PCCP POST GRADUATE COURSE: “Pulmo ABC, atbp.
” - No other associated symptoms such as confusion, difficulty
of breathing, chest tightness
I. PNEUMONIA - Hypertensive, no meds, no monitoring
Dr. Dennis Mark Santos / Dr. Melvin Pasay - Previous bronchitis and appendicitis (as a young adult) and
hemorrhoids
CASE: - Other pertinent data to elicit – history of DM, vaccination
CHIEF COMPLAINT: Cough and fever for four days history (Flu, Pneumo)
- Patient is a non-smoker, non-alcoholic
HISTORY: Mr. ABO is a 68 year old man who developed a
harsh, productive cough four days prior to being seen by a 2. What are the pertinent physical examination findings?
physician. The sputum is thick and yellowish phlegm. He - 152/90; 112 bpm; 31 cpm, labored; 41 C; O2 at 95% RA
developed an undocumented fever, shaking, chills and - Right mid-anterior and right mid-lateral lung fields are dull
malaise along with the cough. Self medicated only with - Bilateral diminished vesicular breath sounds
paracetamol with temporary relief of fever. - Bronchial breath sounds
One day ago he developed pain on his right chest that - Rhonchi and late inspiratory crackles in the area of the right
intensifies with inspiration. "I just thought I had the flu. "He mid-anterior and right mid-lateral lung fields
claims there were no other associated symptoms such as - Remainder of lung fields is clear
confusion, difficulty of breathing, nor chest tightness. The
persistence of cough and fever prompted consult. 3. What is your working impression and basis?
Past history reveals that he has been treated for mild - Community Acquired Pneumonia:
hypertension, bronchitis, appendicitis (as a young adult), and - Productive cough, fever, pleuritic chest pain, crackles
hemorrhoids but stopped all maintenance medications. - MODERATE RISK: tachypnea, high grade fever
Patient was fully vaccinated for COVID given 2 Booster shots
and plans to take bivalent booster. Patient denies to have Main Differential Diagnosis:
heart failure, kidney disease, stroke, liver disease nor cancer. a. COVID-19 infection – cough and fever, but patient was fully
He denies smoking cigarettes and is a non-alcoholic. The vaccinated for COVID
patient is a retired truck driver who lives with his wife. b. Acute Coronary Syndrome – chest pain, but noted to be on
the right side of the chest. Needs work up.
PHYSICAL EXAMINATION:
The patient is an elderly man who appears tired haggard and Others:
underweight. His complexion is sallow. He coughs - Congestive heart failure with pulmonary edema
continuously. Sitting in a chair, he leans to his right side, - Pulmonary embolism
holding his right chest with his left arm. He is oriented to - Pulmonary hemorrhage
Place, person, and time. - Atelectasis
Vital signs are as follow: blood pressure 152/90 mg, apical - Aspiration or chemical pneumonitis
heart rate 112/minute and regular, respiratory rate 31/minute - Drug reactions
and labored, temperature 41C, O2 sat 95% RA. - Lung cancer
Examination of the eyes showed pink palpebral conjunctivae, - Collagen vascular disease
anicteric sclerae, neck reveals non-distended neck veins and - Vasculitis
No cervical lymphadenopathies - Acute exacerbation of bronchiectasis
Both lungs are resonant by percussion with one exception: - Interstitial lung diseases (sarcoidosis, asbestosis)
the right mid-anterior and right mid-lateral lung fields are dull.
Auscultation reveals bilateral diminished vesicular breath Diagnostic Tests and Rationale:
sounds. 1. Chest x-ray high sitting – to check for infiltrates suggestive
Bronchial breath sounds, rhonchi and late inspiratory of infection, signs of consolidation, effusion or congestion,
crackles (are heard) in the area of the right mid-anterior and rule out mass lesion
right mid-lateral lung fields. The remainder of the lung fields 2. Arterial Blood Gas – evaluate acid-base status and level of
is clear. oxygenation appropriate for age
Percussion and auscultation of the heart reveals no 3. Complete Blood Count – check cell counts (WBC, RBC,
significant abnormality. The rest of the physical examination platelets) and look for signs of bacterial infection; to look at
shows essentially normal findings. Hgb and Hct as well.
4. Electrolytes – check for abnormalities that can cause
1. Identify the problems from the history respiratory muscle weakness, e.g. hypokalemia
- Significant Findings: 5. Creatinine, BUN – assess renal function and hydration
- Harsh, productive cough for four days with no consult status; for proper dosing of antibiotics and other medications
- Sputum is thick and yellowish 6. Capillary Blood Glucose – weak looking patient
- Undocumented fever, shaking, chills, and malaise 7. 12L ECG – check for signs of ischemia/MI
- Paracetamol – temporary relief of fever 8. Cardiac enzymes – rule out ACS
- Pain on right chest that intensifies with inspiration.
BENJO CRUZ, MD 1
9. Sputum GSCS – identify causative organism and its
susceptibility fo antibiotics
10. Blood Culture – check for blood stream infection
11. RAT test – rule out possible COVID infection despite
vaccination
12. Respiratory panel – consider PCR testing for multiple
respiratory pathogens (bacterial/viral).
Reading: Density in the projection of right mid lung field,
silhouetting with right heart margin, suggesting RML disease.
Note also right hilar fullness. Lateral view also shows
consolidation in the projection of RML.
ON READING CHEST X-RAYS:
> Check patient details
- First name, surname, date of birth, so as not to interchange
patients
> Check orientation, position, and side description
- Left, right, erect, AP, PA, Supine, Prone
> Check additional information
- Inspiration, expiration
> Check for rotation
- Measure the distance from the medial end of each clavicle
to the spinous process of the vertebra at the same level,
which should be equal
BENJO CRUZ, MD 2
Acidosis Respiratory pH ⬇️ pCO2 ⬆️
Acidosis Metabolic pH ⬇️ pCO2 ⬇️
Alkalosis Respiratory pH ⬆️ pCO2 ⬇️
Alkalosis Metabolic pH ⬆️ pCO2 ⬆️
Example:
In our patient, here is the ABG result at room air:
pH 7.25
pCO2 58.7
pO2 130
HCO3 35.5
SpO2 95%
1. pH = acidosis
2. Which between pCO2 or HCO3 will produce acidosis?
pCO2 = respiratory
ABC’s of CXR 3. Patient has respiratory acidosis
1. Airway – Is trachea visible and at midline? 4. Did compensation happen? HCO3 is above 26, but the
- If intubated, tip of ET should be 3-4 cm from the carina change did not normalize the pH. Thus, it’s partially
- Trachea gets pushed away from abnormality, e.g. pleural compensated.
effusion or tension pneumothorax 5. Partly compensated respiratory acidosis
- Trachea gets pulled towards abnormality, e.g. atelectasis 6. Another important use of ABG is the determination of
- Trachea normally narrows at the vocal cords oxygenation status = adequately oxygenated.
2. Bones – look for fractures, dislocation pO2 = 130 with SpO2 at 95% at room air
3. Cardiac – assess heart size, if more than 50% of total
diameter of the chest (cardiomegaly), check aorta Other labs and ancillary tests:
4. Diaphragm – right side is normally higher than the left. > CBC – Hgb 154, Hct 50.8, WBC 12.8, N 91
- If much higher, think of effusion, lobar collapse, - Indicative of bacterial infection
diaphragmatic paralysis > Electrolytes, Crea and BUN:
- If you cannot see parts of the diaphragm, consider infiltrates Crea 1.20 mg/dl; BUN 30, Na 129, K 3.8, iCa 1.1, Mg 1.9
or effusion - Low sodium may be secondary to poor intake or SIADH due
5. Effusion – look for blunting of the costophrenic angle to pneumonia or chronic lung disease
6. Lung FIELDS – identify the location of infiltrates by use of - Increased BUN/Crea ratio may be due to dehydration and
known radiological phenomena, e.g. loss of heart borders or increased catabolism
of contour of the diaphragm. Pay attention to apices. > CBG 130 mg/dl – weakness not due to hypoglycemia
7. Gastric air bubble > 12L ECG – sinus tachycardia, non specific ST wave
8. Hilum – enlarged lymph nodes, calcified nodules, mass changes. Cardiac enzymes normal. No acute infarction.
lesions > Sputum GS/CS – Gram (+) cocci in chains
- Heavy growth of Streptococcus pneumoniae after 2 days of
Basics of ABG interpretation incubation. Sensitive to Piperacillin, Co-amoxiclav,
1. Identify what is the pH. Is it acidotic or alkalotic? Ceftriaxone, Levofloxacin
- pH < 7.35 – acidotic > Blood culture – no growth after 5 days of incubation
- pH > 7.45 – alkalotic
- This is usually the primary disorder 4. What is your final working impression and basis?
- An acidosis or alkalosis may be present even if the pH is in > COMMUNITY ACQUIRED PNEUMONIA, MODERATE
normal range (7.35-7.45) RISK (CAP-MR).
- Check pCO2 and HCO3: - Basis: productive cough, fever, pleuritic chest pain,
- Normal pCO2: 35-45 crackles.
- Normal HCO3: 22-26 - Moderate risk because patient is tachypneic (RR 31), high
grade fever (41 C), and patient is not intubated and not in
2. Is the disturbance respiratory or metabolic? shock
- What is the relationship between the direction of change in - Labs supporting CAP include CXR findings of pneumonia
the pH and the direction of change in the pCO2? on right middle lobe, WBC elevated with neutrophilic
- In primary respiratory disorders, the pH and pCO2 change predominance, and ABG showing partially compensated
in the opposite directions; in metabolic disorders, the pH and respiratory acidosis, more than adequate oxygenation at
pCO2 change in the same direction. room air. Patient also has elevated BUN and hyponatremia.
5. Will you admit this patient or manage him in the OPD? If
you decide to admit the patient, to Ward or to ICU?
BENJO CRUZ, MD 3
Community Acquired Pneumonia: initial evaluation and site
of care based on severity assessment in adults:
1. MILD
Severity Score: PSI I or II or CURB-65: 0
Use of Pneumonia Severity Index (PSI) and CURB-65 Site of care: Ambulatory care
Microbiologic Testing:
> COVID 19 testing during pandemic
> Influenza testing (when incidence is high and results would
change management). Otherwise, testing is usually not
needed
2. MODERATE
Severity Score: PSI III or IV or CURB-65: 1 to 2
Site of care: General Medical Ward
Microbiologic Testing:
> Blood cultures
> Sputum GS/CS
> Urine streptococcal antigen
> Legionella testing
> Respiratory viral panel during respiratory virus season
> COVID 19 testing
> HIV screening
3. SEVERE
Severity Score: PSI IV or V or CURB-65 > 3 and/or ATS/IDSA
criteria for ICU admission
Site of care: ICU
Microbiologic Testing:
> Blood cultures
> Sputum GS/CS
> Urine streptococcal antigen
> Legionella testing
> Respiratory viral panel during respiratory virus season
> Bronchoscopy specimen for Gram Stain, Fungal stain,
aerobic, fungal culture, and molecular testing (when feasible)
> COVID 19 testing
> HIV screening
BENJO CRUZ, MD 4
ATS and IDSA major criteria for ICU admission include either: Common causes – Streptococcus pneumoniae and
> Septic shock with need for vasopressor support and/or respiratory viruses are the most frequently detected
> Respiratpry failure with need for mechanical ventilation pathogens in patients with CAP.
- The most commonly identified causes of CAP are grouped
If major criteria are not met, patients should also be into three categories:
considered for ICU admission if 3 or more of the following
minor criteria are present: 1. TYPICAL BACTERIA
> Altered mental status - Streptococcus pneumoniae (most common bacterial cause)
> Hypotension requiring fluid support - Haemophilus influenzae
> Temperature < 36.0 C - Moraxella catarrhalis
> Respiratory rate > 30 breaths/min, PF ration < 250 - Staphylococcus aureus
> BUN > 20 mg/dl (7 mmo/L) - Group A Streptococci
> WBC < 4000 cells/mL, Platelet count < 100,000, with - Aerobic Gram negative bacteria (e.g., Enterobacteriaceae
multilobar infiltrates such as Klebsiella spp or Escherichia coli)
- Microaerophlici bacteria and anaerobes (associated with
PSI class and mortality in the Pneumonia PORT validation aspiration)
cohort:
Class Points Mortality Rate 2. ATYPICAL BACTERIA
I No predictors 0.1 % - “Atypical” refers to intrinsic resistance of these organisms to
II < 70 0.6 % beta lactams and their inability to be visualized on Gram stain
III 71 to 90 0.9 % or cultured using traditional techniques
IV 91 to 130 9.3 % - Legionella spp.
V > 130 27.0 % - Mycoplasma pneumoniae
(PORT = Patient Outcomes Research Team) - Chlamydia pneumoniae
- Chlamydia psittaci
Important Points: - Coxiella burnetii
- Severity scores should be used as an adjunct to clinical
judgment 3. RESPIRATORY VIRUSES
- Patients with early signs of sepsis (e.g., patients fulfilling - Influenza A and B viruses
minor ATS/IDSA criteria) or rapidly progressive illness are not - Severe acute respiratory syndrome coronavirus 2 (SARS-
well represented in severity scoring systems COV-2)
- Patients with these features may warrant hospitalization - Other coronaviruses (e.g. CoV-22, CoV-NL63, CoVOC43,
and/or ICU admission regardless of score CoV-HKU1)
- Conversely, older age may be overrepresented in severity - Rhinoviruses
scores; this should be taken into account when determining - Parainfluenza viruses
site of care - Adenoviruses
- Respiratory Syncytial Virus
- Human metapneumovirus
- Human bocavirus
Community-Acquired Pneumonia: Risk Factors for MRSA
and Pseduomonas in adults
BENJO CRUZ, MD 5
Additional Considerations:
- Inpatients with suspected aspiration pneumonia: routine addition of anaerobic coverage is NOT RECOMMENDED, unless lung
abscess or empyema is suspected
- Role of corticosteroids in hospitalized patients: NOT RECOMMENDED routinely in adults with non-severe CAP, in adults with
severe influenza pneumonia. Only recommended for refractory septic shock
- CAP who test positive for influenza: anti-influenza treatment such as Oseltamivir should be prescribed in both out- and in-patient
settings, independent of duration of illness before diagnosis
BENJO CRUZ, MD 6
BENJO CRUZ, MD 7
Transitioning inpatients with CAP from IV to oral antibiotics Goals of Airway Clearance:
SHORT TERM GOALS:
- Provide more effective sputum clearance that improves
ventilation
- Reduce cough and breathlessness
LONG TERM GOALS:
- Reduce further airway damage by halting the vicious cycle
- Reduce pulmonary exacerbations
- Improve quality of life
Mucoactive Agents
1. Expectorants
- Induce discaharge or expulsion of mucus from the
respiratory tract
- e.g. Hypertonic saline and guaifenesin
2. Mucoregulators
- Regulate mucus secretion or interfere with DNA/F-actin
network.
- e.g. Carbocisteine and anticholinergic agents
3. Mucolytics
- Decrease mucus viscosity
- e.g. N-acetylcysteine, erdosteine, and DNAse
Duration of Antibiotic Therapy 4. Mucokinetics
- Guided by a validated measure of clinical stability - Increase mucociliary clearance by acting on the cilia
- Improvement of vital sign abnormalities, ability to eat and - e.g. bronchodilators and surfactants
normal mentation
- Antibiotic therapy should be continued until patient COMPLICATIONS OF CAP
improvement is achieved and for no less than total of 5 days - Sepsis
- Longer courses of antibiotic treatments are recommended - Respiratory failure
for pneumonia with complications like meningitis, - Parapneumonic effusions
endocarditis and others - Cardiovascular events:
> Myocardial infarction
Algorithm for procalcitonin-guided antibiotic discontinuation > Arrhythmias
in clinically stable adult patients with known/suspected CAP > Heart Failure
> Pulmonary Embolism
> Stroke
FOLLOW-UP
- To observe for clinical signs of stability
- Follow up lab parameters to asses for improvement
- In adults with CAP whose symptoms have resolved within
5-7 days obtaining follow up xray is NOT ROUTINELY
RECOMMENDED
Usual duration of findings in treated CAP
Abnormality Duration (days)
Tachycardia and 2
hypotension
Fever, tachypnea, hypoxia 3
Cough 14
Fatigue 14
Infiltrates on CXR 30
BENJO CRUZ, MD 8
PREVENTION
1. Pneumococcal and influenza vaccination
- Vaccination is an effective and important component of
pneumonia prevention
- Annual vaccination against seasonal influenza viruses is
indicated for all patients (without contraindications).
- Pneumococcal vaccination is indicated for all patients > 65
years old and others with specific risk factors (e.g. certain
comorbidities including chronic heart, lung, and liver disease,
immunocompromising conditions, and impaired splenic
function).
*** Prior to giving influenza vaccination, ASK for history of
ALLERGY TO EGGS, since this vaccination uses albumin as
a carrier
2. Smoking cessation
- Should be a goal for patients with CAP who smoke, and we
discuss at this time of diagnosis and when providing follow-
up care
POST TEST
1. Essential tool in diagnosis of pneumonia
A. Chest x-ray
B. Chest CT scan
C. Complete blood count
D. Procalcitonin
2. Which of the following is an atypical pathogen causing
community-acquired pneumonia?
A. H. influenzae
B. Mycoplasma pneumoniae
C. Staphylococcus aureus
D. Streptococcus pneumoniae
3. Which of the following parameters does NOT classify in
low risk CAP?
A. BP 120/80
B. HR 98
C. RR 18
D. Drowsy
4. Which of the following is a treatment option for CAP LR?
A. Azithromycin
B. Ceftriaxone
C. Ertapenem
D. Piperacillin Tazobactam
5. Which of the following is recommended to prevent
pneumonia?
A. Pneumococcal vaccine
B. Influenza vaccine
C. Smoking cessation
D. All of the above
1 A, 2 B, 3 D, 4 A, 5 D
BENJO CRUZ, MD 9
