How do you differentiate and treat Upper Respiratory Infection (URI) versus bronchitis?

Differentiating and Treating Upper Respiratory Infection (URI) versus Bronchitis

For most cases of URI and acute bronchitis, symptomatic treatment is recommended as both conditions are primarily viral in origin, with antibiotics generally not indicated except in specific circumstances. 1, 2

Differentiation Between URI and Bronchitis

Clinical Features

Feature	Upper Respiratory Infection (URI)	Acute Bronchitis
Location	Primarily affects nose, throat, sinuses	Affects trachea and large airways
Cough	Present but less prominent	Predominant symptom
Sputum	Less common, usually clear	More common, often productive [3]
Duration	Typically 7-10 days	Typically 2-3 weeks [4,2]
Lung Exam	Usually normal	More likely to have abnormal findings [3]
Associated Symptoms	Rhinorrhea, sore throat, nasal congestion	May have wheezing, chest discomfort

Key Diagnostic Considerations

• Rule out pneumonia: Consider pneumonia if patient has tachypnea, tachycardia, dyspnea, or abnormal lung findings; chest radiography is warranted in these cases 5
• Consider pertussis: If cough persists >2 weeks with paroxysmal cough, whooping, or post-tussive emesis 5
• Evaluate for asthma: Consider in patients with persistent cough (>2-3 weeks), especially with nocturnal worsening or triggers like cold air/exercise 4

Treatment Approach

Upper Respiratory Infection (URI)

1. Symptomatic management:

   • Adequate hydration to thin secretions
   • Acetaminophen or NSAIDs for fever or pain
   • First-generation antihistamines may help with URI-induced cough 1

2. Antibiotics:

   • Not recommended for uncomplicated URIs 6
   • Consider only if:
     • Patient is systemically very unwell
     • Features suggest serious illness/complications
     • Pre-existing comorbidities increase risk
     • Age >65 with acute cough and risk factors
     • Three or more Centor criteria for pharyngitis 6

Acute Bronchitis

1. First-line treatment:

   • Inhaled ipratropium bromide is recommended as the most effective pharmacologic intervention for cough suppression 4, 1
   • Adequate hydration and rest 1

2. Additional symptomatic options:

   • Guaifenesin (200-400 mg every 4 hours) may help with mucus-related symptoms 1
   • For short-term symptomatic relief:
     • Peripheral cough suppressants (levodropropizine, moguisteine) 4
     • Central cough suppressants (codeine, dextromethorphan) may provide short-term relief 4

3. Antibiotics:

   • Not recommended for uncomplicated acute bronchitis 4, 1, 2
   • Only consider if:
     • Pertussis is suspected (to reduce transmission)
     • Patient is at increased risk of pneumonia (e.g., age ≥65) 2
     • Patient has chronic bronchitis with an acute exacerbation meeting Anthonisen criteria (at least 2 of: increased dyspnea, increased sputum volume, increased sputum purulence) 4, 1

Common Pitfalls to Avoid

1. Misinterpreting sputum color: The presence of colored (e.g., green) sputum does not reliably differentiate between bacterial and viral infections 4, 2

2. Overuse of antibiotics: Viruses cause >90% of acute bronchitis cases; antibiotics provide minimal benefit (reducing illness by only about half a day) while risking adverse effects 2, 5

3. Inadequate patient education: Failure to inform patients that:

   • Cough from bronchitis typically lasts 2-3 weeks regardless of treatment 1, 5
   • Symptoms of URI follow predictable patterns (Figure 1 in 4)
   • Most URIs are self-limiting and resolve within 7-10 days 7

4. Missing red flags requiring further evaluation:

   • Persistent fever (≥39°C) for >3 days
   • Worsening symptoms after initial improvement
   • Symptoms persisting >10 days without improvement
   • Development of dyspnea or respiratory distress 1

By understanding these differences and following evidence-based treatment approaches, unnecessary antibiotic use can be reduced while still providing effective symptom management for patients with URI and bronchitis.