COPD must have their spirometry, or at least peak expiratory flow rate, measured and the results compared with their usual values. Worsening asthma or an exacerbation of COPD may be an indication for hospital referral even if the pneumonia is not thought to be severe. Breathlessness in any patient at any age with no past


history of chest disease who has symptoms suggesting pneumonia is a very worrying combination. Tere may be few signs in the chest but for the patient to be breathless the pneumonia must be extensive and urgent referral is needed. Social factors may also influence the decision to


refer, as will the patient’s own preferences. It goes without saying, of course, that if a sick patient declines referral to hospital this must be fully documented and the patient followed up at home to ensure a good response to treatment, or to suggest again that they should go to hospital (see case study on page 20). Bear in mind that sometimes other diseases such as


pulmonary embolism, pulmonary oedema, pneumothorax, fibrosing alveolitis and lung cancer might be confused in their early stages with chest infections.


co-existing disease usually indicates a good prognosis with home treatment. A score of 1 or 2 indicates an increased risk of death, particularly with a score of 2, and hospital referral should be considered. A score of 3 or 4 indicates the need for urgent hospital admission. Te CRB65 score is useful for highlighting the need


for referral for those with a higher score, but a low score is not completely reassuring. A young breathless patient with a CRB65 score of 1 but feeling very unwell with a respiratory rate of 40/min definitely warrants hospital treatment. Or a patient in his late fiſties with bilateral basal crepitations could score 0, but clearly has extensive infection, would be at high risk of developing severe pneumonia and should be referred.


Beyond the CRB65 Score More information can be obtained by using a pulse oximeter, which are widely available these days. Cyanosis is an unreliable clinical sign, but the pulse oximeter can give useful information – for a patient with pneumonia an oxygen saturation (SaO2) level reduced below 94 per cent is an adverse feature indicating the need for oxygen treatment in hospital. An otherwise fit patient with suspected pneumonia,


a low CRB65 score and who is not too unwell can usually be treated at home, but a chest X-ray is still advisable and a review within 24 to 48 hours is essential, as well as advising the patient to go to A&E if there is any deterioration. Breathlessness with wheeze may be seen in patients


with a history of asthma, and increased treatment for their asthma will be needed as well as antibiotics for the pneumonia. Any patient with known asthma or


SPRING 2012


Giving antibiotics A review of when to prescribe or not prescribe antibiotics is beyond the scope of this article but fit younger patients with a viral acute bronchitis do not usually need them. Older patients and those with a history of lung disease such as asthma, COPD, emphysema or bronchiectasis, or a history of previous pneumonia should have the benefit of a lower threshold for prescribing as they are at increased risk of developing pneumonia. Te clinical assessment should include consideration of the effects of the pneumonia on these conditions and also the effects of an infection on any other chronic conditions which may be present. Again, a relatively low threshold for prescribing antibiotics or referring to hospital may avoid later problems in vulnerable patients.


Conclusion Recognising pneumonia and then deciding whether the patient is suitable for home treatment or should be referred for hospital review is a common but complex scenario. Severity scores such as CRB65 may help, but clinical judgement is much more important. History taking and examination must be thorough, record keeping accurate and existing medical conditions must be taken in to account. If suitable for home treatment, follow-up review in 24 to 48 hours is important. Any cause for concern – significant malaise, fever, tachycardia, breathlessness or confusion – must result in referral for hospital assessment.


n Professor Duncan Empey is a consultant respiratory physician and Professor Emeritus in the School of Postgraduate Medicine at the University of Hertfordshire


REFERENCES


BTS guidelines for the management of community acquired pneumonia in adults: update 2009. Thorax 2009;64 (Suppl III):iii1–iii55. doi:10.1136/thx.2009.121434


Recent changes in the management of community acquired pneumonia in adults. Hannah J Durrington, Charlotte Summers. BMJ 2008; 336:1429-33 doi: 10.1136/bmj.a285


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