Discussants: Ryan Barnicle, Alex Bracey, Barret Zimmerman, Scott Weingart, with a special commentary by Mae West
The Case
A Nasty Case of Pneumonia
Case write-up by Barret Zimmerman MD and Ryan Barnicle MD, edited by Scott Weingart MD
The case:
A 30s-year-old male with no known past medical history presents to the ED with shortness of breath.
Time 0:00
Triaged as ESI 2 for SOB
Initial VS show HR 130s, T 98, SpO2 98% on room air.
Triage RN: “Pt reports fever, cough and vomiting since Friday. Denies being tested for covid. Pt denies chest and abdominal pain, denies sob.”
Time 0:27
Bedside RN: “Patient presents to room on monitor – HR 130s, denies chest pain. AAOx4 in no distress, respirations even and unlabored. Able to move all extremities. MD at bedside to evaluate patient.”
Time 0:40
Peripheral IV placed. Labs, venous blood gas, and blood cultures are obtained.
Time 1:10
VBG results
7.43 43
CXR obtained:
Pause:
This seems like a pneumonia (PNA)…
Are there particular criteria for diagnosing or classifying pneumonia as severe community acquired pneumonia? Severe CAP (sCAP) is an accepted terminology used to describe ICU admitted patients with CAP.
What do you want to know about history / risk factors? Travel history, animal exposures, travel to TB endemic countries or settings, recent healthcare contacts, culture history, viral URI symptoms, pneumonia history, immunocompromised state.
What are our next steps in treatment? Start antibiotics (https://pubmed.ncbi.nlm.nih.gov/35190510/)! Severity of presentation and risk factors will guide treatment. Must have beta-lactam as foundational treatment. Anerobic converge is usually not needed.
- Recent data shows including atypical coverage improves mortality.
- Reyes, Luis Felipe, Esteban Garcia, Elsa D. Ibáñez-Prada, Cristian C. Serrano-Mayorga, Yuli V. Fuentes, Alejandro Rodríguez, Gerard Moreno, et al. “Impact of Macrolide Treatment on Long-Term Mortality in Patients Admitted to the ICU Due to CAP: A Targeted Maximum Likelihood Estimation and Survival Analysis.” Critical Care27, no. 1 (May 31, 2023): 212. https://doi.org/10.1186/s13054-023-04466-x.
- MRSA coverage should also be considered.
Do we add anything special to our workup now? Consider viral testing, HIV, TB, MRSA PCR, urine antigens, PCT, CRP.
What is your threshold for getting CT Chest?
-CXR misses ~⅓ of PNA
-Unusual features of either the patient (e.g. neutropenic) or pathology (as seen in our CXR)
Time: 1:30
CXR final read: IMPRESSION: Left lung consolidation with lung abscess or empyema. CT with intravenous contrast is recommended for further characterization.
Time: 1:40
Dimer 676.
Repeat VS T 102.7, HR 148, RR 16, SpO2 92%.
Piperacillin-tazobactam and vancomycin ordered along with CTA Chest w/ pulmonary embolism protocol and 2L of lactated ringers.
Pause:
When do you add MRSA coverage in PNA? Does this necrotizing process qualify? YES!
What is the Shorr score? – Is it relevant for this patient and setting? Not really.
What is the best agent for MRSA coverage? Linezolid may provide a faster “kill” with excellent MRSA coverage; this may not matter in most cases of CAP, but in a life-and-lung threatening necrotizing PNA, hours matter.
-Wunderink RG, Niederman MS, Kollef MH, Shorr AF, Kunkel MJ, Baruch A, McGee WT, Reisman A, Chastre J. Linezolid in methicillin-resistant Staphylococcus aureus nosocomial pneumonia: a randomized, controlled study. Clin Infect Dis. 2012 Mar 1;54(5):621-9. doi: 10.1093/cid/cir895. Epub 2012 Jan 12. PMID: 22247123. (https://pubmed.ncbi.nlm.nih.gov/22247123/)
-Tsai YF, Ku YH. Necrotizing pneumonia: a rare complication of pneumonia requiring special consideration. Curr Opin Pulm Med. 2012 May;18(3):246-52. doi: 10.1097/MCP.0b013e3283521022. PMID: 22388585.
(https://pubmed.ncbi.nlm.nih.gov/22388585/)
Time: 1:46
Bedside RN: “Patient on monitor HR 150s, MD at bedside. EKG performed. Patient incontinent of urine and stool, patient cleaned and new hospital gown and pants provided. Patient weight updated. 2nd PIV established. Patient marked ready for CT. Placed on 2L O2 via nasal cannula 97%.”
- Sinus tachycardia w/ RBBB + LAFB
Time: 2:00
CBC, CMP, and lactate result. He is now on 2L NC, from room air the hour before. Patient is also now febrile, and his heart rate increased to the 150s EKG showing sinus tachycardia. CBC smost notable for WBC 39,000 with 4% bands. Hgb is 11.6.
Time: 2:30
Although previously described as unlabored, patient developed worsening accessory muscle usage, and NC is up to 3L, HR 145. 1g IV acetaminophen given.
Time: 3:00
He was originally in a medium acuity zone. However, at shift change, due to his trajectory + CXR, the decision was made to move him to a higher acuity area.
Pause:
What is a RECC area and what advantages do they have in the age of boarding?
Our highest acuity critical care area consists of 6 rooms, each with 2-3 beds staffed with specially-trained and selected nurses, typically in 2:1 ratios. Each room contains in-room XR and CC supplies. There is 24/7 coverage by a pair of EM residents: one “medical” and one “trauma”. There is >14 hours / day of dedicated attending coverage. Patients can be directly triaged here from walk-in or present from ambulance triage. All medical codes and trauma activations, and all decompensated patients needing a higher level of care get bumped here from the rest of the department. There is a rapid assessment protocol that allows for patients who were initially triaged to the RECC area to be downgraded and stabilized patients can move out to lower acuity areas.
Time: 3:30
A history and exam is repeated. He endorses four days of cough and fever. The shortness of breath only started last night, and is accompanied by chest pain and vomiting. On exam, he is tachypneic to the mid 30s with increased work of breathing and accessory muscle usage. When he coughs it releases a putrid smell. MRSA Nares, Legionella urine antigen, sputum culture, HIV, a repeat lactate and troponin area all ordered and obtained.
The MICU/Respiratory Intermediate Care Unit (RICU) is called to evaluate the patient for admission. VS: T 97.4, HR 128, BP 121/62, RR 32, SpO2 97% on 3L NC.
PAUSE:
The patient’s HR is consistently >120 and he has been vomiting. He has already received 2L IVF and has a severe PNA; should we give more fluids?
-In general, fluid administration in PNA should be kept to the minimum needed to maintain euvolemia and acceptable blood pressures. Follow national guidelines in sepsis management unless there are extenuating circumstances.
-But In the boarding-era, urine output has become a more important marker of volume status. Patients, families, nurses, and other staff can be empowered to work together to track urine production.
Time: 4:10
Point of care cardiac ultrasound is performed and shows subtle right ventricular strain with otherwise good cardiac function and no effusion.
VS: HR 118, BP 117/65, RR 32, SpO2 94% 3L NC
Time: 4:30
CT PE results: Extensive findings of necrotizing infection throughout the left lung. Contained extraparenchymal air-fluid level appears to represent direct communication with left upper lobe abscess.
Time: 4:45
Bedside RN: “Patient had episode of coughing – not expectorating well. Pulse ox dipped to 85- 87% on 3 L NC foul smell from mouth with cough Oxygen increased to 4 L”
Time: 5:00
Azithromycin and linezolid (after discussion with pharmacy) is ordered along with CRP and ESR.
Time: 6:00
VS: SpO2 88% on 4L NC
Time: 6:10
89% on 6L NC, HR down to 100-110
PAUSE:
Now our patient is hypoxemic on 6L NC, escalating from room air 6 hours ago.
What ventilation strategies are appropriate for someone breathing in the 30s with HR almost 120, on only escalating nasal cannula, but with this imaging? Does this patient just need intubation?
-Frat JP, Thille AW, Mercat A, Girault C, Ragot S, Perbet S, Prat G, Boulain T, Morawiec E, Cottereau A, Devaquet J, Nseir S, Razazi K, Mira JP, Argaud L, Chakarian JC, Ricard JD, Wittebole X, Chevalier S, Herbland A, Fartoukh M, Constantin JM, Tonnelier JM, Pierrot M, Mathonnet A, Béduneau G, Delétage-Métreau C, Richard JC, Brochard L, Robert R; FLORALI Study Group; REVA Network. High-flow oxygen through nasal cannula in acute hypoxemic respiratory failure. N Engl J Med. 2015 Jun 4;372(23):2185-96. doi: 10.1056/NEJMoa1503326. Epub 2015 May 17. PMID: 25981908.
(https://pubmed.ncbi.nlm.nih.gov/25981908/)
-High-flow nasal cannula (HFNC) has many benefits in PNA. Especially with patients having longer stays in the ED, this is an important therapy to utilize. The FLORALI trial suggests that this patient (who has a predicted P/F <200, and who there is some clinical suspicion for immunocompromised status) would be more likely to survive and be less likely to be intubated if they are placed on HFNC for 48 hours as opposed to non-invasive ventilation or standard O2 (non-rebreather, etc).
Time: 6:20
HFNC applied at 25 LPM, 50% fio2, with improvement in SpO2 to 94%.
CRP results at 294 and ESR results at 124.
PAUSE:
How should those inflammatory markers influence our therapy?
-Josh Farkas believes that in the sickest patients with the highest inflammatory markers steroids may have the most benefit. They may be exceptionally beneficial in this sub-population; the heterogeneity of patients presenting with PNA may help explain why studies have vacillated on the impact of steroids for this condition.
What is the role of steroids in PNA?
-Recent well known trials have addressed this question including CAPE COD (PMID: 36942789) and ESCAPE (PMID: 35723686).
- –https://emcrit.org/pulmcrit/cape-cod/
- –https://first10em.com/steroids-for-pneumonia-cape-cod-and-escape/
-Although a decisive answer remains elusive for the blanket diagnosis of PNA, a more nuanced vision is coming into focus, and we feel this patient would stand to benefit.
CT shows necrotizing pneumonia with some bilateral disease. How does the presence of bilateral disease change management?
Do we need to treat this patient as early ARDS?
Can we even diagnose ARDS without a blood gas or in a patient not on PEEP?
-This patient clearly has a left lung necrotizing PNA, but he is about 5 days into his illness and PNA is a common trigger of ARDS. He is presenting with ground glass opacities and consolidation on the R Lung on CT as well, which could indicate early ARDS. His timeline would fit, his trigger would fit, and his P/F ratio places him in a severe ARDS category.
-The treatments early in the course of ARDS are similar to how we would treat PNA. IVF should be kept to only what is needed, head of bead should be kept elevated when he is supine, and the underlying cause (the pneumonia) should be treated. DEXA-ARDS utilized a different steroid regimen than CAPE COD, and it is believed that dexamethasone does not have as much mineralocorticoid activity which can lead to fluid retention.
-There are several alternatives to the Berlin diagnostic criteria for ARDS which do not require an arterial blood gas or 5cmH2O of PEEP including the Kigali modification.
Lots of literature going back/forth on CAP steroids but recent CAPE COD well circulated
ESCAPE 2022
https://pubmed.ncbi.nlm.nih.gov/35723686/
CAPE COD 2023
- Does this apply to ED? Probably since early administration is likely key to benefit
- Hydrocortisone
The ATS / ISDA recommend against their use in severe CAP, however the ESICM / SCCM guidelines favor their use
Severe disease defined by at least 1 of the following:
- Pulmonary severity index (PSI) score > 130
- Mechanical ventilation
- HFNC with FiO2 > 0.5 and P/F ratio < 300
- Rebreathing mask with P/F ratio dependent on O2 flow (e.g. >10L the P/F < 300)
Primary Outcome: Death by day 28: Hydrocortisone 6.2% vs Placebo 11.9%
Josh’s take:
- Steroid is beneficial, but only in a subset of pneumonia patients (the sickest patients, with the most systemic inflammation).
- The benefit of steroid exists, but it's not huge.
- Benefit probably depends on early treatment.
- Demonstration of mortality benefit for any intervention in critical care is incredibly hard
Time: 6:40
20mg decadron given.
he patient is accepted to the RICU.
Time: 6:45
HR 115, BP 121/69, RR 22, SpO2 93%, O2 flow rate 25 LPM, FiO2 50%
Time 10:15
Patient is transferred up to RICU after being stable in the ED on HFNC for several hours.
Hospital Course: Patient ultimately required a complete left pneumonectomy which was complicated by a post-op empyema requiring wash out. However, patient was ultimately discharged stable from the hospital and did will in followup.
Major Takeaways:
- Categorize your CAP – is it severe? Is it necrotizing?
- Have a low threshold for CT to better characterize the diagnosis.
- Expand your workup and broaden your empiric antibiotics for severe CAP – cover for MRSA, pseudomonas, and atypical infections.
- Consider Linezolid over vancomycin for fast onset of action.
- Give antibiotics concurrently when possible, but always prioritize the beta-lactam first.
- Consider steroids if they qualify for severe CAP – i.e. going to ICU
- Patients with escalating O2 requirements need something better than NRB. Trial HFNC as at least a better temporizing measure. You can use CPAP to preoxygenate if needed, even for pneumonia. Seriously consider elective intubation before the patient gets worse.
Additional New Information
More on EMCrit
- PulmCrit Hot Take: Steroid for severe pneumonia (CAPE COD trial)
- PulmCrit: Which patients admitted for pneumonia need MRSA coverage?
- Severe community-acquired pneumonia
- EMCrit 373 – Mike Weinstock with another Critical Care Bounceback: “Asymptomatic Hypertension” - April 18, 2024
- EMCrit Wee – Ross Prager on 10 Heuristics for the New ICU Attending - April 13, 2024
- EMCrit 372 – FoundStab Intubation SOP - April 5, 2024
This really interesting case of necrotizing pneumonia makes me think of PVL-producing S. aureus. I’d be curious if it would be possible to grow this bug from the patients skin, nose or sputum.
This could influence the treatment (linezolid seems to reduce the toxin production) and could be a reason for an effort to decolonize the patient.
Literature:
Panton-Valentine leukocidin-positive Staphylococcus aureus: a position statement from the International Society of ChemotherapyInt J Antimicrob Agents. 2018 Jan;51(1):16-25. doi: 10.1016/j.ijantimicag.2017.11.002.
https://pubmed.ncbi.nlm.nih.gov/29174420/