Guidelines for the management of community ... - Brit Thoracic

BTS guidelines
practice for use in the assessment of patients who may have
pneumonia and other acute respiratory illnesses. Oxygen
saturation below 94% in a patient with CAP is an adverse
prognostic feature and also an indication for oxygen therapy, 309
[IVb]
which will usually require urgent referral to hospital.
Patients who fall outside the low severity criteria for CAP
should be assessed for the need for hospital referral (see Section
6). Social factors will also play an important part in the decision
to refer a patient to hospital. Patients with moderate or high
severity pneumonia should be admitted to hospital and
managed, where possible, with input from a physician with
an interest in respiratory medicine.
Recommendations
c Patients with suspected CAP should be advised to rest,
to drink plenty of fluids and not to smoke. [D]
c Pleuritic pain should be relieved using simple analgesia
such as paracetamol. [D]
c The need for hospital referral should be assessed using
the criteria recommended in section 6. [C]
c Pulse oximetry, with appropriate training, should be
available to general practitioners and others responsible
for the assessment of patients in the out-of-hours
setting for the assessment of severity and oxygen
requirement in patients with CAP and other acute
respiratory illnesses. [D]
Figure 7 Severity assessment of community acquired pneumonia
(CAP) in patients seen in the community (CRB65 severity score plus
clinical judgement). DBP, diastolic blood pressure; SBP, systolic blood
pressure.
anti-inflammatory drugs. Physiotherapy is of no proven benefit
in acute pneumonia. 306 [III] Nutritional status appears important
both to the outcome and the risk of acquiring pneumonia and,
in prolonged illness, nutritional supplements may be helpful.
Patients with pneumonia are often catabolic and those aged
.55 years who are malnourished appear to be at greater risk of
150 307 [III] [III]
developing pneumonia.
Patients with pneumonia often become hypoxic because
pulmonary blood flow takes place through unventilated lung
tissue. The clinical signs of hypoxia are non-specific and often
difficult to recognise in the early stages. They include altered
mental state, dyspnoea and tachypnoea. Respiratory rate should
therefore always be assessed. Central cyanosis is unreliable both
as a clinical sign and also as an indicator of tissue hypoxia. In
contrast, pulse oximetry which measures arterial oxygen
saturation (SpO 2 ) is, in most situations, a simple and reliable
method of assessing oxygenation. However, poor peripheral
perfusion, jaundice and pigmented skin can produce a falsely
low saturation and carboxyhaemoglobin a falsely high saturation.
Pulse oximetry is now widely available in North America.
A survey of 944 outpatients and 1332 inpatients with evidence
of CAP enrolled from five sites in the USA and Canada reported
increasing assessment of arterial oxygen saturation with pulse
oximetry in up to 58% of outpatients and 85% of inpatients. 308
[II]
It is recommended that pulse oximetry, with appropriate
training, should become more widely available in general
Thorax 2009;64(Suppl III):iii1–iii55. doi:10.1136/thx.2009.121434
7.2 What review policy should be adopted in patients managed
in the community?
When to review a patient with CAP in the community will be
determined by the initial severity assessment and other factors
such as reliable help in the home. Patients assessed as being at
low severity should improve on appropriate therapy within
48 h, at which time severity reassessment is recommended.
Those who fail to improve within 48 h should be considered for
hospital admission. Patients who do not fulfil the criteria for
low severity and are being managed at home will require more
frequent review.
Recommendations
c Review of patients in the community with CAP is
recommended after 48 h or earlier if clinically indicated.
Disease severity assessment should form part of
the clinical review. [D]
c Those who fail to improve after 48 h of treatment
should be considered for hospital admission or chest
radiography. [D]
7.3 What general management strategy should be offered to
patients in hospital?
Initial management
There is some evidence that use of a critical care pathway for
patients referred to hospital can reduce the hospital admission
of low-risk patients and can also rationalise inpatient management.
310 [Ib]
All patients referred to hospital with CAP should have a chest
radiograph (if not already performed in the community) and
should have oxygenation assessed by pulse oximetry, preferably
while breathing air. Those with SpO 2 ,94% should have arterial
blood gas measurements, as should all patients with features of
high severity pneumonia. Knowledge of the inspired oxygen
concentration is essential to the interpretation of blood gas
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