Management of Frequent Respiratory Illnesses in a 53-Year-Old Female
The priority is to evaluate for underlying chronic lung disease, particularly asthma or COPD, as up to 45% of patients presenting with recurrent acute cough actually have undiagnosed chronic airways disease that requires different treatment than recurrent infections. 1
Initial Diagnostic Approach
The first critical step is distinguishing whether symptoms represent true recurrent infections versus exacerbations of underlying chronic lung disease masquerading as infections. 1
Key Clinical Features Suggesting Underlying Chronic Airways Disease
Perform lung function testing (spirometry) if the patient has at least two of the following: 1
- Wheezing on examination
- Prolonged expiration
- History of smoking
- Symptoms of allergy
- Female sex (which has predictive value for asthma/COPD) 1
This is particularly important because β-agonists and inhaled corticosteroids are beneficial for exacerbations of chronic lung disease but not for simple viral infections. 1
Exclude Non-Infectious Causes
Before attributing symptoms to recurrent infections, systematically rule out: 1
Pulmonary embolism - Consider if patient has: 1
- History of deep venous thrombosis or prior pulmonary embolism
- Immobilization in past 4 weeks
- Malignant disease
- Pulse >100 bpm
- Hemoptysis
Aspiration pneumonia - Especially if patient has: 1
- Difficulty swallowing
- History of cerebrovascular events
- Certain psychiatric conditions
Heart failure - Evaluate for cardiac causes of dyspnea and cough 1
Differentiation Between Pneumonia and Bronchitis
When acute respiratory symptoms occur, distinguish between pneumonia (requiring antibiotics) and acute bronchitis (typically viral, not requiring antibiotics): 1
Pneumonia is more likely if: 1
- New focal chest signs on examination
- Dyspnea
- Tachypnea
- Heart rate >100 bpm
- Fever >4 days duration
- C-reactive protein >100 mg/L (if available)
Pneumonia is unlikely if: 1
- Absence of tachycardia (HR <100)
- Absence of tachypnea (RR <24)
- Temperature <38°C
- No focal consolidation, egophony, or fremitus on chest examination
- C-reactive protein <20 mg/L with symptoms >24 hours
The gold standard for pneumonia diagnosis is chest radiograph. 1
Management Algorithm
If Chronic Lung Disease is Identified (Asthma/COPD):
Initiate controller therapy: 1, 2
- Inhaled corticosteroids (e.g., fluticasone) for regular use 3
- Long-acting bronchodilators (β-agonists and/or anticholinergics) 1
- Short-acting β-agonists (albuterol) for rescue use 4
For exacerbations, treat with: 1
- Increased bronchodilator therapy
- Systemic corticosteroids
- Antibiotics only if meeting criteria (see below)
If Recurrent True Infections Without Underlying Lung Disease:
Consider immunocompromised state: 5, 6
- Respiratory viral infections occur frequently in immunocompromised patients (27% of respiratory illness episodes in one study) 5
- Evaluate for underlying immune deficiency, diabetes, malignancy, or immunosuppressive medications 5, 6
Diagnostic workup for recurrent infections: 5, 6
- Bronchoscopy with bronchoalveolar lavage if infections are severe or recurrent
- Testing for bacterial, viral, and fungal pathogens 5, 6
- Consider autoimmune evaluation if no infectious cause identified 7
Common Pitfalls to Avoid
Do not assume all respiratory symptoms are infections - A substantial portion (up to 45%) of patients diagnosed with acute bronchitis actually have asthma or COPD. 1
Do not routinely prescribe antibiotics for acute bronchitis - Most cases are viral and do not benefit from antibiotics unless pneumonia is confirmed. 1
Do not overlook the possibility of multiple simultaneous processes - Patients can have both upper and lower respiratory tract infections simultaneously, or infection triggering exacerbation of underlying lung disease. 1
In middle-aged women with chronic cough, consider idiopathic chronic cough syndrome - This predominantly affects middle-aged women, often starts around menopause, and may be associated with autoimmune conditions (particularly hypothyroidism in up to 30% of cases). 1
Specific Treatment Considerations
For confirmed bacterial pneumonia: 1
- Initiate appropriate antibiotics based on severity and risk factors
- Chest radiograph is the gold standard for diagnosis
For viral respiratory infections: 5
- Supportive care is primary treatment
- Influenza-specific antivirals if influenza is confirmed and within appropriate time window
For exacerbations of chronic lung disease: 1
- Increase bronchodilator frequency
- Add systemic corticosteroids
- Antibiotics only if increased dyspnea, increased sputum volume, AND purulent sputum are present