Acute bronchitis
Approach
Treatment strategies are directed at minimising symptoms until the illness resolves. For many patients with minimal cough that disrupts neither daily activity nor sleep, the best approach may be to offer no treatment. For patients with significant symptoms who desire treatment, medications to reduce symptoms include cough suppressants or bronchodilators. Mucolytics, corticosteroids, and antibiotics are of limited effectiveness in treating patients with acute bronchitis.[16] If fever is present, antipyretics may be helpful for patient comfort.
Patient education about acute bronchitis being a self-limited illness that usually resolves in up to 4 weeks without treatment can help with patient satisfaction.
Symptomatic treatment
Treatment of patients with acute bronchitis may include the use of cough suppressants or, if wheezing is present, a bronchodilator. The choice of whether to use a bronchodilator or cough suppressant should be based on the previous experience of the patient, whether symptoms are related to activity, and whether symptoms are wheezing in nature (in which case a bronchodilator may be effective) or focused primarily on the discomfort associated with frequent coughing (in which case a cough suppressant might be most helpful).
The use of salbutamol is based on observations that pulmonary function tests in patients with acute bronchitis resemble those of patients with mild/moderate asthma and that salbutamol can reverse impairments in the forced expiratory volume at 1 second (FEV1) in patients with acute bronchitis.[7][17] For patients with acute bronchitis who experience wheezing, salbutamol has been shown to be helpful for reducing cough and wheezing. However, this potential benefit is not well supported by the available data and must be weighed against the adverse effects associated with its use.[18]
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In the UK, the National Institute for Health and Care Excellence (NICE) does not recommend an oral or inhaled bronchodilator unless the patient has an underlying airways disease (e.g., asthma).[19]
Antitussives may be effective treatments for acute management of severe cough. They are often combined with other agents such as guaifenesin (an expectorant) or antihistamines, but these are of unproven benefit in acute bronchitis.[20] Codeine and dextromethorphan have potential for abuse and dependence. Cough and cold medications that include opioids, such as codeine or hydrocodone, should only be used in adults aged 18 years and older as the risks (slowed or difficult breathing, misuse, abuse, addiction, overdose, and death) outweigh the benefits when used for cough in younger patients.[21] Mucolytics are not recommended.[19]
Clinicians and patients should consider the potential adverse effects of treatment and how these treatments might affect the patient's daily activities. For individuals whose work or hobbies involve fine motor movements, the use of a beta-agonist might produce tremors that would be more disruptive than the cough. Similarly, for individuals who are required to be alert during the day, the use of codeine or other opioid-containing cough suppressants might be contraindicated.
Patients could fall into more than one symptom category during the course of their illness, in which case therapy can either be added on to that previously prescribed, or, if prior therapy is found to be ineffective, it should be stopped and a different option considered. Adverse effects and interactions should be considered prior to prescribing additional treatment.
Antibiotic therapy
Most major regulatory bodies recommend against the use of empirical antibiotic therapy in acute bronchitis as it is usually caused by a virus, and inappropriate antibiotic use can lead to adverse events and contribute to antimicrobial resistance. Local guidance should be consulted to aid treatment decisions, including antibiotic choice.
The Centers for Disease Control and Prevention and the American College of Physicians recommend against routine antibiotic treatment in acute uncomplicated bronchitis in the absence of pneumonia.[3] However, in patients with acute uncomplicated bronchitis and COPD exacerbations who have clinical signs of bacterial infection, the American College of Physicians recommends limiting antibiotic duration to 5 days.[22]
See Acute exacerbation of chronic obstructive pulmonary disease.
In the UK, NICE recommends antibiotics only in patients who are systemically unwell or at a higher risk of complications. Patients who are at higher risk of complications include:[19]
People with a pre-existing comorbidity (e.g., significant renal, hepatic, cardiac, respiratory, or neuromuscular disease, immunosuppression)
Patients aged ≥80 years with one or more of the following, or patients aged ≥65 years with two or more of the following:
Hospitalisation in the past year
Current oral corticosteroid use
Type 1 or type 2 diabetes mellitus
History of congestive heart failure.
Antibiotic therapy is recommended in patients who are systemically unwell. Immediate antibiotic therapy or a delayed prescription can be considered in patients who are at a higher risk of complications.
NICE: Cough (acute): antimicrobial prescribing Opens in new window
NICE recommends that C-reactive protein (CRP) should be ordered if antibiotic therapy is being considered to help guide therapy. Antibiotics are not routinely recommended if CRP is <20 mg/L and symptoms are present for more than 24 hours. Delayed antibiotics are recommended if CRP is 20-100 mg/L, and immediate antibiotics are recommended if CRP is >100 mg/L.[12]
A delayed prescription for antibiotics can be considered alongside advice on the natural history of the illness and symptomatic treatments. Other strategies include shared-decision making and procalcitonin-guided antibiotic therapy.[23]
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However, in one study, procalcitonin levels did not result in less use of antibiotics in patients with suspected lower respiratory tract infection.[24] One cohort study of 28,883 participants found that delayed prescribing may result in a reduced number of repeat consultations for worsening illness.[25] Other studies also support the use of delayed prescribing strategies, as they are associated with substantially reduced antibiotic use compared with immediate prescribing.[26][27] One Cochrane review found that delayed antibiotics achieved lower rates of antibiotic use (31%) compared with immediate antibiotics (93%), with similar rates of patient satisfaction.[28]
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One Cochrane review of 17 trials (3936 participants) found that there is limited evidence to support the use of antibiotics in the treatment of acute bronchitis. Some patients may recover faster with antibiotic treatment; however, the difference (half a day over an 8- to 10-day period) was not considered significant. Antibiotics may have a beneficial effect in some patients (e.g., elderly, existing comorbidities); however, this should be balanced against potential adverse effects and contribution to the development of resistance.[29]
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Despite these recommendations, inappropriate prescribing of antibiotics in acute respiratory infections is widespread. Acute bronchitis leads to more inappropriate antibiotic prescribing than any other acute respiratory tract infection.[3] One German study found that 78% of antibiotic prescriptions for acute bronchitis were not in accordance with local guideline recommendations.[30] Similarly, an Australian study found that the antibiotics are prescribed at rates 4 to 9 times higher than what local guidance recommends.[31]
Treatment of persistent cough
Evaluation for other causes of persistent cough should be considered (e.g., asthmatic cough/eosinophilic bronchitis, reflux, postnasal drip syndrome, upper airways cough syndrome).[32] A careful history to look for occupational or environmental exposures can help indicate whether inhalants could be causing the cough. In patients with risk factors or other symptoms suspicious for gastro-oesophageal reflux disease, an empirical trial with an H2 antagonist or proton-pump inhibitor may be warranted.
Patients whose cough persists for >4 weeks may benefit from a short-acting beta-agonist bronchodilator, although routine use of beta-agonists for chronic cough associated with acute bronchitis is generally not recommended unless the patient has an underlying airways disease.[18][19]
Antibiotics are not indicated simply because of a prolonged duration of cough in acute bronchitis, but may be considered in select patients who are systemically unwell or are at high risk of complications.
There is no evidence that the use of corticosteroids, either inhaled or systemic, is effective for postbronchitic cough. A randomised controlled trial comparing a 5-day course of prednisolone with placebo found that there was no difference in duration of cough, symptom severity, or peak flow in adults with acute cough and at least one lower respiratory tract symptom and no indication for antibiotic treatment. The authors concluded that oral corticosteroids should not be used for this indication in patients without asthma.[33] NICE guidance supports this stance.[19]
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