The Pneumonia Severity Index is a tool that has been widely validated to help determine who should be managed as an inpatient vs outpatient.

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1 Pneumonia Pneumonia 1. What are the criteria for admitting this patient, as opposed to managing them as an outpatient? Why would they come to the hospitalist service (compared to a subspecialist or a transition bed)? The Pneumonia Severity Index is a tool that has been widely validated to help determine who should be managed as an inpatient vs outpatient. It uses medical history, physical examination, laboratory and CXR at the time of patient presentation. This Scoring system assign patents to 5 classes based on 30 day mortality risk Class I & II = outpatient therapy, Class III = observation unit or brief admit, Class IV & V = traditional admission In spite of low mortality prediction there might be other medical or psycho social factors that influence location of treatment. The predication rules are intended to supplement the clinical judgment of the physician. Examples that can influence the decision: Significant pleuritic chest pain Cognitive impairment Poor reliability to take antibiotics Poor ability to recognize deterioration Poor premorbid function Inability to tolerate PO medications Immunocompromised Hospital acquired pneumonia Aspiration pneumonia Suspected tuberculosis or pneumonia during outbreaks (influenza, MERS, SARS ) Preexisting chronic lung disease or neuro muscular disease

2 Another simple scoring system is the CURB-65 score It is based upon five easily measurable factors Confusion or new disorientation to person, place, or time Urea >7 mmol/l Respiratory rate 30 breaths/minute Blood pressure (systolic <90 mmhg or diastolic 60 mmhg) Age 65 years For a score of 2 and more = inpatient treatment For office settings the Urea might not be available in that case a patient with score of 1 or more should be referred for admissio Admission to other services: Internal medicine for cases that require frequent reassessments due to complexity, challenging volume assessments, multiple comorbidities Examples Pneumonia in diabetics with DKA, Pneumonia with significant AKI or AoCKD Pneumonia with superimposed CHF Pneumonia with significant electrolyte abnormalities (hypo Na) Pneumonia in patients with specialized needs re Hemodialysis or PD need to be admitted to site or service that can support such Respiratory Significant preexisting chronic lung disease Asthmatic, severe COPD or ILD with pneumonia Immunocompromised might require further invasive diagnostics re Bronchoscopy /BAL Pneumonia with effusion require thoracentesis management of pleural component of illness Multilobar infitrates high risk to develop respiratory failure Significant Hemoptysis Cavitating pneumonia require specialized diagnostics Diagnostic uncertainty that require specialized diagnostics EBUS, Bronchoscopy

3 ICU Hemodynamic respiratory support required Resp acidosis ph less 7.3 High resp rate - more than 30 risk for respiratory fatigue Hypotention in spite of crystalloids Inapprorate normal or rising PCO2 in hyperventilating patient Altered LOC 2. What is your differential diagnosis? Include at least three most likely, as well as at least one sinister hypothesis. Various non pneumonic processes can percent with a pulmonary infiltrates Various Processes can also be superimposed on each other Ex Pneumonia patient can have superimposed CHF or the pneumonia patient can have a superimposed PE Differential diagnosis : 1) Pulmonary edema due to cardiac causes and non cardiac causes Pulmonary edema can have atypical presentations and can be unilateral Pleural effusions can cause compressive atelectasis 2) PE Splinting is common and could cause atelectasis Later in disease pulmonary infarct could percent as an infiltrate PE can be associated with pleural effusions

4 3) Malignancy with a Post obstructive pneumonia Look for hilar or mediastinal mass in association with the infiltrate. Upper lobe pneumonias should always raise suspicion for Malignancy or other diseases associated with hilar lymphadenopathy such as TB Infectious or non infectious process that cause hilar lymphadenopathy Mycobacterial infection Sarcoidosis Lymphomas 4) COPD exacerbation and bronchopneumonia purulent bronchitis is often difficult to separate Often have to rely on history Sinister disease! 5) Diffuse alveolar hemorrhage (can have a variety of causes infections, toxins, medications, autoimmune disease ) 6) Vascultis Most often due to an auto immune disease Often systemic and the lung issues is in combination with other organ involvement most often the kidneys ex Anti Gbm Good Pasture, Wegeners granulomatosis, Pulmonary renal syndrome Note that there can be large amount of bleeding into alveoli without hemoptysis Often a drop in Hb is a hint to the diagnosis

5 3. What investigations will you order? What ongoing follow-up should be done during the admission? To make diagnosis with confidence seek the following You need a history that points to new respiratory symptoms you would like to see SOB - new or worse, cough, new or change in sputum, hemoptysis, pleuritic CP You need signs of respiratory system disease look at the vitals - increase repertory rate is one of the early mechanism of body to compensate, hypoxia, Remember healthy & fit people might be able to compensate for hypoxia by increasing the respiratory rate, in these cases hypoxia can be a late sign respiratory exam abnormality: chest expansion watch for splinting bronchial breath sounds, increased vocal fremitus and resonance over the consolidate lung, whispering pectorilgoly, crackles You would like to see symptoms and signs of an infectious process - host mmune response Fever, rigors often elderly or immune suppressed don t mount a fever Lab tests that support infection leukocytosis with left shift Look for degree % of Bandemia even with normal WBC More than 10% is significant, The higher the more concerning Am J Med 2012 study showing the higher the bandemia the higher the likelihood for positive cultures including blood cultures and mortality CRP more of a short term marker of infection and inflammation often will change as patient improve sensitive but not specific for infection or inflammation Radiographic signs CXR is gold standard easy to obtain often difficult to know if consolidation vs collapse Always compare with old CXR where able Often chronic changes can mimic infiltrates Example as are eventration of diaphragm, pleural changes Often effusions can obscure. Consider doing a lateral decubitus to see gravitational shifting fluid CXR tend to lag, and might evolve as hypovolemia is corrected CT chest is more sensitive and specific - not first line will often see consolidation before CXR Lab test can help with microbiological diagnosis or explain the trigger 1)Nasopharyngeal swabs virus infection often predisposes to more virulent bacterial infection

6 2) Bloodcultures you need to interpret the results in context of patient and their condition Examples: S pneumonia positive BC could fit with a lobar CAP. E coli positive BC in setting of a clinical / radiographic pneumonia could raise the question why a enteric organism is causing a lung problem? aspiration pneumonia. Often the pleural fluid cultures will yield a organism. 3)Serological test for atypical organism Mycoplasma, Legionella urinary antigen, Coccidioidomycosis Sputum: Often contaminated with saliva so test seldom helpfull Can ask for RT to do induced sputum, typically neb with saline pre induction. Need to be able to follow commands. Often the airway is colonized so positive culture should always be evaluated in context of patient s illness. H flu, Neisseria sp, S pneumonia, Staph, GAS can be seen as non illness colonizers Sputum C&s is important in patients with bronchiectasis & CF It will often confirm presence of pseudomonas and help with antibiotic sensitivities As colonizers they do cause infectious exacerbations of bronchiectasis Sptum for AFB is commonly ordered in suspected TB or MAC 3 Negative AFB typically indicate low risk of infectivity to others and therefore is used to determine isolation status Sputum is typically incubated for 6 weeks since mycobacteria is slow growers Cultures will help determine if tuberculosis vs no TB mycobacteria Cultures important for antibiotic sensitivity ABG : Should be considered if the patient has high or increasing O2 needs Also if concerns about LOC -? unrecognized hypercapnia Any patient that appears septic? degree of acidosis Is there respiratory failure and what type hypoxemic or hypoventalotory? Look at ph resp acidosis indicator for ventilator support?

7 Metabolic acidosis due to sepsis & organ hypo perfusion- need for inotropic support? In hypoxemic respiratory failure the PCO2 often start out low due to hyperventalory compensation but will climb as patient fatigue 4. What will be the management principles for the most likely condition? Include both pharmacologic and nonpharmacologic management. What contra-indications could exist for these choices? Be ready to discuss these with your preceptor in detail. Oxygen : maintain adequate oxygenation in typical healthy individual target saturation typical 92%. Some patients with chronic lung disease are known to retain CO 2 Might have chronic elevated PCO2 on a past ABG Might have a elevated CO2 or bicarb on electrolyte tests Due to chronic hypercapnia their respiratory drive depends on their PO2 Should have their saturation maintained at 88-90%. If concerns can do a ABG Hydration fluid bolus: to maintain heamodynamic stability, manage AKI or Acute on CKD Often there is a component of sepsis with component of distributive shock Often IV volume depletion poor intake and high insensible respiratory loss due to high resp rate and work of breathing Adequate hydration helps reduce respiratory secretions viscosity. Be wary of worsened CHF in those at risk. VTE prophylaxis: Unless contra indicated every patient should be offered DVTp

8 Adjust dose dependent on weight or renal function Typically LMWH preferred above unfractionated heparin In GFR < 30 ml/min BID unfractionated heparin If Heparin Contra indicate consider Sequential pneumatic stockings C/I past HIT, active bleeding, platelets less than 50, other conditions that put patient at high risk for bleeding Supra therapeutic or therapeutic INR is protective and don t warrant prophylactic heparin Antimicrobials Most often we look at empiric treatment at time of diagnosis Attempt to determine the most like organism or combination of organism Principles and factors to consider in the choice of anti microbial : Antibiotic use in last 3 months? Review patients past microbiology and sensitivity patterns MRSA status or risk Influenza season or ILI symptoms? Suspicion for tuberculosis? subacute illness, upper lobe involvent, caviationg pneumonia, origin or travel to at risk region Travel history? Immune compromised? consider ID and pulmonology consultation Is there significant co morbidities present ex CKD, cardiac, diabetes, asplenia, malignancy? Seek a microbiological diagnosis, do blood cultures, pleural fluid analysis where appropriate & sputum cultures Sputum cultures is of most value in Bronchiectasis and COPD patients with recurrent infections High risk for being colonized with resistant organisms that can cause pneumonia Typically delay antibiotics until blood cultures done unless 1 hour delay expected If sepsis don t delay antibiotics Where was pneumonia acquired?

9 Community typical pathogens = respiratory viruses, S pneumonia, H influenza, Atypical organisms Health Care associated typical pathogens = Gram positives such as S pneumonia, MSSA, MRSA, Gram Negatives, Anaerobes Special circumstances: Aspiration pneumonia Community acquired: outpatient Typical 5-7 days Doxycyline 200mg day one then 100mg daily Or Macrolide such as Clarithromycin Community acquired: inpatient Typical 5-7 days Cefuroxime PO or Ceftriaxone IV AND Doxycyline PO or Azithromycin IV or PO HAP: 7-14 days Ceftriaxone IV or Piperacillin Tazobactam Consider MRSA antibiotic if at risk or positive MRSA cultures Aspiration pneumonia : 7-14 days Pneumonitis can also present with CXR infiltrates and hypoxia but will often clear in few hours This often don t require antibiotics If sick and hypoxia persist and poor respiratory reserve, consider antibiotics early Can always stop if quick recover

10 Mono : therapy Amoxil- clavulinate Cefuroxime po & Metronidazole po Ceftriaxone IV & Metronidazole IV Piperacillin Tazobactam IV Swallowing dysfunction: Always seek history or signs that might suggest aspiration Consider SLP consult Do your own bed side assessment what is the LOC?, strength of cough & voice, management of own secretions, cough/hypoxia after liquids or solids PO Any patients who has tachypnea will have a shortened apneic phase of swallowing and therefore be at risk for aspiration In early admit with significant WOB and dyspnea consider temporary down grade of diet and fluid consistency for safety can always be upgraded if improve 5. What complications could arise during this patient s stay? How could you attempt to prevent these? Pulmonary complications: EFFUSIONS : Three types of exudative effusions: Para pneumonic effusion ( exudate by criteria, ph more than 7.2, no puss cells or organism, negative C&S) Complicated Para pneumonic effusion ( exudate by criteria, loculated on imaging, ph less than 7.2, no puss cells or organism on stain, but can be C&S positive ) This is not an empyema yet, but it is high risk to evolve into empyema and is treated with chests drainage similar as empyema Empyema (puss cells or organisms on stain, can be C&S negative ) Typically persistent or worsening hypoxia, persistent fever, persistent leukocytosis, often pleuritic chest pain Effusion will often develop on serial CXR so have low tolerance to repeat CXR if patient is not improving as expected Often effusion is masked by consolidation

11 Useful to do lateral decubitus CXR fluid will layer with gravity and if more than 1 cm is considered significant to be sampled Ultrasound and CT chest can quantify amount of fluid Empyema s will enhance on contrast enhanced CT scan, help to see loculations and septations The gold standard is a diagnostic thoracentesis. Lights criteria uses serum and pleural protein and LD to determine if exsudate The Serum pleural albumin gradient can also be used to determine if exudate vs transudate Similar to SAAG testing in acites if gradient is LESS than 12 it is indicative of an exsudate Microbiology cell count diff and C&S will determine if empyema ph will determine if a pure para pneumonic exudative effusion vs a complicate para pneumonic exudative effusion ( Ph cut off is 7.2 ) If empyema or complicated Para pneumonic effusion you need source control of infection and chest drainage of the infected pleural space. Pulmonary consolation or transfer is typically recommended Often the collections is loculated and will show poor improvement At this point CT chest might be more helpful than CXR tpa can be given into pleural space to lyse the locations Risk is pleural bleeding Might require multiple drains to communicate with loculations Often require Thoracic surgery involvement the risk is that inadequate clearing of the pleural space will lead to a trapped lung Antibiotics is typical 4 weeks total from defervest and improvement Antibiotics is determined by cultures If culture negative use original antibiotic but add anaerobic coverage ( metronidazole ) Amox clavulin is a PO step down option

12 Avoid anti pyretic meds might mask a fever which is a good barometer of recovery NECROTIZING > CAVITATION LUNG > ABCESS - Continuum Typically persistent or persistent hypoxia, prolonged fever & leukocytosis, and often hemoptysis Diagnosis is with CxR and CT chest Need Pulmonary and ID consolation 6. What other resources can you enlist to assist you in the management of this patient? Patients who fail to respond Broad principles Wrong diagnosis? post obstructive pneumonia due to Foreign body or neoplasm or hilar lymphadenopathy?non infectious?cryptogenic organizing pneumonia ( BOOP ) Wrong drug for wrong bug? resistance? revisit your choice of empiric antibiotic Source control? empyema? abcess Host factors? compliance? immune deficiency re HIV Physiotherapy service can assist with chest percussion and postural drainage Flutter or Accapella vibrating mucus clearance devices for patients with bronchiectasis/cf Mucomyst or N-asytyle cysteine can help with mucolysis PO is just as effective as nebulized but not as well tolerated Patients for whom there is a risk of aspiration should be assessed by Speech Pathology Immunize patients with pneumococcal vaccine once prior to discharge and annual influenza vaccine. Smoking cessation and NRT. Resourses :

13 7. How will you know this patient is ready for discharge what parameters will be your guide and what needs to be in place at their residence? Afebrile / normalization of WBC for at least 48 h Renal / electrolytes stable AKI resolved SAIDH resolved Blood cultures negative Able to tolerate appropriate po step down antibiotic Reassured about antibiotic compliance and follow through on treatment Antibiotic used is appropriate for the microbiology cultures Complications appropriately managed Eating and drinking appropriately to maintain self At functional baseline or supported and at safe baseline Follow-up : Typically clinical f/u in 3-7 days with family physician CXR in 8 weeks to ensure radiographic clearance of the infection. Recommended in all smokers and age above 50