Diagnosing Bronchitis

Acute Bronchitis Diagnosis

The American College of Chest Physicians recommends that acute bronchitis be diagnosed clinically based on acute cough with or without sputum production, and routine diagnostic testing should not be performed 1, 2
A chest radiograph can be safely avoided if all four of the following are absent: heart rate >100 beats/min, respiratory rate >24 breaths/min, oral temperature >38°C, and chest examination findings of focal consolidation, egophony, or fremitus 1, 2
If any of these findings are present, obtain a chest radiograph to evaluate for pneumonia, particularly in elderly patients who may present with fewer respiratory symptoms despite having pneumonia 1
For typical acute bronchitis, do not obtain viral cultures, serologic assays, sputum analyses, or chest radiographs (if pneumonia criteria are absent) 1, 2
Purulent sputum does not distinguish between pneumonia and acute bronchitis 1, 2

Chronic bronchitis is diagnosed when a patient has chronic cough and sputum production occurring most days for at least 3 months per year for 2 consecutive years, after excluding other respiratory or cardiac causes 2, 3
Obtain a complete exposure history, including cigarette, cigar, and pipe smoking, which is responsible for 85-90% of cases, as well as passive smoke exposure and occupational and home environmental hazards 2, 3, 4
Patients with stable chronic bronchitis who develop sudden worsening should be considered to have an acute exacerbation if they have increased cough, sputum production, or purulence, and often preceded by upper respiratory infection symptoms 2, 3
Reserve antibiotics for exacerbations only in patients with at least one cardinal symptom (increased dyspnea, sputum production, or purulence) and one risk factor (age ≥65 years, FEV1 <50% predicted, or comorbidities) 1, 2, 3

The American Academy of Pediatrics recommends against routinely obtaining chest radiographs, laboratory studies, or RSV testing in children with bronchiolitis, as these tests do not alter management and may lead to inappropriate antibiotic prescribing 2, 4, 6
Bronchiolitis is diagnosed by identifying age <2 years, viral upper respiratory prodrome, lower respiratory signs (tachypnea, wheezing, rales, cough), and increased respiratory effort (grunting, nasal flaring, intercostal/subcostal retractions) 4, 6
Assess for risk factors for severe disease, including age <12 weeks, prematurity, hemodynamically significant congenital heart disease, chronic lung disease, immunodeficiency, and in utero smoke exposure 4, 5
Count respiratory rate for full 60 seconds, and tachypnea ≥70 breaths/minute suggests increased risk of severe disease 4
Serial observations over time are necessary, and assess effects on feeding, hydration, and mental status 4, 5