2 min read - Pneumonia

A 75 years old female patient with diabetes mellitus, hypertension and ischemic heart disease presented with fever and cough for 3 days duration. She produced yellow color sputum, but there was no hemoptysis. There was right-sided chest pain on breathing. She had nausea and the appetite was poor.

What are the possibilities?

• Fever, cough, sputum and pleuritic chest pain equals pneumonia unless proven otherwise!
• Many conditions can mimic pneumonia. Read and find out!

On examination the patient was ill-looking. She was tachycardic and tachypnoeic. Blood pressure was 100/70mmHg. 

Respiratory examination revealed signs localized to the right lower zone.

• Reduced chest expansion
• Increased vocal fremitus
• Dull percussion note
• Bronchial breathing
• Increased vocal resonance
• Whispering pectoriloquy!

What do these physical signs mean? Read about physical signs and how to interpret them.

• A consolidation in the right lower zone.

With these findings, the clinical diagnosis of right lower lobe pneumonia was made.

Now, what should you do?

• Basic principles of managing pneumonia.
• Confirm the diagnosis
• Prompt initiation of correct empiric antibiotic
• Try to identify the culprit organism
• Identification and management of complications
• Management of comorbidities
• Assess response to treatment
• Once adequately treated, decide on the need for further investigations and follow up

Let's discuss about these aspects briefly

Confirmation of the diagnosis

• Clinical diagnosis is sufficient.
• Take a good erect PA Xray of the chest.
• Basic investigations like WBC, CRP will provide supportive evidence

Empirical antibiotic

• Before starting the antibiotic it's crucial to guess what the organism is.
• Organisms vary according to the place where the patient acquired the infection
• Common places are
• Community 
• Hospital
• ICU
• Read the classification of pneumonia
• Learn 5 organism each which commonly cause the above types
• What are atypical organisms?? Learn the names of a few.

• As most patients we get are from the community, an appropriate combination of antibiotics would be
• 3rd generation cephalosporin (Like cefotaxime, ceftriaxone) + atypical antibiotic
• Beta-lactam (Coamoxyclav) + Atypical antibiotic

• BEFORE STARTING ANY ANTIBIOTIC - TAKE CULTURES!!!

Identify the culprit organism

• Various investigations can be done
• Blood culture
• Sputum culture
• Antigen tests (eg: legionella urinary antigen)
• What else?

Complications

• Sepsis and shock!
• Local complications
• eg: abscess formation, Pleural effusion, Empyema

Note the effusion (and the sternal wires!)

Lung abscess

• Other organ involvement
• eg: hepatitis, arthritis, glomerulonephritis, meningitis
• Systemic problems
• eg: SIADH
• The list goes on and on!! Read.

Comorbidities

• Carefully manage comorbidities
• eg: 
• in diabetic patients its better to omit oral drugs and start on insulin
• antihypertensives may need to be omitted if the patients blood pressure is low

• Comorbid pulmonary diseases can adversely affect the outcome
• eg: Asthma
• Treat those aggressively

Response

• If you have treated well, within 48 hours the patient will clinically improve.

• If there's no improvement something somewhere has gone wrong. Reevaluate!
• See if the diagnosis is correct (it could be TB or cancer)
• See if the patient has developed a complication
• See if the antibiotic is right (is it viral pneumonia?)
• See if the comorbidities are well controlled

• If the response is good, continue antibiotics for total of 7-10 days. (Different units may have different policies)
• Discharge when the patient is stable.

Follow up

• Young otherwise healthy patients may not need to follow up.
• For others, a repeat Xray should be done by around 2 weeks.
• Xray changes can persist up to 6-12 weeks, or even longer.
• Persistent abnormalities in high-risk patients (eg: smokers) may indicate the presence of an underlying illness such as cancer.

Another important consideration!

• Influenza is common, young well patients tolerate it well.
• Elderly patients/ patients with comorbidities are at higher risk of developing severe disease.
• In those, if features are suggestive
• An epidemic is going on
• High fever
• Preceding upper respiratory tract symptoms
• Diarrhea 
• Bilateral involvement in Xray... etc
• start oseltamivir (Tamiflu) as early as possible.

There's a lot more to talk about. Maybe on another day!