Approach Considerations
Therapy is generally focused on alleviation of symptoms.Toward this goal, a doctor may prescribe a combination of medications that open obstructed bronchial airways and thin obstructive mucus so that it can be coughed up more easily. Care for acute bronchitis is primarily supportive and should ensure that the patient is oxygenating adequately. Bed rest is recommended.
The most effective means for controlling cough and sputum production in patients with chronic bronchitis is the avoidance of environmental irritants, especially cigarette smoke.
Also see Pediatric Bronchitis.
Symptomatic Treatment
Based on 2006 American College of Chest Physicians (ACCP) guidelines, [12, 13] central cough suppressants such as codeine and dextromethorphan are recommended for short-term symptomatic relief of coughing in patients with acute and chronic bronchitis. [14]
Also based on 2006 ACCP guidelines, therapy with short-acting beta-agonists ipratropium bromide and theophylline can be used to control symptoms such as bronchospasm, dyspnea, and chronic cough in stable patients with chronic bronchitis. For this group, treatment with a long-acting beta-agonist, when coupled with an inhaled corticosteroid, can be offered to control chronic cough.
For patients with an acute exacerbation of chronic bronchitis, therapy with short-acting agonists or anticholinergic bronchodilators should be administered during the acute exacerbation. In addition, a short course of systemic corticosteroid therapy may be given and has been proven to be effective.
In acute bronchitis, treatment with beta2-agonist bronchodilators may be useful in patients who have associated wheezing with cough and underlying lung disease. Little evidence indicates that the routine use of beta2-agonists is otherwise helpful in adults with acute cough. [15]
Nonsteroidal anti-inflammatory drugs are helpful in treating constitutional symptoms of acute bronchitis, including mild-to-moderate pain. Albuterol and guaifenesin products treat cough, dyspnea, and wheezing.
In patients with chronic bronchitis or chronic obstructive pulmonary disease (COPD), treatment with mucolytics has been associated with a small reduction in acute exacerbations and a reduction in the total number of days of disability. This benefit may be greater in individuals who have frequent or prolonged exacerbations. [16] Mucolytics should be considered in patients with moderate-to-severe COPD, especially in the winter months. [3]
Antibiotic Therapy
Among otherwise healthy individuals, antibiotics have not demonstrated any consistent benefit in the symptomatology or natural history of acute bronchitis. [17, 18] Most reports have shown that 65-80% of patients with acute bronchitis receive an antibiotic despite evidence indicating that, with few exceptions, they are ineffective. [19, 20] An exception is with cases of acute bronchitis caused by suspected or confirmed pertussis infection.
The most recent recommendations on whether to treat patients with acute bronchitis with antibiotics are from the National Institute for Health and Clinical Excellence in the United Kingdom. They recommend not treating acute bronchitis with antibiotics unless a risk of serious complications exists because of comorbid conditions. Antibiotics, however, are recommended in patients older than 65 years with acute cough if they have had a hospitalization in the past year, have diabetes mellitus or congestive heart failure, or are on steroids. [21]
In patients with acute exacerbations of chronic bronchitis, the use of antibiotics is recommended. Trials have shown that antibiotics improve clinical outcomes in such cases, including a reduction in mortality. [22, 23]
A meta-analysis found no difference in treatment success for acute exacerbations of chronic bronchitis with macrolides, quinolones, or amoxicillin/clavulanate. [24] Another meta-analysis comparing the effectiveness of semisynthetic penicillins to trimethoprim-based regimens found no difference in treatment success or toxicity. [25] These findings support earlier studies that have shown antibiotics to be useful in exacerbations of chronic bronchitis, regardless of the agent used.
In addition, a short course of antibiotics (5 d) is as effective as the traditional longer treatments (>5 d) in these patients. [26] Patients with severe exacerbations and those with more severe airflow obstruction at baseline are the most likely to benefit. In stable patients with chronic bronchitis, long-term prophylactic therapy with antibiotics is not indicated.
Influenza Vaccinations
The influenza vaccine may reduce the incidence of upper respiratory tract infections and, subsequently, reduce the incidence of acute bacterial bronchitis. The influenza vaccine may be less effective in preventing illness than it is in preventing serious complications and death. [27]
Influenza vaccine provides reasonable protection against immunized strains. The vaccination becomes effective 10-14 days after administration. Specific recommendations for individuals who should be immunized can be obtained from the CDC, which publishes regular updates of this information (see Seasonal Influenza Vaccination Resources for Health Professionals).
Zinc
Several studies have shown conflicting results on the use of zinc as an adjunct treatment against influenza A. Most studies demonstrated favorable results, but participants complained of a bad taste and significant nausea.
On June 16, 2009, the US Food and Drug Administration (FDA) issued a public health advisory and notified consumers and health care providers to discontinue use of intranasal zinc products. The intranasal zinc products (Zicam Nasal Gel/Nasal Swab products by Matrixx Initiatives) are herbal cold remedies that claim to reduce the duration and severity of cold symptoms and are sold without a prescription. The FDA received more than 130 reports of anosmia (inability to detect odors) associated with intranasal zinc. Many of the reports described the loss of the sense of smell with the first dose. [28]
Consultations
Primary care providers can usually treat acute bronchitis unless severe complications occur or the patient has underlying pulmonary disease or immunodeficiency. Pulmonary medicine specialists and infectious disease specialists also may need to be consulted.
Long-Term Monitoring
Routine follow-up care is usually not necessary. If symptoms worsen (eg, shortness of breath, high fever, vomiting, persistent cough), consider an alternative diagnosis. If symptoms recur (> 3 episodes/y), further investigation is recommended. If symptoms persist beyond 1 month, reassess patient for other causes of cough.
