Pneumonia: Difference between revisions

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imported>Robert Badgett
imported>Robert Badgett
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{{Infobox_Disease |
Name          = Pneumonia |
Image          = |
Caption        = |
DiseasesDB    = 10166 |
ICD9          = {{ICD9|480}}-{{ICD9|486}} |
}}
'''Pneumonia''' is defined as "inflammation of the lungs."<ref>{{MeSH}}</ref>
==Classification==
Pneumonia can be classified along various dimensions including clinical setting, underlying etiology, and its gross appearance (bronchopneumonia versus lobar pneumonia).
===Aspiration pneumonia===
===Community acquired pneumonia===
====Atypical pneumonia====
===Nosocomial pneumonia===
====Ventilator associated pneumonia====
==Diagnosis==
===History and physical examination===
A [[clinical prediction rule]] found the five following signs from the medical history and [[physical examination]] best predicted infiltrates on the chest [[radiography|radiograph]] of 1134 patients presenting to an emergency room:<ref name="pmid2221647">{{cite journal |author=Heckerling PS, Tape TG, Wigton RS, ''et al'' |title=Clinical prediction rule for pulmonary infiltrates |journal=Ann. Intern. Med. |volume=113 |issue=9 |pages=664–70 |year=1990 |pmid=2221647 |doi=}}</ref>
*Temperature > 100 degrees F (37.8 degrees C)
*Pulse > 100 beats/min
*[[Rales|Crackles]]
*Decreased breath sounds
*''Absence'' of [[asthma]]
The probability of an infiltrate in two separate validations was based on the number of findings:
*5 findings - 84% to 91% probability
*4 findings - 58% to 85%
*3 findings - 35% to 51%
*2 findings - 14% to 24%
*1 findings - 5% to 9%
*0 findings - 2% to 3%
A subsequent study<ref name="pmid1952308">{{cite journal |author=Emerman CL, Dawson N, Speroff T, ''et al'' |title=Comparison of physician judgment and decision aids for ordering chest radiographs for pneumonia in outpatients |journal=Annals of emergency medicine |volume=20 |issue=11 |pages=1215–9 |year=1991 |pmid=1952308| doi = 10.1016/S0196-0644(05)81474-X <!--Retrieved from CrossRef by DOI bot-->}}</ref> comparing four [[clinical prediction rule]]s to physician judgment found that two [[clinical prediction rule]]s, the one above<ref name="pmid2221647"/> and another<ref name="pmid2745948">{{cite journal |author=Gennis P, Gallagher J, Falvo C, Baker S, Than W |title=Clinical criteria for the detection of pneumonia in adults: guidelines for ordering chest roentgenograms in the emergency department |journal=The Journal of emergency medicine |volume=7 |issue=3 |pages=263–8 |year=1989 |pmid=2745948 |doi=}}</ref> were more accurate than physician judgment because of the increased [[sensitivity and specificity|specificity]] of the prediction rules.
==Treatment==
===Antibiotics===
====Aspiration pneumonia====
====Community acquired pneumonia====
The 'respiratory [[quinolone]]s' ([[levofloxacin]], [[moxifloxacin]], [[gemifloxacin]]) may be the best choices.<ref name="pmid19047608">{{cite journal |author=Vardakas KZ, Siempos II, Grammatikos A, Athanassa Z, Korbila IP, Falagas ME |title=Respiratory fluoroquinolones for the treatment of community-acquired pneumonia: a meta-analysis of randomized controlled trials |journal=CMAJ |volume=179 |issue=12 |pages=1269–1277 |year=2008 |month=December |pmid=19047608 |pmc=2585120 |doi=10.1503/cmaj.080358 |url=http://www.cmaj.ca/cgi/pmidlookup?view=long&pmid=19047608 |issn=}}</ref>
The optimal duration of [[antibiotic]] treatment for community acquired pneumonia is not clear.<ref name="pmid17765048">{{cite journal |author=Li JZ, Winston LG, Moore DH, Bent S |title=Efficacy of short-course antibiotic regimens for community-acquired pneumonia: a meta-analysis |journal=Am. J. Med. |volume=120 |issue=9 |pages=783–90 |year=2007 |pmid=17765048 |doi=10.1016/j.amjmed.2007.04.023}}</ref>
====Ventilator associated pneumonia====
===Treatments that are ineffective===
Chest physiotherapy includes postural drainage, percussion, and vibration and has been call the 'ketchup-bottle method'<ref name="pmid431639">{{cite journal |author=Murray JF |title=The ketchup-bottle method |journal=N. Engl. J. Med. |volume=300 |issue=20 |pages=1155–7 |year=1979 |pmid=431639 |doi= |issn=}}</ref> of treating pneumonia.  Chest physiotherapy and intermittent positive-pressure breathing have been shown not to help in a small [[randomized controlled trial]].<ref name="pmid355879">{{cite journal |author=Graham WG, Bradley DA |title=Efficacy of chest physiotherapy and intermittent positive-pressure breathing in the resolution of pneumonia |journal=N. Engl. J. Med. |volume=299 |issue=12 |pages=624–7 |year=1978 |pmid=355879 |doi= |issn=}}</ref>
==Prognosis==
===Short term prognosis and the decision to hospitalize===
The prognosis of community acquired pneumonia can be estimated with several [[clinical prediction rule]]s:
* [[Pneumonia severity index]] (PSI) - the PSI may be more accurate than the CURB-65<ref name="pmid15808136">{{cite journal |author=Aujesky D, Auble TE, Yealy DM, ''et al'' |title=Prospective comparison of three validated prediction rules for prognosis in community-acquired pneumonia |journal=Am. J. Med. |volume=118 |issue=4 |pages=384-92 |year=2005 |pmid=15808136 |doi=10.1016/j.amjmed.2005.01.006}}</ref> and is available online ([http://pda.ahrq.gov/clinic/psi/psicalc.asp Pneumonia Severity Index Calculator]).
** Patients with PSI Risk groups I-III can usually be treated as an outpatient.<ref name="pmid15684204">{{cite journal |author=Carratalà J, Fernández-Sabé N, Ortega L, ''et al'' |title=Outpatient care compared with hospitalization for community-acquired pneumonia: a randomized trial in low-risk patients |journal=Ann. Intern. Med. |volume=142 |issue=3 |pages=165–72 |year=2005 |month=February |pmid=15684204 |doi= |url= |issn=}}</ref>
* [[CURB-65]]
* SMART-COP is a new clinical prediction rule that may be better according to a single study.<ref name="pmid18558884">{{cite journal |author=Charles PG, Wolfe R, Whitby M, ''et al'' |title=SMART-COP: a tool for predicting the need for intensive respiratory or vasopressor support in community-acquired pneumonia |journal=Clin. Infect. Dis. |volume=47 |issue=3 |pages=375–84 |year=2008 |month=August |pmid=18558884 |doi=10.1086/589754 |url=http://www.journals.uchicago.edu/doi/abs/10.1086/589754?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dncbi.nlm.nih.gov |issn=}}</ref> Patients are high risk if they have three or more points from the following:
**systolic blood pressure < 90 (2 points)
**multilobar chest radiography involvement (1 point)
**albumin level < 3.5 mg/dl (1 point)
**high respiratory rate. 25 or more breaths per minute if less than 50 years old, else 30 or more breaths per minute (1 point)
**tachycardia of 125 or more bpm (1 point)
**confusion, new onset (1 point)
**poor oxygenation. Either of the following adds 2 points:
***PaO<sub>2</sub> < 70 mm Hg if less than 50 years old, else < 60 mm Hg
***PaO<sub>2</sub>/FiO<sub>2</sub> < 333 if less than 50 years old, else if less than 250.
**arterial pH < 7.35 (2 points)
* SCAP score is a new [[clinical prediction rule]] that may be better than the [[Pneumonia severity index]] and [[CURB-65]]<ref name="pmid19141524">{{cite journal |author=Yandiola PP, Capelastegui A, Quintana J, ''et al.'' |title=Prospective comparison of severity scores for predicting clinically relevant outcomes for patients hospitalized with community-acquired pneumonia |journal=Chest |volume=135 |issue=6 |pages=1572–9 |year=2009 |month=June |pmid=19141524 |doi=10.1378/chest.08-2179 |url=http://www.chestjournal.org/cgi/pmidlookup?view=long&pmid=19141524 |issn=}}</ref>
* PIRO is another [[clinical prediction rule]] specifically for severe pneumonia.<ref name="pmid19114916">{{cite journal |author=Rello J, Rodriguez A, Lisboa T, Gallego M, Lujan M, Wunderink R |title=PIRO score for community-acquired pneumonia: A new prediction rule for assessment of severity in intensive care unit patients with community-acquired pneumonia |journal=Crit. Care Med. |volume= |issue= |pages= |year=2009 |month=December |pmid=19114916 |doi=10.1097/CCM.0b013e318194b021 |url=http://meta.wkhealth.com/pt/pt-core/template-journal/lwwgateway/media/landingpage.htm?doi=10.1097/CCM.0b013e318194b021 |issn=}}</ref>
====C-reactive protein and procalcitonin====
====C-reactive protein and procalcitonin====
Several studies have compared the [[c-reactive protein]] and [[procalcitonin]] in the prognosis of pneumonia.<ref name="pmid17727748">{{cite journal |author=Holm A, Pedersen SS, Nexoe J, ''et al.'' |title=Procalcitonin versus C-reactive protein for predicting pneumonia in adults with lower respiratory tract infection in primary care |journal=Br J Gen Pract |volume=57 |issue=540 |pages=555–60 |year=2007 |month=July |pmid=17727748 |pmc=2099638 |doi= |url=http://openurl.ingenta.com/content/nlm?genre=article&issn=0960-1643&volume=57&issue=540&spage=555&aulast=Holm |issn=}}</ref><ref name="pmid17335562">{{cite journal |author=Müller B, Harbarth S, Stolz D, ''et al.'' |title=Diagnostic and prognostic accuracy of clinical and laboratory parameters in community-acquired pneumonia |journal=BMC Infect. Dis. |volume=7 |issue= |pages=10 |year=2007 |pmid=17335562 |pmc=1821031 |doi=10.1186/1471-2334-7-10 |url=http://www.biomedcentral.com/1471-2334/7/10 |issn=}}</ref><ref name="pmid11952722">{{cite journal |author=Brunkhorst FM, Al-Nawas B, Krummenauer F, Forycki ZF, Shah PM |title=Procalcitonin, C-reactive protein and APACHE II score for risk evaluation in patients with severe pneumonia |journal=Clin. Microbiol. Infect. |volume=8 |issue=2 |pages=93–100 |year=2002 |month=February |pmid=11952722 |doi= |url=http://www3.interscience.wiley.com/resolve/openurl?genre=article&sid=nlm:pubmed&issn=1198-743X&date=2002&volume=8&issue=2&spage=93 |issn=}}</ref><ref name="pmid17959641">{{cite journal |author=Krüger S, Ewig S, Marre R, ''et al.'' |title=Procalcitonin predicts patients at low risk of death from community-acquired pneumonia across all CRB-65 classes |journal=Eur. Respir. J. |volume=31 |issue=2 |pages=349–55 |year=2008 |month=February |pmid=17959641 |doi=10.1183/09031936.00054507 |url=http://erj.ersjournals.com/cgi/pmidlookup?view=long&pmid=17959641 |issn=}}</ref> The procalcitonin may<ref name="pmid18986278">{{cite journal |author=Niederman MS |title=Biological markers to determine eligibility in trials for community-acquired pneumonia: a focus on procalcitonin |journal=Clin. Infect. Dis. |volume=47 Suppl 3 |issue= |pages=S127–32 |year=2008 |month=December |pmid=18986278 |doi=10.1086/591393 |url=http://www.journals.uchicago.edu/doi/abs/10.1086/591393?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dncbi.nlm.nih.gov |issn=}}</ref><ref name="pmid17959641"/><ref name="pmid17335562"/><ref name="pmid11952722"/> or may not<ref name="pmid17727748"/> be more accurate.
Several studies have compared the [[c-reactive protein]] and [[procalcitonin]] in the prognosis of pneumonia.<ref name="pmid17727748">{{cite journal |author=Holm A, Pedersen SS, Nexoe J, ''et al.'' |title=Procalcitonin versus C-reactive protein for predicting pneumonia in adults with lower respiratory tract infection in primary care |journal=Br J Gen Pract |volume=57 |issue=540 |pages=555–60 |year=2007 |month=July |pmid=17727748 |pmc=2099638 |doi= |url=http://openurl.ingenta.com/content/nlm?genre=article&issn=0960-1643&volume=57&issue=540&spage=555&aulast=Holm |issn=}}</ref><ref name="pmid17335562">{{cite journal |author=Müller B, Harbarth S, Stolz D, ''et al.'' |title=Diagnostic and prognostic accuracy of clinical and laboratory parameters in community-acquired pneumonia |journal=BMC Infect. Dis. |volume=7 |issue= |pages=10 |year=2007 |pmid=17335562 |pmc=1821031 |doi=10.1186/1471-2334-7-10 |url=http://www.biomedcentral.com/1471-2334/7/10 |issn=}}</ref><ref name="pmid11952722">{{cite journal |author=Brunkhorst FM, Al-Nawas B, Krummenauer F, Forycki ZF, Shah PM |title=Procalcitonin, C-reactive protein and APACHE II score for risk evaluation in patients with severe pneumonia |journal=Clin. Microbiol. Infect. |volume=8 |issue=2 |pages=93–100 |year=2002 |month=February |pmid=11952722 |doi= |url=http://www3.interscience.wiley.com/resolve/openurl?genre=article&sid=nlm:pubmed&issn=1198-743X&date=2002&volume=8&issue=2&spage=93 |issn=}}</ref><ref name="pmid17959641">{{cite journal |author=Krüger S, Ewig S, Marre R, ''et al.'' |title=Procalcitonin predicts patients at low risk of death from community-acquired pneumonia across all CRB-65 classes |journal=Eur. Respir. J. |volume=31 |issue=2 |pages=349–55 |year=2008 |month=February |pmid=17959641 |doi=10.1183/09031936.00054507 |url=http://erj.ersjournals.com/cgi/pmidlookup?view=long&pmid=17959641 |issn=}}</ref> The procalcitonin may<ref name="pmid18986278">{{cite journal |author=Niederman MS |title=Biological markers to determine eligibility in trials for community-acquired pneumonia: a focus on procalcitonin |journal=Clin. Infect. Dis. |volume=47 Suppl 3 |issue= |pages=S127–32 |year=2008 |month=December |pmid=18986278 |doi=10.1086/591393 |url=http://www.journals.uchicago.edu/doi/abs/10.1086/591393?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dncbi.nlm.nih.gov |issn=}}</ref><ref name="pmid17959641"/><ref name="pmid17335562"/><ref name="pmid11952722"/> or may not<ref name="pmid17727748"/> be more accurate.
===Prognosis at the time of discharge===
Abnormal [[sign (medical)|medical signs]] at discharge are associated with higher mortality with 30 days.<ref name="pmid18490403">{{cite journal |author=Capelastegui A, España PP, Bilbao A, ''et al'' |title=Pneumonia: criteria for patient instability on hospital discharge |journal=Chest |volume=134 |issue=3 |pages=595–600 |year=2008 |month=September |pmid=18490403 |doi=10.1378/chest.07-3039 |url=http://www.chestjournal.org/cgi/pmidlookup?view=long&pmid=18490403 |issn=}}</ref>
===Long term prognosis===
==Prevention==
{{main|Pneumococcal vaccine}}
[[Clinical practice guideline]]s are available for administering vaccines for pneumonia at http://www.cdc.gov/vaccines/.
==References==
<references/>

Revision as of 09:10, 19 June 2009

C-reactive protein and procalcitonin

Several studies have compared the c-reactive protein and procalcitonin in the prognosis of pneumonia.[1][2][3][4] The procalcitonin may[5][4][2][3] or may not[1] be more accurate.

  1. ↑ 1.0 1.1 Holm A, Pedersen SS, Nexoe J, et al. (July 2007). "Procalcitonin versus C-reactive protein for predicting pneumonia in adults with lower respiratory tract infection in primary care". Br J Gen Pract 57 (540): 555–60. PMID 17727748. PMC 2099638. [e]
  2. ↑ 2.0 2.1 Müller B, Harbarth S, Stolz D, et al. (2007). "Diagnostic and prognostic accuracy of clinical and laboratory parameters in community-acquired pneumonia". BMC Infect. Dis. 7: 10. DOI:10.1186/1471-2334-7-10. PMID 17335562. PMC 1821031. Research Blogging.
  3. ↑ 3.0 3.1 Brunkhorst FM, Al-Nawas B, Krummenauer F, Forycki ZF, Shah PM (February 2002). "Procalcitonin, C-reactive protein and APACHE II score for risk evaluation in patients with severe pneumonia". Clin. Microbiol. Infect. 8 (2): 93–100. PMID 11952722. [e]
  4. ↑ 4.0 4.1 Krüger S, Ewig S, Marre R, et al. (February 2008). "Procalcitonin predicts patients at low risk of death from community-acquired pneumonia across all CRB-65 classes". Eur. Respir. J. 31 (2): 349–55. DOI:10.1183/09031936.00054507. PMID 17959641. Research Blogging.
  5. ↑ Niederman MS (December 2008). "Biological markers to determine eligibility in trials for community-acquired pneumonia: a focus on procalcitonin". Clin. Infect. Dis. 47 Suppl 3: S127–32. DOI:10.1086/591393. PMID 18986278. Research Blogging.
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