In an otherwise healthy adult with uncomplicated acute bronchitis, are systemic or inhaled corticosteroids indicated?

Steroids in Acute Bronchitis: Not Recommended

For otherwise healthy adults with uncomplicated acute bronchitis, neither systemic nor inhaled corticosteroids are indicated and should not be prescribed. 1

The Evidence Against Corticosteroids

The 2020 CHEST Expert Panel conducted a systematic review and found insufficient evidence to support routine prescription of either inhaled or oral corticosteroids for acute bronchitis in immunocompetent adults. 1 The guideline explicitly recommends against routine use of:

• Oral corticosteroids 1
• Inhaled corticosteroids 1
• Antibiotics, antivirals, antitussives, inhaled beta-agonists, inhaled anticholinergics, oral NSAIDs, or other therapies 1

This is an ungraded consensus-based statement reflecting the lack of evidence demonstrating that these treatments make cough less severe or resolve sooner. 1

A 2013 systematic review of inhaled corticosteroids for acute cough following respiratory tract infection found mixed results with insufficient evidence to recommend routine use. 2 Two trials showed equivalence to placebo, while two showed modest benefits, but outcomes were too heterogeneous to meta-analyze and most trials had unclear risk of bias. 2

Why Steroids Don't Work in Acute Bronchitis

Acute bronchitis is viral in 89-95% of cases, caused by influenza, parainfluenza, RSV, coronavirus, adenovirus, and rhinovirus. 3 Since the underlying pathology is viral infection rather than inflammatory airway disease, corticosteroids—which target inflammation—are biologically ineffective for treating the root cause. 3

Purulent sputum occurs in 89-95% of viral bronchitis cases and reflects inflammatory cells, not bacterial infection or a steroid-responsive process. 3

Critical Diagnostic Distinction: Rule Out Conditions That DO Require Steroids

Before labeling a patient with "acute bronchitis," you must exclude pneumonia and underlying reactive airway disease (asthma or COPD exacerbation), which have entirely different management pathways. 3

Pneumonia Exclusion Criteria

Obtain a chest radiograph if any of the following are present: 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 are absent in adults <70 years without comorbidities, pneumonia is unlikely and chest X-ray is not required. 3

Asthma/COPD Exacerbation—When Steroids ARE Indicated

Approximately one-third of patients labeled with "recurrent acute bronchitis" actually have undiagnosed asthma or COPD. 3, 4 These conditions do require corticosteroids:

Cough-Variant Asthma or Non-Asthmatic Eosinophilic Bronchitis

• Rapid improvement with inhaled corticosteroids (within 1 week, complete resolution by 8 weeks) suggests cough-variant asthma or eosinophilic bronchitis rather than viral bronchitis. 5
• Consider this diagnosis in patients with persistent cough >2-3 weeks that worsens at night or with exercise. 5
• Confirm with methacholine challenge (positive in asthma), induced sputum eosinophils >3%, or elevated FeNO. 5
• Treatment: Inhaled corticosteroids ± inhaled β₂-agonist for asthma; ICS alone for eosinophilic bronchitis. 5

Acute Exacerbation of Chronic Bronchitis/COPD

• Systemic corticosteroids are indicated when patients with known COPD meet ≥2 of the 3 Anthonisen criteria: increased dyspnea, increased sputum volume, increased sputum purulence. 3, 6, 7
• Prednisone 40 mg daily for 5-7 days improves lung function, oxygenation, shortens recovery time, and reduces hospital length of stay. 3, 6, 7
• A 1980 randomized controlled trial in patients with chronic bronchitis and acute respiratory insufficiency showed methylprednisolone 0.5 mg/kg IV every 6 hours for 72 hours produced significantly greater improvement in FEV₁ compared to placebo (P<0.001). 7
• Low-dose oral corticosteroids are as efficacious as high-dose IV regimens while minimizing adverse effects. 6

What TO Do for Uncomplicated Acute Bronchitis

Patient Education (Most Important)

• Cough typically lasts 10-14 days and may persist up to 3 weeks, even without treatment. 3, 8
• The illness is self-limiting and viral; steroids and antibiotics provide no benefit while exposing patients to unnecessary risks. 3, 8
• Physician-patient communication has a greater impact on patient satisfaction than prescribing medications. 3, 8

Symptomatic Treatment

• Antitussives (codeine or dextromethorphan) for bothersome dry cough, especially if it disrupts sleep—provides modest relief. 3, 4
• Short-acting β₂-agonists (albuterol) only for patients with documented wheezing; not for routine use. 3, 4
• Environmental measures: remove irritants (dust, allergens) and use humidified air. 3

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 and isolate for 5 days. 3

Red-Flag Criteria for Reassessment

Advise patients to return if: 3

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

Common Pitfalls to Avoid

• Do not prescribe steroids based on purulent sputum—this occurs in 89-95% of viral cases. 3
• Do not use cough duration alone to justify steroids; viral cough normally lasts 10-14 days. 3
• Do not miss undiagnosed asthma—about one-third of "recurrent bronchitis" cases are actually reactive airway disease requiring inhaled corticosteroids. 3, 5
• Do not assume early fever (first 1-3 days) indicates bacterial infection; only fever >3 days raises concern. 3

Special Populations

Patients with COPD, chronic bronchitis, heart failure, immunosuppression, or age >75 years with comorbidities require individualized management and may need corticosteroids for exacerbations—these are not uncomplicated acute bronchitis. 3, 6