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270.e1
CHAPTER
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32
Pneumonia
KEY TEACHING POINTS
• Many of the classic physical findings of lobar consolidation—diminished chest excursion,
dullness, diminished breath sounds, bronchial breath sounds, egophony, and crackles—
are accurate signs of pneumonia in patients with cough and fever. Nonetheless, these
findings appear in only the minority of patients with proven pneumonia; their absence is
therefore diagnostically unhelpful.
• In patients with cough and fever, the presence of normal vital signs (i.e., temperature,
pulse rate, respiratory rate) decreases probability of pneumonia.
• The Heckerling scoring scheme combines five independent findings of pneumonia
(tachycardia, fever, crackles, diminished breath sounds, and absence of asthma) and
greatly increases the clinician’s diagnostic accuracy.
• The CURB-65 score, which combines five findings to accurately predict the prognosis of
patients with pneumonia, provides essential information when making decisions about
patient triage and care.
Introduction
I.
Like most of the pulmonary examination, the traditional findings of lobar pneumonia were
described in 1819 by Laennec, who wrote that clinicians using his newly invented stethoscope
could detect acute pneumonia “in every possible case.”
the earliest findings of pneumonia are crackles and diminished breath sounds, followed by
dullness to percussion, increased tactile fremitus and vocal resonance, and bronchial breath
2
sounds.
II.
Clinical Significance
A.
INDIVIDUAL FINDINGS
EBM Box 32.1 reviews the findings from over 12,000 patients presenting with acute fever, cough,
sputum production, or dyspnea, all of whom underwent chest radiography (the diagnostic standard for pneumonia). e findings increasing probability of pneumonia, in descending order of
their LRs, are asymmetric chest expansion (likelihood ratio [LR] = 44.1), egophony (LR = 4.1),
cachexia (LR = 4), percussion dullness (LR = 3.6), bronchial breath sounds (LR = 3.3), oxygen
saturation of less than 95% (LR = 3), crackles (LR = 2.8), respiratory rate greater than 28/min
(LR = 2.7), temperature greater than 37.8°C (LR = 2.5), diminished breath sounds (LR = 2.4),
heart rate greater than 100/min (LR = 2.1), and abnormal mental status (LR = 1.9).
1
According to traditional teachings,
273
274
LRs
PNEUMONIA
Asymmetric chest expansion
Oxygen saturation <95%
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EBM BOX 32.1 Pneumonia*
7—SELECTED PULMONARY DISORDERS
Finding (Reference)
General appearance
3
Cachexia
Abnormal mental status
Vital signs
Heart rate >100/min
Temperature >37.8°C
Respiratory rate >28/min
Oxygen saturation <95%
All vital signs normal
†
4–6
3–14
3–17
5–7,16
8,13,16,17
5,8,11,13,18,19
Lung findings
Asymmetric chest expansion
Chest wall tenderness
Percussion dullness
Diminished breath
Bronchial breath sounds
Egophony
Crackles
Wheezing
sounds
3–6,9,10,13–15,20,21,24
4,5,9,10,13,14,20–22,24
3–5
4–6,9,13,15,20,21,24
15
3–5,20–23
4,22
Sensitivity
(%)
10 97 4.0 NS
12–14 92–95 1.9 NS
12–65 60–96 2.1 0.8
16–75 44–95 2.5 0.7
7–36 80–99 2.7 0.9
32–52 80–99 3.0 0.7
3–38 24–81 0.3 2.3
3
5 100 44.1 NS
5 96 NS NS
4–26 82–99 3.6 NS
7–60 73–98 2.4 0.8
14–19 94–96 3.3 0.9
4–16 96–99 4.1 NS
19–67 36–97 2.8 0.8
4–36 50–96 0.8 NS
Diagnostic score (Heckerling et al)
Specificity
(%)
4,18
Likelihood Ratio‡ if Finding Is
Present Absent
0 or 1 findings 7–29 33–65 0.3 …
2 or 3 findings 48–55 … NS …
4 or 5 findings 38–41 92–97 8.2 …
*Diagnostic standard: for pneumonia, infiltrate on chest radiograph.
†
Definition of findings: for low oxygen saturation, <93%13 or <95% (all other studies); for all vital signs
normal, most studies required 3 normal vital signs: temperature (<37.8°C), pulse (≤100/min), and
respirations (<24/min13 or ≤20 [all other studies]); Kahli19 also required oxygen saturation >95%; for
Heckerling diagnostic score, the clinician scores 1 point for each of the following 5 findings that are
present: temperature >37.8°C, heart rate >100/min, crackles, diminished breath sounds, and absence
of asthma.
‡
Likelihood ratio (LR) if finding present = positive LR; LR if finding absent = negative LR.
NS, Not significant.
0.1 0.2 0.5 12510
Heckerling score, 0–1
Decrease Increase
Probability
+45%+30%+15%–15%–30%–45%
LRs
44
Heckerling score, 4–5
Egophony
Cachexia
Percussion dullness
Bronchial breath sounds
32—PNEUMONIA
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275
e only finding decreasing the probability of pneumonia was the finding that all vital signs
were normal (LR = 0.3). In many studies, wheezing was found more often in patients without
pneumonia, primarily because the cause of the acute respiratory complaints in these patients was
asthma, not pneumonia.
4,5,20,21
B. LAENNEC VS. MODERN STUDIES
ere are three reasons why the studies in EBM Box 32.1 contradict Laennec’s assertion that physi-
cal diagnosis is the perfect diagnostic tool: (1) Patients diagnosed with pneumonia today include
those with more mild disease than in Laennec’s time, when the only available diagnostic standard
was postmortem examination (i.e., his conclusions were drawn only from patients dying from severe
disease). (2) Many traditional findings appear only after several days of illness, times when the modern clinician, already familiar with the chest radiograph, often examines patients in a more cursory
fashion. In contrast, Laennec examined each of his patients diligently day after day, concluding that
bronchial breath sounds and bronchophony usually appeared only after 1 to 3 days of hospitalization,
and dullness to percussion appeared only after day 4.
the course of the physical findings. For example, in the preantibiotic era, fever usually lasted 7 days in
patients with lobar pneumonia26; in the antibiotic era it lasts usually only 3 or 4 days.
1,25
(3) Antimicrobial medications probably alter
27,28
Even so, many great clinicians of the past tempered Laennec’s enthusiasm and taught that auscultation was an imperfect diagnostic tool. Writing just 20 years after Laennec’s treatise, omas
Addison* stated it was high time “to strip the stethoscope of the extravagant and meretricious
pretensions thrust upon it...and to state fairly what it will not, as well as what it will do…”
29
C. COMBINED FINDINGS
Combining findings improves the accuracy of bedside examination. One of the best models, validated in four different populations,
4,18
scores 1 point for each of the following five findings: (1)
temperature greater than 37.8°C, (2) heart rate more than 100/min, (3) crackles, (4) diminished
breath sounds, and (5) absence of asthma. EBM Box 32.1 shows that a score of 4 or 5 argues
compellingly for pneumonia (LR = 8.2), whereas a score of 0 or 1 argues against pneumonia (LR
= 0.3), which, in some groups of patients, may reduce the probability of pneumonia enough that
a chest radiograph becomes unnecessary (e.g., in patients presenting to a community office with
cough, in whom the probability of pneumonia is 10% or less, a score of 0 or 1 reduces the probability of pneumonia to 3% or less).
D. PNEUMONIA AND PROGNOSIS
In studies of immunocompetent adults hospitalized with community-acquired pneumonia, the 30
day mortality rate is 4% to 15%. Of the individual findings that predict an increased risk of death
(EBM Box 32.2), the most compelling ones are hypotension (LR = 5.3), abnormal mental status
(LR = 3.9), and hypothermia (LR = 3.5).
Several different scoring schemes combine bedside findings to predict mortality in patients with
pneumonia. One of the best validated is the Pneumonia Severity Index,68 which unfortunately
has the disadvantage of requiring knowledge of 20 different clinical variables, making it difficult
to recall and apply at the bedside. A much simpler rule is the CURB-65 score, based on five prognostic variables† identified decades ago by the British oracic Society44: (1) confusion, (2) blood
urea nitrogen (BUN) levels over 19 mg/dL (>7 mmol/L), (3) respiratory rate of 30 breaths/min
*omas Addison, the discoverer of adrenal insufficiency, was also a recognized master of percussion and
auscultation.
†
CURB-65 is an acronym for Confusion, Urea, Respiratory rate, Blood pressure, and Age ≥65 years.
276
LRs
PNEUMONIA: PREDICTORS OF MORTALITY
Systolic blood pressure <90 mm Hg
Hypothermia
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7—SELECTED PULMONARY DISORDERS
EBM BOX 32.2 Pneumonia: Predictors of Hospital Mortality
Likelihood Ratio† if Finding Is
Finding* (Reference) Sensitivity (%) Specificity (%)
General appearance
Abnormal mental
30–40
status
11–65 70–98 3.9 0.8
Vital signs
Heart rate
>125/min
35,38,39
Systolic blood
pressure <90 mm
31,40–43
Hg
Hypothermia
Respiratory rate
>30/min
Oxygen saturation
<90%
31,42
31,32,35–39,44–46
47,48
“CURB-65” prognostic score
6–33 86–98 2.6 NS
11–47 87–99 5.3 0.7
14–43 93 3.5 NS
9–85 63–99 2.4 0.9
18–52 75–96 2.8 NS
37,39,49–67
0 findings 0–16 41–92 0.2 …
1 finding 3–38 … 0.6 …
2 findings 17–51 … 1.3 …
3 findings 13–61 … 2.5 …
4 findings 4–35 … 5.4 …
5 findings 1–12 99–100 8.4 …
*Definition of findings: for hypothermia, body temperature <36.1°C31 or <37.0°C42; for CURB-65
prognostic score, the clinician scores 1 point for each of the following findings that are present: confusion;
blood urea nitrogen >19 mg/dL; respiratory rate ≥30/min; low blood pressure (either systolic blood
pressure ≤90 mm Hg or diastolic blood pressure ≤60 mm Hg); and age ≥65 years.
†
Likelihood ratio (LR) if finding present = positive LR; LR if finding absent = negative LR.
NS, Not significant.
Present Absent
0.1 0.2 0.5 12510
CURB-65 score, 0 findings
or higher, (4) hypotension (i.e., diastolic blood pressure ≤60 mm Hg or systolic blood pressure
≤90 mm Hg), and (5) age 65 years or older. e presence of three or more of these CURB-65 vari-
ables is associated with increased hospital mortality (LR = 2.5 for three findings, LR = 5.4 for four
findings, and LR = 8.4 for five findings, EBM Box 32.2), whereas the absence of all CURB-65
variables is associated with decreased hospital mortality (LR = 0.2 for 0 findings).
Probability
Decrease Increase
+45%+30%+15%–15%–30%–45%
LRs
CURB-65 score, 5 findings
CURB-65 score, 4 findings
Abnormal mental status
32—PNEUMONIA
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277
e CURB-65 score requires knowledge of the patient’s blood urea nitrogen (BUN), which may
not be immediately available to office-based clinicians. Related scores that omit laboratory values
have also been developed, such as the “CRB-65” score, which is simply the CURB-65 without the
BUN (thus creating possible scores of 0 to 4). ough less extensively studied than CURB-65, 10
studies of CRB-65 show it to be an accurate predictor of mortality (LR = 0.3 for a CRB-65 score of
0; 0.7 for 1 point; 1.9 for 2 points; 4.7 for 3 points; and 10.1 for 4 points).
35,36,50,54–57,66,69–71
E. HOSPITAL COURSE
Among survivors of pneumonia, abnormalities of the vital signs—fever, tachycardia, tachypnea,
and hypotension—usually become normal within 2 to 4 days.
27,28
Once this occurs, subsequent
clinical deterioration is rare, and fewer than 1% of patients will require subsequent intensive care,
coronary care, or telemetry monitoring.27 If patients are discharged from the hospital before normalization of vital signs, there is an increased risk of readmission and death.
72–74
References may be accessed online at Elsevier eBooks for Practicing Clinicians.
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Chest.
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CHAPTER 33
https://t.me/medicina_free
Chronic Obstructive Lung Disease
KEY TEACHING POINTS
• The most accurate physical signs of chronic obstructive lung disease are also infrequent,
occurring in fewer than 50% of patients.
• In patients with chronic dyspnea, many findings increase the probability of obstructive
lung disease: early inspiratory crackles, diminished breath sound score, subxiphoid
cardiac impulse, hyperresonance of the chest, accessory muscle use, and pursed lip
breathing.
• Two findings decrease the probability of obstructive lung disease: a breath sound score
of 16 or more and a forced expiratory time less than 3 seconds.
• In patients with exacerbations of obstructive lung disease, the BAP-65 score, which
combines the patient’s age and three findings (blood urea nitrogen >25 mg/dL, altered
mental status, and pulse rate ≥110 beats/min), accurately predicts the risk of mechanical
ventilation or death.
I. Introduction
Although descriptions of emphysema date to autopsy reports from the 1600s, it was Laennec
who in 1819 recorded the clinical features associated with the disease, including dyspnea, hyperresonance, faint breath sounds, and wheezes.1 Over the last 200 years, others have embellished
Laennec’s description, but the principal bedside findings are the same. Writing in 1892, Osler
stated that emphysema could be recognized “at a glance” from its characteristic features, including rounded shoulders; barrel chest; prominent epigastric cardiac impulse; hyperresonant chest;
loss of cardiac, liver, and splenic dullness; enfeebled breath sounds; and prolonged expiration.
In the 1920s, clinicians began to recognize that these traditional physical signs had shortcomings.3 In 1927, Cabot wrote that only about 5% of patients with emphysema at autopsy were
recognized during life and that, of patients diagnosed with emphysema during life, only 25%
actually had it at autopsy.4 Spirometry, invented in 1846 and used in many forms (stethometers,
pneumatometers, doppelstethograms) to supplement bedside diagnosis, gained favor because of
these deficiencies and eventually became the favored diagnostic tool.
is chapter compares the traditional physical signs with spirometry. As a general rule, the
most accurate physical signs are also infrequent, occurring in fewer than 50% of affected patients,
usually only those with the most severe disease.
mild and moderate disease that is hidden from the eyes of the bedside examiner but is detectable
by spirometry.
1
5,6
For decades or longer, patients may harbor
2
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