Clinical Practice Guideline for Treatment of Acute Bronchitis

Acute bronchitis consistently ranks as one of the top 10 conditions for which patients seek
medical care, with cough being the most frequently mentioned symptom necessitating office
evaluation. The disorder affects approximately 5% of adults annually, with a higher incidence
observed during the winter and fall.
Even though acute bronchitis is a common diagnosis, its definition is unclear. Acute bronchitis
usually designates an acute respiratory tract infection in which a cough lasting 1-3 weeks, with or
without phlegm, is a predominant feature. Although most physicians consider cough to be
necessary to the diagnosis of acute bronchitis, they vary in additional requirements. Other signs
and symptoms may include sputum production, dyspnea, wheezing, chest pain, fever,
hoarseness, malaise, rhonchi, and rales. Each of these may be present in varying degrees or may
be absent altogether. Sputum may be clear, white, yellow, green, or even tinged with blood.
Peroxidase released by the leukocytes in sputum causes the color changes; hence, color alone
should not be considered indicative of bacterial infection. Leukocytosis is present in about 20%
of patients; significant leukocytosis is more likely with a bacterial infection than with bronchitis.
The evaluation of adults with an acute cough illness or a presumptive diagnosis of uncomplicated
acute bronchitis should focus on ruling out serious illness, including asthma, exacerbation of
COPD, heart failure, or pneumonia. In healthy, non-elderly adults, pneumonia is uncommon in
the absence of vital sign abnormalities or asymmetrical lung sounds, and chest radiography is
usually not indicated. In patients with cough lasting 3 weeks or longer, chest radiography may
be warranted in the absence of other known causes. Fever and hemoptysis are important
additional factors that likely point to more than a “viral” cause to acute bronchitis and would
likely indicate at least a chest radiograph, and possibly antibiotic, antitussive or anti-
inflammatory therapy.
Viruses are usually considered the cause of acute bronchitis. The most commonly identified
viruses are Rhinovirus, Enterovirus, Influenza A and B, Parainfluenza, Coronavirus, Human
Metapneumovirus, and RSV. Bacteria are detected in 1% to 10% of cases of acute bronchitis.
Atypical bacteria, such as Mycoplasma pneumoniae, Chlamydophila pneumoniae, and Bordetella
Pertussis, are rare causes of acute bronchitis. Routine antibiotic treatment of uncomplicated
acute bronchitis is not recommended, regardless of duration of cough. According to the 2001
guidelines of the American College of Physicians, for the treatment of uncomplicated acute
bronchitis, antibiotic treatment is not recommended, regardless of duration of cough. In the 2006
guidelines of the American College of Chest Physicians (ACCP) the recommendations for
treating acute bronchitis reiterates routine treatment with antibiotics is not justified,
antitussive agents are only occasionally useful, and there is no routine role for inhaled
bronchodilators (except in select patients) or mucolytic agents.

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Inappropriate antibiotic treatment of adults with acute bronchitis is of clinical concern, especially
since misuse and overuse of antibiotics lead to drug resistance. Antibiotics have also been
shown to provide only minimal benefit, reducing the cough or illness by about half a day, and
have adverse effects, including allergic reactions, nausea and vomiting, and Clostridium Difficile
infection. Life-threatening complications of upper respiratory tract infections are rare.
Patient satisfaction with care for acute bronchitis depends most on physician-patient
communication rather than on antibiotic treatment. Physicians should be sure to explain the
diagnosis and treatment of acute bronchitis. It may be helpful to refer to acute bronchitis as
a“chest cold”. The physician should also discuss realistic expectations about the clinical course.

Explain to the patient to expect to have a cough for 10-14 days after the visit. They need to
know that antibiotics are probably not going to be beneficial and that treatment with antibiotics is
associated with significant risks and side effects. If the patient cannot sleep due to cough,
antitussive therapy such as codeine, dextromethorphan, and benzonatate may be helpful.
Consider using expectorants such as guaifenesin, or honey to manage acute bronchitis symptoms.
Avoid using inhaled beta2 agonists for the routine treatment of acute bronchitis unless wheezing
is present

Management of Acute Bronchitis

Patient with cough and chest symptom
consistent with acute bronchitis

Is the bronchitis complicated

(hx of pulmonary disease, hx of smoking, ect) ?

No Yes

History and physical examination;

History and physical examination to rule consider chest radiography, pulmonary
out consolidation or other causes of cough function testing, peak flow
measurement, sputum culture;
consider antibiotic therapy

Acute bronchitis? No Treat cause of cough.

Yes

Treat with expectorant, specific or nonspecific antitussives,

or bronchodilators as symptoms dictate; discuss follow-up.

Symptoms persists for two-three weeks or more despite appropriate treatment of symptoms *

*-- After two weeks, 26 percent of patients with acute bronchitis are still coughing. Some studies
recommend waiting 30 days before changing therapy.
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 Figure 1. Algorithm for the treatment of patients with acute bronchitis.

References
 American Family Physician: “Acute Bronchitis” SCOTT KINKADE, MD, MSPH, and
NATALIE A. LONG, MD, University of Missouri School of Medicine, Columbia,
Missouri 2016 Oct 1;94(7):560-565.
● American Family Physician: “Diagnosis and Management of Acute Bronchitis”.
Vol.65/No. 10 (May 15, 2002).
● Annals of Internal Medicine: “Principles of Appropriate Antibiotic Use for Treatment of
Uncomplicated Acute Bronchitis: Background”. 20 March 2001, Volume 134, Issue 6,
Pages 521-529.
● Annals of Internal Medicine: “Uncomplicated Acute Bronchitis”. 19 December 2000,
Volume 133, Issue 12, Pages 981-991.
● The New England Journal of Medicine: “Acute Bronchitis”. 16 November 2006,
Volume 355, No. 20, Pages 2125-2130.

Original: 08/07 Reviewed: 12/11 Reviewed: 01/18

Reviewed: 10/08 Revised: 12/12 Revised: 06/20
Reviewed: 10/09 Reviewed: 07/14
Reviewed: 12/10 Reviewed: 04/16

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