What is the complete history and physical examination for diagnosing and managing acute bronchitis, Chronic Obstructive Pulmonary Disease (COPD), and emphysema?

Complete History and Physical Examination for Acute Bronchitis, COPD, and Emphysema

History Taking

Key Presenting Symptoms to Document

For Acute Bronchitis:

• Acute cough (with or without sputum production) lasting less than 3 weeks is the hallmark symptom 1
• Preceding viral upper respiratory prodrome (rhinorrhea, sore throat) 1
• Absence of fever >4 days, dyspnea, tachypnea, or pulse >100 (which would suggest pneumonia rather than bronchitis) 2
• Duration of symptoms—acute bronchitis is self-limiting, typically resolving within 2-3 weeks 1

For COPD/Emphysema:

• Progressive dyspnea that worsens with exercise and persists over time is the cardinal symptom 3
• Chronic cough (may be intermittent and unproductive) 3
• Chronic sputum production for ≥3 months in 2 consecutive years (classic definition of chronic bronchitis component) 3
• Wheezing and chest tightness that varies between days 3
• Recurrent "winter colds" or lower respiratory tract infections 3
• In severe disease: fatigue, weight loss, anorexia 3
• Exercise tolerance—document specific limitations with daily activities 3

Essential Risk Factor Assessment

Smoking History (Critical for COPD):

• Document pack-years: >40 pack-years is the best predictor of airflow obstruction; >55 pack-years with wheezing essentially confirms it 4
• Current smoking status and willingness to quit 3
• Environmental tobacco smoke exposure 3

Occupational and Environmental Exposures:

• Smoke from home cooking and heating fuels 3
• Occupational dusts, vapors, fumes, gases 3

Past Medical History:

• Asthma, allergy, sinusitis, nasal polyps 3
• Childhood respiratory infections 3
• Previous hospitalizations for respiratory disorders 3
• History of prematurity (if applicable) 3

Comorbidities:

• Heart disease, osteoporosis, musculoskeletal disorders, malignancies 3
• Immunodeficiency states 3

Exacerbation History:

• Frequency of exacerbations (≥2 per year defines "frequent exacerbator" phenotype) 3
• Previous hospitalizations for exacerbations 3

Functional Impact:

• Limitation of daily activities 3
• Missed work and economic impact 3
• Depression or anxiety symptoms 3
• Social and family support 3

Physical Examination

Vital Signs and General Appearance

Acute Bronchitis:

• Vital signs are typically normal; fever >4 days suggests pneumonia, not bronchitis 2
• Respiratory rate usually normal 1

COPD/Emphysema:

• Respiratory rate (tachypnea in severe disease) 3
• Oxygen saturation at rest and with exertion 3
• Weight, height, BMI (weight loss common in advanced disease) 3
• Assess breathlessness using modified Medical Research Council (mMRC) dyspnea scale 3

Respiratory Examination

Inspection:

• Signs of chronic hyperinflation: increased anteroposterior chest diameter ("barrel chest"), decreased cricosternal distance, loss of cardiac dullness 3
• Use of accessory muscles, intercostal/subcostal retractions 3
• Nasal flaring 3
• Pursed-lip breathing (in severe COPD) 3

Palpation:

• Decreased chest expansion 3

Percussion:

• Hyperresonance (positive likelihood ratio >5.0 for COPD when combined with diminished breath sounds) 3

Auscultation:

• Diminished breath sounds (positive likelihood ratio >5.0 for COPD) 3
• Wheezes/rhonchi (especially on forced expiration) 3
• Prolonged expiratory phase 3
• Crackles/rales 3
• Quiet breath sounds become apparent as COPD progresses; normal examination is common in mild disease 3

Cardiovascular Examination (for COPD/Emphysema)

• Central cyanosis (indicates hypoxemia, though absence doesn't exclude it) 3
• Peripheral edema (suggests cor pulmonale) 3
• Raised jugular venous pressure 3
• Right ventricular heave 3
• Loud pulmonary second heart sound 3
• Tricuspid regurgitation murmur 3
• Bounding pulse (may indicate hypercapnia) 3

Neurological Signs (for severe COPD)

• Flapping tremor/asterixis (indicates hypercapnia) 3
• Drowsiness or altered mental status (hypercapnia) 3

Diagnostic Confirmation

When Physical Examination is NOT Diagnostic

Acute Bronchitis:

• Acute bronchitis is a clinical diagnosis; diagnostic testing (chest X-ray, laboratory studies) should NOT be obtained routinely 1
• Order chest X-ray only if pneumonia is suspected (new focal chest signs, dyspnea, tachypnea, pulse >100, fever >4 days) 2

COPD/Emphysema:

• Physical examination is rarely diagnostic and physical signs are usually not identifiable until significantly impaired lung function is present 3
• Spirometry is REQUIRED to establish the diagnosis—it is the most reproducible and objective measurement 3, 4
• Post-bronchodilator FEV1/FVC <0.70 confirms airflow limitation consistent with COPD 3, 4
• Chest radiography should be performed during initial evaluation to exclude other diseases, but is frequently normal in early COPD 3

Severity Classification (COPD)

Based on Post-Bronchodilator Spirometry:

• Mild: FEV1/FVC <0.70 and FEV1 ≥80% predicted 4
• Moderate: FEV1/FVC <0.70 and FEV1 50-79% predicted 4
• Severe: FEV1/FVC <0.70 and FEV1 30-49% predicted 4
• Very severe: FEV1/FVC <0.70 and FEV1 <30% predicted 4

Critical Pitfalls to Avoid

• Do not rely solely on clinical examination to rule out pneumonia in acute bronchitis—physical signs may be normal or non-specific 2
• Do not diagnose COPD without objective spirometric confirmation 3, 4
• Do not order antibiotics for acute bronchitis—they decrease cough duration by only 0.5 days while exposing patients to adverse effects 1
• The fixed FEV1/FVC ratio of 0.70 may overdiagnose COPD in patients >60 years and underdiagnose in those <45 years 4
• Do not use frequent repeat spirometry to guide treatment in stable COPD—base adjustments on symptoms, exacerbation frequency, and functional status 4