In this article, we will focus on more practical concerns when managing a patient with pneumonia for junior doctors. Covid-19 is not discussed here. 

History
  • Basics: fever, productive cough with yellow-green sputum, shortness of breath & pleuritic chest pain
  • In the context of patients with underlying respiratory disease, ask what about the sputum & SOB is different
  • Consider an aspiration event - did the patient or nursing staff note coughing on trying to eat or drink? Do they have any speech or swallow issues? Did they have reduced consciousness at any point leading up to their admission?
  • Ask if there is haemoptysis, weight loss, night sweats & travel history to consider the wider differential of tuberculosis & malignancy
  • Never forget smoking & occupational history. Hobbies (e.g. keeping birds) can be helpful as this may make you consider atypical pneumonia
  • Ask how the patient is managing with their ADLs as outpatient management could be considered
  • Also if it affects E&D or they are passing less urine, this is more concerning
  • Ask if they have recently been in hospital, received antibiotics or are from a care home as this will impact your antibiotic choices
  • Never forget allergies as most first-line choices are penicillins
Examination
  • Basics include reduced breath sounds or crackles in the affected areas. This can be helpful to focus your review of the CXR
  • More importantly, is how well they look - do they have significant respiratory distress or hypoxia which means you need to escalate. Drowsiness or confusion is also of concern.
Investigations
  • Basics include blood tests, chest x-ray, sputum, blood culture, HIV
  • ABGs can be of value in patients who are significantly hypoxic for consideration of HDU/ITU level of care or when there's concern about type 2 respiratory failure
CXR
The difference between a lower respiratory tract infection & pneumonia is the presence of radiological changes in the latter.


Lobar Pneumonia Diffuse Infiltrates


More frequently bacterial (e.g. streptococcus pneumoniae)
Bacterial, viral or atypical (e.g. chlamydia or mycoplasma)

Management
  • Consider whether the patient may be septic. Do they require fluid boluses or more broad-spectrum antibiotics or a stat dose of aminoglycosides (as per your local microbiology policy)
  • CURB-65 is a very helpful score for community acquired pneumonia to consider whether oral & outpatient management may be preferred. Admitting a patient isn't in itself a reason for intravenous therapy. 
CURB-65
  • Confusion
  • Urea >7mmol/L
  • Respiratory Rate >30
  • Systolic BP <90 or diastolic Bp <60mmHg.
  • More than 65 years
One point is scored for each. A score of 0-1 should be considered for outpatient management and a score of 2 for either inpatient or outpatient management. Those scoring 3 or higher should be admitted & urgently evaluated to see if they are septic.

Treatment includes antibiotics (as per trust policy), oxygen & fluids. Analgesia is important for pleuritic chest pain as uncontrolled pain could lead to the patient being unable to breathe properly.

Hospital-Acquired Pneumonia
For patients in whom you diagnose pneumonia after 48 hours of admission or have had a recent admission (definition of this varies by trust). It should also be considered in those from a care home, particularly if it is a nursing home. They will usually have a different first-line antibiotic.

Aspiration Pneumonia
Those with impaired swallow (stroke, myasthenia gravis, oesophageal diseases) or impaired mental status are at higher risk of aspiration. If you're unsure if the swallow is impaired, if the patient is otherwise quite well and able to follow instructions - consider asking them to drink a small sip of water and observe if they have issues.

Often aspiration causes a non-infective pneumonitis rather than bacterial pneumonia. This can mimic an infection as there is an inflammatory response when the body attacks the foreign substances. If there are concerns of a significant food or fluid bolus, this needs to be removed - antibiotics will not help. Treatment is supportive with ensuring the patient is nil by mouth whilst awaiting an assessment from the SALT team who might recommend thickened fluids to reduce this risk.

Contrary to popular belief, bacterial infections are more commonly caused by the usual gram positive bacteria such as streptococcus pneumoniae. However, anaerobes could be possible and hence the antibiotic choices tend to be more broad-spectrum e.g. co-amoxiclav.

Complications:
Pleural effusion - it takes around 300ml before chest x-rays can detect a pleural effusion. Pleural aspiration may be done for diagnostic or therapeutic purposes. Diagnostic purposes if there is a clinical suspicion of more sinister pathology e.g. malignancy. Therapeutic when there is a large effusion impacting oxygenation.

Empyema - is a collection of pus with the pleural cavity and is exudative. Antibiotics may have difficulty penetrating this collection, thus it is often drained and the patient is treated with intravenous antibiotics. A sample of the pus may help identify the organism and aid in targeted therapy.

Other complications include a lung abscess or respiratory failure.

Prevention and follow up
Consider the pneumococcal vaccine in high risk patients
  • Over 65 years of age
  • Those with chronic heart, liver, kidney or lung diseases
  • Diabetes
  • Immunosuppressed (e.g. medications, HIV, hyposplenic)
Consolidation on the chest x-ray can obscure an underlying malignancy. Thus often those with a higher risk of malignancy (smokers, over 50 years of age) have it repeated at 6 weeks to ensure resolution.

Further Reading & References
Written by Monica Boughdady FY2 & Dr Akash Doshi CT2