Pneumonia

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This editable Main Article is under development and subject to a disclaimer.

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Pneumonia

ICD-9  | 480

-486

Pneumonia is defined as "inflammation of the lungs."[1]

## Contents

* 1 Classification
* 1.1 Aspiration pneumonia
* 1.2 Community acquired pneumonia
* 1.2.1 Atypical pneumonia
* 1.3 Nosocomial pneumonia
* 1.3.1 Ventilator associated pneumonia
* 2 Diagnosis
* 2.1 Community acquired pneumonia
* 2.1.1 History and physical examination
* 2.1.2 Blood tests
* 2.1.3 Diagnostic imaging
* 2.2 Nosocomial pneumonia
* 3 Treatment
* 3.1 Antibiotics
* 3.2 Corticosteroids
* 3.2.1 Aspiration pneumonia
* 3.2.2 Community acquired pneumonia
* 3.2.3 Ventilator associated pneumonia
* 3.3 Treatments that are ineffective
* 4 Prognosis
* 4.1 Short term prognosis and the decision to hospitalize
* 4.1.1 C-reactive protein and procalcitonin
* 4.2 Prognosis at the time of discharge
* 4.3 Long term prognosis
* 5 Prevention
* 6 References

## Classification[edit]

Pneumonia can be classified along various dimensions including clinical setting, underlying etiology, and its gross appearance (bronchopneumonia versus lobar pneumonia).

### Aspiration pneumonia[edit]

### Community acquired pneumonia[edit]

The most common cause, streptococcus pneumonia, causes about a third of episodes.[2]

#### Atypical pneumonia[edit]

### Nosocomial pneumonia[edit]

#### Ventilator associated pneumonia[edit]

## Diagnosis[edit]

### Community acquired pneumonia[edit]

#### History and physical examination[edit]

A clinical prediction rule found the five following signs from the medical history and physical examination best predicted infiltrates on the chest radiograph of 1134 patients presenting to an emergency room:[3]

* Temperature > 100 degrees F (37.8 degrees C)
* Pulse > 100 beats/min
* Crackles
* Decreased breath sounds
* Absence of asthma

The probability of an infiltrate based on the number of findings.[4] [3] Number of findings | Primary care[4] | Emergency Room[3]

|
|

5 | 47% | 75%
4 | 27 | 56
3 | 8 | 22
2 | 4 | 11
1 | 1 | 3
0 | 1 | 2

* 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[5] comparing four clinical prediction rules to physician judgment found that two clinical prediction rules, the one above[3] and another[6] were more accurate than physician judgment because of the increased specificity of the prediction rules.

#### Blood tests[edit]

Some, but not all[7] experts recommend prompt blood cultures.

Procalcitonin levels may help prognosticate.

#### Diagnostic imaging[edit]

Ultrasonography can diagnose community acquired pneumonia in one study with accuracy of:[8]

* Sensitivity 93%
* Specificity 98%

### Nosocomial pneumonia[edit]

The accuracy of findings for ventilator-associated pneumonia.[9] Finding | Sensitivity | Specificity

|
|

Fever | 45%-67% | 33%-76%
Purulent sputum | 50%-83% | 33%-67%
Chest x-ray showing new infiltrate | 87%-91% | 33%-50%

Bronchoalveolar lavage with quantitative culture of the bronchoalveolar-lavage fluid or endotracheal aspiration with nonquantitative culture of the aspirate can help diagnose ventilator-associated pneumonia.[10]

## Treatment[edit]

Clinical practice guidelines are available.[11]

### Antibiotics[edit]

Some, but not all[7] experts recommend prompt antibiotics.

### Corticosteroids[edit]

In a randomized controlled trial of adults with community-acquired pneumonia, the relative risk ratio of prednisone 50 mg daily for 7 days, as compared to placebo, reduced the time to median time to clinical stability from 4.4 to to 1.3 days. [12]

In another randomized controlled trial of adults with community-acquired pneumonia, dexamethasone can reduce length of hospital stay. [13]

One trial reported increase in late-failures.[14]

#### Aspiration pneumonia[edit]

#### Community acquired pneumonia[edit]

The 'respiratory quinolones' (levofloxacin, moxifloxacin, gemifloxacin) may be the best choices[15] although the evidence is not clear[16] and some studies show macrolides may be better[17].

The optimal duration of antibiotic treatment for community acquired pneumonia is not clear.[18]

#### Ventilator associated pneumonia[edit]

### Treatments that are ineffective[edit]

Chest physiotherapy includes postural drainage, percussion, and vibration and has been call the 'ketchup-bottle method'[19] of treating pneumonia. Chest physiotherapy and intermittent positive-pressure breathing have been shown not to help in a small randomized controlled trial.[20] A subsequent systematic review did not find benefit.[21]

## Prognosis[edit]

### Short term prognosis and the decision to hospitalize[edit]

The prognosis of community acquired pneumonia can be estimated with several clinical prediction rules of similar accuracy:[22][23]

* Pneumonia severity index (PSI) - the PSI may[24] or may not[23] be more accurate than the CURB-65 and is available online (Pneumonia Severity Index Calculator).
* Patients with PSI Risk groups I-III can usually be treated as an outpatient.[25]
* CURB-65
* SMART-COP is a new clinical prediction rule that may be better according to a single study.[26] 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:
* PaO2 < 70 mm Hg if less than 50 years old, else < 60 mm Hg
* PaO2/FiO2 < 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[27]
* PIRO is another clinical prediction rule specifically for severe pneumonia.[28]

#### C-reactive protein and procalcitonin[edit]

Several studies have compared the c-reactive protein and procalcitonin in the prognosis of pneumonia.[29][30][31][32] The procalcitonin may[33][32][30][31] or may not[29] be more accurate.

### Prognosis at the time of discharge[edit]

Abnormal medical signs at discharge are associated with higher mortality with 30 days.[34]

### Long term prognosis[edit]

## Prevention[edit]

For more information, see: Pneumococcal vaccine.

Clinical practice guidelines are available for administering vaccines for pneumonia at http://www.cdc.gov/vaccines/.

## References[edit]

1. ↑ Anonymous (2025), Pneumonia (English). Medical Subject Headings. U.S. National Library of Medicine.
2. ↑ Sorde, Roger; Vicenc Falco, Michael Lowak, Eva Domingo, Adelaida Ferrer, Joaquin Burgos, Mireia Puig, Evelyn Cabral, Oscar Len, Albert Pahissa (2010-09-27). "Current and Potential Usefulness of Pneumococcal Urinary Antigen Detection in Hospitalized Patients With Community-Acquired Pneumonia to Guide Antimicrobial Therapy". Arch Intern Med: archinternmed.2010.347. DOI:10.1001/archinternmed.2010.347. Retrieved on 2010-09-28. Research Blogging.
3. ↑ 3.0 3.1 3.2 3.3 Heckerling PS, Tape TG, Wigton RS, et al (1990). "Clinical prediction rule for pulmonary infiltrates". Ann. Intern. Med. 113 (9): 664–70. PMID 2221647. [e]
4. ↑ 4.0 4.1 Ebell MH (2007). "Predicting pneumonia in adults with respiratory illness.". Am Fam Physician 76 (4): 560-2. PMID 17853631. [e]
5. ↑ Emerman CL, Dawson N, Speroff T, et al (1991). "Comparison of physician judgment and decision aids for ordering chest radiographs for pneumonia in outpatients". Annals of emergency medicine 20 (11): 1215–9. DOI:10.1016/S0196-0644(05)81474-X. PMID 1952308. Research Blogging.
6. ↑ Gennis P, Gallagher J, Falvo C, Baker S, Than W (1989). "Clinical criteria for the detection of pneumonia in adults: guidelines for ordering chest roentgenograms in the emergency department". The Journal of emergency medicine 7 (3): 263–8. PMID 2745948. [e]
7. ↑ 7.0 7.1 Nazarian DJ, Eddy OL, Lukens TW, Weingart SD, Decker WW (2009). "Clinical policy: critical issues in the management of adult patients presenting to the emergency department with community-acquired pneumonia.". Ann Emerg Med 54 (5): 704-31. DOI:10.1016/j.annemergmed.2009.07.002. PMID 19853781. Research Blogging.
8. ↑ Reissig A, Copetti R, Mathis G, Mempel C, Schuler A, Zechner P et al. (2012). "Lung ultrasound in the diagnosis and follow-up of community-acquired pneumonia: a prospective, multicenter, diagnostic accuracy study.". Chest 142 (4): 965-72. DOI:10.1378/chest.12-0364. PMID 22700780. Research Blogging.
9. ↑ Klompas M (2007). "Does this patient have ventilator-associated pneumonia?". JAMA 297 (14): 1583-93. DOI:10.1001/jama.297.14.1583. PMID 17426278. Research Blogging.
10. ↑ Canadian Critical Care Trials Group (2006). "A randomized trial of diagnostic techniques for ventilator-associated pneumonia.". N Engl J Med 355 (25): 2619-30. DOI:10.1056/NEJMoa052904. PMID 17182987. Research Blogging. Review in: ACP J Club. 2007 May-Jun;146(3):62
11. ↑ Mandell LA, Wunderink RG, Anzueto A, Bartlett JG, Campbell GD, Dean NC et al. (2007). "Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults.". Clin Infect Dis 44 Suppl 2: S27-72. DOI:10.1086/511159. PMID 17278083. Research Blogging. Free pdf access
12. ↑ Blum CA, Nigro N, Briel M, Schuetz P, Ullmer E, Suter-Widmer I et al. (2015). "Adjunct prednisone therapy for patients with community-acquired pneumonia: a multicentre, double-blind, randomised, placebo-controlled trial.". Lancet. DOI:10.1016/S0140-6736(14)62447-8. PMID 25608756. Research Blogging.
13. ↑ Meijvis SC, Hardeman H, Remmelts HH, Heijligenberg R, Rijkers GT, van Velzen-Blad H et al. (2011). "Dexamethasone and length of hospital stay in patients with community-acquired pneumonia: a randomised, double-blind, placebo-controlled trial.". Lancet 377 (9782): 2023-30. DOI:10.1016/S0140-6736(11)60607-7. PMID 21636122. Research Blogging.
14. ↑ Snijders D, Daniels JM, de Graaff CS, van der Werf TS, Boersma WG (2010). "Efficacy of corticosteroids in community-acquired pneumonia: a randomized double-blinded clinical trial.". Am J Respir Crit Care Med 181 (9): 975-82. DOI:10.1164/rccm.200905-0808OC. PMID 20133929. Research Blogging.
15. ↑ Vardakas KZ, Siempos II, Grammatikos A, Athanassa Z, Korbila IP, Falagas ME (December 2008). "Respiratory fluoroquinolones for the treatment of community-acquired pneumonia: a meta-analysis of randomized controlled trials". CMAJ 179 (12): 1269–1277. DOI:10.1503/cmaj.080358. PMID 19047608. PMC 2585120. Research Blogging.
16. ↑ Bjerre LM, Verheij TJ, Kochen MM (2009). "Antibiotics for community acquired pneumonia in adult outpatients.". Cochrane Database Syst Rev (4): CD002109. DOI:10.1002/14651858.CD002109.pub3. PMID 19821292. Research Blogging.
17. ↑ Martin-Loeches I, Lisboa T, Rodriguez A, Putensen C, Annane D, Garnacho-Montero J et al. (2010). "Combination antibiotic therapy with macrolides improves survival in intubated patients with community-acquired pneumonia.". Intensive Care Med 36 (4): 612-20. DOI:10.1007/s00134-009-1730-y. PMID 19953222. Research Blogging.
18. ↑ Li JZ, Winston LG, Moore DH, Bent S (2007). "Efficacy of short-course antibiotic regimens for community-acquired pneumonia: a meta-analysis". Am. J. Med. 120 (9): 783–90. DOI:10.1016/j.amjmed.2007.04.023. PMID 17765048. Research Blogging.
19. ↑ Murray JF (1979). "The ketchup-bottle method". N. Engl. J. Med. 300 (20): 1155–7. PMID 431639. [e]
20. ↑ Graham WG, Bradley DA (1978). "Efficacy of chest physiotherapy and intermittent positive-pressure breathing in the resolution of pneumonia". N. Engl. J. Med. 299 (12): 624–7. PMID 355879. [e]
21. ↑ Yang M, Yuping Y, Yin X, Wang BY, Wu T, Liu GJ et al. (2010). "Chest physiotherapy for pneumonia in adults.". Cochrane Database Syst Rev 2: CD006338. DOI:10.1002/14651858.CD006338.pub2. PMID 20166082. Research Blogging.
22. ↑ Chalmers JD, Singanayagam A, Akram AR, Mandal P, Short PM, Choudhury G et al. (2010). "Severity assessment tools for predicting mortality in hospitalised patients with community-acquired pneumonia. Systematic review and meta-analysis.". Thorax 65 (10): 878-83. DOI:10.1136/thx.2009.133280. PMID 20729231. Research Blogging.
23. ↑ 23.0 23.1 Ochoa-Gondar O, Vila-Corcoles A, Rodriguez-Blanco T, Ramos F, de Diego C, Salsench E et al. (2011). "Comparison of three predictive rules for assessing severity in elderly patients with CAP.". Int J Clin Pract 65 (11): 1165-72. DOI:10.1111/j.1742-1241.2011.02742.x. PMID 21951687. Research Blogging.
24. ↑ Aujesky D, Auble TE, Yealy DM, et al (2005). "Prospective comparison of three validated prediction rules for prognosis in community-acquired pneumonia". Am. J. Med. 118 (4): 384-92. DOI:10.1016/j.amjmed.2005.01.006. PMID 15808136. Research Blogging.
25. ↑ Carratalà J, Fernández-Sabé N, Ortega L, et al (February 2005). "Outpatient care compared with hospitalization for community-acquired pneumonia: a randomized trial in low-risk patients". Ann. Intern. Med. 142 (3): 165–72. PMID 15684204. [e]
26. ↑ Charles PG, Wolfe R, Whitby M, et al (August 2008). "SMART-COP: a tool for predicting the need for intensive respiratory or vasopressor support in community-acquired pneumonia". Clin. Infect. Dis. 47 (3): 375–84. DOI:10.1086/589754. PMID 18558884. Research Blogging.
27. ↑ Yandiola PP, Capelastegui A, Quintana J, et al. (June 2009). "Prospective comparison of severity scores for predicting clinically relevant outcomes for patients hospitalized with community-acquired pneumonia". Chest 135 (6): 1572–9. DOI:10.1378/chest.08-2179. PMID 19141524. Research Blogging.
28. ↑ Rello J, Rodriguez A, Lisboa T, Gallego M, Lujan M, Wunderink R (December 2009). "PIRO score for community-acquired pneumonia: A new prediction rule for assessment of severity in intensive care unit patients with community-acquired pneumonia". Crit. Care Med.. DOI:10.1097/CCM.0b013e318194b021. PMID 19114916. Research Blogging.
29. ↑ 29.0 29.1 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]
30. ↑ 30.0 30.1 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.
31. ↑ 31.0 31.1 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]
32. ↑ 32.0 32.1 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.
33. ↑ 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.
34. ↑ Capelastegui A, España PP, Bilbao A, et al (September 2008). "Pneumonia: criteria for patient instability on hospital discharge". Chest 134 (3): 595–600. DOI:10.1378/chest.07-3039. PMID 18490403. Research Blogging.