Transcript Pneumonia

Pneumonia
Still the “Old man’s friend?”
-Bacterial, Viral, Chemical, Aspiration,
Nosocomial, Community Acquired,
“Walking,” Bronchopneumonia,
Necrotizing, Ventilator Associated…
True story (and disclaimer)
• A Family Practice doc is at the nurse’s
station and asks the Respiratory Therapist
standing next to him (who’s charting on a
different patient), “What antibiotic do you
think I should prescribe for this guy?”
• The RT replies, “Don’t ask me, I’m just the
plumber.”
Diagnosis?
• A pulmonogist with 25+ years
experience guesses he is only
correct 60% of the time when
diagnosing pneumonia before
seeing the CXR. A little better
than a coin-toss.
Guidelines
• CXR is considered the Gold Standard
• Leukocytosis with leftward shift common
• Tachypnea, fever, sputum production, and
abnormal lung sounds are helpful, but not
definitive.
• Blood cultures- controversial, recommended for
sickest patients.
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Infectious Diseases Society of America/American Thoracic Society consensus
guidelines on the management of community-acquired pneumonia in adults.
AUMandell LA; Wunderink RG; Anzueto A; Bartlett JG; Campbell GD; Dean NC;
Dowell SF; File TM Jr; Musher DM; Niederman MS; Torres A; Whitney CG SOClin
Infect Dis. 2007 Mar 1;44 Suppl 2:S27-72.
CXR dilemma
• It looks like pneumonia, talks like it, walks like it, but the
CXR is inconclusive. Sometimes the diagnosis will still
be made.
• There’s a theory that a dehydrated, sick patient won’t
have the infiltrate “appear” on their CXR until their
volume is increased. This might be a fact in 7% of
patients with all the other symptoms, but negative initial
CXR. 1
• A CT Scan is not recommended if only looking for
pneumonia, due to cost, and lack of outcome data.
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Patients admitted to hospital with suspected pneumonia and normal chest radiographs:
epidemiology, microbiology, and outcomes. AUBasi SK; Marrie TJ; Huang JQ; Majumdar SR
SOAm J Med 2004 Sep 1;117(5):305-11.
Sputum Cultures
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The 2007 IDSA/ATS consensus guidelines for which patient to obtain a culture from:
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Intensive care unit admission
Failure of outpatient antibiotic therapy
Cavitary lesions
Active alcohol abuse
Severe obstructive or structural lung disease
Positive urine antigen test for pneumococcus
Positive urine antigen test for legionella (special culture needed)
Pleural effusion
Sputum continued….
• The specimen should be a deep cough specimen
obtained prior to antibiotics.
• Cultures should be performed rapidly after collection,
preferably within two hours; the alternative for rapid
plating of the sample is to retain the specimen at 4ºC if
the delay is two to 24 hours
• A "good" sputum sample is one with polymorphonuclear
leukocytes (PMNs) but a low or absent number of
squamous epithelial cells (SECs) on Gram stain.
Ways to Obtain Sample
• Good, deep cough. (These are the best, but the patient
has to be strong enough to cough well, and the sputum
well hydrated. Tough to find in the sickest patients.)
• Naso-Tracheal suctioning- very uncomfortable for
patient, but sometimes the most effective way.
• BAL Cath (Broncho-Alveolar-Lavage) catheter is
manufactured to allow samples to be obtained with
minimal contamination.
• Bronchoscopy- most direct method, but expensive and
resource consuming.
• Hypertonic Saline via Nebulizer and CPT…
Chest Physical Therapy
• Not always effective- needs the right kind of “phlegm”
and patient cooperation.
• Pneumonia can be thought of as peanut butter, stuck in
a jar. You can’t really tip the jar upside down and whack
the peanut butter out of it.
• CPT needs mobile, well-hydrated phlegm, and can aid
it’s drainage.
• Very helpful if patient has fairly effective cough to assist
clearance.
• Limited by patient tolerance for being in Trendelenburg,
surgical wounds, sore ribs from coughing or previous
CPT.
Nebulizers/Bronchodilators
• Not really effective with pneumonia, unless
wheezing/bronchospasm are present.
• Patients who have a history of lung dz and
are more prone to pneumonia, may need
an increase of their bronchodilators during
the illness.
• Mucolytics can be helpful with mucous
plugging; administered before CPT.
Data for Best Practice
• A multicenter controlled trial using cluster randomization
in 1743 patients with CAP who presented to the
Emergency Department in 19 hospitals; the trial
compared conventional care to the use of a critical
pathway algorithm for hospitalization and treatment [1].
• The care pathway included therapy with intravenous and
oral levofloxacin; in comparison, levofloxacin was not
available to physicians in the conventional treatment
hospitals.
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1. A controlled trial of a critical pathway for treatment of community-acquired pneumonia. CAPITAL
Study Investigators. Community-Acquired Pneumonia Intervention Trial Assessing Levofloxacin.
AUMarrie TJ; Lau CY; Wheeler SL; Wong CJ; Vandervoort MK; Feagan BG SOJAMA 2000 Feb
9;283(6):749-55.
It Works
• Patients treated according to the algorithm had
significant reductions in the number of bed days per
patient admitted (4.4 versus 6.1 days) and in the
proportion of low-risk patients who were admitted (31
versus 49 percent).
• Although inpatients at critical pathway hospitals had
more severe disease, they required significantly fewer
days of intravenous therapy and were more likely to be
treated with a single class of antibiotic.
• These reductions in the use of hospital resources were
not associated with any adverse clinical effects, as
complications, readmission, mortality, and quality of life
were not different between the two groups.
General Ward Abx guidelines
• Beta-lactam (ceftriaxone, cefotaxime,
ampicillin/sulbactam, ertapenem) plus
macrolide (can use doxycycline if
macrolide not tolerated)
• OR
• Antipneumococcal fluoroquinolone alone
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1. Clin Infect Dis. 2007.
(ATS/IDSA; 2007)
Severe/ICU Patient
• Beta-lactam (ceftriaxone, cefotaxime,
ampicillin/sulbactam) plus IV azithromycin or IV
fluoroquinolone
• If concern for Pseudomonas (eg, presence of
structural lung disease such as bronchiectasis):
antipseudomonal agent (piperacillin/tazobactam,
imipenem, meropenem, or cefepime) plus
antipseudomonal fluoroquinolone (ciprofloxacin
or high dose levofloxacin);
• If concern for MRSA: add vancomycin or
linezolid
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1. Clin Infect Dis. 2007.
(ATS/IDSA; 2007)
Causes of community-acquired pneumonia in hospitalized
patients (non-ICU)
Table from UpToDate:
1. Arch Intern Med 1997; 157:1709.
2. Ir J Med Sci 1989; 158:230.
3. Lancet 1982; 2:255.
4. Thorax 1991; 46:508.
5. Infection 1987; 15:328.
www.meddean.luc.edu
http://www.cdc.gov/ncidod/eid/vol6no1/scrimgeourG2.htm
Why the Right Side with aspiration?
• When looking down the trachea, the RLL
is a “direct shot” for anything aspirated.
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http://math.lbl.gov/~deschamp/html/gallery.html
The Sickest Patients
• Mechanical Ventilation– As the pneumonia takes over healthy space in the
lung, patients may not be able to compensate, or
have the energy to keep up with the increased work
of breathing.
– An endotracheal tube can be placed and the
ventilator can now assist with respiration.
– Air provided to the patient is humidified to 100%, and
warmed to 37 degrees, helping to thin secretions.
– In-line suction catheters allow for easy removal of
retained secretions.
– PEEP (Positive End Expiratory Pressure) can be used
to possibly recruit collapsed air sacs and improve
oxygenation.
VAP and Prevention
(What works for us)
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Wash hands (of course)
Subglottic Suction Tube (Hi Lo Evac)
HOB at 30 degrees
Orogastric Tube as opposed to Nasogastric
Mouth Care
Heated wire vent circuit
Don’t “break” the circuit if at all possible!
Gastric acid suppression may increase risk of VAP. Care
should be taken to avoid proton pump inhibitors or H2
blockers if pt is low risk for stress ulcers.
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(Strategies to prevent ventilator-associated pneumonia in acute care hospitals. AUCoffin SE; Klompas M; Classen D; Arias KM; Podgorny
K; Anderson DJ; Burstin H; Calfee DP; Dubberke ER; Fraser V; Gerding DN; Griffin FA; Gross P; Kaye KS; Lo E; Marschall J; Mermel LA;
Nicolle L; Pegues DA; Perl TM; Saint S; Salgado CD; Weinstein RA; Wise R; Yokoe DS SOInfect Control Hosp Epidemiol. 2008 Oct;29
Suppl 1:S31-40.
• The use of an endotracheal or tracheostomy
tube with aspiration of subglottic secretions
seems to decrease the incidence of VAP and
should be recommended in patients expected to
require more than 72 h of mechanical
ventilation. The decontamination of subglottic
space remains an attractive idea that needs
further confirmation.
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Anesthesiology: Pneumatikos, Ioannis A. M.D., Ph.D., F.C.C.P.; Dragoumanis, Christos K. M.D., Ph.D.; Bouros,
Demosthenes E. M.D., Ph.D., F.C.C.P.
March 2009 - Volume 110 - Issue 3 - pp 673-680