Diagnosing and Managing Acute Respiratory Infections in Elderly Patients

Clinical Presentation and Diagnosis

The American College of Chest Physicians recommends differentiating acute bronchitis from acute nasopharyngitis in elderly patients with chronic respiratory disease by the predominance of lower respiratory symptoms, specifically cough as the primary complaint lasting up to 3 weeks, versus upper respiratory symptoms of nasal stuffiness, discharge, sneezing, and sore throat that characterize nasopharyngitis 1, 2
Acute nasopharyngitis presents with nasal stuffiness and discharge as hallmark symptoms, sneezing and sore throat predominating, and cough present in up to 83% within the first 2 days, but as a secondary symptom 1
Acute bronchitis presents with cough as the predominant manifestation, with or without sputum production, and cough lasting up to 3 weeks 1, 2

The American College of Chest Physicians recommends ruling out pneumonia first by excluding it if any of the following are present: heart rate >100 beats/min, respiratory rate >24 breaths/min, oral temperature >38°C, or focal chest examination findings (consolidation, egophony, fremitus) 3
Consider lung function testing if at least two of the following are present: wheezing, prolonged expiration, smoking history, or symptoms of allergy, to identify masked asthma or COPD exacerbation 4, 5

The American College of Chest Physicians recommends that antibiotics are not indicated for routine acute bronchitis and should not be offered, as viruses cause >90% of acute bronchitis and antibiotics may decrease cough duration by only 0.5 days while exposing patients to adverse effects 3
Supportive care and symptom management are recommended for nasopharyngitis, with an expected duration of symptoms typically resolving within 2 weeks, and no antibiotics indicated 1

Obtain chest radiograph (PA and lateral views) if any vital sign abnormalities or focal findings are present to exclude pneumonia 3
Consider CRP testing, as <20 mg/L makes pneumonia highly unlikely and >100 mg/L makes it likely 6
No routine microbiological testing, cultures, or sputum analysis in primary care for acute bronchitis or nasopharyngitis 6, 7

The American College of Chest Physicians recommends differentiating acute bronchitis from asthma by identifying whether cough is a new, self-limited symptom lasting less than 3 weeks (acute bronchitis) versus recurrent episodes of dyspnea, wheeze triggered by allergens, or symptoms persisting beyond 3 weeks (asthma) 8
May have transient wheezing or airflow obstruction that resolves within 6 weeks in approximately 40% of patients 8
No history of recurrent similar episodes 8
Recurrent attacks of respiratory symptoms rather than isolated episodes 8
Symptoms persisting beyond 3 weeks suggest asthma rather than acute bronchitis 8, 9
Wheezing as a prominent feature 10
Prolonged expiration on examination is a predictor of asthma 10
History of allergy is a predictor of asthma 10
Up to 45% of patients with acute cough lasting more than 2 weeks actually have asthma or COPD 10
Reversibility of FEV1 greater than 15% has been demonstrated in 17% of patients with presumed acute bronchitis, suggesting underlying reactive airway disease 8

Approximately 40% of previously healthy individuals with acute viral respiratory infections develop transient airflow obstruction and bronchial hyperresponsiveness that resolves within 6 weeks 8
Patients with multiple episodes of presumed acute bronchitis over time likely have undiagnosed asthma with recurrent exacerbations rather than repeated infections 8

Beta-agonists and steroids are beneficial for asthma exacerbations but not indicated for routine acute bronchitis 10