Should prednisone be used to treat uncomplicated acute bronchitis in an otherwise healthy adult?

Prednisone for Acute Bronchitis: Not Recommended

Prednisone and other systemic corticosteroids should not be used for uncomplicated acute bronchitis in otherwise healthy adults, as major guideline panels explicitly recommend against their routine use due to lack of demonstrated clinical benefit. 1

Why Corticosteroids Don't Work in Acute Bronchitis

The pathophysiology does not support steroid use:

• Acute bronchitis is viral in 89-95% of cases, caused by influenza, parainfluenza, RSV, coronavirus, adenovirus, and rhinovirus—none of which respond to anti-inflammatory therapy. 1, 2
• Bacterial pathogens account for fewer than 10% of cases, limited almost exclusively to Mycoplasma pneumoniae, Chlamydophila pneumoniae, and Bordetella pertussis—each representing less than 1% of routine cases. 2
• The cough results from transient bronchial hyperresponsiveness triggered by viral epithelial damage, not from a steroid-responsive inflammatory process. 3

Guideline-Based Recommendations

The 2020 CHEST Expert Panel explicitly recommends against routine prescription of oral corticosteroids for uncomplicated acute bronchitis in immunocompetent adults, stating no clinically meaningful benefit has been demonstrated. 1

Additional therapies to avoid:

• Inhaled corticosteroids 1
• Oral NSAIDs at anti-inflammatory doses 1
• Expectorants and mucolytics 1
• Routine antibiotics (shorten cough by only ~0.5 day while increasing adverse events; RR 1.20,95% CI 1.05-1.36) 1

When Corticosteroids ARE Indicated: COPD/Chronic Bronchitis Exacerbations

Approximately one-third of patients labeled with "recurrent acute bronchitis" actually have undiagnosed asthma or COPD. 1 This is a critical diagnostic pitfall.

Diagnostic Algorithm to Identify COPD Exacerbation (Not Simple Bronchitis)

Check for these features that distinguish COPD exacerbation from acute bronchitis:

1. Known history of chronic bronchitis or COPD 1
2. At least 2 of 3 Anthonisen criteria:
   • Increased dyspnea
   • Increased sputum volume
   • Increased sputum purulence 1
3. Risk factors: age >65 years, moderate-to-severe airflow obstruction (FEV₁ <50%), cardiac failure, insulin-dependent diabetes, or serious neurological disorders 1

Steroid Regimen for COPD Exacerbations

When the above criteria are met, prednisone 40 mg daily for 5-7 days improves lung function, oxygenation, and shortens recovery time—this is supported by moderate-to-strong evidence. 1

The landmark 1980 trial by Albert et al. demonstrated that methylprednisolone 0.5 mg/kg IV every 6 hours for 72 hours produced significantly greater improvement in FEV₁ (P <0.001) compared to placebo in patients with chronic bronchitis and acute respiratory insufficiency. 4

Proper Management of Uncomplicated Acute Bronchitis

Exclude Pneumonia First

Before diagnosing acute bronchitis, check vital signs and perform a focused lung examination. 1

Obtain chest radiography if any of the following are present:

• Heart rate >100 beats/min
• Respiratory rate >24 breaths/min
• Oral temperature >38°C
• Abnormal lung findings (crackles, egophony, increased tactile fremitus) 1

Patient Education (Most Important Intervention)

• Cough typically lasts 10-14 days and may persist up to 3 weeks, even without treatment. 1
• The illness is self-limiting and viral. 1
• Purulent (green/yellow) sputum occurs in 89-95% of viral cases and does not indicate bacterial infection. 1, 2
• Physician-patient communication has greater impact on satisfaction than prescribing medications. 1

Symptomatic Relief Options

For bothersome dry cough (especially nocturnal):

• Codeine or dextromethorphan provide modest relief 1

For wheezing accompanying cough:

• Short-acting β₂-agonists (e.g., albuterol) may be useful—reserve only for documented wheeze 1, 3

Environmental measures:

• Remove irritants (dust, allergens) and use humidified air 1

Pertussis Exception

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

• Prescribe a macrolide antibiotic (azithromycin or erythromycin) immediately 1
• Isolate the patient for 5 days from treatment start 1
• Early therapy reduces cough paroxysms and limits transmission 1

Red-Flag Criteria for Reassessment

Advise patients to return if:

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

Critical Pitfalls to Avoid

• Do not prescribe prednisone based on purulent sputum alone—it occurs in 89-95% of viral cases 1, 2
• Do not use cough duration as justification for steroids—viral cough normally lasts 10-14 days 1
• Do not miss undiagnosed asthma or COPD—about one-third of "recurrent bronchitis" cases are actually reactive airway disease requiring different management 1
• Do not assume early fever (first 1-3 days) indicates need for steroids—only fever >3 days raises concern for bacterial superinfection 1