Treatment of Bronchitis in COPD

First-Line Bronchodilator Therapy

The American Thoracic Society recommends ipratropium bromide as first-line therapy to improve cough in stable COPD patients with chronic bronchitis (Grade A recommendation) 3
Standard dosing is ipratropium bromide 36 μg (2 inhalations) four times daily 1, 4
Short-acting β-agonists should be used to control bronchospasm and relieve dyspnea; they may also reduce chronic cough in some patients (Grade A recommendation) 3, 5

For patients with low symptom burden and low exacerbation risk, the European Respiratory Society suggests starting with a bronchodilator to reduce breathlessness 1
For patients with severe airflow obstruction (FEV1 <50%) or frequent exacerbations, consider adding an inhaled corticosteroid with a long-acting β-agonist 6, 7

The American College of Chest Physicians recommends antibiotics for acute exacerbations of chronic bronchitis, particularly for patients with severe exacerbations and those with more severe airflow obstruction at baseline (Grade A recommendation) 3, 8
During acute exacerbations, both short-acting β-agonists and anticholinergic bronchodilators should be administered 5
A short course (10-15 days) of systemic corticosteroid therapy is recommended for acute exacerbations; IV therapy for hospitalized patients and oral therapy for ambulatory patients 6, 5

Theophylline may be considered to control chronic cough in stable patients with chronic bronchitis, but careful monitoring for complications is necessary (Grade A recommendation) 3, 5
Roflumilast may be considered for patients with severe COPD with characteristics of chronic bronchitis and a history of exacerbations 7

Long-term prophylactic therapy with antibiotics is not recommended for stable patients with chronic bronchitis (Grade I recommendation) 3, 8
Currently available expectorants have not been proven effective for cough in chronic bronchitis and should not be used 6, 5

Smoking cessation is the most effective means to improve or eliminate the cough of chronic bronchitis, with 90% of patients reporting resolution of cough after smoking cessation 8
For troublesome cough that requires temporary suppression, codeine and dextromethorphan can be effective, reducing cough counts by 40-60% 6, 2