What is the most likely diagnosis for a 63-year-old man with a 2-year history of productive cough, no smoking history, and a history of working in a factory, presenting with vital stability and ronchi on auscultation?

Occupational Chronic Bronchitis (Byssinosis)

The most likely diagnosis is occupational chronic bronchitis (byssinosis), given the 2-year history of productive cough occurring "most days," prolonged factory work exposure, non-smoking status, and presence of ronchi on auscultation. 1

Clinical Reasoning

Why Occupational Chronic Bronchitis is Most Likely

• The patient meets diagnostic criteria for chronic bronchitis: productive cough for at least 3 months per year for 2 consecutive years, which this patient clearly satisfies with "most of the days" over 2 years 1

• The temporal relationship is highly suggestive: symptoms began precisely 2 years ago when he retired from factory work, indicating chronic inflammation persists despite cessation of exposure 1

• Factory exposure is a recognized risk factor: approximately 15% of chronic bronchitis and COPD cases are attributable to occupational exposures, particularly organic dust, cotton, hemp, linen, jute, sisal, and other industrial dusts 2, 1

• Physical examination findings support this diagnosis: ronchi (not wheezes) indicate chronic airway inflammation and mucus hypersecretion, which are hallmark features of chronic bronchitis rather than reversible airway obstruction 1

• Non-smoking status makes this diagnosis more specific: while most COPD is tobacco-related, this patient's lack of smoking history points toward occupational etiology 2

Why Other Options Are Less Likely

Asthma (Option A) is unlikely because:

• The patient lacks typical asthma features such as episodic symptoms, wheezing, dyspnea, or variable airflow obstruction 1
• Ronchi rather than wheezes suggest chronic bronchitis rather than reversible airway obstruction 1
• No history of atopy or marked bronchodilator response is mentioned 2

COPD (Option B) is possible but less precise because:

• COPD diagnosis requires spirometry showing fixed airflow obstruction (FEV1 <80% predicted and FEV1/FVC <70%) which has not been performed 2
• While up to 15% of COPD is occupational, the diagnosis cannot be confirmed without pulmonary function testing 1, 3
• COPD is an umbrella term that encompasses chronic bronchitis, but the specific occupational etiology makes "occupational chronic bronchitis" the most accurate diagnosis 2

Chronic eosinophilic pneumonia (Option C) is unlikely because:

• No systemic symptoms such as fever, weight loss, or night sweats are present 1
• No mention of peripheral eosinophilia or infiltrates on chest X-ray 1
• Clinical presentation does not fit this rare condition

Chronic aspergillosis (Option D) is unlikely because:

• No risk factors mentioned (prior TB, sarcoidosis, or cavitary lung disease)
• Productive cough alone without other features is insufficient
• This diagnosis typically requires imaging and serologic confirmation

Essential Next Steps

Spirometry with bronchodilator testing must be performed to:

• Objectively confirm or exclude fixed airflow obstruction consistent with COPD 2, 3
• Assess severity using FEV1 and FEV1/FVC ratio 2
• Determine if there is any reversible component (>200 mL and 15% increase suggests asthma) 2

Detailed occupational history is critical to:

• Document specific exposures (cotton, hemp, linen, jute, sisal, bagazo, or other organic dusts) 1
• Establish temporal relationship between exposure and symptom onset 4, 5
• Assess eligibility for workers' compensation, as occupational chronic bronchitis is recognized in European occupational disease lists (code 304.02) 1

Chest radiograph should be obtained to:

• Exclude alternative diagnoses such as malignancy, bronchiectasis, or emphysema 2
• Assess for complications or coexisting conditions 2

Management Implications

• Bronchodilator therapy should be initiated if spirometry confirms airflow obstruction, starting with short-acting beta-2 agonists or anticholinergics as needed 2

• Smoking cessation counseling is not applicable but avoidance of further occupational exposures or environmental irritants should be emphasized 2

• Consider corticosteroid trial if moderate to severe airflow obstruction is documented (30 mg prednisolone daily for 2 weeks with pre- and post-spirometry) 2

Critical Pitfalls to Avoid

• Do not diagnose COPD without spirometry: history and physical examination alone are neither sensitive nor specific for diagnosing COPD 3, 6

• Do not miss the occupational link: approximately 15% of COPD cases are occupational, yet this diagnosis is commonly missed by clinicians 1, 4

• Do not assume all chronic bronchitis is smoking-related: occupational exposures are a significant and under-recognized cause 2, 1

• Do not overlook compensation eligibility: early identification allows appropriate advice about occupational mobility and legal compensation, which improves both clinical and socioeconomic outcomes 1, 4