PNEUMONIA

Recognition

Definition

• “Pneumonia is an infection of the lung tissue” (NICE pneumonia in adults diagnosis and management)
• Pneumonia is normally categorised by where the infection was acquired, either community acquired or hospital acquired pneumonia

Risk Factors (BMJ Best Practice)

• Age > 65 years
• Alcohol abuse
• Chronic Obstructive Pulmonary Disease (COPD)
• Contact with children
• Live in a nursing home
• Poor oral hygiene
• Use of proton pump inhibitor

History

If possible, ascertain if patient has:

• Previous admissions with pneumonia or respiratory conditions
• Any operations or treatment for respiratory conditions
• Any allergies

General symptoms (LTHT guidance)

• Cough
• Dyspnoea
• Sputum production
• Fever
• Chest pain
• Pale
• Clammy
• Sweating
• Cool peripheries
• Fever
• Fatigue
• Confusion
• Myalgia

General Signs

• Tachypnoeic
• Low oxygen saturations
• Bronchial breathing
• Delayed capillary refill time
• Reduced skin turgor
• Dry mucous membranes
• Hypotensive
• Tachycardic
• Decreased urine output

Severity MDcalc guidance

• CURB - 65
  • Confusion – New confusion with an Abbreviated Mental Test Score ≤ 8
    • Ask the patient the following questions. Each correct answer scores one point
      1. Age
      2. Time to the nearest hour
      3. Give patient an address to remember and ask them to repeat it at the end of the test
      4. Year
      5. The name of the hospital
      6. To recognise two people and give their names or jobs
      7. Date of birth
      8. Date of First or Second World War
      9. Name of the present monarch
      10. Count backwards from 20 to 1
  • Urea > 7 mmol/L
  • Respiratory rate ≥ 30 breaths/minute
  • Blood Pressure – Systolic < 90 mmHg or Diastolic ≤ 60 mmHg
  • Age ≥ 65
  • One point is scored for each feature present
• CURB – 65 management
  • 0 – 1
    • Low risk - The patient is most likely suitable for home management
  • 2
    • Intermediate risk - The patient will require short stay inpatient treatment
  • ≥ 3
    • High risk - The patient has a sever pneumonia and will require in hospital management

Initial Assessment and Investigations

• ABCDE assessment
• Sit patient up if able to tolerate
• Assess patient’s airway
• Monitor oxygen saturations and respiratory rate
  • If patient is hypoxic give Oxygen (O₂) to achieve target saturations. Initially give 15 L/min via a reservoir mask if the patient is acutely unwell
• Target saturations:
  • 94 - 98% for patients not at risk of hypercapnic respiratory failure
  • 88 - 92% for patients at risk of hypercapnic respiratory failure due to conditions such as Chronic Obstructive Pulmonary Disease (COPD)
• Examine patient’s chest
  • Listen for:
    • Asymmetric breath sounds,
    • Crepitations
    • Increased resonance
    • Pleural rub
• Arterial blood gas (ABG)
• Chest X-ray should be requested. If the patient is unwell request a portable X-ray
• Consider collection of sputum sample if no previous antibiotics during this episode
• Obtain intravenous access by placing 2 large bore cannulae in the antecubital fossa. Take blood to check Full Blood Count (FBC), Urea and Electrolytes (U&Es), Glucose, C-Reactive Protein (CRP) and blood cultures
• Check Capillary Refill Time (CRT) - hold for five seconds and refilling should occur in 3 seconds
• Assess pulse rate, rhythm and character
• Monitor heart rate and blood pressure
• Listen to patient’s heart sounds
• Check urine output and consider catheterisation
• Intravenous (IV) fluids as required by clinical picture and balanced with patients’ risk of fluid overload. See more details in the “Circulation” Chapter in the “Response” Section under “Fluid Challenge”
• Consider sepsis six if sepsis suspected. For further information see “Sepsis” Section in “Medical Emergencies” Chapter
• Call for senior help if not done already
• Check pupils are equal and reactive
• Assess Glasgow Coma Scale or ACVPU using the NEWS2 chart
• Check patient’s temperature and blood sugar
• Consider pneumococcal and legionella urinary antigen test
• Examine patient’s abdomen and legs
• Consider venous thromboembolism prophylaxis

Response

Management

Immediate pharmacological management

• Patients will initially require broad spectrum antibiotics until culture results are available and direct antibiotic therapy (as per trust guidelines)
• Antibiotics should not be delayed whilst trying to get sputum cultures

Referrals

• Discuss with senior member of the team
• Contact critical care outreach team
• Consider referral to respiratory team
• Consider referral to Intensive Care Unit (ICU) if:
  • Failure to respond to medical management
  • Patient requires ventilatory support to encompass NIV and invasive ventilation
  • Patient requires blood pressure support
  • Deterioration of blood gas following medical management

Future management

• In cases of bacterial pneumonia consider HIV test
• Atypical screen
• Consider review in respiratory outpatient clinic and chest X-ray in follow up clinic approximately 6 weeks after discharge to ensure full radiological resolution