Pneumonia diagnostic algorithm: Difference between revisions

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Revision as of 16:56, 8 December 2014

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Alejandro Lemor, M.D. [2]

Overview

Diagnostic Algorithm

Shown below is an algorithm for the diagnostic approach of pneumonia.^[1]^[2]
Abbreviations: HCAP: Healthcare-associated pneumonia; CAP: Community-acquired pneumonia

Respiratory Tract Infection Symptoms:
❑ Fever
❑ Cough with sputum
❑ Dyspnea
❑ Pleuritic chest pain

Physical Examination:

❑ Fever
❑ Tachypnea
❑ Tachycardia
❑ Dull percussion on affected side

❑ Bronchial breath sounds
❑ Rales and/or
❑ Increased vocal fremitus
❑ Pleural friction rub

Order Labs:
❑ Complete blood count (CBC)
❑ Blood urea nitrogen (BUN)
❑ Sputum gram stain
❑ Sputum culture
❑ Blood culture if necessary
❑ If suspecting atypical pneumonia obtain:

❑ Urine legionella antigen

❑ Enyzme Immunoassay (EIA)

❑ Immunofluorescence

❑ Polymerase chain reaction (PCR) for atypical and viral including influenza

❑ Order a chest X-ray if the patient presents with any of the following:^[3]

Fever (>37.8° C / 100° F)
Tachypnea (> 20 breaths/min)
Tachycardia (> 100 bpm)
Decreased breath sounds and crackles in the physical exam

Does the patient meets any of the following criteria for HCAP?^[4]

Hospitalized in an acute care hospital for 2 or more days within 90 days of the infection;
Resided in a nursing home or long-term care facility;
Received recent intravenous antibiotic therapy, chemotherapy, or wound care within the past 30 days of the current infection;
Attended a hospital or hemodialysis clinic

YES

NO
The patient has CAP

Does the infection occurred ≥48 hours after admission and it was not present at admission?

Does the patient meets any of the Severity Criteria?

Minor Criteria

Respiratory rate >30 breaths/min
PaO2/FiO2 ratio <250
Multilobar infiltrates
Confusion/disorientation
Uremia (BUN level, >20 mg/dL)
Leukopenia (WBC count, <4000 cells/mm3)
Thrombocytopenia (platelet count, < 100,000 cells/mm3)
Hypothermia (core temperature, <36 degrees C)
Hypotension requiring aggressive fluid resuscitation

Major criteria

Invasive mechanical ventilation

Septic shock with the need for vasopressors

YES
Admit the patient

NO
Outpatient antibiotic regimen

References

↑ "http://cid.oxfordjournals.org/content/44/Supplement_2/S27.full.pdf+html". Retrieved 13 March 2014. External link in |title= (help)
↑ "MMS: Error".
↑ Watkins RR, Lemonovich TL (2011). "Diagnosis and management of community-acquired pneumonia in adults". Am Fam Physician. 83 (11): 1299–306. PMID 21661712.
↑ Attridge RT, Frei CR (2011). "Health care-associated pneumonia: an evidence-based review". The American Journal of Medicine. 124 (8): 689–97. doi:10.1016/j.amjmed.2011.01.023. PMID 21663884. Retrieved 2012-09-02. Unknown parameter |month= ignored (help)

[cid.oxfordjournals.org-1] "http://cid.oxfordjournals.org/content/44/Supplement_2/S27.full.pdf+html". Retrieved 13 March 2014. External link in |title= (help)

[www.nejm.org-2] "MMS: Error".

[pmid21661712-3] Watkins RR, Lemonovich TL (2011). "Diagnosis and management of community-acquired pneumonia in adults". Am Fam Physician. 83 (11): 1299–306. PMID 21661712.

[pmid21663884-4] Attridge RT, Frei CR (2011). "Health care-associated pneumonia: an evidence-based review". The American Journal of Medicine. 124 (8): 689–97. doi:10.1016/j.amjmed.2011.01.023. PMID 21663884. Retrieved 2012-09-02. Unknown parameter |month= ignored (help)

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[2]

[3]

[4]

@@ Line 6: / Line 6: @@
 ==Diagnostic Algorithm==
 Shown below is an algorithm for the diagnostic approach of pneumonia.<ref name="cid.oxfordjournals.org">{{Cite web  | last =  | first =  | title = http://cid.oxfordjournals.org/content/44/Supplement_2/S27.full.pdf+html | url = http://cid.oxfordjournals.org/content/44/Supplement_2/S27.full.pdf+html | publisher =  | date =  | accessdate = 13 March 2014 }}</ref><ref name="www.nejm.org">{{Cite web  | last =  | first =  | title = MMS: Error | url = http://www.nejm.org/doi/full/10.1056/NEJMcp1214869 | publisher =  | date =  | accessdate = }}</ref>
-<br><small>'''Abbreviations:''' HCAP: Healthcare-associated Pneumonia </small>
+<br><small>'''Abbreviations:''' '''HCAP:''' Healthcare-associated pneumonia; '''CAP:''' Community-acquired pneumonia</small>
 <div style="font-size:85%; float:center">
 {{familytree/start}}
@@ Line 12: / Line 12: @@
 {{familytree | | | | | | | | | |!| | | | | | | | | | | | | | | | | | }}
 {{familytree | | | | | | | | | B01 | | | | | | | | | | | | | | | | | B01=<div style="float: left; text-align: left; width: 30em; padding:1em;">'''Physical Examination:''' <br>
+{{col-begin|width=100%}}
+{{col-break|width=50%}}
 ❑ [[Fever]] <br>
 ❑ [[Tachypnea]] <br>
 ❑ [[Tachycardia]] <br>
 ❑ [[Percussion|Dull percussion]] on affected side<br>
+{{col-break|width=50%}}
 ❑ [[Breath sounds|Bronchial breath sounds]]<br>
 ❑ [[Rales]] and/or <br>
 ❑ [[Vocal fremitus|Increased vocal fremitus]] <br>
-❑ [[Whispered pectoriloquy]]<br>
 ❑ [[Pleural friction rub]]
+{{col-end|}}
 </div>}}
 {{familytree | | | | | | | | | |!| | | | | | | | | | | | | | | | | | }}
@@ Line 41: / Line 44: @@
 * Attended a hospital or hemodialysis clinic</div>}}
 {{familytree | | | | |,|-|-|-|-|^|-|-|-|-|.| | | | | | | | | | | | | }}
-{{familytree | | | | F01 | | | | | | | | F02 | | | | | | | F01=<div style="float: left; text-align: center; width: 10em; padding:1em;">'''YES'''</div> |F02=<div style="float: left; text-align: center; width: 10em; padding:1em;">'''NO'''</div>}}
+{{familytree | | | | F01 | | | | | | | | F02 | | | | | | | F01=<div style="float: left; text-align: center; width: 20em; padding:1em;">'''YES'''</div> |F02=<div style="float: left; text-align: center; width: 20em; padding:1em;">'''NO'''<br> The patient has '''CAP'''</div>}}
 {{familytree | | | | |!| | | | | | | | | |!| | | | | | | | | | | | | }}
-{{familytree | | | | G01 | | | | | | | | G02 | | | | | | | G01=<div style="float: left; text-align: left; width: 10em; padding:1em;">Does the infection occurred ≥48 hours after admission and it was not present at admission?</div> |G02=<div style="float: left; text-align: left; width: 10em; padding:1em;">The patient has '''CAP''' <br> Severity Criteria</div>}}
+{{familytree | | | | G01 | | | | | | | | G02 | | | | | | | G01=<div style="float: left; text-align: left; width: 20em; padding:1em;">Does the infection occurred ≥48 hours after admission and it was not present at admission?</div> |G02=<div style="float: left; text-align: left; width: 20em; padding:1em;">Does the patient meets any of the Severity Criteria?<br>
+<small>'''Minor Criteria'''
+* Respiratory rate >30 breaths/min
+* PaO2/FiO2 ratio <250
+* Multilobar infiltrates
+* [[Confusion]]/[[disorientation]]
+* [[Uremia]] ([[BUN]] level, >20 mg/dL)
+* [[Leukopenia]] (WBC count, <4000 cells/mm3)
+* [[Thrombocytopenia]] (platelet count, < 100,000 cells/mm3)
+* [[Hypothermia]] (core temperature, <36 degrees C)
+* [[Hypotension]] requiring aggressive fluid resuscitation
+'''Major criteria'''
+* Invasive [[mechanical ventilation]]
+* [[Septic shock]] with the need for [[vasopressors]]</small></div>}}
 {{familytree | |,|-|-|^|-|-|.| | | |,|-|-|^|-|-|.| | | | | | | | | | }}
-{{familytree | H01 | | | | H02 | | H03 | | | | H04 | | | | | | | | | H01=<div style="float: left; text-align: center; width: 10em; padding:1em;"> </div> |H02=<div style="float: left; text-align: center; width: 10em; padding:1em;"> </div> |H03=<div style="float: left; text-align: center; width: 10em; padding:1em;"> </div> |H04=<div style="float: left; text-align: center; width: 10em; padding:1em;"> </div>}}
+{{familytree | H01 | | | | H02 | | H03 | | | | H04 | | | | | | | | | H01=<div style="float: left; text-align: center; width: 10em; padding:1em;"> </div> |H02=<div style="float: left; text-align: center; width: 10em; padding:1em;"> </div> |H03=<div style="float: left; text-align: center; width: 10em; padding:1em;">'''YES''' <br> Admit the patient</div> |H04=<div style="float: left; text-align: center; width: 10em; padding:1em;">'''NO''' <br> Outpatient antibiotic regimen</div>}}
 {{familytree/end}}</div>

Pneumonia diagnostic algorithm: Difference between revisions

Revision as of 16:56, 8 December 2014

Overview

Diagnostic Algorithm

References

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