Pneumonia Management
Risk stratify patient, noting possibility of immunocompromise/recent hospital admission, and decide whether inpatient or outpatient treatment is appropriate.
Identify the septic patient (identifying sepsis in ED pathway) and ensure intravenous antibiotics are administered within 60 minutes.
Consider early isolation and contact precautions for those you suspect of having a communicable infection.
Remember the importance of ongoing supportive therapy: bronchodilators for airflow limitation/mucociliary clearance, analgesia for pleuritic chest pain, VTE prophylaxis and chest physiotherapy.
Emergency treatment of the unstable patient with pneumonia involves:
Oxygen supplementation aiming for sats Sp0²>94% avoiding hyperoxia (lower saturations may be acceptable in those with chronic respiratory conditions and known CO2 retainers). Consider use of high flow humidifies oxygen if patient has work of breathing.
Maintenance of end organ perfusion with fluid boluses of up to 20ml/kg, inotropes if no sustained response to IVF.
Early IV antibiotics in accordance with local or eTG guidelines.
Trial of NIV if patient develops respiratory failure and has underlying obstructive airways disease (COPD or asthma) or a concurrent exacerbation of CCF.
RSI and lung protective ventilation strategies for those patients presenting in extremis, where NIV has failed or NIV contraindicated. Consider use of Ketamine for induction - bronchodilatory properties and less risk of hypotension compared to other induction agents (particularly important if your patient is septic).
Referral to an inpatient respiratory physician for ward management (the majority of patients with CAP) or HDU/ICU if in respiratory failure, severe sepsis requiring inotropes, NIV dependant or intubated.
Although predominantly an ICU decision, V-V ECMO should be considered in the unventilatable patient with Acute Respiratory Distress Syndrome (ARDS).