Pneumonia March 2018 | by EMauthor Pneumonia is a common ED presentation. The BTS have published guidance on the management of adults (and children) who have a community acquired pneumonia. Definition of community acquired pneumonia The BTS guidance defines community acquired pneumonia (CAP) in patients admitted to hospital as: symptom and signs consistent with an acute lower respiratory tract infection (e.g. cough, dyspnoea, tachypnoea, pleural pain, fever, new focal signs on chest examination, etc.), and; new radiographic shadowing for which there is no other explanation (e.g. not pulmonary oedema or infarction). Causes of community acquired pneumonia •Bacterial: Strep. pneumoniae (commonest), H . influenza, Legionella, Staph. aureus. •Viral: influenza A and B, respiratory syncytial virus. •The atypical pathogens that may cause CAP are: oMycoplasma pneumoniae. oChlamydia pneumoniae. oChlamydia psittaci. oCoxiella burnetii. CURB-65 is a well-established tool for assessing the severity of pneumonia in adults ; 1 point is gained for each feature present. Investigations in community acquired pneumonia •CXR: should be performed on all admitted patients with suspected CAP as soon as possible to confirm or refute the diagnosis. •Blood tests: FBC, urea and electrolytes (to inform severity), LFTs, and CRP (to aid diagnosis and as a baseline measure) are recommended by BTS. •Oxygen saturations and, if necessary, arterial blood gases in accordance with the BTS guideline for emergency oxygen use •Microbiological testing: guided by the severity of the CAP. Patients with moderate (CURB-65 = 2) or high severity (CURB-65 = 3–5) CAP should have the following performed: oBlood cultures. oSputum culture. oPneumococcal urine antigen testing. oSputum testing for Mycobacterium tube factors for TB (e.g. social deprivation, ethnic origin, elderly). oLegionella urine antigen: should be performed in those with high severity CAP or where legionella is suspected. •Patients with mild pneumonia do not routinely require a full range of microbiological tests and these should be guided by clinical factors, epidemiological factors, and prior antibiotic therapy. ED treatment of community acquired pneumonia •Oxygen therapy — should be given, if required, to maintain saturations between 94 and 98 % . If the patient is at risk of hypercapnic respiratory failure, target saturations between 88 and 92 % initially and then guide oxygen therapy based on arterial blood gas measurements. •Intravenous fluids— should be given if there is evidence of volume depletion. •Antibiotic therapy — guided by local microbiology policy. •Prophylaxis of VTE with LMWH should be considered in patients who are not fully mobile. |
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