History

Fact Explanation
Fever Pneumonia is an acute lower respiratory infection involving the lung parenchyma. The patient will be febrile due to the systemic response to infection. The patient may experience chills and rigors during a severe infection. Pneumonia is commonly of bacterial or viral origin. The presenting symptoms differ according to the causative organism.[1][2]
Cough Cough is a prominent symptom of pneumonia. Initially the patient may complain of dry cough which gradually becomes productive.[3]
Sputum production The color of the sputum is initially white and may turn yellow with time. Presence of neutrophils in sputum results in the color change. Rusty colored sputum is characteristically seen with Pneumococcal pneumonia. Pseudomonas, Klebsiella species produce yellow-green colored sputum.[3]
Chest pain Inflammation of the lung parenchyma spreads to the nearby pleura. The inflamed pleura may cause pleuritic type chest pain. The pain is usually localized to the sides of the chest. Breathing and coughing worsens the chest pain.[3]
Haemoptysis Results due to the local hyperemia and vascular congestion associated with infection and inflammation. The alveoli are filled with red blood cells, bacteria and white blood cells. This results in the production of the rust-colored, purulent sputum. This is classically seen with Pneumococcal infection. Virulent pathogens such as Staphylococcus aureus, Pseudomonas aeruginosa may result in blood vessel invasion with infarction which also leads to the development of haemoptysis.[4]
Malaise/ Anorexia Due to the inflammation associated with lung infection.[3]
Unconsciousness Unconsciousness may be the only presenting symptom in elderly patients.[3]
Extra-pulmonary symptoms Extra-pulmonary symptoms are common associated with atypical organisms such as Legionella pneumophilia, Mycoplasma pneumoniae and Chlamydia species. The patient may develop symptoms such as headache, myalgia & arthralgia, diarrhea, vomiting, hepatitis, renal failure, confusion and coma. [5], [6]
Symptoms to differentiate between typical and atypical pneumonia Pneumonia is classified into community acquired, hospital acquired, aspirational pneumonia and pneumonia in immunocompromised hosts. The causative organisms differ in each type.[4] Certain aspects of the history can be used to differentiate the causative organism - age of patient, risk factors, context of acquiring infection. Typical organisms present with prominent chest symptoms, while atypical pneumonia present with minimum chest symptoms and prominent extra-pulmonary symptoms. Patients with mycoplasma or chlamydia infection may develop complications such as meningo-encephalitis, skin rashes, autoimmune hemolytic anemia, hepatitis etc.[7]
References
  1. GUIDELINES FOR THE MANAGEMENT OF COMMUNITY ACQUIRED PNEUMONIA IN ADULTS. THE BRITISH THORACIC SOCIETY, 2009 [Viewed on 29 June 2014]. Available from : https://www.brit-thoracic.org.uk/Portals/0/Guidelines/Pneumonia/CAPQuickRefGuide-web.pdf
  2. WOODHEAD MA, MACFARLANE JT, MCCRACKEN JS, ROSE DH, FINCH RG. Prospective study of the aetiology and outcome of pneumonia in the community. Lancet [online] 1987 Mar 21, 1(8534):671-4 [viewed 01 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/2882091
  3. BRANDENBURG JA, MARRIE TJ, COLEY CM, SINGER DE, OBROSKY DS, KAPOOR WN, FINE MJ. Clinical Presentation, Processes and Outcomes of Care for Patients with Pneumococcal Pneumonia J Gen Intern Med [online] 2000 Sep, 15(9):638-646 [viewed 18 September 2014] Available from: doi:10.1046/j.1525-1497.2000.04429.x
  4. BOUSSAUD V, PARROT A, MAYAUD C, WISLEZ M, ANTOINE M, PICARD C, DELISLE F, ETIENNE J, CADRANEL J. Life-threatening hemoptysis in adults with community-acquired pneumonia due to Panton-Valentine leukocidin-secreting Staphylococcus aureus. Intensive Care Med [online] 2003 Oct, 29(10):1840-3 [viewed 18 September 2014] Available from: doi:10.1007/s00134-003-1918-5
  5. JOHNSON DH, CUNHA BA. Atypical pneumonias. Clinical and extrapulmonary features of Chlamydia, Mycoplasma, and Legionella infections. Postgrad Med [online] 1993 May 15, 93(7):69-72, 75-6, 79-82 [viewed 01 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/8493198
  6. TORRES A., PEETERMANS W. E., VIEGI G., BLASI F.. Risk factors for community-acquired pneumonia in adults in Europe: a literature review. Thorax [online] December, 68(11):1057-1065 [viewed 01 July 2014] Available from: doi:10.1136/thoraxjnl-2013-204282
  7. WIśNIEWSKA-LIGIER M, WOźNIAKOWSKA-GESICKA T, SOBAńSKA A, WIERZBICKA E. [Extrapulmonary complications of Mycoplasma pneumoniae infections]. Przegl Lek [online] 2003, 60(12):832-5 [viewed 01 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/15058027

Examination

Fact Explanation
General examination : Fever Due to the systemic response to infection.[1]
General examination : Cyanosis Seen with severe infection due to the impaired gas exchange.[1]
Cardiovascular system examination : Tachycardia, hypotension Due to sepsis. The patient may also develop septic shock.[2]
Respiratory system : Diminished chest movement/ expansion On inspection and palpation the affected side side of the chest will show reduced chest movements. It is due to involvement of underlying lung.[1]
Respiratory system : Tracheal position Trachea is usually not deviated. It may be deviated to the opposite side if a parapneumonic effusion develops.[1]
Respiratory system : Increased tactile vocal fremitus, increased vocal resonance Due to inflammation of the lung parenchyma and consolidation the sound waves are transmitted better to the chest wall.[1]
Respiratory system : Dull percussion note Due to consolidation of the underlying lung.[1]
Respiratory system : Bronchial breathing Normal vesicular breathing will be replaced by bronchial breathing over the affected areas. The time duration of inspiration and expiration will be equal, no gap would be audible in between and the expiratory phase will be higher in pitch. Bronchial breathing occurs due to consolidation where breath sounds are now transmitted to the chest wall without being filtered.[3]
Respiratory system examination : Pleural rub Pleural rub is a sign of pleurisy. It is heard when the inflamed pleura rub on each other.[1]
References
  1. BRANDENBURG JA, MARRIE TJ, COLEY CM, SINGER DE, OBROSKY DS, KAPOOR WN, FINE MJ. Clinical Presentation, Processes and Outcomes of Care for Patients with Pneumococcal Pneumonia J Gen Intern Med [online] 2000 Sep, 15(9):638-646 [viewed 18 September 2014] Available from: doi:10.1046/j.1525-1497.2000.04429.x
  2. GARCIA-VIDAL C, ARDANUY C, TUBAU F, VIASUS D, DORCA J, LIñARES J, GUDIOL F, CARRATALà J. Pneumococcal pneumonia presenting with septic shock: host- and pathogen-related factors and outcomes. Thorax [online] 2010 Jan, 65(1):77-81 [viewed 01 July 2014] Available from: doi:10.1136/thx.2009.123612
  3. HARRIS WJ. Bronchial and Vesicular Breathing Br Med J [online] 1897 Nov 13, 2(1924):1418-1420 [viewed 01 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2407936

Differential Diagnoses

Fact Explanation
Pneumonitis Pneumonitis is non-infective inflammation of the lung parenchyma. Heavy metals, chemicals and drugs may cause pneumonitis. Antibiotic drugs such as sulfamethoxazole-trimethoprim, anti-TB drugs and herbal medications can cause interstitial pneumonitis.[1] Secondary bacterial infection may superimpose on the inflamed lung.
Acute exacerbation of chronic obstructive pulmonary disease COPD is a chronic airway obstructive disease which is non-reversible. The patient will have a long standing history of progressive exertional dyspnea and cough.[2] The patient is usually a heavy smoker. The presentation of acute exacerbation is with worsening of existing symptoms and deterioration of lung functions. Acute exacerbation of COPD may be infective or non-infective. The patient is prone to develop complications such as respiratory failure and fluid retention.
Bronchiectasis Bronchiectasis is a condition with pathological dilatation of bronchi and bronchioles. Characteristic features of the disease are long standing cough with production of large volumes of foul smelling purulent sputum. Intermittent haemoptysis may be present. On examination finger clubbing, bilateral coarse crepitations may be elicited. Diagnosis of the condition is by chest X-ray and HRCT-chest.[3]
References
  1. KONDO A. [Drug-induced pneumonitis]. Kekkaku [online] 1999 Jan, 74(1):33-41 [viewed 19 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/10067054
  2. SUTHERLAND E. RAND, CHERNIACK REUBEN M.. Management of Chronic Obstructive Pulmonary Disease. N Engl J Med [online] 2004 June, 350(26):2689-2697 [viewed 01 July 2014] Available from: doi:10.1056/NEJMra030415
  3. BARKER ALAN F.. Bronchiectasis. N Engl J Med [online] 2002 May, 346(18):1383-1393 [viewed 01 July 2014] Available from: doi:10.1056/NEJMra012519

Investigations - for Diagnosis

Fact Explanation
Objectives of investigation The main objectives of investigations are to establish the diagnosis, identify the causative organism and determine the severity. [1]
Chest X-ray The chest X-ray may show lobar or multilobar infiltrates, pleural effusion or cavitation. The chest X-ray pattern may also be used to identify the causative organism. [2]
Sputum : Microscopy & Culture For identification of the causative organism. Gram stain is a sensitive and highly specific investigation for the diagnosis of pneumococcal and H. influenzae pneumonia.[3] Antibiotic sensitivity studies are also done with the culture to determine the appropriate antibiotic.
Blood culture For identification of the pathogen. However the detection rate of blood culture is low.[4]
Pleural fluid aspiration Assessment of pleural fluid parameters help in confirmation of the diagnosis. Samples can also be used for microscopic examination and culture.[1]
Bronchoscopy and bronchoalveolar lavage Rarely required. May be considered when the diagnosis is incorrect, illness is refractory to treatment, ventilator associated pneumonia or the patient is immunocompromised.[5]
Specific tests used to identify organisms Identification of atypical organisms would require additional special investigations. Legionella can be identified by sputum culture and urine antigen testing.[6] Serology may be useful to isolate viruses and certain bacteria.
References
  1. GUIDELINES FOR THE MANAGEMENT OF COMMUNITY ACQUIRED PNEUMONIA IN ADULTS. THE BRITISH THORACIC SOCIETY, Update 2009 [Viewed on 29 June 2014]. Available from : https://www.brit-thoracic.org.uk/Portals/0/Guidelines/Pneumonia/CAPQuickRefGuide-web.pdf
  2. RUIZ M, AROSIO C, SALMAN P, BAUER TT, TORRES A. Diagnosis of pneumonia and monitoring of infection eradication. Drugs [online] 2000 Dec, 60(6):1289-302 [viewed 01 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/11152012
  3. ROSóN BEATRIZ, CARRATALà JORDI, VERDAGUER RICARD, DORCA JORDI, MANRESA FREDERIC, GUDIOL FRANCESC. Prospective Study of the Usefulness of Sputum Gram Stain in the Initial Approach to Community‐Acquired Pneumonia Requiring Hospitalization. CLIN INFECT DIS [online] 2000 October, 31(4):869-874 [viewed 01 July 2014] Available from: doi:10.1086/318151
  4. CHAM G, YAN S, HENG BH, SEOW E. Predicting positive blood cultures in patients presenting with pneumonia at an Emergency Department in Singapore. Ann Acad Med Singapore [online] 2009 Jun, 38(6):508-7 [viewed 01 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/19565101
  5. FAGON JY. Diagnosis and treatment of ventilator-associated pneumonia: fiberoptic bronchoscopy with bronchoalveolar lavage is essential. Semin Respir Crit Care Med [online] 2006 Feb, 27(1):34-44 [viewed 19 September 2014] Available from: doi:10.1055/s-2006-933672
  6. FIELDS BS, BENSON RF, BESSER RE. Legionella and Legionnaires' disease: 25 years of investigation. Clin Microbiol Rev [online] 2002 Jul, 15(3):506-26 [viewed 19 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/12097254

Investigations - Fitness for Management

Fact Explanation
Full blood count Neutrophilic leucocytosis will be seen. [1]
Erythrocyte sedmentation rate/ CRP Markers of inflammation will be elevated.[1]
Assess oxygenation/ ABG To monitor the patient’s oxygen saturation. Arterial blood gas analysis is indicated in severe infection. Patients with severe infection may develop type 1 respiratory failure. [2]
Serum electrolytes/ Blood urea/ Serum creatinine To monitor renal functions.[1]
References
  1. GUIDELINES FOR THE MANAGEMENT OF COMMUNITY ACQUIRED PNEUMONIA IN ADULTS. THE BRITISH THORACIC SOCIETY, Update 2009 [Viewed on 29 June 2014]. Available from : https://www.brit-thoracic.org.uk/Portals/0/Guidelines/Pneumonia/CAPQuickRefGuide-web.pdf
  2. BTS Guidelines for the Management of Community Acquired Pneumonia in Adults. Thorax [online] 2001 December, 56(Supplement 4):iv1-iv64 [viewed 01 July 2014] Available from: doi:10.1136/thx.56.suppl_4.iv1

Management - General Measures

Fact Explanation
Patient education The patient should be provided adequate information about the natural course of the disease, complications, investigations and treatment options.[1]
Monitoring of patient Parameters that should be monitored are pulse rate, blood pressure, respiratory rate, oxygen saturation and urine output. Considered transfer to an intensive care unit if septic shock, hypoxia or respiratory failure develops.[1]
References
  1. BRAR NK, NIEDERMAN MS. Management of community-acquired pneumonia: a review and update. Ther Adv Respir Dis [online] 2011 Feb, 5(1):61-78 [viewed 30 June 2014] Available from: doi:10.1177/1753465810381518

Management - Specific Treatments

Fact Explanation
Determine severity of infection The ‘CURB-65’ criteria is used for this purpose. A score of 0-1 is considered mild infection which can be managed in the home setting, a score of 2 requires hospital based treatment and a score of 3 and above is considered severe infection which would require intensive care. The parameters that are used are : Confusion, blood urea >7mmol/l, Respiratory rate > 30 per minute, Blood pressure (Systolic < 90mmHg & diastolic < 60mmHg) and age more than 65yrs.[1]
Antibiotic therapy : Community acquired pneumonia Oral antibiotics may be used in mild to moderate infection. Intravenous antibiotics are required in severe infection and patients with persistent vomiting. In mild infection amoxicillin(500mg-1g/8h) or erythromycin 500mg/6h may be used. In moderate infection a combination of amoxicillin and erythromycin oral or IV may be used. In severe infection co-amoxiclav IV/ Iv cephalosporin with erythromycin is required. If legionella infection is suspected use clarithromycin and rifampin. Chlamydia species requires therapy with tetracycline.[2]
Hospital acquired pneumonia The common causative organisms are gram negative bacilli and pseudomonas. Treatment is with IV aminoglycoside + IV antipseudomonal penicillin or 3rd generation cephalosporin.[3]
Aspirational pneumonia Treatment is with cefuroxime and metronidazole.[3]
Pneumonia in immunocompromised patients Both typical and atypical organisms (Legionella & Nocardia) can cause pneumonia in these patients.[4] Majority of patients may have a polymicrobial infection. In these patients a combination of intravenous aminoglycoside + antipseudomonal penicillin + cephalosporin is used.
Oxygen therapy Maintain oxygen saturation >92%.[5]
Symptomatic treatment The pleuritic chest pain can be treated with analgesics such as paracetamol.[5]
Chest physiotherapy Chest physiotherapy is routinely not indicated. It may be beneficial in elderly patients who find expectoration of sputum difficult and in patients who suppress cough due to pleural pain.[5]
Complications of pneumonia Observe the patient for development of complications. Commonly seen complications are formation of pleural effusion, empyema, lung abscess formation, respiratory failure, septicaemia etc.[6]
Pneumonia Caused by Methicillin-Resistant Staphylococcus aureus(MRSA) Pneumonia caused by MRSA has increased in prevalence in both community and hospital setting.[7] These patients require hospitalization and rapid initiation of IV antibiotics. Vancomycin is commonly used as treatment while new drugs such as linezolid, telavancin are also being used. Apart from precise antibiotic treatment it is important to limit spread of the infection among other patients and to de-escalate the drug regime to prevent emergence of resistant strains.
References
  1. PARSONAGE M, NATHWANI D, DAVEY P, BARLOW G. Evaluation of the performance of CURB-65 with increasing age. Clin Microbiol Infect [online] 2009 Sep, 15(9):858-64 [viewed 01 July 2014] Available from: doi:10.1111/j.1469-0691.2009.02908.x
  2. MANDELL L. A., WUNDERINK R. G., ANZUETO A., BARTLETT J. G., CAMPBELL G. D., DEAN N. C., DOWELL S. F., FILE T. M., MUSHER D. M., NIEDERMAN M. S., TORRES A., WHITNEY C. G.. Infectious Diseases Society of America/American Thoracic Society Consensus Guidelines on the Management of Community-Acquired Pneumonia in Adults. Clinical Infectious Diseases [online] 2007 March, 44(Supplement 2):S27-S72 [viewed 01 July 2014] Available from: doi:10.1086/511159
  3. FILE TM JR. Recommendations for treatment of hospital-acquired and ventilator-associated pneumonia: review of recent international guidelines. Clin Infect Dis [online] 2010 Aug 1:S42-7 [viewed 01 July 2014] Available from: doi:10.1086/653048
  4. CONCES DJ JR. Bacterial pneumonia in immunocompromised patients. J Thorac Imaging [online] 1998 Oct, 13(4):261-70 [viewed 19 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/9799134
  5. GUIDELINES FOR THE MANAGEMENT OF COMMUNITY ACQUIRED PNEUMONIA IN ADULTS. THE BRITISH THORACIC SOCIETY, 2009 [Viewed on 29 June 2014]. Available from : https://www.brit-thoracic.org.uk/Portals/0/Guidelines/Pneumonia/CAPQuickRefGuide-web.pdf
  6. CILLóNIZ C, EWIG S, POLVERINO E, MUñOZ-ALMAGRO C, MARCO F, GABARRúS A, MENéNDEZ R, MENSA J, TORRES A. Pulmonary complications of pneumococcal community-acquired pneumonia: incidence, predictors, and outcomes. Clin Microbiol Infect [online] 2012 Nov, 18(11):1134-42 [viewed 01 July 2014] Available from: doi:10.1111/j.1469-0691.2011.03692.x
  7. RUBINSTEIN ETHAN, KOLLEF MARIN H., NATHWANI DILIP. Pneumonia Caused by Methicillin‐Resistant . CLIN INFECT DIS [online] 2008 June, 46(S5):S378-S385 [viewed 01 July 2014] Available from: doi:10.1086/533594