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Pneumonia

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Pneumonia
ICD-9 480

-486

Pneumonia is defined as "inflammation of the lungs."[1]

Contents

Classification

Pneumonia can be classified along various dimensions including clinical setting, underlying etiology, and its gross appearance (bronchopneumonia versus lobar pneumonia).

Aspiration pneumonia

Community acquired pneumonia

The most common cause, streptococcus pneumonia, causes about a third of episodes.[2]

Atypical pneumonia

Nosocomial pneumonia

Ventilator associated pneumonia

Diagnosis

Community acquired pneumonia

History and physical examination

A clinical prediction rule found the five following signs from the medical history and physical examination best predicted infiltrates on the chest radiograph of 1134 patients presenting to an emergency room:[3]

  • Temperature > 100 degrees F (37.8 degrees C)
  • Pulse > 100 beats/min
  • Crackles
  • Decreased breath sounds
  • Absence of asthma
The probability of an infiltrate based on the number of findings.[4] [3]
Number of findingsPrimary care[4] Emergency Room[3]
5 47% 75%
4 27 56
3 8 22
2 4 11
1 1 3
0 1 2


  • 5 findings - 84% to 91% probability
  • 4 findings - 58% to 85%
  • 3 findings - 35% to 51%
  • 2 findings - 14% to 24%
  • 1 findings - 5% to 9%
  • 0 findings - 2% to 3%

A subsequent study[5] comparing four clinical prediction rules to physician judgment found that two clinical prediction rules, the one above[3] and another[6] were more accurate than physician judgment because of the increased specificity of the prediction rules.

Blood tests

Some, but not all[7] experts recommend prompt blood cultures.

Procalcitonin levels may help prognosticate.

Diagnostic imaging

Ultrasonography can diagnose community acquired pneumonia in one study with accuracy of:[8]

  • Sensitivity 93%
  • Specificity 98%

Nosocomial pneumonia

The accuracy of findings for ventilator-associated pneumonia.[9]
Finding Sensitivity Specificity
Fever 45%-67% 33%-76%
Purulent sputum 50%-83% 33%-67%
Chest x-ray showing new infiltrate 87%-91% 33%-50%

Bronchoalveolar lavage with quantitative culture of the bronchoalveolar-lavage fluid or endotracheal aspiration with nonquantitative culture of the aspirate can help diagnose ventilator-associated pneumonia.[10]

Treatment

Clinical practice guidelines are available.[11]

Antibiotics

Some, but not all[7] experts recommend prompt antibiotics.

Corticosteroids

"Dexamethasone can reduce length of hospital stay when added to antibiotic treatment in non-immunocompromised patients with community-acquired pneumonia" according to a randomized controlled trial. [12]

Aspiration pneumonia

Community acquired pneumonia

The 'respiratory quinolones' (levofloxacin, moxifloxacin, gemifloxacin) may be the best choices[13] although the evidence is not clear[14] and some studies show macrolides may be better[15].

The optimal duration of antibiotic treatment for community acquired pneumonia is not clear.[16]

Ventilator associated pneumonia

Treatments that are ineffective

Chest physiotherapy includes postural drainage, percussion, and vibration and has been call the 'ketchup-bottle method'[17] of treating pneumonia. Chest physiotherapy and intermittent positive-pressure breathing have been shown not to help in a small randomized controlled trial.[18] A subsequent systematic review did not find benefit.[19]

Prognosis

Short term prognosis and the decision to hospitalize

The prognosis of community acquired pneumonia can be estimated with several clinical prediction rules of similar accuracy:[20][21]

  • Pneumonia severity index (PSI) - the PSI may[22] or may not[21] be more accurate than the CURB-65 and is available online (Pneumonia Severity Index Calculator).
    • Patients with PSI Risk groups I-III can usually be treated as an outpatient.[23]
  • CURB-65
  • SMART-COP is a new clinical prediction rule that may be better according to a single study.[24] Patients are high risk if they have three or more points from the following:
    • systolic blood pressure < 90 (2 points)
    • multilobar chest radiography involvement (1 point)
    • albumin level < 3.5 mg/dl (1 point)
    • high respiratory rate. 25 or more breaths per minute if less than 50 years old, else 30 or more breaths per minute (1 point)
    • tachycardia of 125 or more bpm (1 point)
    • confusion, new onset (1 point)
    • poor oxygenation. Either of the following adds 2 points:
      • PaO2 < 70 mm Hg if less than 50 years old, else < 60 mm Hg
      • PaO2/FiO2 < 333 if less than 50 years old, else if less than 250.
    • arterial pH < 7.35 (2 points)
  • SCAP score is a new clinical prediction rule that may be better than the Pneumonia severity index and CURB-65[25]
  • PIRO is another clinical prediction rule specifically for severe pneumonia.[26]

C-reactive protein and procalcitonin

Several studies have compared the c-reactive protein and procalcitonin in the prognosis of pneumonia.[27][28][29][30] The procalcitonin may[31][30][28][29] or may not[27] be more accurate.

Prognosis at the time of discharge

Abnormal medical signs at discharge are associated with higher mortality with 30 days.[32]

Long term prognosis

Prevention

For more information, see: Pneumococcal vaccine.

Clinical practice guidelines are available for administering vaccines for pneumonia at http://www.cdc.gov/vaccines/.

References

  1. Anonymous (2014), Pneumonia (English). Medical Subject Headings. U.S. National Library of Medicine.
  2. Sorde, Roger; Vicenc Falco, Michael Lowak, Eva Domingo, Adelaida Ferrer, Joaquin Burgos, Mireia Puig, Evelyn Cabral, Oscar Len, Albert Pahissa (2010-09-27). "Current and Potential Usefulness of Pneumococcal Urinary Antigen Detection in Hospitalized Patients With Community-Acquired Pneumonia to Guide Antimicrobial Therapy". Arch Intern Med: archinternmed.2010.347. DOI:10.1001/archinternmed.2010.347. Retrieved on 2010-09-28. Research Blogging.
  3. 3.0 3.1 3.2 3.3 Heckerling PS, Tape TG, Wigton RS, et al (1990). "Clinical prediction rule for pulmonary infiltrates". Ann. Intern. Med. 113 (9): 664–70. PMID 2221647[e]
  4. 4.0 4.1 Ebell MH (2007). "Predicting pneumonia in adults with respiratory illness.". Am Fam Physician 76 (4): 560-2. PMID 17853631[e]
  5. Emerman CL, Dawson N, Speroff T, et al (1991). "Comparison of physician judgment and decision aids for ordering chest radiographs for pneumonia in outpatients". Annals of emergency medicine 20 (11): 1215–9. DOI:10.1016/S0196-0644(05)81474-X. PMID 1952308. Research Blogging.
  6. Gennis P, Gallagher J, Falvo C, Baker S, Than W (1989). "Clinical criteria for the detection of pneumonia in adults: guidelines for ordering chest roentgenograms in the emergency department". The Journal of emergency medicine 7 (3): 263–8. PMID 2745948[e]
  7. 7.0 7.1 Nazarian DJ, Eddy OL, Lukens TW, Weingart SD, Decker WW (2009). "Clinical policy: critical issues in the management of adult patients presenting to the emergency department with community-acquired pneumonia.". Ann Emerg Med 54 (5): 704-31. DOI:10.1016/j.annemergmed.2009.07.002. PMID 19853781. Research Blogging.
  8. Reissig A, Copetti R, Mathis G, Mempel C, Schuler A, Zechner P et al. (2012). "Lung ultrasound in the diagnosis and follow-up of community-acquired pneumonia: a prospective, multicenter, diagnostic accuracy study.". Chest 142 (4): 965-72. DOI:10.1378/chest.12-0364. PMID 22700780. Research Blogging.
  9. Klompas M (2007). "Does this patient have ventilator-associated pneumonia?". JAMA 297 (14): 1583-93. DOI:10.1001/jama.297.14.1583. PMID 17426278. Research Blogging.
  10. Canadian Critical Care Trials Group (2006). "A randomized trial of diagnostic techniques for ventilator-associated pneumonia.". N Engl J Med 355 (25): 2619-30. DOI:10.1056/NEJMoa052904. PMID 17182987. Research Blogging. Review in: ACP J Club. 2007 May-Jun;146(3):62
  11. Mandell LA, Wunderink RG, Anzueto A, Bartlett JG, Campbell GD, Dean NC et al. (2007). "Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults.". Clin Infect Dis 44 Suppl 2: S27-72. DOI:10.1086/511159. PMID 17278083. Research Blogging. Free pdf access
  12. Meijvis SC, Hardeman H, Remmelts HH, Heijligenberg R, Rijkers GT, van Velzen-Blad H et al. (2011). "Dexamethasone and length of hospital stay in patients with community-acquired pneumonia: a randomised, double-blind, placebo-controlled trial.". Lancet 377 (9782): 2023-30. DOI:10.1016/S0140-6736(11)60607-7. PMID 21636122. Research Blogging.
  13. Vardakas KZ, Siempos II, Grammatikos A, Athanassa Z, Korbila IP, Falagas ME (December 2008). "Respiratory fluoroquinolones for the treatment of community-acquired pneumonia: a meta-analysis of randomized controlled trials". CMAJ 179 (12): 1269–1277. DOI:10.1503/cmaj.080358. PMID 19047608. PMC 2585120. Research Blogging.
  14. Bjerre LM, Verheij TJ, Kochen MM (2009). "Antibiotics for community acquired pneumonia in adult outpatients.". Cochrane Database Syst Rev (4): CD002109. DOI:10.1002/14651858.CD002109.pub3. PMID 19821292. Research Blogging.
  15. Martin-Loeches I, Lisboa T, Rodriguez A, Putensen C, Annane D, Garnacho-Montero J et al. (2010). "Combination antibiotic therapy with macrolides improves survival in intubated patients with community-acquired pneumonia.". Intensive Care Med 36 (4): 612-20. DOI:10.1007/s00134-009-1730-y. PMID 19953222. Research Blogging.
  16. Li JZ, Winston LG, Moore DH, Bent S (2007). "Efficacy of short-course antibiotic regimens for community-acquired pneumonia: a meta-analysis". Am. J. Med. 120 (9): 783–90. DOI:10.1016/j.amjmed.2007.04.023. PMID 17765048. Research Blogging.
  17. Murray JF (1979). "The ketchup-bottle method". N. Engl. J. Med. 300 (20): 1155–7. PMID 431639[e]
  18. Graham WG, Bradley DA (1978). "Efficacy of chest physiotherapy and intermittent positive-pressure breathing in the resolution of pneumonia". N. Engl. J. Med. 299 (12): 624–7. PMID 355879[e]
  19. Yang M, Yuping Y, Yin X, Wang BY, Wu T, Liu GJ et al. (2010). "Chest physiotherapy for pneumonia in adults.". Cochrane Database Syst Rev 2: CD006338. DOI:10.1002/14651858.CD006338.pub2. PMID 20166082. Research Blogging.
  20. Chalmers JD, Singanayagam A, Akram AR, Mandal P, Short PM, Choudhury G et al. (2010). "Severity assessment tools for predicting mortality in hospitalised patients with community-acquired pneumonia. Systematic review and meta-analysis.". Thorax 65 (10): 878-83. DOI:10.1136/thx.2009.133280. PMID 20729231. Research Blogging.
  21. 21.0 21.1 Ochoa-Gondar O, Vila-Corcoles A, Rodriguez-Blanco T, Ramos F, de Diego C, Salsench E et al. (2011). "Comparison of three predictive rules for assessing severity in elderly patients with CAP.". Int J Clin Pract 65 (11): 1165-72. DOI:10.1111/j.1742-1241.2011.02742.x. PMID 21951687. Research Blogging.
  22. Aujesky D, Auble TE, Yealy DM, et al (2005). "Prospective comparison of three validated prediction rules for prognosis in community-acquired pneumonia". Am. J. Med. 118 (4): 384-92. DOI:10.1016/j.amjmed.2005.01.006. PMID 15808136. Research Blogging.
  23. Carratalà J, Fernández-Sabé N, Ortega L, et al (February 2005). "Outpatient care compared with hospitalization for community-acquired pneumonia: a randomized trial in low-risk patients". Ann. Intern. Med. 142 (3): 165–72. PMID 15684204[e]
  24. Charles PG, Wolfe R, Whitby M, et al (August 2008). "SMART-COP: a tool for predicting the need for intensive respiratory or vasopressor support in community-acquired pneumonia". Clin. Infect. Dis. 47 (3): 375–84. DOI:10.1086/589754. PMID 18558884. Research Blogging.
  25. Yandiola PP, Capelastegui A, Quintana J, et al. (June 2009). "Prospective comparison of severity scores for predicting clinically relevant outcomes for patients hospitalized with community-acquired pneumonia". Chest 135 (6): 1572–9. DOI:10.1378/chest.08-2179. PMID 19141524. Research Blogging.
  26. Rello J, Rodriguez A, Lisboa T, Gallego M, Lujan M, Wunderink R (December 2009). "PIRO score for community-acquired pneumonia: A new prediction rule for assessment of severity in intensive care unit patients with community-acquired pneumonia". Crit. Care Med.. DOI:10.1097/CCM.0b013e318194b021. PMID 19114916. Research Blogging.
  27. 27.0 27.1 Holm A, Pedersen SS, Nexoe J, et al. (July 2007). "Procalcitonin versus C-reactive protein for predicting pneumonia in adults with lower respiratory tract infection in primary care". Br J Gen Pract 57 (540): 555–60. PMID 17727748. PMC 2099638[e]
  28. 28.0 28.1 Müller B, Harbarth S, Stolz D, et al. (2007). "Diagnostic and prognostic accuracy of clinical and laboratory parameters in community-acquired pneumonia". BMC Infect. Dis. 7: 10. DOI:10.1186/1471-2334-7-10. PMID 17335562. PMC 1821031. Research Blogging.
  29. 29.0 29.1 Brunkhorst FM, Al-Nawas B, Krummenauer F, Forycki ZF, Shah PM (February 2002). "Procalcitonin, C-reactive protein and APACHE II score for risk evaluation in patients with severe pneumonia". Clin. Microbiol. Infect. 8 (2): 93–100. PMID 11952722[e]
  30. 30.0 30.1 Krüger S, Ewig S, Marre R, et al. (February 2008). "Procalcitonin predicts patients at low risk of death from community-acquired pneumonia across all CRB-65 classes". Eur. Respir. J. 31 (2): 349–55. DOI:10.1183/09031936.00054507. PMID 17959641. Research Blogging.
  31. Niederman MS (December 2008). "Biological markers to determine eligibility in trials for community-acquired pneumonia: a focus on procalcitonin". Clin. Infect. Dis. 47 Suppl 3: S127–32. DOI:10.1086/591393. PMID 18986278. Research Blogging.
  32. Capelastegui A, España PP, Bilbao A, et al (September 2008). "Pneumonia: criteria for patient instability on hospital discharge". Chest 134 (3): 595–600. DOI:10.1378/chest.07-3039. PMID 18490403. Research Blogging.
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