Glaser Fuss: IDSA Guidelines for Pneumonia Part 1

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Nurses Edition Commentary

Kathy Garvin, RN and Lisa Chavez, RN
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Ian L., Dr -

What about symptoms and signs -cough sputum shortness of breathe sudden onset aches and pains a temperature noises in the lungs on auscultation - looks unwell age past history and predisposing factors alcohol overuse and COPD . -How many misdiagnosis before pulmonary ultrasound where there ?

David G., M.D. -

For better or worse, the diagnosis of pneumonia remains a largely clinical one, and the more elements you have in support of the diagnosis (history, exam, imaging), the easier the call. It's disturbing how poorly sensitive CXR is, so if your practice has been to not call pneumonia unless you see an infiltrate on CXR, you've no doubt been missing a lot of pneumonia.

The flip side is calling every URI pneumonia, which will lead to a vast over-diagnosis of the illness and inappropriate abx usage.

In my own practice, I'm very fastidious about looking for fever (I'm a big fan of rectal temps), but I certainly don't consider myself terribly adept at lung ultrasound, and--despite the ample evidence in support of u/s--I'm sure I under-utilize this modality. I've wondered why I can send a patient off to ultrasound to look for gallstones, but I can't send them there to look for pneumonia. (Guess I should just get better at ultrasound!)

And now, of course in the age of COVID, we all have an increased appreciation of viral pneumonia, so when do we pull the trigger on antibiotics? At the time I recorded this segment (last spring) most everyone with CAP got abx, but I think we've all pulled back on that quite a bit these days and so reserve abx for patients we somehow don't think have run-of-the-mill COVID--however we're making that determination.

David Glaser

Jacob P. -

Any chance you have a reference for that 2014 study of POCUS sensitivity in pneumnia dx?

David G., M.D. -

PERFORMANCE COMPARISON OF LUNG ULTRASOUND AND CHEST X-RAY FOR THE DIAGNOSIS OF PNEUMONIA IN THE ED Bourcier, J.E., et al, Am J Emerg Med 32(2):115, February 2014

Stuart N. -

Great fan of yours still -for calling a spade a spade. Just shows how many domains remain where we once considered there was concensus but even there much uncertainty reigns. I regret not finding all of the references of the studies you quoted. Especially, I would appreciate the one mentioned that CXR is a poor predictor of actual infection of lower RT inflammation compared to gold standard of CT imaging, thanks.

Sody , Israel

David G., M.D. -

Hi Sody,
Good to hear from you! Sorry COVID quashed your plans to travel to Denver last year!

I think this is the reference you're looking for:
EARLY CHEST COMPUTED TOMOGRAPHY SCAN TO ASSIST DIAGNOSIS AND GUIDE TREATMENT DECISION FOR SUSPECTED COMMUNITY-ACQUIRED PNEUMONIA, Chaessens, Y.E., et al, Am J Respir Crit Care Med. 2015 Oct 15;192(8):974-82

Let me know if that's not the one.

David

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