(1)
Division of Pulmonary Medicine, Department of Medicine, University of Alberta, Edmonton, AB, Canada
Asthma Exacerbation
Differential Diagnosis of Wheezing
EXTRATHORACIC AIRWAY OBSTRUCTION
oropharynx—enlarged tonsils, retropharyngeal abscess, obesity, post-nasal drip
larynx—laryngeal edema, laryngostenosis, laryngocele, epiglottitis, anaphylaxis, severe laryngopharyngeal reflux, laryngospasm
vocal cords—vocal cord dysfunction, paralysis, hematoma, tumor, cricoarytenoid arthritis
INTRATHORACIC AIRWAY OBSTRUCTION
tracheal obstruction—tracheal stenosis, tracheomalacia, tracheobronchitis (herpetic, fungal), malignancy, benign tumor, aspiration, foreign body
tracheal compression—goiter, right-sided aortic arch
lower airway obstruction—asthma, COPD, bronchiolitis, bronchiectasis, carcinoid tumor, aspiration, malignancy
parenchyma—pulmonary edema
vascular—pulmonary embolism
Pathophysiology
EXACERBATORS OF ASTHMA
infections—viral, bacterial, fungal
outdoors—respirable particulates, ozone, sulfur dioxide, cold air, humidity, smoke
indoors—smoke, dust mites, air conditioners, humidity, perfumes, scents, mold, animal dander
non-adherence
Clinical Features
HISTORY
—history of asthma and any life-threatening exacerbations, number of ER visits/hospital admissions in the last 6 months (or ever), any ICU admissions, previous prednisone use, triggers for attacks, usual peak expiratory flow rate, change in peak flow rates, wheezing, cough, dyspnea, decreased function, exercise limitation, nocturnal symptoms, absenteeism from work/school, postnasal drip, recurrent sinusitis, GERD, past medical history, medication history, psychosocial issues, occupational and work environment, home environment (pets, heating source, filter changes)
PHYSICAL
—HR ↑, RR ↑, pulsus paradoxus, O2 requirement, moderate-severe dyspnea, barrel chest, cyanosis, hyperresonance, decreased breath sounds, wheezing, forced expiratory time
TYPES OF WHEEZING
—inspiratory wheeze and expiratory wheeze are classically associated with extrathoracic and intrathoracic airway obstruction, respectively. However, they are neither sensitive nor specific and cannot help to narrow differential diagnosis
Investigations
BASIC
labs—CBCD, lytes, urea, Cr, troponin/CK
microbiology—sputum Gram stain/AFB/C&S, nasopharyngeal swab for viral studies
imaging—CXR
SPECIAL
ABG—if acute respiratory distress
peak flow meter—need to compare bedside reading to patient’s baseline
spirometry/PFT (non-acute setting)—↑ FEV1 >12% and an absolute ↑ by 200 mL post-bronchodilator suggests asthma
methacholine challenge (non-acute setting)—if diagnosis of asthma not confirmed by spirometry alone. A decrease of FEV1 >20% after methacholine challenge suggests asthma. Sens 95%
sputum eosinophil counts (non-acute setting)—performed in specialized centres for monitoring of asthma control in patients with moderate to severe asthma
Can Resp J 2012 19:2
Acute Management
ABC
—O 2 to keep sat >92%, IV
BRONCHODILATORS
—salbutamol 100 μg MDI 2 puffs q6h ATC + q1h PRN and ipratropium 20 μg MDI 2 puffs q6h ATC (frequency stated is only a guide, may increase or decrease on a case by case basis)
STEROID
—prednisone 0.5–1 mg/kg PO daily × 7–14 days (may be shorter depending on response) or methylprednisolone 0.4–0.8 mg/kg IV daily (until conversion to prednisone)
OTHERS
—if refractory case and life-threatening, consider IV epinephrine, IV salbutamol, theophylline, inhaled anesthetics, MgSO4
MECHANICAL VENTILATION
—BiPAP, intubation
Long-Term Management
EDUCATION
—smoking cessation (see p. 480). Asthma action plan. Puffer technique education and review
ENVIRONMENTAL CONTROL
—avoidance of outdoor/indoor allergens, irritants, and infections; home environment cleanliness (e.g. steam cleaning)
VACCINATIONS
—influenza vaccine annually and pneumococcal vaccine every 5 years
FIRST LINE
—SABA (salbutamol 100 μg MDI 2 puffs PRN). Proceed to second line if using more than 2×/week or 1×/day for exercise-induced symptoms, symptoms >2×/week, any nocturnal symptoms, activity limitation or PEF <80%
SECOND LINE
—low-dose ICS plus short-acting β2-agonist PRN
THIRD LINE
—moderate-dose ICS, combined ICS plus LABA (note that long-acting β2-agonist should never be used alone in asthma), or leukotriene receptor antagonist (most effective in asthma complicated with sinus disease and exercise-induced asthma). May also consider using single inhaler budesonide/formoterol combination therapy as both a controller and an acute reliever
FOURTH LINE
—anti-IgE therapy (omalizumab) for refractory allergic asthma, administered subcutaneously q2–4 weeks, dosed by IgE level and body weight, for add-on therapy or inadequately controlled moderate-to-severe allergic asthma despite use of high doses of inhaled corticosteroid therapy
NEJM 2009 360:10
Can Resp J 2012 19:2
Treatment Issues
ASTHMA CONTROL CRITERIA
Characteristic | Frequency or value |
---|---|
Daytime symptoms | <4 days/week |
Night-time symptoms | <1 night/week |
Physical activity | Normal |
Exacerbations | Mild, infrequent |
Absence from work or school due to asthma | None |
Need for a SABA | <4 doses/week |
FEV1 or PEF | ≥90% personal best |
PEF diurnal variationa | <10–15% |
Sputum eosinophils | <2–3% |
COMMON INHALED MEDICATIONS
short-acting β–agonists (SABA)—salbutamol MDI 100 μg 1–2 puffs PRN or 2.5 mg NEB PRN, fenoterol MDI 100 μg 1–2 puffs PRN, terbutaline 500 μg INH PRN
short-acting anticholinergics—ipratropium MDI 20 μg 2 puffs QID or 500 μg NEB QID
long-acting β–agonists (LABA)—formoterol 6–24 μg INH BID, salmeterol diskus 50 μg i puff BID
long-acting anticholinergics—tiotropium 18 μg INH daily
inhaled corticosteroids—beclomethasone 125–250 μg INH BID, budesonide turbuhaler 200–400 μg INH BID or 0.5–1 mg NEB BID, fluticasone 125–250 μg INH BID, ciclesonide MDI 100–400 μg INH daily (only indicated for asthma at this time, not COPD), mometasone twisthaler 100–400 μg INH BID
Related Topics
Chronic Obstructive Pulmonary Disease (p. 4)
Pulmonary Function Tests (p. 25)
ADMISSION CRITERIA
FEV1 (L) | PEF (L/min) | PaO2 | Action | |
---|---|---|---|---|
Very severe | – | – | <90% with O2 | Admit |
Severe | <1.6 (<40%) | <200 (<40%) | <90% | Admit |
Moderate | 1.6–2.1 | 200–300 | >90% | Admit? |
Mild | >2.1 (>60%) | >300 (>60%) | >90% | Send home |
DISCHARGE CRITERIA—consider discharging patient if peak flow >70% of usual (or predicted) value for at least 1 h after bronchodilator
OXYGEN DELIVERY DEVICES
Device | Flow rates | Delivered O2 |
---|---|---|
Nasal cannula | 1 L/min | 21–24% |
2 L/min | 25–28% | |
3 L/min | 29–32% | |
4 L/min | 33–36% | |
5 L/min | 37–40% | |
6 L/min | 41–44% | |
Simple oxygen face mask | 6–10 L/min | 35–60% |
Face mask with oxygen reservoir (non-rebreather mask) | 6 L/min | 60% |
7 L/min | 70% | |
8 L/min | 80% | |
9 L/min | 90% | |
10–15 L/min | 95 + % | |
Venturi mask | 4–8 L/min | 24–40% |
10–12 L/min | 41–50% |
NOTE: delivered O2 (FiO2) is approximate. Oxygen delivery can approach 100% with intubation and mechanical ventilation
Specific Entities
EXERCISE-INDUCED ASTHMA
pathophysiology—mild asthma with symptoms only during exercise due to bronchoconstriction as a result of cooling of airways associated with heat and water loss
diagnosis—spirometry. Exercise or methacholine challenge may help in diagnosis
treatments—prophylaxis with salbutamol 2 puffs MDI, given 5–10 min before exercise. Consider leukotriene antagonists or inhaled glucocorticoids if frequent use of prophylaxis
TRIAD ASTHMA
(Samter’s syndrome)—triad of asthma, aspirin/NSAIDs sensitivity, and nasal polyps. Cyclooxygenase inhibition → ↓ prostaglandin E2 → ↑ leukotriene synthesis → asthma symptoms. Management include ASA/NSAIDs avoidance and leukotriene antagonists (montelukast)
ALLERGIC BRONCHOPULMONARY ASPERGILLOSIS (ABPA)
pathophysiology—associated with asthma and cystic fibrosis. Due to colonization of the airways by Aspergillus fumigatus, leading to an intense, immediate hypersensitivity-type reaction in the airways
clinical features—history of asthma, recurrent episodes of fever, dyspnea, and productive cough (brownish sputum). Peripheral eosinophilia. CXR findings of patchy infiltrates and central bronchiectasis, CT chest findings of central bronchiectasis, “finger-in-glove” appearance (i.e. mucous-filled dilated bronchi)
diagnosis—above clinical features plus Aspergillus extract skin test, serum IgE level, sputum for Aspergillus and/or serologic tests (IgE and IgG against Aspergillus)
treatments—systemic glucocorticoids, itraconazole
COPD Exacerbation
NEJM 2004 250:26
Differential Diagnosis of Acute Dyspnea
RESPIRATORY
airway—COPD exacerbation, asthma exacerbation, acute bronchitis, infectious exacerbation of bronchiectasis, foreign body obstruction
parenchyma—pneumonia, cryptogenic organizing pneumonia (COP), ARDS, acute exacerbation of interstitial lung disease
vascular—pulmonary embolism, pulmonary hypertension
pleural—pneumothorax, pleural effusion
CARDIAC
myocardial—HF exacerbation, myocardial infarction
valvular—aortic stenosis, acute aortic regurgitation, mitral stenosis, endocarditis
pericardial—pericardial effusion, tamponade
SYSTEMIC
—sepsis, metabolic acidosis, anemia
OTHERS
—neuromuscular, psychogenic, anxiety
Pathophysiology
PRECIPITANTS OF COPD EXACERBATION
—infections, lifestyle/environmental (10% [cigarette smoke, dust, pollutants, cold air]), non-adherence, pulmonary embolism, pulmonary edema, pneumothorax, progression of COPD
Clinical Features
RATIONAL CLINICAL EXAMINATION SERIES: DOES THE CLINICAL EXAMINATION PREDICT AIRFLOW LIMITATION?
LR+ | LR– | |
---|---|---|
History | ||
Smoking >40 pack-years | 12 | 0.63 |
Smoking ever | 1.8 | 0.16 |
Sputum >1/4 cup | 4 | 0.84 |
Chronic bronchitis Sx | 3 | 0.78 |
Wheezing | 3.8 | 0.66 |
Any exertional dyspnea | 2.2 | 0.83 |
Coughing | 1.8 | 0.69 |
Any dyspnea | 1.2 | 0.55 |
Physical | ||
Barrel chest | 10 | 0.90 |
Decreased cardiac dullness | 10 | 0.88 |
Match test | 7.1 | 0.43 |
Rhonchi | 5.9 | 0.95 |
Hyperresonance | 4.8 | 0.73 |
FEV1 >9 s | 4.8 | – |
FEV1 6–9 s | 2.7 | – |
FEV1 <6 s | 0.45 | – |
Subxyphoid cardiac apical impulse | 4.6 | 0.94 |
Wheezing | 4.4 | 0.88 |
Maximum laryngeal height ≤4 cm | 4.2 | 0.70 |
Pulsus paradoxus (>15 mmHg) | 3.7 | 0.62 |
Decreased breath sounds | 2.6 | 0.66 |
Accessory muscle use | – | 0.70 |
Clinical Judgement | ||
Overall Clinical Prediction of Moderate-Severe Disease | 5.6 | – |
Overall Clinical Prediction of Mild Disease | 2.3 | – |
APPROACH—“no single item or combination of items from the clinical examination rules out airflow limitation. The best findings associated with increased likelihood of airflow limitation are objective wheezing, FEV1 >9 s, positive match test, barrel chest, hyperresonance and subxyphoid cardiac impulse. Three findings predict the likelihood of airflow limitation in men: years of cigarette smoking, subjective wheezing and either objective wheezing or peak expiratory flow rate”
JAMA 1995 273:4
UPDATE—multivariate ‘Rule In’ Obstructive Disease Model (history of obstructive airways disease, smoking >40 pack-years, age ≥45, and laryngeal height ≤4 cm) has posterior odds of disease of 220. Multivariate ‘Rule Out’ Obstructive Disease Model (smoking <30 years, no wheezing symptoms, and no auscultated wheezing) has posterior odds of disease of 0.02.
The Rational Clinical Examination. McGraw-Hill, 2009
Investigations
BASIC
labs—CBCD, lytes, urea, Cr, troponin/CK, Ca, Mg, PO4
microbiology—sputum Gram stain/AFB/C&S/fungal, nasopharyngeal swab for viral studies
imaging—CXR
ECG—left atrial enlargement, atrial fibrillation, sinus tachycardia
spirometry / PFT—FEV1/FVC <0.7, may be partially reversible. Severity based on FEV1
ABG—if acute respiratory distress
SPECIAL
BNP—if suspect HF
D-dimer, CT chest—if suspect PE
echocardiogram
Prognostic Issues
PROGNOSIS OF PATIENTS WITH ACUTE EXACERBATION OF COPD
—in-hospital mortality 5–10%
GOLD CLASSIFICATION 2007
—all have FEV1/FVC <0.7
stage I ( mild )—FEV1 ≥ 80% predicted
stage II ( moderate )—FEV1 50–79% predicted
stage III ( severe )—FEV1 30–49% predicted
stage IV ( very severe )—FEV1 < 30% predicted, or <50% predicted + cor pulmonale
BODE INDEX
BMI—0 points = >21, 1 point = ≤21
obstruction (post-bronchodilator FEV1)—0 points = ≥65% predicted, 1 point = 50–64%, 2 points = 36–49%, 3 points = ≤35%
distance walked in 6 min—0 points = ≥350 m, 1 point = 250–349 m, 2 points = 150–249 m, 3 points = ≤149 m
exercise MMRC dyspnea scale—0 points = 0–1, 1 point = 2, 2 points = 3, 3 points = 4
scoring—total BODE score calculated as sum of all points. Relative risk for death (any cause) is increased by 34% per one-point increase in BODE score. Relative risk for death (from respiratory failure, pneumonia, or pulmonary embolism) is increased by 62% per one-point increase in BODE score
NEJM 2004 350:10
Acute Management
ABC
—O 2 to keep sat >90%, or 88–92% if CO2 retainer, IV
BRONCHODILATORS
—salbutamol 100 μg MDI 2 puffs q4h ATC + q1h PRN and ipratropium 20 μg MDI 2 puffs q4h ATC
STEROIDS
—prednisone 40–60 mg PO daily × 5–14 days (tapering dose not always necessary) or methylprednisolone 60–125 mg IV q6-12 h (inpatient)
ANTIBIOTICS
—give if any two of the following criteria are met: ↑ sputum purulence, ↑ dyspnea or ↑ sputum volume. Other considerations include the need for non-invasive mechanical ventilation and “at risk” for poor outcome (substantial comorbidities, severe COPD, frequent exacerbations >3/year, recent antibiotics within 3 months); choices depend on clinical circumstance (levofloxacin 500 mg PO daily × 7–10 days [or 750 mg PO daily × 5 days if no renal disease], doxycycline 100 mg PO BID × 7–10 days, amoxicillin 500 mg PO BID × 7 days, cefuroxime 250–500 mg PO BID × 10 days, or azithromycin 500 mg PO × 1 day then 250 mg PO daily × 4 days)
MECHANICAL VENTILATION
—BiPAP, intubation
OTHERS
—DVT prophylaxis (unfractionated heparin 5000 U SC q8-12 h, enoxaparin 40 mg SC q24h, dalteparin 5000 U SC q24h), physiotherapy
NEJM 2002 346:13
Long-Term Management
EDUCATION
—smoking cessation (see p. 480). Disease-specific self-management program. Puffer technique education and review
VACCINATIONS
—influenza vaccine annually and pneumococcal vaccine booster every 5 years
REHABILITATION
—education and exercise training (increases quality of life and exercise tolerance); pulmonary rehabilitation associated with ↓ risk of recurrent exacerbation in patients with moderate to very severe COPD and recent AECOPD (<4 weeks)
FIRST LINE
—SABA or short-acting anticholinergic on an as-needed basis
SECOND LINE
—LABA or long-acting anticholinergic (tiotropium 1 puff [18 μg/puff] INH daily) plus SABA PRN. Consider early initiation of long-acting agents if requiring regular PRN short-acting agents as long-acting agents are superior
THIRD LINE
—LABA plus long-acting anticholinergic, with SABA PRN
FOURTH LINE
—long-acting anticholinergic plus LABA/ICS (e.g. Advair, Symbicort). No role for ICS monotherapy. Consider phosphodiesterase-4 inhibitor (roflumilast 500 μg PO daily) as adjuvant maintenance therapy in moderate to severe COPD with ≥1 exacerbation in previous year. Consider mucolytic agents (N-acetylcysteine 10–20% solution NEB TID-QID, carbocysteine 375–750 mg PO TID) if ≥2 exacerbations in previous 2 years. Chronic antibiotic therapy generally not recommended
FIFTH LINE
—fourth line plus theophylline 400 mg PO daily × 3 days, then 400–600 mg PO daily, therapeutic level 10–20 μg/mL
SIXTH LINE—
fifth line plus home O 2
SEVENTH LINE
—lung volume reduction surgery (may be beneficial if upper lobe involvement and poor functional capacity) or lung transplant
Canadian Thoracic Society COPD Guidelines 2007
American College of Chest Physicians (CHEST) and
Canadian Thoracic Society (CTS) Joint Guidelines 2014
Treatment Issues
FACTORS FOR IMPENDING INTUBATION
—cardiac or respiratory failure, hemodynamic instability, markedly elevated respiratory rate (>35/min), fatigue and labored respiration, use of accessory muscles, worsening hypercapnia, acidosis (especially lactic), stridor (impending upper airway obstruction), agonal breathing (impending respiratory arrest)
LIFE-PROLONGING MEASURES FOR COPD
—smoking cessation, supplemental O2, lung transplant
INDICATIONS FOR SUPPLEMENTAL HOME O2
—ABG done at room air. PaO2 <55 mmHg alone or PaO2 <60 mmHg in the presence of bilateral ankle edema, cor pulmonale, or hematocrit >56%
Specific Entities
α1-ANTITRYPSIN DEFICIENCY
pathophysiology—production of an abnormal protease inhibitor (homozygous ZZ) with impaired transport out of the liver. Serum level is only 10–15% of normal → increased protease activity leads to emphysema and cirrhosis (10%)
diagnosis—α1-antitrypsin levels; targeted testing should be considered in patients with COPD diagnosed before 65 years of age or with a smoking history of <20 pack years
treatments—similar to COPD, α1-antitrypsin replacement
BRONCHIOLITIS OBLITERANS
pathophysiology—severe inflammation of bronchioles → airflow obstruction. Very different from bronchiolitis obliterans organizing pneumonia (BOOP)/cryptogenic organizing pneumonia (COP), a parenchymal lung disorder
causes—infection (viral, mycoplasma), inflammatory (ulcerative colitis, rheumatoid arthritis), transplant (bone marrow, lung), toxic fumes, idiopathic
treatments—bronchiolitis obliterans (with an organizing intraluminal exudate and proliferative granulation tissue polyp) is usually steroid responsive. Constrictive bronchiolitis (late, fibrotic, concentric) is not responsive to glucocorticoids
BRONCHIECTASIS
pathophysiology—airway obstruction, destruction, altered immunity → ↑ cellular and mediator inflammatory response → ↑ elastase, sputum production → recurrent infections → vicious cycle → permanent dilatation of bronchi. Major types of bronchiectasis include
cylindrical or tubular bronchiectasis—dilated airways alone, sometimes represents residual effect of pneumonia and may resolve
varicose bronchiectasis—focal constrictive areas along the dilated airways
saccular or cystic bronchiectasis—most severe form. Progressive dilatation of the airways, resulting in large cysts or saccules
causes
focal—broncholith, post-infectious, tumor, extrinsic lymph node compression, post-lobar resection, recurrent aspiration
diffuse
post-infectious—bacterial (Pseudomonas, Haemophilus), mycobacterium, fungal, viral (adenovirus, measles, influenza, HIV)
immunodeficiency—cancer, chemotherapy, hypogammaglobulinemia, immunosuppression, sequelae of toxic inhalation or aspiration of foreign body
interstitial lung disease—traction bronchiectasis
inflammatory—RA, SLE, Sjogren’s syndrome, relapsing polychondritis, IBD
inherited—α1-antitrypsin deficiency, cystic fibrosis, primary ciliary dyskinesia (Kartagener’s syndrome, Young’s syndrome), tracheobronchomegaly (Mounier–Kuhn syndrome), cartilage deficiency (Williams–Campbell syndrome), Marfan’s syndrome
diagnosis—high-resolution CT chest (signet ring sign), PFT (obstruction ± reversibility)
treatments—exercises, chest physiotherapy, and bronchodilators similar to COPD; however, if reversible, inhaled corticosteroids should be given early. Ensure adequate systemic hydration. Effective treatment of exacerbations
NEJM 2002 346:18
Related Topics
Cryptogenic Organizing Pneumonia (p. 18)
Pulmonary Function Tests (p. 25)
Smoking (p. 480)
Pneumonia
NEJM 2002 345:25; NEJM 2001 344:9
Types of Pneumonia
COMMUNITY-ACQUIRED PNEUMONIA
bacterial—Streptococcus pneumoniae, Staphylococcus aureus, Haemophilus, Moraxella
atypical—Mycoplasma, Chlamydia, Legionella, TB, community-acquired MRSA
viral—influenza, parainfluenza, metapneumovirus, RSV, adenovirus
fungal—blastomycosis, cryptococcus, histoplasmosis
ASPIRATION PNEUMONIA
polybacterial including anaerobes—Bacteroides, Peptostreptococcus, Fusobacterium species and other Gram-positive bacilli
chemical pneumonitis
PNEUMONIA IN THE IMMUNOCOMPROMISED
(see p. 291)
NOSOCOMIAL PNEUMONIA
—begins in non-intubated patient within 48 hours of admission
polybacterial—Staphylococcus aureus, MRSA, Pseudomonas aeruginosa, Enterobacteriaceae (Klebsiella, Escherichia coli, Serratia), Haemophilus, Acinetobacter
viral—influenza
VENTILATOR-ASSOCIATED PNEUMONIA
—begins >48 hours after the patient is intubated (see p. 107)
HEALTHCARE ASSOCIATED PNEUMONIA
—pneumonia that (A) occurs within 90 days of hospitalization of 2 days or more, a stay at nursing home, or a visit to an oral puncture care facility, hospital-based clinic or hemodialysis facility; or (B) occurs within 3 days of receiving antibiotics, chemotherapy, or any type of wound care
Pathophysiology
COMPLICATIONS OF PNEUMONIA
pulmonary—ARDS, lung abscess ± cavitary formation, parapneumonic effusion/empyema, pleuritis ± hemorrhage
extrapulmonary
—purulent pericarditis, hyponatremia (from SIADH), sepsis
Clinical Features
RATIONAL CLINICAL EXAMINATION SERIES: DOES THIS PATIENT HAVE COMMUNITY-ACQUIRED PNEUMONIA?
LR+ | LR– | |
---|---|---|
History | ||
Cough | 1.8 | 0.31 |
Sputum | 1.3 | 0.55 |
Dyspnea | 1.4 | 0.67 |
Fever | 1.7–2.1 | 0.59–0.71 |
Asthma | 0.1 | 3.8 |
Dementia | 3.4 | 0.94 |
Immunosuppression | 2.2 | 0.85 |
Physical | ||
RR >25 | 1.5–3.4 | 0.78–0.82 |
Dullness to percussion | 2.2–4.3 | 0.79–0.93 |
Decreased breath sounds | 2.3–2.5 | 0.64–0.78 |
Crackles | 1.6–2.7 | 0.62–0.87 |
Bronchial breath sounds | 3.5 | 0.9 |
Egophony | 2.0–8.6 | 0.76–0.96 |
PREDICTION RULE—Diehr model (rhinorrhea = −2 points, sore throat = −1 point, night sweats = +1 point, myalgias = +1 point, sputum all day = +1 point, RR >25 = +2 points, temp ≥37.8 °C [≥100 °F] = +2 points. If score ≥3, LR 14; if ≥1, LR 5.0; if < −1 LR 0.22)
APPROACH—“individual or combinations of symptoms and signs have inadequate test characteristics to rule in or rule out the diagnosis of pneumonia. Decision rules that use the presence or absence of several symptoms and signs to modify the probability of pneumonia are available, the simplest of which requires the absence of any vital sign abnormalities to exclude the diagnosis. If diagnostic certainty is required in the management of a patient with suspected pneumonia, then chest radiography (gold standard) should be performed”
JAMA 1997 278:17
Update: The Rational Clinical Examination. McGraw-Hill, 2009
SURFACE LUNG MARKINGS
inferior margin of the lungs—level of 6th rib at the mid-clavicular line, level of 8th rib at the mid-axillary line, and level of 10th rib at the mid-scapular line
oblique (major) fissures—draw a line diagonally from T3 vertebral body posteriorly to the 6th rib anteriorly
horizontal ( minor ) fissure—draw a horizontal line at the level of right anterior 4th rib
Related Topics
Hypoxemia (p. 102)
Parapneumonic Effusion and Empyema (p. 12)
Ventilator-Associated Pneumonia (p. 107)
Investigations
BASIC
labs—CBCD, lytes, urea, Cr, troponin/CK, AST, ALT, ALP, bilirubin, urinalysis
microbiology—blood C&S, sputum Gram stain/AFB/C&S/fungal, urine C&S
imaging—CXR ± CT chest
ABG—if respiratory distress, and for PSI if deciding on possible hospitalization
SPECIAL
bronchoscopy
nasopharyngeal swab—if suspect viral infection, check for influenza A/B, parainfluenza, human metapneumovirus, RSV, adenovirus
mycoplasma I gM
urine for L egionella antigen
Diagnostic and Prognostic Issues
PNEUMONIA SEVERITY OF ILLNESS (PSI) SCORE
scoring—age, female (−10), nursing home (+10), cancer (+30), liver disease (+20), heart failure (+10), CVA (+10), renal failure (+10), altered mental status (+20), RR >30 (+20), SBP <90 mmHg (+20), temp >40°C [>104°F] (+15), HR >125 (+10), pH <7.35 (+30), BUN >10.7 mmol/L [>30 mg/dL] +20, Na <130 mmol/L (+20), glucose >13.9 mmol/L [>250 mg/dL] +10, hematocrit <30% (+10), PaO2 <60 mmHg or O2 saturation <90% on room air (+10), pleural effusion (+10)
utility—originally developed as a prognostic tool. Consider admission if PSI score >90. Clinical judgment more important than PSI in determining admission
NEJM 2002 347:25
Management
ACUTE
—ABC, O 2 , IV, consider salbutamol 100 μg MDI 2 puffs q6h + q1h PRN
ANTIBIOTICS
community-acquired pneumonia—see treatment issues for an approach to selecting the appropriate regimen (remember to adjust for renal function)
tetracycline—doxycycline 100 mg PO BID × 10 days
macrolides—azithromycin 500 mg PO first day, then 250 mg PO daily × 4 days; clarithromycin 250–500 mg PO BID × 10 daysStay updated, free articles. Join our Telegram channel
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