Diagnosis and Management of Pneumonia in the Emergency Department
Gregory J. Moran, MD, FACEP, FAAEMa,b,c,*, David A. Talan, MD, FACEP, FAAEM, FIDSAa,b,c, Fredrick M. Abrahamian, DO, FACEPa,c
David Geﬀen School of Medicine at University of California Los Angeles, Los Angeles, CA, USA b Department of Medicine, Division of Infectious Diseases, OliveView-University of California Los Angeles Medical Center, 14445 Olive View Drive, North Annex, Sylmar, CA 91342–1438, USA c Department of Emergency Medicine, Olive View-University of California Los Angeles Medical Center, 14445 Olive View Drive, North Annex, Sylmar, CA 91342–1438, USA
Pneumonia remains a major cause of death in developed countries . Patients with community-acquired pneumonia(CAP) are most often managed in an outpatient setting. The mortality rate in this patient population is low (!1%) in contrast to patients who require hospitalization, who have a mortality rate of approximately 15%. Because most patients with pneumonia are managed by emergency and primary care physicians, infectious disease specialists tend to see a population of patients with pneumonia that is skewedtoward more complicated and severe infections. Emergency physicians may be less inclined than infectious diseases specialists to pursue aggressive diagnostic testing and cultures, except in patients who are seriously ill. Whereas in the past decisions regarding initial antibiotic therapy were deferred to admitting primary care and consulting physicians, quality standards currently reinforcetimely initiation of antibiotics in the emergency department (ED). The practicality and ultimate consequences of arbitrary time standards are debated, however. Pneumonia management remains challenging because of several constantly changing factors,
* Corresponding author. Department of Emergency Medicine, Olive View-University of California, Los Angeles Medical Center, 14445 Olive View Drive, NorthAnnex, Sylmar, CA 91342–1438. E-mail address: firstname.lastname@example.org (G.J. Moran). 0891-5520/08/$ - see front matter Ó 2008 Elsevier Inc. All rights reserved. doi:10.1016/j.idc.2007.10.003
including an expanding spectrum of pathogens, changing antibiotic resistance patterns, the availability of newer antimicrobial agents, and increasing emphasis on costeﬀectiveness and outpatient management. For patients with classic complaints of fever and productive cough, the clinical diagnosis of pneumonia is straightforward, especially when accompanied by pulmonary inﬁltrate on plain chest radiographs. More challenging, however, is identifying pneumonia in patients who present with atypical complaints (eg, abdominal pain). Once pneumonia is diagnosed, thepriorities in the ED are to provide appropriate respiratory support, assess the severity of disease, initiate appropriate empiric antibiotic therapy based on the most likely pathogens, and make decisions regarding hospitalization and the need for isolation. Issues for which emergency physicians and infectious disease specialists may have diﬀerent perspectives include the use of blood and sputum cultures,indications for hospital admission, appropriate level of care, and the breadth of antimicrobial spectrum for empiric therapy.
Diagnostic testing for pneumonia in the emergency department Cough is a common presenting complaint; however, only a small fraction of patients who present with cough are diagnosed with pneumonia (4% in one large series) . Patients with respiratory complaints shouldbe screened with pulse oximetry at triage because hypoxia may not be otherwise clinically suspected, and its presence is an important diagnostic clue with therapeutic implications . In most healthy older children and adults, the diagnosis of pneumonia can be reasonably excluded on the basis of history and physical examination, with suspected cases further evaluated by chest radiography....