Pneumonia diagnostic algorithm: Difference between revisions

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Revision as of 18:58, 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

Symptoms that suggest a lower respiratory tract infection:
❑ Fever
❑ Cough with sputum
❑ Dyspnea
❑ Pleuritic chest pain

Physical Examination Findings:

❑ Fever
❑ Tachypnea
❑ Tachycardia
❑ Dullness to percussion on affected side

❑ Bronchial breath sounds
❑ Rales
❑ 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, rapid influenza test

❑ Enyzme Immunoassay

❑ 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 has at least 2 of the following CURB65 criteria?

Confusion (defined as an AMT of 8 or less)
Urea greater than 7 mmol/l (Blood Urea Nitrogen > 20)
Respiratory rate of 30 breaths per minute or greater
Blood pressure less than 90 systolic or diastolic blood pressure 60 or less
Age 65 or older

YES

NO
The patient has HCAP

YES
Admit the patient and administer empiric inpatient antibiotic regimen

NO
Administer empiric 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)
↑ Solomon, Caren G.; Wunderink, Richard G.; Waterer, Grant W. (2014). "Community-Acquired Pneumonia". New England Journal of Medicine. 370 (6): 543–551. doi:10.1056/NEJMcp1214869. ISSN 0028-4793.
↑ 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)

[SolomonWunderink2014-2] Solomon, Caren G.; Wunderink, Richard G.; Waterer, Grant W. (2014). "Community-Acquired Pneumonia". New England Journal of Medicine. 370 (6): 543–551. doi:10.1056/NEJMcp1214869. ISSN 0028-4793.

[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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@@ Line 38: / Line 38: @@
 * Decreased [[breath sounds]] and [[crackles]] in the physical exam </div>}}
 {{familytree | | | | | | | | |!| | | | | | | | | | | }}
-{{familytree | | | | | | | | E01 | | | | | | | | | | E01=<div style="float: left; text-align: left; width: 28em; padding:0.5em;">Does the patient meets any of the following criteria for HCAP?<ref name="pmid21663884">{{cite journal |author=Attridge RT, Frei CR |title=Health care-associated pneumonia: an evidence-based review |journal=[[The American Journal of Medicine]] |volume=124 |issue=8 |pages=689–97 |year=2011 |month=August |pmid=21663884 |doi=10.1016/j.amjmed.2011.01.023 |url=http://linkinghub.elsevier.com/retrieve/pii/S0002-9343(11)00291-9 |accessdate=2012-09-02}}</ref><br>
+{{familytree | | | | | | | | E01 | | | | | | | | | | E01=<div style="float: left; text-align: left; width: 28em; padding:0.5em;">'''Does the patient meets any of the following criteria for HCAP?'''<ref name="pmid21663884">{{cite journal |author=Attridge RT, Frei CR |title=Health care-associated pneumonia: an evidence-based review |journal=[[The American Journal of Medicine]] |volume=124 |issue=8 |pages=689–97 |year=2011 |month=August |pmid=21663884 |doi=10.1016/j.amjmed.2011.01.023 |url=http://linkinghub.elsevier.com/retrieve/pii/S0002-9343(11)00291-9 |accessdate=2012-09-02}}</ref><br>
 * 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;
@@ Line 46: / Line 46: @@
 {{familytree | | | | F01 | | | | | | F02 | | | | | F01=<div style="float: left; text-align: center; width: 15em; padding:0.5em;">'''YES'''</div> |F02=<div style="float: left; text-align: center; width: 15em; padding:0.5em;">'''NO'''<br> The patient has '''CAP'''</div>}}
 {{familytree | | | | |!| | | | | | | |!| | | | | | }}
-{{familytree | | | | G01 | | | | | | G02 | | | | | G01=<div style="float: left; text-align: left; width: 15em; padding:0.5em;">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: 15em; padding:0.5em;">Does the patient meets any of the Severity Criteria?<div class="mw-collapsible-content"> <div class="mw-collapsible mw-collapsed"><br>
+{{familytree | | | | G01 | | | | | | G02 | | | | | G01=<div style="float: left; text-align: left; width: 15em; padding:0.5em;">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: 15em; padding:0.5em;">'''Does the patient has at least 2 of the following CURB65 criteria? '''
-<small>'''Minor Criteria'''
+* '''C'''onfusion (defined as an [[abbreviated mental test score|AMT]] of 8 or less)
-* Respiratory rate >30 breaths/min
+* '''U'''rea greater than 7 mmol/l (Blood Urea Nitrogen > 20)
-* PaO2/FiO2 ratio <250
+* '''R'''espiratory rate of 30 breaths per minute or greater
-* Multilobar infiltrates
+* '''B'''lood pressure less than 90 systolic or diastolic blood pressure 60 or less
-* [[Confusion]]/[[disorientation]]
+* Age '''65''' or older</div>}}
-* [[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></div></div>}}
 {{familytree | |,|-|-|^|-|.| | | |,|-|^|-|.| | | }}
 {{familytree | H01 | | | H02 | | H03 | | | H04 | H01=<div style="float: left; text-align: center; width: 10em; padding:0.5em;">'''YES'''</div> |H02=<div style="float: left; text-align: center; width: 10em; padding:0.5em;">'''NO''' <br>  The patient has '''HCAP''' </div> |H03=<div style="float: left; text-align: center; width: 10em; padding:0.5em;">'''YES''' <br> Admit the patient and administer [[Community-acquired pneumonia medical therapy#Empirical Treatment|empiric inpatient antibiotic regimen]]</div> |H04=<div style="float: left; text-align: center; width: 10em; padding:0.5em;">'''NO''' <br> Administer [[Community-acquired pneumonia medical therapy#Empirical Treatment|empiric outpatient antibiotic regimen]]</div>}}

Pneumonia diagnostic algorithm: Difference between revisions

Revision as of 18:58, 8 December 2014

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Diagnostic Algorithm

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