Definition
A.Pneumonia is inflammation and consolidation of lung tissue due to a bacterial pathogen. The causative agent and the anatomic location classify pneumonia. It is not uncommon to have acute viral and bacterial pneumonia concurrently.
B.Other types of pneumonia and pulmonary inflammation occur secondary to smoking, exposure to chemicals or fungi, near drowning, and recurrent aspiration with gastroesophageal reflux.
C.Hospitalization is recommended in severe cases of pneumonia.
D.The Pneumonia Severity Index Calculator is a tool to estimate pneumonia mortality and assist in determining whether the patient should best be treated in the inpatient or outpatient setting. See https://www.mdcalc.com/psi-port-score-pneumonia-severity-index-cap.
Incidence
A.Pneumonia is a leading cause of death for patients older than 65 years.
B.Bacterial pneumonia is more prevalent in the very old and very young.
C.A higher mortality rate occurs in persons with immunodeficiency, comorbid conditions, abnormal vital signs, and virulent pathogens.
D.The incidence rate also varies by pathogens.
Pathogenesis
A.Pneumonia results from inflammation of the alveolar space. Lobar pneumonia has four stages:
1.Vascular congestion and alveolar edema within the first 24 hours of infection.
2.Red hepatization (2–3 days), characterized by erythrocytes, neutrophils, and fibrin within the alveoli.
3.Gray hepatization (2–3 days), characterized by a gray-brown to yellow color secondary to exudate.
4.Resorption and restoration of the pulmonary architecture. A rub may still be auscultated due to the fibrinous inflammation.
B.Bacterial causes include Streptococcus pneumoniae (the most common pathogen), Hib (the second most common pathogen), Staphylococcus aureus, Legionella, Chlamydia trachomatis, Chlamydia pneumoniae, Mycoplasma pneumoniae, Pseudomonas, Klebsiella, and Pneumocystis jiroveci pneumonia (PCP) in patients with HIV.
Predisposing Factors
A.Advanced age.
B.Impaired mentation.
C.Smoking.
D.Chronic obstructive pulmonary disease (COPD).
E.Alcoholism.
F.Aspiration.
G.Heart failure.
H.Diabetes.
I.Heart disease.
J.Crowded conditions (dormitories, long-term care centers).
K.Immunodeficiency.
L.Congenital anomalies.
M.Abnormal mucus clearance.
N.Lack of immunization.
O.Measles.
P.Indoor air pollutants from cooking or heating with wood.
Q.History of pneumonia.
R.Lung cancer.
Common Complaints
Acute onset of these symptoms:
A.Fever.
B.Shaking chills.
C.Dyspnea, rapid, labored breathing.
D.Cough.
E.Rust-colored sputum.
Other Signs and Symptoms
A.Increased respiratory rate (tachypnea).
B.Chest pain, localized.
C.Upper respiratory infection (URI) symptoms such as pharyngitis.
D.Headache.
E.Nausea.
F.Vomiting.
G.Vague abdominal pain.
H.Diarrhea.
I.Myalgia.
J.Arthralgias.
K.Anorexia.
L.Change in level of consciousness (LOC), including confusion.
Subjective Data
A.Determine the onset, duration, and course of illness.
B.Has the patient had fever or shaking chills?
C.Has there been breathing trouble? Are the breathing problems interfering with eating and drinking?
D.If diabetic, take home blood sugar readings.
E.Is there a cough? Is the cough productive? What color is the sputum?
F.Are any other family members ill?
G.Has the patient ever been hospitalized for pneumonia or respiratory distress before?
H.Review the history for any chronic diseases.
I.Has the patient ever been immunized for influenza or pneumonia?
J.Review all medications, including over-the-counter (OTC) and herbal products. Specifically review whether the patient has been on any antibiotics in the past 3 months. Recent exposure to an antibiotic is a risk factor for antibiotic resistance. Continued or repeated use of that class of antibiotics is not recommended.
K.Ask about change in sexual partners (including elderly) for risk of HIV or chlamydia infections.
Physical Examination
A.Temperature, blood pressure (BP), pulse, and weight:
1.In the elderly the BP can be low; this is a consideration for sepsis.
B.Inspect:
1.Observe overall appearance. Does the patient appear ill? Consider the clinical presentation, age of the person, and history.
2.Observe breathing pattern and the use of accessory muscles, grunting, retractions, and tachypnea.
3.Obtain a pulse oximetry to assess oxygen saturation. An O2 saturation less than 92% is an indicator of severity and the need for oxygen therapy.
4.Check nail beds and lips for cyanosis.
5.Examine the eyes, nose, ears, and throat.
6.Examine skin for turgor and mucous membranes for dehydration.
C.Auscultate:
1.Auscultate heart.
2.Auscultate lungs for the following (auscultate bases first in geriatric patients):
a.Crackles (present in 80% of patients), wheezes, and decreased breath sounds.
b.Whispered pectoriloquy (increased loudness of whisper during auscultation).
c.Egophony (patient’s e
sounds like a
during auscultation).
d.Bronchophony (voice sounds louder than usual).
3.Auscultate abdomen (usually hypoactive bowel sounds).
D.Percuss chest to identify areas of consolidation.
E.Palpate:
1.Palpate chest for tactile fremitus (increased conduction when patient says 99
).
2.Palpate lymph nodes for adenopathy.
3.Palpate sinuses for tenderness. Sinusitis is a sign of Mycoplasma infection.
Diagnostic Tests
A.The World Health Organization (WHO) defines pneumonia solely on the basis of clinical findings observed by inspection and timing of respirations.
B.Chest radiograph (CXR):
1.Infiltrates confirm diagnosis. False negatives result from dehydration, evaluation in first 24 hours, and infection.
2.Ordering a posterior, anterior, and lateral CXR ensures adequate visualization for diagnosis.
C.Complete blood count (CBC) with differential.
D.BUN, creatinine level, and glomerular filtration rate (GFR) if acute renal failure secondary to dehydration or sepsis is a concern.
E.Cultures:
1.Blood cultures if critically ill, immunocompromised, or for persistent symptoms.
2.Sputum cultures are reserved for very ill patients for unusual presentations.
F.Consider rapid viral testing.
G.Consider skin testing for tuberculosis (TB) for high-risk exposure risk.
Differential Diagnoses
A.Pneumonia:
1.Bacterial pneumonia.
2.Viral pneumonia.
3.Aspiration pneumonia.
4.Chemical-induced pneumonia.
5.Fungal pneumonias (especially in immunocompromised or diabetes out of control).
B.Asthma.
C.Bronchitis/bronchiolitis.
D.Pertussis.
E.Heart failure.
F.Pulmonary embolus.
G.Empyema and abscess.
H.Aspiration of foreign body.
Plan
A.General interventions:
1.Encourage rest during acute phase.
2.Encourage patients to avoid smoking/secondhand smoke.
3.A vaporizer may be used to increase humidity.
4.Encourage good handwashing or use of hand sanitizer.
B.
See Section III: Patient Teaching Guide Pneumonia, Bacterial.
C.Dietary management: Encourage a nutritious diet with increased fluid intake.
D.Chest physiotherapy is not prescribed for pneumonia.
E.Pharmaceutical therapy:
1.S. pneumonia is the most common bacterial pathogen, and resistance against antibiotics is a concern. Resistance is seen more commonly in:
a.Age greater than 65 years.
b.Use of a beta-lactam antibiotic or fluoroquinolones in the past 6 months.
c.Alcoholism.
d.Chronic illness/comorbidities.
e.Immunosuppression therapy or illness.
f.Exposure to a child at a day care center.
2.The Pneumonia Severity Index Calculator should be used prior to initiation of antibiotic therapy; it is available at www.mdcalc.com/psi-port-score-pneumonia-severity-index-cap.
3.Treatment with antibiotics is empirical. Oral therapy should continue 7 to 10 days:
a.If antimicrobials have not been used in the past 3 months:
i.Macrolide antibiotics.
ii.Doxycycline.
b.If antimicrobials have been used in the past 3 months:
i.Respiratory quinolones.
ii.Augmentin or high-dose amoxicillin.
4.Administer acetaminophen (Tylenol) for fever.
5.Avoid cough suppressants. Suppression of a cough may interfere with airway clearance.
6.Vaccines:
a.Pneumococcal vaccine is recommended for anyone older than the age of 19 with chronic lung disease, including asthma; immunocompromised adults; and in the elderly 65 years and older.
Follow-Up
A.Patients should know the signs of increasing respiratory distress and seek immediate medical attention.
B.Follow up by telephone in 24 hours.
C.If there is no improvement after 48 hours on antibiotics, the patient is advised to call back.
D.Schedule a return visit in 2 weeks for evaluation, unless elderly and living alone: Follow up in person within a week.
E.Follow up with a CXR in 4 to 6 weeks for patients older than 60 years and for those who smoke. However, if the patient is younger than 60 years, a nonsmoker, and feels well at 6-week follow-up, there is no need to follow up with a CXR.
Emergent Issues/Instructions
A.Patients demonstrating the following should receive same-day ED evaluation:
1.Respiratory compromise.
2.Neurologic changes including obvious CNS involvement.
3.Profound dehydration or alterations in vital signs.
Consultation/Referral
A.Patients who are immunocompromised or have signs of toxicity or hypoxia may need hospitalization. Refer them to a physician.
B.If the patient is in any level of respiratory distress, dehydrated, or hypoxemic, consult with or refer the patient to a physician/hospital.
C.Poor prognostic signs that require referral are age older than 65 years, respiration rate greater than or equal to 30 breaths per minute, systolic BP less than 90 or diastolic BP less than 60, temperature greater than 101°F, altered mental status, extrapulmonary infection, and white blood cell (WBC) less than 4,000 or greater than 30,000.
D.Physician consultation is needed for suspected PCP.