Acute Bronchitis Management

Initial Evaluation and Exclusion of Severe Conditions

The American College of Chest Physicians recommends excluding pneumonia by verifying vital signs, including tachycardia, tachypnea, and fever with systemic illness, in a young and healthy patient with cough, wheezing, and recent fever 1
A physical examination of the chest is necessary to check for dullness to percussion, bronchial breath sounds, or crackles 1, 2
In a young and healthy patient without these findings, a chest radiograph is not indicated 3

The American College of Chest Physicians recommends against prescribing antibiotics for acute bronchitis, as they have no role in this condition 4, 1
Wheezing requires bronchodilator treatment, and transient wheezing that resolves with coughing in an otherwise healthy patient may not require long-term bronchodilators 1

The American College of Chest Physicians explicitly recommends that antibiotic therapy has no role in acute bronchitis, as it is not a bacterial infection 4, 1
Antibiotics provide no benefits, contribute to antimicrobial resistance, and cause adverse effects, including allergic reactions and C. difficile infection 5, 1

Simple home remedies like honey and lemon are recommended as an initial approach for productive cough with mucus, being cost-effective and having no adverse effects 6, 2
Guaifenesina is approved by the FDA to help fluidify mucus and bronchial secretions, representing a safe over-the-counter option 1
Ipratropium bromide inhaler (2-3 puffs four times a day) may be considered if cough persists and compromises quality of life 4, 1, 5

Cough from uncomplicated viral infection is worst in the first days and should gradually improve over 1-2 weeks 2
If symptoms worsen after initial improvement or persist beyond 2-3 weeks without constant improvement, re-evaluation for complications is necessary 2
Cough persisting for ≥3 weeks but <8 weeks is defined as post-infectious cough and may require inhaled corticosteroids if it compromises quality of life 4, 1

Do not prescribe antibiotics (amoxicillin, azithromycin) for uncomplicated acute bronchitis 3, 4, 1
Do not use nasal decongestant sprays for more than 3-5 days due to the risk of rebound congestion 5
Do not ignore wheezing: it requires evaluation and bronchodilator treatment 1
Do not jump directly to prednisone: it is reserved for severe post-infectious cough paroxysms after failure of other therapies 4, 1

Suspect pertussis if present: paroxysmal cough with post-tussive vomiting or "whooping" sound 4, 5
In this case, obtain a nasopharyngeal swab for culture and start macrolides (azithromycin or clarithromycin) 5
Consider cough variant asthma if: persistent cough >2-3 weeks without wheezing, worsening at night or with exposure to cold/exercise, and requires bronchial provocation test with methacholine or therapeutic trial with bronchodilators 3

For dry, bothersome cough, especially at night, the European Respiratory Society suggests considering dextromethorphan or codeine for cough suppression, but notes that cough suppression is not logical when the patient produces significant sputum 7, 8
The European Respiratory Society recommends against using expectorants (other than guaifenesin), mucolytics, antihistamines, or bronchodilators for uncomplicated acute cough without wheezing 7, 8

The American Thoracic Society suggests considering pertussis if the patient has a paroxysmal cough with post-tussive vomiting or a "whooping" sound, and recommends obtaining a nasopharyngeal swab for culture and starting macrolides (azithromycin or clarithromycin) if suspected 9
The European Respiratory Society recommends considering antibiotics only in COPD exacerbations, specifically if the patient has known COPD with increased dyspnea, increased sputum volume, and increased sputum purulence (Type I exacerbation), or two cardinal symptoms including purulent green sputum (Type II exacerbation) 10