Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

cough ≤4 weeks

1st line – observation

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ACUTE
|
cough ≤4 weeks
1st line – 

observation

Because acute bronchitis is most commonly related to virally-mediated infections, treatment strategies are directed at minimizing symptoms until the illness resolves. For many patients with a minimal cough that does not disrupt daily activities or interrupt sleep, the best approach may be to offer no treatment.

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.

Cough severity should be assessed before and after treatment initiation.[12]

Consider – antipyretic

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ACUTE
|
cough ≤4 weeks
Consider – 

antipyretic

Treatment recommended for SOME patients in selected patient group

An antipyretic (e.g., acetaminophen) may be helpful for patient comfort if fever is present.

Primary options

acetaminophen: 325-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

Consider – bronchodilator

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ACUTE
|
cough ≤4 weeks
Consider – 

bronchodilator

Treatment recommended for SOME patients in selected patient group

Albuterol (a short-acting beta-agonist) can be used for patients with 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.[25] [ Cochrane Clinical Answers logo ] ​ 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).[28]

Use is associated with reductions in cough frequency at 1 week and overall symptom improvement at 1 week.[50][51] Combining albuterol with an antibiotic has showed no additional benefit over albuterol alone, although outcomes at >1 week have not been studied.[50] The treatment benefits must be balanced by the adverse effects of nervousness and tremor, which may be more disruptive to the patient than the underlying cough.

Primary options

albuterol inhaled: 90-180 micrograms (1-2 puffs) every 4-6 hours when required; 2.5 mg nebulized every 4-6 hours when required

Consider – antitussive

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ACUTE
|
cough ≤4 weeks
Consider – 

antitussive

Treatment recommended for SOME patients in selected patient group

Although acute cough is typically self-limiting, antitussives are often used in practice for the management of severe acute cough. They are usually combined with other agents such as guaifenesin (an expectorant) or antihistamines, but these are of unproven benefit in acute bronchitis.[29]

Options include dextromethorphan (a nonopioid antitussive) or codeine (an opioid). Other antitussives may also be available.

While codeine is frequently used as an antitussive, there is a lack of evidence to support its use, and it is not generally recommended due to its potential for misuse and safety issues (e.g., slowed or difficult breathing, misuse, addiction, overdose, and death).​[30][31][32][33]​​ Dextromethorphan also has the potential for misuse and dependence.

Evidence for nonprescription remedies is weak, and many antitussives are likely no better than placebo.[31][32]

Honey may be useful for cough, although there is no strong evidence either for or against its use.[32][34]

Primary options

dextromethorphan: 20 mg orally every 4 hours when required, or 30 mg every 6-8 hours when required; maximum 120 mg/day

Plus – consider immediate or delayed antibiotics

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ACUTE
|
cough ≤4 weeks
|
systemically unwell; high risk of complications
Plus – 

consider immediate or delayed antibiotics

Treatment recommended for ALL patients in selected patient group

Antibiotic therapy should be carefully considered on a case-by-case basis, as they do not provide a clinical benefit for most patients.[36][37]

Less than 10% of acute bronchitis cases have a bacterial cause; however, in instances where a bacterial cause is indicated, the choice of antibiotic will depend on the bacterial pathogen (e.g., Mycoplasma pneumoniae, Chlamydia pneumonia, Bordetella pertussis).[38]​ See Mycoplasma pneumoniae infection, Chlamydia pneumoniae infection, or Pertussis.

Most major regulatory bodies recommend against the use of empiric antibiotic therapy in acute bronchitis. Local guidance should be consulted to aid treatment decisions, including antibiotic choice.

Antibiotic therapy may be considered if acute bronchitis worsens if a complicating bacterial infection is suspected.[16]

In the UK, the National Institute for Health and Care Excellence (NICE) recommends antibiotics only in patients who are systemically very unwell or at a higher risk of complications (i.e., people with a pre-existing comorbidity; patients ages ≥80 years with one or more of the following, or patients ages ≥65 years with two or more of the following: hospitalization in the past year, current oral corticosteroid use, type 1 or 2 diabetes mellitus, or a history of congestive heart failure).[28]

NICE also recommends that C-reactive protein (CRP) should be ordered after clinical assessment if it is unclear whether antibiotic therapy is needed.[17]​ Antibiotics are not routinely recommended if CRP is <20 mg/L. Delayed antibiotics are recommended if CRP is 20-100 mg/L, and immediate antibiotics are recommended if CRP is >100 mg/L.[17]​​

Delayed prescription can be considered alongside advice on the natural history of the illness and symptomatic treatments.[28] One cohort study found that delayed prescribing may result in a reduced number of repeat consultations for worsening illness.[42] Other studies also support the use of delayed prescribing strategies, as they are associated with substantially reduced clinical adverse outcomes and antibiotic use compared with immediate prescribing.[37][43][44]​​​​ 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.[37]​​​

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 (one-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., older adults, existing comorbidities); however, this should be balanced against potential adverse effects and contribution to the development of resistance.[36] [ Cochrane Clinical Answers logo ] [ Cochrane Clinical Answers logo ]

ONGOING

cough >4 weeks

1st line – evaluate for other causes

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ONGOING
|
cough >4 weeks
1st line – 

evaluate for other causes

Evaluation for other causes of persistent cough should be considered (e.g., asthmatic cough/eosinophilic bronchitis, reflux, postnasal drip syndrome, upper airway cough syndrome, lung cancer).[48]​ The longer the duration of cough, the greater the need for a chest x-ray to rule out lung cancer or other serious pathologies.

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 gastroesophageal reflux disease, an empiric trial with an H2 antagonist or proton-pump inhibitor (PPI) may be warranted.

Consider – bronchodilator

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ONGOING
|
cough >4 weeks
Consider – 

bronchodilator

Treatment recommended for SOME patients in selected patient group

Patients whose cough persists for >4 weeks may benefit from a short-acting beta-agonist (e.g., albuterol), 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.[25][28]

Albuterol can be used for wheezing in patients with persistent symptoms. However, this potential benefit is not well supported by the available data and must be weighed against the adverse effects associated with its use.[25] [ Cochrane Clinical Answers logo ]

Use is associated with reductions in cough frequency at 1 week and overall symptom improvement at 1 week.[50][51]

Combining albuterol with an antibiotic has showed no additional benefit over albuterol alone, although outcomes at >1 week have not been studied.[50]

The treatment benefits must be balanced by the adverse effects of nervousness and tremor, which may be more disruptive to the patient than the underlying cough.

Primary options

albuterol inhaled: 90-180 micrograms (1-2 puffs) every 4-6 hours when required; 2.5 mg nebulized every 4-6 hours when required

Consider – consider immediate or delayed antibiotics

Back
ONGOING
|
cough >4 weeks
|
systemically unwell; high risk of complications
Consider – 

consider immediate or delayed antibiotics

Treatment recommended for SOME patients in selected patient group

Antibiotics are not indicated simply because of a prolonged duration of cough in acute bronchitis, but may be considered in select patients.

Antibiotic therapy should be carefully considered on a case-by-case basis, as they do not provide a clinical benefit for most patients.[36][37]

Less than 10% of acute bronchitis cases have a bacterial cause; however, in instances where a bacterial cause is indicated, the choice of antibiotic will depend on the bacterial pathogen (e.g., Mycoplasma pneumoniae, Chlamydia pneumonia, Bordetella pertussis).[38]​ See Mycoplasma pneumoniae infection, Chlamydia pneumoniae infection, or Pertussis.

Most major regulatory bodies recommend against the use of empiric antibiotic therapy in acute bronchitis. Local guidance should be consulted to aid treatment decisions, including antibiotic choice.

Antibiotic therapy may be considered if acute bronchitis worsens if a complicating bacterial infection is suspected.[16]

In the UK, the National Institute for Health and Care Excellence (NICE) recommends antibiotics only in patients who are systemically very unwell or at a higher risk of complications (i.e., people with a pre-existing comorbidity; patients ages ≥80 years with one or more of the following, or patients ages ≥65 years with two or more of the following: hospitalization in the past year, current oral corticosteroid use, type 1 or 2 diabetes mellitus, or a history of congestive heart failure).[28]

NICE also recommends that C-reactive protein (CRP) should be ordered after clinical assessment if it is unclear whether antibiotic therapy is needed.[17]​ Antibiotics are not routinely recommended if CRP is <20 mg/L. Delayed antibiotics are recommended if CRP is 20-100 mg/L, and immediate antibiotics are recommended if CRP is >100 mg/L.[17]​​

Delayed prescription can be considered alongside advice on the natural history of the illness and symptomatic treatments.[28] One cohort study found that delayed prescribing may result in a reduced number of repeat consultations for worsening illness.[42] Other studies also support the use of delayed prescribing strategies, as they are associated with substantially reduced antibiotic use compared with immediate prescribing.[43][44] 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.[37]​​​

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 (one-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., older adults, existing comorbidities); however, this should be balanced against potential adverse effects and contribution to the development of resistance.[36] [ Cochrane Clinical Answers logo ] [ Cochrane Clinical Answers logo ]

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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