An Emergency Approach to Respiratory Distress: Pneumonia

Summary

The meeting began with technical adjustments to share presentation slides and introductions from Subarna and Pranav, who described their emergency medicine background and the purpose of their bi-monthly sessions focused on practical emergency medicine topics. Maniraj expressed gratitude for the opportunity to present and mentioned his previous interaction with the audience from Nepal. The session aimed to discuss respiratory distress, building on a previous introductory session, with an emphasis on practical, day-to-day applications rather than theoretical discussions. The conversation ended with a brief mention of framing the discussion through a case study, though the content of the discussion was not detailed in the transcript.

Pneumonia Diagnosis and Mortality Challenges

Maniraj discussed the high burden of pneumonia, noting that while significant progress has been made globally and in Nepal, the mortality rate in Nepal still lags behind the global average. He highlighted the diagnostic challenges of community-acquired pneumonia, citing a study from 112 U.S. VA hospitals that found over 50% diagnostic discordance. Maniraj then presented a real case of a 58-year-old male with multiple comorbidities, including AFib, COPD, and a recent rib fracture, who presented with increasing shortness of breath and chest pain. The patient was found to be hypoxic and tachycardic, with decreased breath sounds and tenderness on the left side of his chest.

Managing COPD and Rib Fracture

The team discussed a patient with multiple comorbidities, including COPD and a recent rib fracture, who presented with shortness of breath and tachycardia. They considered differential diagnoses such as pulmonary embolism and discussed the importance of collecting additional information, including travel history, COVID exposure, and recent hospital admissions. The group also touched on the use of incentive spirometry in Nepal, particularly for patients with rib fractures, and emphasized the need for a thorough clinical assessment to guide management.

Rural Emergency Respiratory Care Challenges

The group discussed approaches to diagnosing and treating a patient presenting with refracture and respiratory distress, considering both emergency department settings in the United States and rural hospitals in Nepal. They explored differential diagnoses including pneumothorax and PE, and discussed diagnostic and treatment options such as labs, imaging, and bronchodilators. The conversation highlighted the challenges of limited resources in rural settings, where clinical skills and referral systems are crucial. Maniraj presented a case study showing the patient's rapid diagnostic workup and treatment in an emergency department, including the use of a respiratory viral panel, which sparked a discussion about the availability, cost, and indication of such tests in Nepal.

Viral Panel Testing in Nepal

The group discussed the availability and cost of viral panels in Nepali hospitals, with Dr. Hem confirming that while TU Teaching Hospital doesn't have the extended BioFire panel, spot tests for influenza and SARS-CoV-2 are available at a lower cost. They agreed that for community-acquired pneumonia, the recommended tests are just influenza and SARS-CoV-2, as the extended panel is not cost-effective and doesn't improve mortality or length of stay. The discussion concluded with a brief conversation about procalcitonin testing, where participants shared that while it's sometimes used for antibiotic de-escalation in admitted patients, it's not commonly ordered in emergency departments due to variable results and long turnaround times.

Imaging Strategy for Pneumonia and PE

The group discussed imaging options for a patient with suspected pneumonia and potential pulmonary embolism. They agreed that chest x-ray would be the first imaging test, as it is the standard of care for acute respiratory illness according to American College of Radiology guidelines. The group also discussed the use of point-of-care ultrasound (POCUS) for lung evaluation, noting that it is observer and experience-dependent, and should only be performed by trained personnel. For this particular patient, they determined that a CT pulmonary angiogram was indicated due to unexplained hypoxia, history of pulmonary embolism, and risk factors for DVT. The Wells score was discussed as a tool to help determine the likelihood of PE, though the group noted some uncertainty in applying it to this specific case.

Pneumonia Diagnosis and Treatment Debate

The team discussed a patient with right middle lobe consolidation, a small pleural effusion, and mild emphysema, diagnosing him with community-acquired pneumonia and potential COPD exacerbation. They debated the utility of CT scans in pneumonia diagnosis, noting that while CT improves diagnostic accuracy, it has not been shown to impact mortality outcomes. The team also considered the patient's elevated BNP levels, discussing whether to administer fluids or antibiotics first, and whether the patient's tachycardia and sepsis might affect treatment decisions.

Community-Acquired Pneumonia Treatment Protocol

The team discussed a patient with community-acquired pneumonia and severe sepsis, deciding to admit him for IV antibiotics. They agreed to start ceftriaxone and azithromycin, as the patient did not have risk factors for MRSA or pseudomonas. The discussion highlighted the importance of clinical judgment over scoring systems in determining patient disposition, and emphasized following IDSA guidelines for antibiotic choice based on severity of illness.

Pneumonia Antibiotic Treatment Guidelines

The discussion focused on antibiotic choices for pneumonia treatment, with consensus that azithromycin and ceftriaxone remain the preferred drugs, while fluoroquinolones should be reserved for tuberculosis cases due to resistance concerns. The team discussed risk factors for MRSA and pseudomonas infections, including previous infections, gram-negative bacilli growth, and intravenous antibiotic use within the past three months. They also addressed the shift toward shorter antibiotic courses for pneumonia, with a recommended duration of 5 days of intravenous antibiotics followed by oral medications, though some participants noted that shorter courses of 3 days have shown similar efficacy in studies.

Severe CAP Management Guidelines

The meeting focused on the management of severe community-acquired pneumonia (CAP), with Maniraj presenting guidelines and recent studies on treatment approaches. Key points included the judicious use of antibiotics, the importance of early steroid administration within 24 hours for severe cases, and the use of CRP and procalcitonin to guide antibiotic discontinuation in viral CAP. A recent study from Kenya, relevant to low-resource settings like Nepal, showed that steroids reduced 30-day mortality in non-ICU settings, with a number needed to treat of 30. The discussion emphasized clinical judgment over scoring systems for disposition decisions and highlighted the need for cultures only in severe cases to aid antibiotic de-escalation.