History and exam

Key diagnostic factors

common

cough with increasing sputum production

Relative to a patient's baseline cough status. For example, patients with COPD often have a baseline cough with production of white sputum.

HAP is often accompanied by a cough with thick yellow or green sputum.

dyspnoea

Present in most patients with HAP. However, also consider other serious diagnoses (e.g., pulmonary embolism).

fever

Fever has a low specificity and high sensitivity for HAP. Critically ill patients may even present with hypothermia.

presence of risk factors

People at higher risk of HAP due to multidrug-resistant bacteria include those with:[7]

  • Symptoms or signs starting more than 5 days after hospital admission

  • Relevant comorbidity, such as severe lung disease or immunosuppression

  • Recent use of broad-spectrum antibiotic

  • Colonisation with multidrug-resistant bacteria

  • Recent contact with health or social care settings before current admission.

Consider other risk factors that predispose a patient to HAP such as:

  • Intubation and mechanical ventilation; mechanical ventilation is the most significant risk factor for HAP (ventilator-associated pneumonia is not covered in this topic)[19][20]

  • Acid-suppression drugs[21] 

  • Aspiration[19] 

  • Depressed consciousness[20] 

  • Chest or upper abdominal surgery.[19][20] 

Other diagnostic factors

common

chest pain

May be present as a result of pleural involvement of HAP, or secondary to intercostal muscle overuse after persistent coughing.

asymmetrical expansion of the chest

This may be noted with a suppressed motion on the side of the pneumonia. This sign is less likely to be appreciated in bilateral pneumonia.

diminished resonance

Resonance, noted by percussing a patient's chest, may be dull on the side of the consolidation.

abnormal auscultatory findings

None, some, or all of the following may be present:

  • Crackles or rhonchi

  • Aegophony: a change in the sound of a patient's voice (e.g., an 'eee' sound is heard as 'aaa').

  • Whisper pectoriloquy: a whisper is heard clearly and loudly while auscultating over the affected part of the lung

  • Bronchial breathing: harsh breath sounds with a gap between the inspiratory and expiratory phases

  • Increased vocal resonance: more audible vocal sounds (e.g., while the patient says “99”).

tachycardia

General fever can cause tachycardia, but if a pericardial effusion associated with HAP is present, tachycardia may be due to a more localised cause.

malaise/anorexia

These systemic symptoms are common in people with HAP, but are non-specific.

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