD patient experiences sudden deterioration with increased cough, sputum production, sputum purulence, and/or worsening dyspnea, often preceded by upper respiratory symptoms 1.
• Exclude other causes: pneumonia, pulmonary embolism, pneumothorax, congestive heart failure 1.

Antibiotic Therapy

Indications for Antibiotics

• Prescribe antibiotics when at least 2 of 3 Anthonisen criteria are met: increased dyspnea, increased sputum volume, increased sputum purulence 1, 5.
• Patients with severe exacerbations and those with more severe baseline airflow obstruction (FEV₁ <50%) are most likely to benefit 1, 5.

Antibiotic Selection

• First-line for simple chronic bronchitis (no risk factors): amoxicillin, doxycycline, or trimethoprim-sulfamethoxazole 5.
• For complicated chronic bronchitis (age >65, FEV₁ <50%, cardiac disease, ≥3 exacerbations/year): amoxicillin-clavulanate, respiratory fluoroquinolones (levofloxacin, moxifloxacin), or second/third-generation cephalosporins 6, 5.
• For Pseudomonas aeruginosa risk (severe COPD, recent hospitalization, frequent antibiotics): ciprofloxacin or anti-pseudomonal β-lactam 6, 5.

Duration

• Treat for 7–10 days for most exacerbations; 14 days may be appropriate for documented bacterial pathogens 1, 5.

Bronchodilator Therapy

• Administer short-acting β₂-agonists or anticholinergic bronchodilators during acute exacerbations 1.
• If no prompt response, add the other agent after maximizing the first 1.
• Do not use theophylline for acute exacerbations—it provides no benefit and increases adverse events 1.

Stable Chronic Bronchitis Management

• Short-acting β₂-agonists should be used to control bronchospasm and relieve dyspnea; may also reduce chronic cough 1.
• Ipratropium bromide should be offered to improve cough 1.
• Theophylline may be considered for chronic cough control with careful monitoring for toxicity 1.
• No role for long-term prophylactic antibiotics in stable patients 1.
• Smoking cessation is the most effective intervention—90% of patients experience cough resolution after quitting 1.

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Common Pitfalls to Avoid

• Do not prescribe antibiotics based on purulent sputum color alone—this occurs in 89–95% of viral cases 1, 2, 3.
• Do not use cough duration as justification for antibiotics—viral cough normally lasts 10–14 days 1, 2.
• Do not assume early fever (first 1–3 days) indicates bacterial infection—only fever >3 days raises concern 1, 2.
• Do not miss undiagnosed asthma—consider spirometry in patients with recurrent episodes or wheezing 1, 2, 3.
• Referring to acute bronchitis as a "chest cold" reduces patient expectations for antibiotics 1, 3.

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Patient Communication Strategy

• Explain that antibiotics do not shorten the illness and cause side effects (diarrhea, rash, yeast infections) while promoting resistance 1, 2.
• Emphasize that patient satisfaction depends more on clear communication than on receiving an antibiotic prescription 1, 2, 4.
• Provide a self-management plan with specific return criteria (fever >3 days, cough >3 weeks, worsening symptoms) 1, 2.