Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
PNEUMONIA IN THE ELDERLY 1 A Primer to Clinical Documentation WI ACDIS Chapter Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, FCS, PCS, CCDS, C-CDIS PNEUMONIA PneumoniaInfection of the aleveoli, distal airways, and interstitium of the lungs Inflammatory disease of the lung characterized by the production of a vascular response (hyperemia and vascular permeability) and an exudate Caused by bacteria, viruses, fungi, and parasites Typically classified as “community acquired” or “healthcare/hospital acquired” 2 PNEUMONIA Community Acquired Pneumonia- diagnosed outside the hospital or is diagnosed within 48 hours after admission to the hospital in a patient who has not been hospitalized in an acute care setting for 2 or more days within 90 days of the infection or has not been hospitalized or residing in a long term care facility for more than 14 days before the onset of symptoms. Hospital Acquired Pneumonia/Nosocomial Pneumonia- acquired in hospital setting. Develops at least 48 hrs after hospital admission Nursing Home Acquired Pneumonia- acquired in extended care setting. 3 HOSPITAL ACQUIRED PNEUMONIA HAP Carries highest morbidity and mortality rates of all nosocomial infections Adds 7-9 days to hospital stays Increases costs by $2 billion annually Crude mortality rates range from 30 to 70% HAP defined as new or progressive infiltrate on CXR plus at least two of the following: Fever of > 37.8• C Leukocytosis with >10,000 WBCs/uL Production of purulent sputum Dyspnea, hypoxemia, and pleuritic chest pain may occur 4 IMMUNOCOMPETENT VS. IMMUNOCOMPROMISED Immunocompromised Patients HIV disease Absolute neutrophil count < 1000/mcL Current or recent exposure to myelosuppressive or immonosuppressive drugs Currently taking prednisone in dosage >5mg/d 5 CLINICAL PRESENTATION Temperature > 38 •C(100.4F) Cough with/without sputum, hemoptysis Pleuritic chest pain Myalgia Gastrointestinal symptoms Dyspnea Malaise, fatigue Rales, rhonchi, wheezing Egophony, bronchial breath sounds Dullness to percussion Atypical symptoms in older patients 6 RISK FACTORS PNEUMONIA Increased Morbidity & Mortality Advanced age Alcoholism Comorbid medical conditions Altered mental status Respiratory rate >=30 breaths/minute Hypotension (systolic blood pressure < 90 mm Hg or diastolic < 60 mm Hg Increased BUN Overall Risk Factors Age > 65 years HIV or Immunocompromised Recent antibiotic therapy or resistance to antibiotics Comorbidities Asthma Cerebrovascular disease COPD CRF CHF Diabetes Liver disease Neoplastic disease 7 DIAGNOSIS OF PNEUMONIA Radiographic studies-CXR usually adequate, can have a auscultation-radiographic disassociation, may be negative in early phase of pneumonia Lobar consolidation in typical pneumonia Bilateral, more diffuse infiltrates commonly seen in atypical pneumonia “Chest X-Ray Negative” pneumonia (dehydration, CHF, pulmonary fibrosis) Blood cultures should precede antibiotic therapy Positive in 6-20% of cases Most commonly yielding S. pneumoniae (approx 60%), S. aureus or E. Coli Sputum stain and culture > 25 WBC and < 10 squamous adequate specimen Sputum cultures only adequate in only 50% patients, only 44% of those samples contain pathogens Single, predominant organism on Gram’s stain suggest etiology Other stains indicated as appropriate (e.g., acid-fast stains for M tuberculosis, special stains for fungi or monoclonal antibodies stains for Pneumocystis 8 ROUTES OF INFECTION Routes of infection Aspiration of contaminated secretions-most common Inhalation of infected airborne droplets Bacteremia, and Direct extension of an acute inflammatory process from an adjacent organ or structure 9 DEFENSE MECHANISMS In the normal respiratory system there are a number of important defense mechanisms that protect the lung from infection. These include: Reflex closure of the vocal cords Cough reflex Mucociliary clearance Macrophage activity 10 DEFENSE MECHANISMS Increased risk of bacterial infections associated with impairment of defense mechanisms, as in any of these clinical situations: Loss of consciousness Immunodeficiency state Pulmonary edema Neutropenia Chronic airway obstruction Viral infection 11 CLASSIFICATION OF PNEUMONIA Classification of pneumonia Causative organism Pattern of anatomic involvement: lobar pneumonia or bronchopneumonia Lobar pneumonia- exudative inflammation involving whole lobe, or large portion of lung 90-95% cases caused by Streptococcus pneumoniae. Sometimes caused by Kleb pneumoniae, Staphylococcus, Streptococcus, H influenzae, or Gram negative bacteria Bronchopneumonia Characterized by focal areas of suppurative inflammation, in a patchy distribution, involving one or more lobes Streptococcus pneumoniae is most common cause of community-acquired bronchopneumonia 12 COMPLICATIONS OF PNEUMONIA Abscess formation Spread of the infection to the pleural cavity (empyema) Organization of the exudate (replacement of exudate by fibroblasts) Bacteremia with spread of the infection to the distant sites 13 CHARACTERISTICS OF SELECTED PNEUMONIAS Organism; Appearance on sputum Streptococcus pneumoniae. Grampositive diplocci H influenzae. Pleomorphic gram negative cocbacilli Clinical Setting Chronic cardiopulmonary disease; follows upper respiratory tract infection Chronic cardiopulmonary disease; follows upper respiratory tract infection 14 CHARACTERISTICS OF SELECTED PNEUMONIAS Clinical Setting Organism; Appearance on sputum Staphylococcus aurerus. Plump grampositive cocci in clumps Klebsiella pneumoniae Plump gram-negative encapsulated rods Residence in chronic care facility, hospital acquired, influenza epidemics, cystic fibrosis, bronchiectasis, injection drug use Alcohol abuse, diabetes mellitus, hospital acquired 15 CHARACTERISTICS OF SELECTED PNEUMONIAS Organism; Appearance on sputum Escherichia Coli Gram-negative rods Pseudomonas aeruginosa. Gram negative rods Clinical Setting Hospital acquired; rarely community acquired Hospital acquired, cystic fibrosis; cystic fibrosis, bronchiectasis Anaerobes Mixed flora Aspiration, poor dental hygiene 16 CHARACTERISTICS OF SELECTED PNEUMONIAS Organism; Appearance on sputum Mycoplasma pneumoniae. PMNs and monocytes; no bacteria Legionella species Clinical Setting Young adults; summer and fall Summer and fall; exposure to contaminated construction site, water source, air conditioner; community-acquired or hospital- acquired 17 CHARACTERISTICS OF SELECTED PNEUMONIAS Organism; Appearance on sputum Chlamydophilia pneumoniae Nonspecific Clinical Setting Clinically similar to M pneumoniae, but prodromal symptoms last longer (up to two weeks). Sore throat with hoarseness common. Mild pneumonia in teenagers and young adults 18 CHARACTERISTICS OF SELECTED PNEUMONIAS Organism; Appearance on sputum Moraxella catarrhalis. Gram-negative diplcocci Pneumocystis jiroveci. Non-specific Clinical Setting Preexisting lung disease; elderly; corticosteroid or immunosuppressive therapy AIDS, immunosuppressive or cytotoxic drug therapy, cancer 19 CDI TASK Know Thy Antibiotic Coverage and pharmacokinetics Pay Attention to Minimum Inhibition Coverage values and antibiotic selection Query for Clinical Clarification and Specificity when clinically appropriate Clinical Relevance/Context is key 20 INPATIENT ADMISSION PNEUMONIA Hospitalization for pneumonia Nursing home residents and older adults Adults with any of the following: Respiratory rate > 28/min SBP <90 mmHg or 30 mm Hg below baseline Altered mental status Hypoxemia Unstable comorbid illness Multilobar pneumonia Pleural effusion that is > 1 cm on lateral decubitus CXR & ahs characteristics of a complicated parapneumonic effusion on pleural fluid analysis 21 PNEUMONIA SEVERITY INDEX Pneumonia Severity Index- Risk model to assist physicians in identifying patients higher risk of complications and more likely to benefit from hospitalization Clinical guideline for physician management, supplemented by physician clinical judgment CDIS- cognizance of severity index when contemplating pneumonia principal diagnosis selection with concomitant conditions. 22 PNEUMONIA SEVERITY INDEX Patient Characteristics Points Demographics Male Age (years) Female Age (years) – 10 Nursing home resident + 10 Comorbid illness Neoplastic disease Liver disease Congestive heart failure Cerebrovascular disease Renal disease + 30 + 20 + 10 + 10 +10 23 PNEUMONIA SEVERITY INDEX Physical examination findings Altered mental status + 20 Respiratory rate >30 breaths per minute + 20 Systolic blood pressure < 90 mm Hg + 20 Temperature < 35°C (95°F) or >40°C (104°F) + 15 Pulse rate >125 beats per minute + 10 24 PNEUMONIA SEVERITY INDEX Laboratory and radiographic findings Arterial pH < 7.35 + 30 Blood urea nitrogen >64 mg per dL (22.85 mmol per L) +20 Sodium < 130 mEq per L (130 mmol per L) + 20 Glucose >250 mg per dL (13.87 mmol per L) + 10 Hematocrit < 30 percent + 10 25 PNEUMONIA SEVERITY INDEX Recommended Site of Care Risk Class Point Total Risk Risk lass No Low I Predictors <=70 Low II 71 to 90 91 to 130 Low III Mortality care Recommend Site of .1 Outpatient .6 Outpatient 2.8 (briefly) Inpatient 8.2 Inpatient 29.2 Inpatient Moderate IV 26 POSTOPERATIVE RESPIRATORY FAILURE National Quality Measures Clearinghouse Definition Acute Respiratory Failure Acute Respiratory Failure in the secondary diagnosis field 518.81- Acute respiratory failure 518.84- Acute-on-Chronic respiratory failure Discharges meeting the following criteria with 518.81 or 518.84 in secondary diagnosis field Mechanical Ventilation for 96 consecutive hours or more - zero or more days after the major operating room procedure code Mechanical Ventilation for less than 96 consecutive hours or undetermined - two or more days after the major operating room procedure code Reintubation - one or more days after the major operating room procedure code 27 POSTOP RESPIRATORY FAILURE CODES 518.5 Pulmonary insufficiency following trauma and surgery New code 518.51 Acute respiratory failure following trauma and surgery Respiratory failure, not otherwise specified, following trauma and surgery Excludes: Acute respiratory failure in other conditions (518.81) New code 518.52 Other pulmonary insufficiency, not elsewhere classified, following trauma and surgery Adult respiratory distress syndrome Pulmonary insufficiency following: surgery trauma Shock lung related to trauma and surgery 28 POSTOP RESPIRATORY FAILURE CODES New code 518.53 Acute and chronic respiratory failure following trauma and surgery Excludes: Acute and chronic respiratory failure in other conditions (518.84) 518.8 Other diseases of lung See revisions for ICD-9 codes 518.81 and 518.82 and 518.84 29