Pneumonia management

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Dr.Swati's Presentation on pneumonia management during the 3rd Ask A Doc Dinner

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Pneumonia management

  1. 1. Pneumonia Dr Swati DasConsultant Pulmonologist
  2. 2. Is It Pnemonia?Clinical Radiological
  3. 3.  Pneumonia is an acute infection of lung parenchyma Can be subdivided into different types according to epidemiological criteria
  4. 4. Epidemiological classification of Pneumonia CAP: Community Acquired Pneumonia HCAP: Health Care Associated Pneumonia HAP or NP: Hospital Acquired Pneumonia VAP: Ventilator Associated Pneumonia
  5. 5. Incidence of CAP Unknown in the most of countries 5-11/1000 adults in US & UK* *Eur Respir Mon, 2009, 43, 111–132
  6. 6. Pneumonia: a difficult diagnosis ?
  7. 7. Mr. SM 69 years Does not smoke (anymore since two years) No co-morbids Cough since five days Coughs up some green phlegm Looks unwell
  8. 8. Mr. SM Pulse 92 reg BP 130/90mm Hg RR 20/min Temp 38.5 C Percussion: normal Auscultation: some scattered rhonchi
  9. 9. Mr. SM Diagnosis? Acute bronchitis Pneumonia Exacerbation COPD
  10. 10. Aetiology Signs & DiagnosisBacterial symptoms BronchitisViral Cough COPDTumor Fever Heart failureCardiac Crackles Pneumonia Rales Lung cancer Nothing specific
  11. 11. Searching for the correct diagnosis
  12. 12. Questions on diagnosis How to detect pneumonia? Diagnostic value of signs and symptoms ??? Additional value of tests?
  13. 13. Most important tests
  14. 14. Diagnostic models• Hopstaken et al •Dry cough, diarrhoea, temp > 38 C •If all three present: 76% CAP, if none present: 6%• Diehr et al •Absence of rhinorrhoea and sore throat, presence of night sweats, myalgia, sputum all day, resp rate > 25, fever • Score 1: 9% CAP, score 4, 27%, score 6 100%• Khalil et al •Cough, chest pain, shortness of breath, temp>38, heart rate>100, Not Of help Resp rate>20, pulse oximetry<95% •Pos pred value 30%, neg pred value 99%• Gonzales Ortiz et al• pathologic auscultation, neutrophilia, pleural pain, dyspnoea• pos pred value 23%, neg pred value 88%• Melbye et al• Absence of coryza and sore throat, presence of dyspnoea, chest pain, crackles •Pos pred value 17%, neg pred value 79%
  15. 15. Additional tests Radiological investigations Tests to detect bacterial pathogens  Gram stain, sputum c/s, blood c/s  Urine test for Streptococcus pneumoniae sen>70%,specificity>95%,  Legionella antigen Tests to detect viral pathogens  Test for influenza Biomarkers  CRP  Procalcitonine/adrenomodulin
  16. 16. Site of care ?
  17. 17. AD, 50 ys Hello doctor, … I’ve got fever and dry cough since two days BP 120/70 HR 88r RR 18’ TEMP 39.0°C Breath sound diminished on right base HOSPITAL ADMISSION?
  18. 18. Hospital admission?1. No, mild clinical syndrome2. Yes, high fever3. What about history? Otherwise healthy man
  19. 19. Hospital admission?1. No, mild clinical syndrome in otherwise healthy man Pneumonia = 4  medium risk = 10%
  20. 20. DFE, 34• Fever (38.5°C) 2days• Dry cough 3days• Physical examination: Chest x-ray• non-ill; BP 130/80 HR 96r RR 20’• rales right lung base You - his physician – decide …
  21. 21. … to hospitalise him WHY?
  22. 22. History is lacking: the patient underwent splenectomy 2 years before He is immunocompromised at risk for development of severe fulminant sepsis (especially by S. pneumoniae and H. influenzae)
  23. 23. FP, 81 ys• Fever (37.7°C) started one day before• non-productive cough• Non-ill; BP 120/85 HR 90 RR 20’• Co-morbids-DM, CHF; What would you do?
  24. 24. FP, 81 ys1. admit to hospital2. treat him as outpatient admit to hospital: patient at risk for adverse outcome
  25. 25. Pneumonia + age + CHF + DM = 9  complications risk = 31%
  26. 26. DA, 63 ys•Fever (37.9°C) started two days before• non-productive cough You - his physician - decide that your patient is a candidate for hospital admission Why?
  27. 27. DA, 63 ys, otherwise healthy• Fever (37.9°C) started two days before• non-productive cough The speech is interrupted by frequent breaths Hello doctor I’ve got fever and dry cough since two daysbreath breath breath breath breath
  28. 28. CRB-65 predicts death from community-acquired pneumonia•Analysis performed on 1343 patients (208 out-patients and 1135 hospitalized)with all data sets completed for the calculation of CURB, CRB and CRB-65•Validated in 1967 patients (482 out-patients and 1485 hospitalized) Bauer TT et al. J Intern Med. 2006; 260:93-101
  29. 29. CURB–65 scoreScore one point for presence of each Clinical feature (0 – 5) 1. Confusion 2. Urea > 7 mmol/l 3. Respiratory rate  30/min 4. Blood pressure (SBP <90 or DBP  60mmHg) 5. Age  65yrs (Albumin < 30 g/dl had an OR 4.7 [2.5-8.7] <0.001) Lim et al Thorax 2003;58:377-382
  30. 30. CURB 65 0-1=Outpatient 2=Hospital >=3 HDU/ICU
  31. 31. RESULTS: Overall 30-day mortality was 4.3% (0.6% in out-patients and 5.5% in hospitalized patients,p<0.0001). Overall, the CURB, CRB and CRB-65 scores provided comparable predictions for death from CAPCONCLUSIONS: Both the CURB and CRB-65 scores can be used in the hospital andout-patients setting to assess pneumonia severity and the risk of deathGiven that the CRB-65 is easier to handle, we favor the use of CRB-65 where bloodurea nitrogen is unavailable Bauer TT et al. J Intern Med. 2006; 260:93-101
  32. 32. SCAP score Major Minor  RR >30 breaths/min — 9 points  PaO2/FIO2 <250 mmHg — 6 Arterial pH <7.30 — 13 points points Systolic blood pressure <90  BUN >30 mg/dL (10.7 mmol/L) mmHg — 11 points — 5 points  Altered mental status — 5 points  Age ≥80 years — 5 points  Multilobar/bilateral infiltrates on x-ray — 5 points >=10 severe CAP
  33. 33. EMPIRIC TREATMENT? YES !!! Based on knowledge…. …..You need to know Epidemiology in YOUR area Rate of antibiotic resistance in YOUR area Please do not forget Microbiology work up…… EVEN IF IT COSTS….
  34. 34. Factors in empirical antibiotic choice for CAP GEOGRAPHY Spectrum of causative pathogen Acquired antibiotic resistance THE PATIENT Illness severity Other characteristics (eg age, vomiting) THE ANTIBIOTIC Randomised controlled trial Drug side effects Cost
  35. 35. GEOGRAPHICAL VARIATION IN (32 prospective studies; n = 8211)CAP % 0 10 20 30 40S pneumoniae H influenzae LegionellaStaph aureus GNEB UK Europe AUS + NZ N America
  36. 36. GEOGRAPHICAL VARIATION IN (32 prospective studies; n = 8211)CAP % 0 5 10 15 20M pneumoniaeC pneumoniae C psittaci C burnetii Viruses UK Europe AUS + NZ N America
  37. 37. ANTIBIOTIC THERAPYS pneumoniaeH influenzae B-lactam MacrolideMycoplasma TetracyclineChlamydia FluoroquinoloneLegionellaGram-negative bacteria Cephalosporin
  38. 38. ATS/IDSAINPATIENT – NON-ICUFluoroquinolone (strong recommendation; level I evidence)-lactam + macrolide (strong recommendation; level I evidence) Mandell et al Clin Infect Dis 2007;44(Suppl 2):S27-S72
  39. 39. ATS/IDSA GUIDELINES INPATIENT – ICU-lactam +Either Azithromycin (level II evidence)or Fluoroquinolone (strong recommendation; level I evidence) For Pseudomonas Anti-pseudomonal -lactam + Either cipro or levo (level II evidence) or above -lactam + gentamicin + azithromycin or above -lactam + antipneumococcal fluoroquinolone (weak recommendation; level III evidence) Mandell et al Clin Infect Dis 2007;44(Suppl 2):S27-S72
  40. 40. 34 yrs, Chinese; ER visit for fever and blood-tinged sputum
  41. 41. Risk factors for TB Yes/NoIF YES NO QUINOLONES
  42. 42. Antibiotic within 6 hoursand oxygen therapy
  43. 43. Conclusion Clinical assessment Know your local epidemiology Be aware of national and international outbreaks Never forget Mycobacterium tuberculosis

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