How To Rule Out Pneumonia

Inclusion And Exclusion Criteria

Our search was designed to identify studies that used a CDR to diagnose, predict, or rule out CAP in the outpatient setting. A study was included if it used a CXR or computed tomography scan as the primary reference standard and was given to all patients enrolled in the study. If the reference standard was used in a random or systematic sample of low-risk CAP patients to minimize radiation exposure, the study was also included. Studies had to gather data prospectively and only studies that recruited adults or adolescents in an outpatient setting were included.

Studies where a majority of the enrolled patients had hospital-acquired or ventilator-associated pneumonia, were immunocompromised, or that were conducted in special populations such as military or nursing homes were excluded. We excluded studies that were not prospective, such as case-control studies, case reports, and outbreak investigations. An exception was made if the case-control study enrolled symptomatic patients prospectively, such as a consecutive series where patients with similar symptoms but with and without CAP were matched.

How Long Does It Take To Recover From Pneumonia

Pneumonia is a serious illness that can take quite a toll on a persons lungs and body. It can take anywhere from a week to several months to fully recover from it, says Dr. Rayman Lee, pulmonologist at Houston Methodist.

The length of time it takes for you to recover from pneumonia is influenced by:

• Your age
• The severity of your illness
• Whether you have other health conditions
• The type of pneumonia

If youre generally healthy and have only a mild case of pneumonia, your symptoms should begin to improve one to two days after starting treatment.

Most people with mild pneumonia are able to return to their everyday activities in a week, although fatigue and cough can linger for an entire month, says Dr. Lee.

Recovery timelines become more murky for people who have severe pneumonia.

For more serious cases that require hospitalization, were not only focused on clearing the infection, were also focused on preventing or treating complications that can develop including difficulty breathing, fluid buildup in the lungs, sepsis, acute respiratory distress syndrome and lung abscesses, warns Dr. Lee.

Pneumonia and its complications can wreak havoc on a persons lungs and body. And, it can take anywhere from one to six months for a person to recover and regain strength after being hospitalized for pneumonia.

How Do You Rule Out Differential Diagnosis

Steps involved in a differential diagnosis Whatre your symptoms? How long you have been experiencing these symptoms? Is there anything that triggers your symptoms? Is there anything that makes your symptoms worse or better? Do you have a family history of specific symptoms, conditions, or diseases?.

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Tests To Assess Lung Function

Pneumonia directly affects the lungs, so the doctor may recommend one or more pulmonary function tests to check how well your lungs are working to provide oxygen to your body.

One type of pulmonary function test is pulse oximetry, which checks whether there is enough oxygen in your blood. The test uses a sensor clipped to your ear or finger that estimates your blood oxygen levels.

Another way of evaluating your blood oxygen levels is with an arterial blood gases test. This test uses a sample of blood taken from an artery and measures the amount of oxygen, blood pH, and carbon dioxide.

Confidently Rule Out Cap In The Outpatient Setting

J Fam Pract

South Baldwin Regional Medical Center Family Medicine Residency, Foley, AL

DEPUTY EDITORAnne Mounsey, MDDepartment of Family Medicine, University of North Carolina, Chapel Hill

A focus on specific signs and symptomswithout imagingmay rule out community-acquired pneumonia in outpatients.

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What Can I Do At Home To Feel Better

In addition to taking any antibiotics and/or medicine your doctor prescribes, you should also:

• Get lots of rest. Rest will help your body fight the infection.
• Drink plenty of fluids. Fluids will keep you hydrated. They can help loosen the mucus in your lungs. Try water, warm tea, and clear soups.
• Stop smoking if you smoke and avoid secondhand smoke. Smoke can make your symptoms worse. Smoking also increases your risk of developing pneumonia and other lung problems in the future. You should also avoid lit fireplaces or other areas where the air may not be clean.
• Stay home from school or work until your symptoms go away. This usually means waiting until your fever breaks and you arent coughing up mucus. Ask your doctor when its okay for you to return to school or work.
• Use a cool-mist humidifier or take a warm bath. This will help clear your lungs and make it easier for you to breathe.

Tests To Assess Overall Health

Because pneumonia can trigger a range of potential complications, it is common for tests that assess your overall health to be included as part of pneumonia testing. Examples of these tests include:

• Complete blood count with differential: This test measures the amount of each type of blood cell in a blood sample taken from a vein in your arm. In addition to providing insight about overall health, a CBC can show if there is an elevated level of white blood cells, which is associated with some infections.
• Basic metabolic panel : This is another routine blood test that assesses kidney function, electrolytes, and blood sugar levels.

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What Diagnostic Procedures Will Be Helpful In Making Or Excluding The Diagnosis Of Hap

Bacterial culture is considered the gold standard for confirmation of pneumonia. Cultures can be obtained from sputum, nasotracheal suction, bronchoscopy or blood cultures. Pneumonia can be complicated by pleural effusions and empyemas and a thoracentesis can reveal an infected pleural space consistent with a parapneumonic effusion.

The diagnostic utility of sputum culture varies as oral and tracheal contamination can lead to false positive results, especially in patients with chronic lung diseases or chronic tracheostomy. HAP is not always due to bacterial infection and a negative sputum culture does not rule out HAP. Viral oropharyngeal swabs can be considered in the appropriate clinical context.

Data Abstraction And Analysis

We first abstracted the study characteristics, including the combination of signs, symptoms, or POC tests that were used to diagnose CAP. Articles were assessed for bias using the Quality Assessment Tool for Diagnostic Accuracy Studies framework adapted for our study. The evaluation consists of 4 areas: patient selection, index test, reference standard, and flow and timing. For each, a set of questions assess the article for bias, answering yes, no, high, low, or unknown. A final overall assessment for each article was given a low, moderate, or high risk for bias.

When available, true positive , false positive , true negative and false negative rates of each CDR were recorded. When not directly provided, they were calculated using data from the study. These data were used to calculate positive and negative likelihood ratios for CDRs reporting a dichotomous outcome of CAP versus no CAP, and stratum-specific likelihood ratios for CDRs reporting more than 2 possible outcomes . Post-test probabilities were calculated for standardized low-prevalence and high-prevalence populations, to represent typical outpatient primary care and emergency department populations respectively, using summary estimates of likelihood ratios for high-performing CDRs.,

Lastly, we calculated 3 risk groups as part of a post-hoc analysis of any CDR that was based on a multichotomous score., The risk groups were assigned based on the distribution of likelihood ratios from the studies’ published data.

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Your Best Defence: Vaccination

In addition to the influenza vaccine available each fall, there are specific vaccines for pneumonia. The Pneumovax vaccine and the Prevnar 13 vaccine are used to prevent pneumococcal infections, but only Prevnar 13 protects effectively against pneumococcal pneumonia.

These vaccines increase your ability to defend yourself against pneumococcal infection by incorporating small amounts of bacteria into your body. These vaccines stimulate the production of your antibodies that will stay in your body, ready to protect you from future bacterial infections.

What To Expect At Home

You will still have symptoms of pneumonia after you leave the hospital.

• Your cough will slowly get better over 7 to 14 days.
• Sleeping and eating may take up to a week to return to normal.
• Your energy level may take 2 weeks or more to return to normal.

You will need to take time off work. For a while, you might not be able to do other things that you are used to doing.

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Complications Caused By Pneumonia

Pneumonia can sometimes have complications. They include:

• pleurisy where the pleura, the thin linings between your lungs and ribcage, become inflamed, leading to chest pain. If you have pleurisy, you are more likely to develop fluid on the lungs.
• fluid on the lungs – about 1 in 10 people with pneumonia develop fluid around the lung, called a pleural effusion which can become infected. This may require a sample of the fluid to be taken by inserting a needle between the ribs under local anaesthetic, and if infected is likely to need a longer course of antibiotics. Occasionally, a tube is inserted into the lung to remove fluid as well.
• a lung abscess a rare complication thats mostly seen in people with a serious pre-existing illness or history of alcohol misuse.
• blood poisoning, also called septicaemia – this is where infection spreads from the lungs to the blood stream. This can cause low blood pressure and a severe illness that might need intensive care treatment.
• respiratory failure this is where pneumonia causes low levels of oxygen in the blood even in people given oxygen. This might also require intensive care treatment.

The vast majority of people recover from pneumonia and return to good health. However, pneumonia can be very serious and some people with severe pneumonia dont survive, despite the best available care. Those who are elderly or have other health problems are most at risk of severe or fatal pneumonia.

When Should I See My Doctor

Pneumonia can be life-threatening if left untreated, especially for certain at-risk people. You should call your doctor if you have a cough that wont go away, shortness of breath, chest pain, or a fever. You should also call your doctor if you suddenly begin to feel worse after having a cold or the flu.

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Who Should Receive Pneumococcal Vaccination

The people who are most vulnerable to infections and who should be vaccinated include:

• People aged 65 and up.

Other groups at increased risk are children under 2 years of age and adults who have one or more of the following risk factors:

• Cardiovascular, pulmonary or renal disease
• Diabetes, alcoholism, absence or dysfunction of the spleen
• Certain types of anemia
• HIV infection or other diseases related to a deficiency of the immune system
• People recovering from a serious illness
• People living in a long-term care hospital centre.

What Other Problems Can Pneumonia Cause

Sometimes pneumonia can cause serious complications such as:

• Bacteremia, which happens when the bacteria move into the bloodstream. It is serious and can lead to .
• Lung abscesses, which are collections of pus in cavities of the lungs
• Pleural disorders, which are conditions that affect the pleura. The pleura is the tissue that covers the outside of the lungs and lines the inside of your chest cavity.
• Respiratory failure

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What Laboratory Studies Should You Order To Help Make The Diagnosis And How Should You Interpret The Results

Pneumonia is suspected in a patient with new changes on CXR with a clinical constellation of fever, leukocytosis and purulent sputum with a decline in oxygenation. The diagnosis of pneumonia is based on clinical evidence and radiographic findings, not laboratory evidence however, lab studies can be used to support or refute the clinical assessment. Specifically, a CBC is important when assessing a patient for HAP. Leukocytosis or leukopenia, while nonspecific for pneumonia, can be used to support an infectious etiology such as pneumonia.

The IDSA/ATS guidelines recommend non-invasive sputum sampling, such as endotracheal aspirate to diagnose HAP rather than invasive sampling such as bronchoscopy. They also recommend against using procalcitonin, C-reactive protein, and CPIS score for diagnosis.

The evidence for blood cultures is controversial. 15% of VAP patients are bacteremic so prior guidelines did recommend obtaining blood cultures in suspected VAP patients. The evidence for blood cultures in HAP patients is even more limited as only a minority of patients are bacteremic. Blood cultures, however, may provide further guidance for treatment and de-escalation of organism specific antibiotic therapy.

What Other Considerations Exist For Patients With Hap

Patients who meet diagnostic criteria for pneumonia may not have an infectious etiology for their symptoms. Acute exacerbations of inflammatory lung diseases can mimic clinical pneumonia. Input from a pulmonologist in patients with inflammatory lung diseases is advised. Patients who present with recurrent, non-resolving pneumonia should be considered for possible malignancy as the etiology for their symptoms.

Table I is adapted from Kalil et al. Empiric antibiotic choice based on risk of mortality and infection with MRSA. High-risk mortality includes ventilator-dependent respiratory failure or septic shock. High-risk MRSA includes prior culture positive for MRSA, > 20% S. aureus isolated as MRSA in the unit, or IV antibiotic exposure within the prior 90 days. MRSA: methicillin-resistant Staphylococcus aureus.

No sponsor or advertiser has participated in, approved or paid for the content provided by Decision Support in Medicine LLC. The Licensed Content is the property of and copyrighted by DSM.

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Beware: There Are Other Diseases That Can Mimic Healthcare

It is important to consider other diagnoses when considering HAP. Atelectasis, CHF, ARDS, pulmonary embolus with infarction, pulmonary hemorrhage, lung contusion , and aspiration pneumonitis can all mimic pneumonia. The 2016 IDSA/ATS guidelines recommend that clinical criteria with a new lung infiltrate be used to diagnosis HAP however, as mentioned above, the clinical findings are nonspecific. Clinical criteria include new onset fever, leukocytosis, hypoxia and purulent sputum. When assessing the accuracy of different clinical criteria to diagnose VAP, one study showed that the presence of a new or progressive infiltrate plus â¥2 clinical features, either fever, leukocytosis or purulent sputum, resulted in a 69% sensitivity and 75% specificity for the diagnosis of pneumonia. The clinical pulmonary infection score which includes the previously mentioned clinical criteria plus oxygenation and tracheal aspirate has not been shown to be superior to conventional clinical criteria. Non-invasive and invasive sampling techniques have diagnostic values comparable to clinical criteria.

Can Pneumonia Be Prevented Or Avoided

There are many factors that can raise your risk for developing pneumonia. These include:

People who have any of the following conditions are also at increased risk:

• chronic obstructive pulmonary disease
• asthma
• sickle cell disease

You can help prevent pneumonia by doing the following:

• Get the flu vaccine each year. People can develop bacterial pneumonia after a case of the flu. You can reduce this risk by getting the yearly flu shot.
• Get the pneumococcal vaccine. This helps prevent pneumonia caused by pneumococcal bacteria.
• Practice good hygiene. Wash your hands frequently with soap and water or an alcohol-based hand sanitizer.
• Dont smoke. Smoking damages your lungs and makes it harder for your body to defend itself from germs and disease. If you smoke, talk to your family doctor about quitting as soon as possible.
• Practice a healthy lifestyle. Eat a balanced diet full of fruits and vegetables. Exercise regularly. Get plenty of sleep. These things help your immune system stay strong.
• Avoid sick people. Being around people who are sick increases your risk of catching what they have.

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How Long Does It Last

It takes a certain amount of time to start to feel sick after getting exposed to a germ. This length of time is called the incubation period, and it depends on many things, especially which bug is causing the illness.

With influenza pneumonia, for example, someone may become sick as soon as 12 hours or as long as 3 days after exposure to the flu virus. But with walking pneumonia, a person may not feel it until 2 to 3 weeks after becoming infected.

Most types of pneumonia clear up within a week or two, although a cough can linger for several weeks more. In severe cases, it may take longer to completely recover.

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Tests To Find The Cause Of Pneumonia

Pneumonia testing may include a range of tests to identify why pneumonia occurred. There are many potential causes of pneumonia including an infection with a bacteria, virus, or fungus. When the cause is known, the doctor can choose a tailored therapy that offers the most benefit and least risk.

This kind of testing is not routinely performed in patients with mild cases of pneumonia. Trying to identify the cause is of greater importance when a patient is hospitalized or at higher risk of severe complications from pneumonia.

Although many tests are available to look for the underlying cause, in the majority of cases, no single cause can be conclusively identified.

The following sections describe different types of tests that may be used to detect the cause of pneumonia. Each section is organized based on the type of sample that is used for testing.

Sputum tests

Sputum is a thick kind of mucus produced in the lungs that is also known as phlegm. It is distinct from saliva or spit because its thickness helps it trap and remove pathogens from the lungs. For this reason, sputum can be analyzed to check for signs of bacteria, viruses, or other pathogens.

There are three main ways that a sputum sample can be obtained. The least invasive way of collecting sputum is by coughing deeply so that sputum can be spit into a cup. Before this, you may inhale a vapor that makes it easier to produce a testable amount of sputum.

Throat or nasal swab tests

Blood tests

Urine tests

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