Renal function,

+ /- d-dimer,

+/- BNP,

+/- cardiac markers,

+/- ECG

Oxygen,

Albuterol,

Atrovent,

+/- Steroids

+I- Antibiotics

.A. Figure 22-2. COPD diag nostic algorithm. BNP, brain natriuretic peptide; BPAP, bi level positive airway pressu re;

CBC, complete blood count; COPD, chronic obstructive pulmonary disease; CPAP, continuous positive airway

pressure; CXR, chest x-ray; ECG, electrocardiogram; ICU, intensive care unit.

Antibiotics are frequently given to patients with COPD

exacerbations and are indicated for patients with signs of

infection such as fever and an increase in sputum production or a change in sputum purulence or color. Because

most COPD exacerbations are caused by respiratory infections, most patients receive antibiotics. Although only a

subset of patients have bacterial infections, it is effectively

impossible to differentiate these patients clinically.

Admitted patients should be given ceftriaxone or a respiratory tluoroquinolone such as levotloxacin. Discharged

patients are candidates for azithromycin (or other macrolides), doxycycline, or levotloxacin.

DISPOSITION

..... Admission

Patients with COPD have very little reserve capacity, are

slow to recover from exacerbations, and often have multiple comorbidities. As a result, most patients presenting to

CHRONIC OBSTRUCTIVE PU LMONARY DISEASE

the ED with a COPD exacerbation should be admitted to

the hospital, including all patients presenting with a respiratory acidosis.

..... Discharge

Patients with mild symptoms that respond rapidly to

minimal therapy may be amenable to discharge. In

such cases, it is helpful to incorporate the patient into

the decision-making process, as they often have a sense

of whether they can safely manage their disease as an

outpatient.

SUGGESTED READING

Bates CG, Cydulka RK. Chronic obstructive pulmonary clisease. In:

Tintinalli JE, Stapczynski JS, Ma OJ, Clince DM, Cydulka, RK,

Meckler GD. Tintinalli's Emergency Medicine: A Comprehensive

Study Guide. 7th ed. New York, NY: McGraw-Hill, 201 1;5 1 1-5 17.

Gruber P, Swadron S. The acute presentation of chronic obstructive pulmonary clisease in the emergency department: A challenging oxymoron. Emerg Med Pract. 2008;10:1-28.

Brulotte CA. Acute exacerbations of chronic obstructive pulmonary clisease in the emergency department. Emerg Med Clin

North Am. 2012;30:223-247.

Pneumonia

Brandon C. Tudor, MD

Key Points

• Focus on diagnosing pneumonia early.

• Identify risk factors that influence treatment decisions

(eg, antibiotic choice and disposition).

• Blood cultures and empiric antibiotics should be started

in the emergency department for patients admitted

with pneumonia.

INTRODUCTION

Pneumonia is the sixth leading cause of death and the leading cause of death from an infectious disease in the United

States. The annual incidence of community-acquired

pneumonia (CAP) in the United States is 4 million cases,

and it results in about 1 million hospitalizations. Most

deaths occur in the elderly or immunocomprornised.

Pneumonia is an infection of the pulmonary alveoli

caused by aspiration, inhalation, or hematogenous seeding

of pathogens. An inflammatory response in the alveoli

leads to sputum production and a cough, although atypical

organisms may produce other fmdings such as mental

status changes or wealcness.

Pneumonia can be divided into 4 categories based on

where it is acquired. CAP occurs in patients who have not

been recently in a nursing home or hospitalized. Hospitalacquired pneumonia (HAP) occurs more than 2 days after

hospital admission. Ventilator-associated pneumonia

(VAP) occurs 2-3 days after endotracheal intubation.

Health care-associated pneumonia (HCAP) occurs within

90 days of a 2-day hospital stay; in a nursing home

resident; within 30 days of receiving N antibiotics, chemotherapy, or wound care, or after a hospital or hemodialysis

clinic visit; or in any patient in contact with a multidrugresistant pathogen.

• Tuberculosis should be considered for patients with

human immunodeficiency virus or other significant risk

factors to avoid further spread.

In about half of cases of pneumonia, the etiology will

not be determined. In those whose cause can be determined, "typical" pathogens (Streptococcus pneumoniae,

Haemophilus influenzae, and Klebsiella pneumoniae)

account for about 25%, with S. pneumoniae being the most

common bacterial pathogen identified. ''Atypical" pathogens (Mycoplasma pneumoniae, Chlamydia pneumoniae,

and Legionella) account for 1 5%. Viral pathogens (influenza, parainfluenza, and adenovirus) account for about

1 7%. HCAP may also be due to other agents, including

Pseudomonas aeruginosa, Staphylococcus aureus, and

Enterobacter species. In patients with diminished mental

status, aspiration of a foreign substance (eg, gastric contents) into the lungs leads to a pneumonitis and a polymicrobial infection. Determining risk factors, such as

comorbidities, alcohol abuse, and the patient's environment, can help guide therapies and disposition decisions.

CLINICAL PRESENTATION

� History

In most adults and adolescents, the diagnosis of pneumonia can be made by history and physical examination

alone. Patients will typically complain of a cough productive of purulent sputum, fevers, shortness of breath,

1 00

fatigue, and pleuritic chest pain. Patients at the extremes of

age (children and the elderly) and immunocompromised

patients often present with atypical symptoms. In many

cases, they present with mental status changes or deterioration of baseline function alone.

Be sure to ask about risk factors for pulmonary tuberculosis (TB) (history of TB, exposure to TB, persistent

weight loss, night sweats, hemoptysis, incarceration,

human immunodeficiency virus [HIV]/acquired immune

deficiency syndrome [AIDS], homelessness, alcohol abuse,

immigration from a high-risk area) .

..... Physical Examination

Vital sign changes can include tachycardia, hypotension,

increased respiratory rate, or decreased pulse oximetry. These

can be late findings and may not be present. On e xamination,

patients may have coarse rales or rhonchi in the involved segments. Other evidence of pulmonary consolidation includes

decreased breath sounds, dullness to percussion, egophony,

and tactile fremitus. Test for egophony by asking the patient