Diagnosis and Management of Acute Bronchitis

Clinical Presentation and Diagnosis

The American College of Chest Physicians recommends that acute bronchitis be diagnosed based on a constellation of productive cough, muscle aches, fatigue, low-grade fever, and bilateral rhonchi, which is classic for an acute respiratory infection manifested by cough with or without sputum production lasting up to 3 weeks 1, 2.
The absence of infiltrate on chest radiograph distinguishes acute bronchitis from pneumonia, and a chest X-ray should only be obtained if there are clinical features suggesting pneumonia, such as new focal chest signs on examination, fever >4 days, dyspnoea/tachypnoea, or vital sign abnormalities 1, 3.
Approximately one-third of patients presenting with acute cough are misdiagnosed with acute bronchitis when they actually have acute asthma, and if a patient has had two or more similar episodes in the past 5 years, underlying asthma should be considered 1.

The American College of Chest Physicians recommends that routine antibiotic treatment for acute bronchitis is not justified and should not be offered, as the infection is viral, not bacterial 1, 2.
Symptomatic relief can be offered with antitussive agents, such as codeine or dextromethorphan, for short-term relief of coughing, and first-generation antihistamine plus decongestant, such as brompheniramine/pseudoephedrine, has been shown to decrease cough severity and hasten resolution in viral respiratory infections 1, 6.
Naproxen, a nonsteroidal anti-inflammatory drug, has demonstrated benefit for cough in controlled studies, and reassurance that the condition is self-limited and expected to resolve within 3 weeks is also important 1, 6.

If cough persists 3-8 weeks, consider post-infectious cough and treat with inhaled ipratropium bromide as first-line therapy, and reassure the patient that spontaneous resolution is expected 4, 7.
If cough persists >8 weeks, reclassify as chronic cough and initiate systematic evaluation starting with treatment for upper airway cough syndrome, then asthma, then GERD if prior treatments fail 4, 7.

Prescribing antibiotics reflexively based on productive sputum or low-grade fever, which are typical viral features and do not indicate bacterial infection, should be avoided 1, 2.
Missing underlying asthma in patients with recurrent episodes, and failing to recognize the 3-week and 8-week thresholds that change the diagnostic approach and treatment strategy, should also be avoided 1, 4.
Overlooking pertussis in patients with characteristic paroxysmal cough, especially if there are household contacts with similar symptoms, is also a common pitfall to avoid 5, 4.