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 minimising symptoms until the illness resolves. For many patients with a minimal cough that does not disrupt daily activity 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.

Consider – antipyretic

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ACUTE
|
cough ≤4 weeks
Consider – 

antipyretic

Additional treatment recommended for SOME patients in selected patient group

An antipyretic may be helpful for patient comfort if fever is present.

Primary options

paracetamol: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

Consider – short-acting beta-agonist bronchodilator

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ACUTE
|
cough ≤4 weeks
Consider – 

short-acting beta-agonist bronchodilator

Additional treatment recommended for SOME patients in selected patient group

Salbutamol 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.[18] [ Cochrane Clinical Answers logo ] In the UK, the National Institute for Health and Care Excellence does not recommend an oral or inhaled bronchodilator unless the patient has an underlying airways disease (e.g., asthma).[19]

Use is associated with reductions in cough frequency at 1 week and overall symptom improvement at 1 week.[34][35] Combining salbutamol with an antibiotic has showed no additional benefit over salbutamol alone, although outcomes at >1 week have not been studied.[34] 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

salbutamol: 100-200 micrograms (1-2 puffs) inhaled every 4-6 hours when required; 2.5 mg nebulised every 4-6 hours when required

Consider – antitussive

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ACUTE
|
cough ≤4 weeks
Consider – 

antitussive

Additional treatment recommended for SOME patients in selected patient group

May be effective for acute management of severe cough. Antitussives are often combined with other agents such as guaifenesin (an expectorant) or antihistamines, but these are of unproven benefit in acute bronchitis. Codeine and dextromethorphan have potential for abuse and dependence.[20]

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]

Primary options

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

OR

codeine phosphate: 15-30 mg orally 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

Most major regulatory bodies recommend against the use of empirical antibiotic therapy in acute bronchitis. 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]

In the UK, the National Institute for Health and Care Excellence (NICE) recommends antibiotics only in patients who are systemically unwell or at a higher risk of complications (i.e., people with a pre-existing comorbidity; 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 2 diabetes, or a history of congestive heart failure.[19]

NICE also recommends that C-reactive protein (CRP) be used to guide therapy if after clinical assessment a diagnosis of pneumonia has not been made. 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]

Delayed prescription can be considered alongside advice on the natural history of the illness and symptomatic treatments.[19] One cohort study 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]​​

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] [ 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 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.

Consider – short-acting beta-agonist bronchodilator

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ONGOING
|
cough >4 weeks
Consider – 

short-acting beta-agonist bronchodilator

Additional treatment recommended for SOME patients in selected patient group

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]

Salbutamol 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.[18] [ Cochrane Clinical Answers logo ]

Use is associated with reductions in cough frequency at 1 week and overall symptom improvement at 1 week.[34][35]

Combining salbutamol with an antibiotic has showed no additional benefit over salbutamol alone, although outcomes at >1 week have not been studied.[34]

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

salbutamol inhaled: 100-200 micrograms (1-2 puffs) inhaled every 4-6 hours when required; 2.5 mg nebulised 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

Additional 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.

Most major regulatory bodies recommend against the use of empirical antibiotic therapy in acute bronchitis. 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]

In the UK, the National Institute for Health and Care Excellence (NICE) recommends antibiotics only in patients who are systemically unwell or at a higher risk of complications (i.e., people with a pre-existing comorbidity; 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 2 diabetes, or a history of congestive heart failure.[19]

NICE also recommends that C-reactive protein (CRP) be used to guide therapy if after clinical assessment a diagnosis of pneumonia has not been made. 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]

Delayed prescription can be considered alongside advice on the natural history of the illness and symptomatic treatments.[19] One cohort study 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]​​

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] [ 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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