History: • 65 yr old, female
• DM,HT,IHD,hypothyroidism
• Presented to the ED
• C/O: Chest pain
• Shortness of breath 1/365
• Sweating
• HPC: Central, non pleuritic type, moderate intensity, no radiation,
• No N & V, PND or orthopnea
• No cough, sputum or fever
• No recent hospitalizations or exposure to health
• care facility
• No hx of recent Immobilization
• No calf pain or swelling.
•
PMH: DM x13yrs :Gliclazide 60mg bd
HT x 13yrs: Nifedipine 20mg bd
Hypothyroidism: levothyroxine 75 mg/d
IHD:TVD, NSTEMI 11/2015
on statin & dual antiplatelets.
PSH : not significant
FH :
SH: mother of 2, lives with husband & children.
Allergy: no known
O/E:
concious, rational.
sweating & mild dyspneic.
afebrile.
no ankle edema or calf tenderness.
RS
RR 32/min, Coarse creps on B/L lower zones with
B/L few rhonchi.
SPO2 95% on air.
CVS
JVP not elevated
PR 110bpm/regular/good volume
BP 170/70 mmHg
Working diagnosis: ACS + LVF.
INVESTIGATIONS:
ECG: No acute ischemic change.
repeated in ½ hr: no any changes of ischemia.
Troponin I : negative.
FBC :sent.
Treated with:
O2 via face mask
IV morphine 2.5 mg stat
IV phenergan 25mg stat
was admitted to the casuality medical ward.
10hrs after the admission,
Became more dyspneic .
RR of 38/min,SpO2 89% on air,
B/L difffuse rhonci and B/L fine creps,
+ R/ lower zonal coarse creps
PR 118bpm, BP 180/70mmHg
Ix: Urgent ECG repeated : NAD
Urgent CXR taken
ABG done
Blood cultures taken
Working DD:
1. Acute LVF
2. Community acquired pneumonia with BHR
3. LRTI + LVF
4. Pulmonary embolism
Management:
1. propped up
2. O2 via face mask 6l/min– spo2 to 96 %
3. Nebulized salbutamol 5mg (back to back)+ Ipravent
4. IVI furosemide 5mg/hr
5. IV Merapenam 1g bd
6. IV Levofloxacin 500mg daily
7. moved to the HDU in the ward.
Other Investigations
1. Trop T :negative
2. Trop I :negative
3. WBC :14000/µl
N% :85%
L% :9.1%
Hb :10g/dl
Plt :350 x 10^3/µl
4. CRP :12mg/l (<6mg/l)
5. BU :6.2mmol/l (2.9-8.2)
6. Blood cultuers: NG after 24hrs & 5 days incubation.
7. Sputum cultures: She did not produce any sputum.
8. D dimer: < 0.2mg/l
9. Na :131 mmol/l
10. K : 5.1mmol/l
11. SGOT: 45
12. SGPT: 30
13. Thyroid profile : normal.
14. S.Cr : 102µmol/l (60-120)
15. 2D echo: EF 56%,mild LVH, Grade I DD
• Mild anterior wall dyskinesia
• Mild MR
• Preserved LV & RV sys. Functions
•
•
•
Further management
1. IVI Frusemide 5mg/hr continued
2. IVI GTN added
3. IV Hydrcortisone 100mg 6hrly
4. Nebulisation with sal & ipra 6 hrly
5. S/C enoxparin 40mg /d + DVT stockings
6. Glycemic control acieved with SI: target 140-180mg/dl
7. Catheterised IP/OP monitored.
8. RR, PR,BP,SpO2 was monitored.
9. Intake 1.2l/d
CXR repeated due to poor response!
Definition of CAP is a syndrome in which, acute infection of
the lungs develops in a person who have not
been hospitalized recently and not have had
regular exposure to the health care system. n engl j med 371;17 nejm.org october 23, 2014
Epidemiology
1. Annual incidence in the community: 5–11 per 1000
adult population. [Ib]
2. Sixth leading cause of death world wide.
3. The leading cause of death from infectious diseases
worldwide.
Thorax 2009;64(Suppl III):iii1–iii55. doi:10.1136/thx.2009.121434
ETIOLOGY
Common
Streptococcus pneumoniae,
1. Haemophilus influenzae,
2. Staphylococcus aureus,
3. Influenza virus
4. Other respiratory viruses
5. n engl j med 371;17 nejm.org october 23, 2014
Less common
• Pseudomonas aeruginosa or other gram-negative rods. Pneumocystis jirovecii.
• Moraxella catarrhalis.
• mixed microaerophilic and
• anaerobic oral flora.
• n engl j med 371;17 nejm.org october 23, 2014
•
UNCOMMON
Mycobacterium tuberculosis,
Nontuberculous mycobacteria,
Nocardia species,
Legionella species,
Mycoplasma pneumoniae,
Chlamydophila pneumoniae,
Chlamydophila psittaci,
Coxiella burnetii,
Histoplasma capsulatum,
Coccidioides species,
Blastomyces dermatitidis,
Cryptococcus
Aspergillus species n engl j med 371;17 nejm.org october 23, 2014
CLINICAL FEATURES
• Pneumonia should be suspected in patients
• with:
• ● fever
• ● new cough
• ● rigors
• ● change in sputum colour
• ● pleuritic chest pain
• ● dyspnoea • Many patients with these features: will not have pneumonia
In certain groups (esp in the elderly): classic clinical
features are unlikely.
My patient
66yr old
Presented with
Non pleuritic chest pain
SOB
Sweating
No history of
Fever
Cough
Sputum
therefore a high index of suspicion is needed !
RADIOLOGICAL
1.Role of CXR
Out patients
Not necessary unless [D] :
1. The diagnosis is in doubt.
2. Progress following treatment not satisfactory at review.
3. Pt at risk of underlying lung pathology such as lung CA
Hospitalized pts
Needed in all patients ASAP to confirm/refute the
diagnosis.[D]
2.Role of CT lung
Currently has no routine role in CAP.
Thorax 2009;64(Suppl III):iii1–iii55. doi:10.1136/thx.2009.121434
GENARAL INVESTIGATIONS
Out patients
1. Not necessary for the majority.
2. Pulse oximetry assessment of oxygenation is adequate.
Hospitalized patients
All should have the following performed on admission:
1. Oxygen sat by pulse oximetry. [B+]
2. Arterial blood gases (when necessary)[B+]
3. CXR to allow accurate diagnosis. [B+]
4. BU and SE for severity assessment[B+]
5. CRP to aid diagnosis and as a baseline measure. [B+]
6 FBC. [B2]
7. LFTs. [D]
Thorax 2009;64(Suppl III):iii1–iii55. doi:10.1136/thx.2009.121434
MICROBIOLOGICAL INVESTIGATIONS
Out patients
Not recommended routinely.[D]
Thorax 2009;64(Suppl III):iii1–iii55 doi:10.1136/thx.2009.121434
MICROBIOLOGICAL Ix cont…..
Hospitalized patients
1.Blood cultures: are recommended for all patients with
moderate to severity CAP, preferably before
antibiotic therapy is commenced. [D]
2.Culture of sputum: or other lower respiratory tract
samples should also be performed for all patients with
moderate to severe CAP
3.Sputum Gram stain: can give an immediate
indicator of the likely pathogen.
Thorax 2009;64(Suppl III):iii1–iii55. doi:10.1136/thx.2009.121434
4.Tests for Streptococcus pneumoniae
5.Tests for Legionnaires’ disease
6.Tests for Mycoplasma pneumoniae
Thorax 2009;64(Suppl III):iii1–iii55. doi:10.1136/thx.2009.121434
RISK STRATIFICATION
NEEDED:
1. For triaging pts for the site of Rx.
2. For ordering Ixs.
3. For starting empiric Rx.
4. For prognostication.
• Aided by various scoring systems. o
•
Scoring systems
Well validated scoring systems:
• 1. CURB 65
• 2. Pneumonia severity index (PSI)
• 3. SMART COP
• 4. ATS/IDSA criteria
Other (poorly validated):
• 1. A DROP
• 2. REA-ICU index
• 3. CAP-PIRO
• 4. ESPANA scale
CURB65 score Guide in triaging pts for site of care.
5 prognostic variables
• c Confusion: New mental confusion.
• c Urea: >7 mmol/l
• c Respiratory rate: ≥ 30/min.
• c Blood pressure: SBP<90 mmHg and/or DBP ≤60 mmHg
• c Age≥ 65 years.
• Score Decision
• 0,1 probably Rxed as out pt.
• 2 should be admitted.
• 3 or > should be considered for ICU care.
•
•
PNEUMONIA SEVERITY INDEX (PSI) 1. A prognosis prediction rule
2. 20 variables, stratified into 5 classes
3. Defines severity based on predicted risk of mortality at
30 days.
4. Five classes I-V
• 0- 50 points (class i) : 0.1% mortality
• 51-70 points (class ii) : 0.6%
• 71-90 points (class iii): 0.9%
• 91-130 points (class iv): 9.3%
• 130-395 points (class v) : 27%
PSI
Factor Score Demographic
• Age Age in years
• Sex −10 if female
• Nursing home (not hostel) resident +10
Coexisting illness
• Neoplastic disease +30
• Liver disease +20
• Congestive cardiac failur e +10
• Cerebrovascular disease +10
• Chronic renal disease +10
Signs on examination
• Acutely altered mental state +20
• Respiratory rate ≥30/min +20
• Systolic blood pressure <90 mmHg +20
• Temperature <35°C or ≥40°C +15
• Pulse rate ≥125/min +10
Investigations
• Arterial pH <7.35 +30
• Serum urea ≥11 mmol/L +20
• Serum sodium <130 mmol/L +20
• Serum glucose ≥14 mmol/L +10
• Haematocrit <30% +10
• PaO2 <60 mmHg or SpO2 <90% +10
• Pleural effusion on CXR +10
To treat as out patient or as in patient?
Factors to consider…..
1.Severity of illness : most critical factor.
2 Ability of maintaining oral intake.
3 Likelihood of compliance.
4 Mental illness & cognitive impairement.
5 Living situation.
6 Pt functional status.
7 Hx of substance abuse.
GENERAL MANAGEMENT
Out patients
Should be advised
1. To rest,
2. To drink plenty of fluids,
3. Not to smoke. [D]
4. Pleuritic pain :simple analgesics such as paracetamol. [D]
5. Review policy: recommended after 48hrs
• Thorax 2009;64(Suppl III):iii1–iii55. doi:10.1136/thx.2009.121434
Hopitalized pts: Initial Mx
1. Appropriate oxygen therapy for all [D]
2. Assess for volume depletion: IV fluids as needed
3. Prophylaxis of VTE with LMWH: for all who are not fully
mobile[A+]
4. Nutritional support :in prolonged illness. [C]
5. Uncomplicated pts with CAP should be mobilized[A+]
6. Advice regarding expectoration of sputum. [D] Thorax 2009;64(Suppl III):iii1–iii55. doi:10.1136/thx.2009.121434
When should the first dose of antibiotics be given to
patients admitted to hospital?
As soon as the diagnosis of CAP is confirmed. [D]
Thorax 2009;64(Suppl III):iii1–iii55. doi:10.1136/thx.2009.121434
COMPLICATIONS OF CAP •
1. Para pneumonic effusion. [D]
2. Empyema
3. Lung abscess. [D]
4. Respiratory failure
5. Vascular complications : common!
4. Cardio vascular: AMI
5. New or worsening HF
6. Cerebro vascular: Stroke
6. Cardiac arrhythmias.
References
1. Thorax 2009;64(Suppl III):iii1–iii55. doi:10.1136/thx.2009.121434
2. n engl j med 371;17 nejm.org october 23, 2014
3. uptodate