Management of Bronchitis
For acute bronchitis in otherwise healthy adults, do not prescribe antibiotics—they shorten cough by only 12 hours while causing significant adverse effects; instead, provide patient education that cough will last 10-14 days and offer symptomatic relief with antitussives only if cough is severely bothersome. 1, 2
Acute Bronchitis
Diagnostic Approach
Rule out pneumonia first by checking vital signs and performing a focused chest examination. 3 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)—obtain a chest radiograph to exclude pneumonia before treating as bronchitis. 3, 2
Approximately one-third of patients labeled with "recurrent acute bronchitis" actually have undiagnosed asthma or COPD, so consider spirometry in patients who smoke, have recurrent episodes, or whose cough worsens at night or with exercise. 3
Why Antibiotics Are Not Indicated
Respiratory viruses cause 89-95% of acute bronchitis cases, making antibiotics completely ineffective against the underlying cause. 3, 1 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), including diarrhea, rash, yeast infections, and C. difficile infection. 3, 2
Purulent (green or yellow) sputum occurs in 89-95% of viral bronchitis and does not indicate bacterial infection—it reflects inflammatory cells, not bacteria. 3, 1 Do not prescribe antibiotics based on sputum color or cough duration alone. 3
Patient Education (Critical Component)
Inform patients that cough typically lasts 10-14 days and may persist up to 3 weeks, even without antibiotics. 3, 1, 2 Referring to the illness as a "chest cold" rather than "bronchitis" reduces patient expectations for antibiotics. 3, 2
Explain that antibiotics provide no clinical benefit while exposing them to adverse effects and contributing to antibiotic resistance. 3, 1 Patient satisfaction depends more on physician-patient communication than whether an antibiotic is prescribed. 3
Symptomatic Management
- Antitussives (codeine or dextromethorphan) may provide modest relief for bothersome dry cough, especially if it disrupts sleep. 3, 4
- Short-acting β₂-agonists (e.g., albuterol) should be used only when wheezing accompanies the cough—not routinely. 3, 4
- Environmental measures: remove irritants (dust, allergens) and use humidified air. 3
Therapies to Avoid
Do not prescribe expectorants, mucolytics, antihistamines, inhaled or oral corticosteroids, or NSAIDs at anti-inflammatory doses—none have demonstrated consistent benefit. 3, 1
Exception: Pertussis
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 the patient for 5 days from treatment start. 3, 4, 2 Early treatment reduces cough paroxysms and limits transmission. 3
Red-Flag Criteria for Reassessment
Advise patients to return if:
- Fever persists >3 days (suggests bacterial superinfection or pneumonia) 3
- Cough persists >3 weeks (consider asthma, COPD, pertussis, GERD) 3, 2
- Symptoms worsen rather than gradually improve 3
Chronic Bronchitis (Stable Disease)
First-Line Bronchodilator Therapy
Ipratropium bromide is the preferred initial treatment for cough in stable COPD patients with chronic bronchitis, with Grade A evidence demonstrating reduction in cough frequency, cough severity, and sputum volume. 5, 6 Standard dosing is ipratropium bromide 36 μg (2 inhalations) four times daily. 5, 6
Short-acting β-agonists should be used to control bronchospasm and relieve dyspnea; in some patients, they may also reduce chronic cough (Grade A recommendation). 5
Advanced Therapy for Severe Disease
For patients with FEV₁ <50% predicted or frequent exacerbations, treatment with a long-acting β-agonist combined with an inhaled corticosteroid should be offered to control chronic cough (Grade A recommendation). 5, 7
Theophylline may be considered to control chronic cough in stable patients, but requires careful monitoring for complications due to its narrow therapeutic index (Grade A recommendation). 5
Therapies Without Proven Benefit
- Long-term prophylactic antibiotics have no role in stable chronic bronchitis (Grade I recommendation). 5
- Currently available expectorants are not effective and should not be used (Grade I recommendation). 5
- Postural drainage and chest percussion have not been proven beneficial and are not recommended (Grade I recommendation). 5
Most Effective Intervention
Smoking cessation is the single most effective intervention—90% of patients experience cough resolution after quitting, typically within the first month (Grade A recommendation). 5, 6 This provides twice the benefit on lung-function decline compared with inhaled medications. 7
Acute Exacerbations of Chronic Bronchitis
Indications for Antibiotic Therapy
Antibiotics are recommended for acute exacerbations, especially in patients with severe exacerbations and those with more severe airflow obstruction at baseline (Grade A recommendation). 5 Patients most likely to benefit are those with at least 2 of the 3 Anthonisen criteria: increased dyspnea, increased sputum volume, or increased sputum purulence. 3, 8
Antibiotic Selection
- First-line for moderate exacerbations: doxycycline 100 mg twice daily for 7-10 days, or a newer macrolide. 3, 8
- For severe exacerbations: high-dose amoxicillin-clavulanate 625 mg three times daily for 14 days, or a respiratory fluoroquinolone. 3, 8
Bronchodilator and Corticosteroid Therapy
During acute exacerbations, both short-acting β-agonists and anticholinergic bronchodilators should be administered. 5, 7 If the patient does not show a prompt response, add the other agent after the first is administered at maximal dose (Grade A recommendation). 5
A short course (10-15 days) of systemic corticosteroids is recommended for acute exacerbations: IV therapy for hospitalized patients and oral therapy for ambulatory patients (Grade A recommendation). 5, 7
Theophylline should not be used for treatment of acute exacerbations (Grade D recommendation). 5
Common Pitfalls
- Do not use postural drainage and chest percussion during acute exacerbations—clinical benefits have not been proven (Grade I recommendation). 5
- Do not prescribe antibiotics for stable chronic bronchitis—reserve them exclusively for acute exacerbations. 5
- Ensure proper inhaler technique for optimal bronchodilator delivery. 6