Management of Bronchitis

Diagnosis and Classification

Acute bronchitis is defined as self-limited inflammation of the large airways with cough lasting up to 6 weeks, often accompanied by mild constitutional symptoms 1
Chronic bronchitis is defined as cough with sputum production occurring on most days for at least 3 months of the year and for at least 2 consecutive years 2, 3
Purulent sputum does not indicate bacterial infection; it results from inflammatory cells or sloughed mucosal epithelial cells 1
Pneumonia should be ruled out before diagnosing uncomplicated bronchitis by assessing for tachycardia, tachypnea, fever, and abnormal chest examination findings 1

Antibiotics should not be prescribed for uncomplicated acute bronchitis unless pneumonia is suspected 1
The American College of Physicians recommends that antibiotics may be considered only in specific high-risk populations, such as patients aged ≥75 years with fever 1
The European Respiratory Society suggests that antibiotics may be considered for patients with cardiac failure 4
Antibiotic use for acute bronchitis leads to more inappropriate prescribing than any other acute respiratory tract infection in adults 1
Short-acting β-agonists like albuterol may be beneficial in reducing cough duration and severity in patients with evidence of bronchial hyperresponsiveness 5, 6
Ipratropium bromide may improve cough in some patients 7
Dextromethorphan or codeine are recommended for short-term symptomatic relief of bothersome cough 7, 8

Short-acting β-agonists should be used to control bronchospasm and may reduce chronic cough 7
Ipratropium bromide should be offered to improve cough 7
Long-acting β-agonists combined with inhaled corticosteroids should be offered to control chronic cough 7
Inhaled corticosteroids should be offered to patients with chronic bronchitis and FEV1 <50% predicted or those with frequent exacerbations 7

Short-acting β-agonists or anticholinergic bronchodilators should be administered during acute exacerbations 7
A short course (10-15 days) of systemic corticosteroids is effective for acute exacerbations 7

Provide realistic expectations for cough duration (typically 10-14 days after the office visit) 5, 8
Consider referring to the illness as a "chest cold" rather than bronchitis to reduce patient expectation for antibiotics 5, 8
Explain that patient satisfaction depends more on the quality of the clinical encounter than on receiving antibiotics 5, 6
Discuss the risks of unnecessary antibiotic use, including side effects and development of antibiotic resistance 5, 8

Prescribing antibiotics based solely on presence of colored sputum 1
Failing to distinguish between acute bronchitis and pneumonia 1
Overuse of expectorants, mucolytics, and antihistamines which lack evidence of benefit 4
Not considering underlying conditions that may be exacerbated by bronchitis (asthma, COPD, cardiac failure, diabetes) 4
Using theophylline for acute exacerbations of chronic bronchitis 7

The American Thoracic Society recommends smoking cessation as the most effective intervention for chronic bronchitis, with 90% of patients experiencing cough resolution after quitting 9
The American College of Chest Physicians suggests removing passive smoke exposure and workplace/environmental irritants to improve symptoms in patients with chronic bronchitis 10
Short-acting β-agonists should be used to control bronchospasm, relieve dyspnea, and may reduce chronic cough in patients with chronic bronchitis, as recommended by the Global Initiative for Chronic Obstructive Lung Disease 9, 11, 12
Ipratropium bromide should be offered to improve cough and reduce sputum volume in patients with chronic bronchitis, according to the American College of Chest Physicians 9, 11, 12

The American Thoracic Society recommends administering short-acting β-agonists or anticholinergic bronchodilators immediately for acute exacerbations of chronic bronchitis 11, 12
Antibiotics are recommended for patients with severe exacerbations of chronic bronchitis, especially those with baseline FEV1 <50%, as suggested by the Global Initiative for Chronic Obstructive Lung Disease 9
A short course (10-15 days) of systemic corticosteroids should be given to patients with acute exacerbations of chronic bronchitis, according to the American College of Chest Physicians 10, 11

The American College of Chest Physicians recommends against using long-term oral corticosteroids for stable chronic bronchitis due to lack of evidence and high risk of side effects 10, 11
Expectorants and mucolytics should not be used in any form of bronchitis, as they have no evidence of benefit, according to the American Thoracic Society 10, 11