MS and Pneumonia: Understanding Respiratory Complications in Multiple Sclerosis

13.07.202112.07.2023 by alexxlab

How does multiple sclerosis affect breathing. What are the common respiratory issues in MS patients. Can MS cause pneumonia. How to manage respiratory problems in multiple sclerosis. What treatments are available for breathing difficulties in MS.

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The Link Between Multiple Sclerosis and Respiratory Problems

Multiple sclerosis (MS) is a complex neurological condition that can affect various bodily functions, including breathing. While respiratory issues are not among the most common symptoms of MS, they can significantly impact a person’s quality of life when they do occur.

Respiratory problems in MS patients typically stem from muscle weakness rather than direct damage to the autonomic nervous system. As MS progresses, it can weaken the muscles in the chest and abdomen that are crucial for breathing. This weakness can lead to difficulties in inhaling and exhaling, causing fatigue and other complications.

Common Respiratory Symptoms in MS Patients

Difficulty breathing deeply
Increased effort to inhale and exhale
Fatigue related to breathing
Speech difficulties due to respiratory muscle weakness
Chest tightness (MS hug)

Is shortness of breath a direct symptom of MS? Generally, shortness of breath is not considered a primary symptom of multiple sclerosis. However, the weakening of respiratory muscles can lead to breathing difficulties that may feel similar to shortness of breath. If you experience sudden or severe breathing problems, it’s crucial to seek immediate medical attention.

The MS Hug: A Unique Respiratory Sensation

One peculiar respiratory-related symptom experienced by some MS patients is known as the “MS hug” or dysesthesia. This sensation is characterized by a feeling of tightness or constriction around the chest or torso. While not directly related to breathing function, it can cause discomfort and anxiety that may affect respiration.

How can you manage the MS hug? Some strategies include:

Wearing loose, comfortable clothing
Applying heat or cold to the affected area
Practicing relaxation techniques
Using over-the-counter pain relievers (with doctor’s approval)
Considering medication prescribed by your neurologist

Pneumonia Risk in Multiple Sclerosis Patients

People with MS may be at an increased risk of developing pneumonia, particularly aspiration pneumonia. This condition occurs when food, liquid, or other substances are inhaled into the lungs instead of being swallowed properly.

Why are MS patients more susceptible to aspiration pneumonia? There are several factors:

Swallowing difficulties (dysphagia) common in MS
Weakness in muscles responsible for coughing and clearing secretions
Reduced mobility leading to shallow breathing and mucus accumulation
Weakened immune system due to MS treatments

Can MS directly cause pneumonia? While MS itself doesn’t cause pneumonia, it can create conditions that increase the risk of developing respiratory infections, including pneumonia. Proper management of MS symptoms and regular check-ups can help reduce this risk.

Evaluating and Diagnosing Respiratory Issues in MS

Identifying respiratory problems in MS patients requires a comprehensive approach. Healthcare providers specializing in respiratory function often conduct these evaluations.

What tests are used to assess breathing problems in MS patients?

Pulmonary function tests (PFTs)
Chest X-rays
Blood gas analysis
Sleep studies to check for sleep-disordered breathing
Swallowing assessments

Early detection of respiratory issues is crucial for effective management and prevention of complications. If you’re experiencing any breathing difficulties, it’s important to discuss them with your healthcare provider promptly.

Treatment Strategies for Respiratory Problems in MS

Managing respiratory issues in MS patients often involves a multidisciplinary approach. Treatment strategies may include:

1. Respiratory Muscle Training

Specific exercises can help strengthen the muscles involved in breathing. These may include:

Diaphragmatic breathing exercises
Pursed-lip breathing techniques
Inspiratory muscle training using specialized devices

2. Physical Therapy

A physical therapist can design a program to improve overall muscle strength and endurance, including exercises that target respiratory muscles.

3. Occupational Therapy

Occupational therapists can teach energy conservation techniques and strategies to make daily activities less taxing on the respiratory system.

4. Speech and Language Therapy

For patients experiencing speech difficulties due to respiratory muscle weakness, a speech-language pathologist can provide exercises and tools to enhance communication.

5. Medication Management

Careful monitoring of medications is crucial, as some drugs used in MS treatment can affect respiratory function. Your healthcare provider may adjust dosages or switch medications if necessary.

Assistive Devices for Respiratory Support in MS

In some cases, MS patients may benefit from assistive devices to support their respiratory function. These can include:

Incentive spirometers for breathing exercises
Positive expiratory pressure (PEP) devices
Non-invasive ventilation systems for nighttime use
Cough assist devices to help clear secretions

How do these devices help MS patients breathe better? Assistive devices can provide support to weakened respiratory muscles, help maintain lung capacity, and assist in clearing mucus from the airways. Your healthcare provider can determine which devices, if any, are appropriate for your specific situation.

Lifestyle Modifications to Support Respiratory Health in MS

In addition to medical interventions, certain lifestyle changes can significantly improve respiratory function and overall well-being for MS patients:

1. Smoking Cessation

Quitting smoking is crucial for maintaining respiratory health. Smoking can exacerbate MS symptoms and increase the risk of respiratory infections.

2. Regular Exercise

Engaging in appropriate physical activity can help maintain muscle strength, including respiratory muscles. Consult with your healthcare provider or a physical therapist to develop a safe exercise routine.

3. Maintaining a Healthy Weight

Excess weight can put additional strain on respiratory muscles. Maintaining a healthy weight through proper diet and exercise can help alleviate this burden.

4. Proper Positioning

Learning and using proper posture and positioning techniques can help optimize breathing, especially for those with limited mobility.

5. Stress Management

Stress and anxiety can affect breathing patterns. Incorporating relaxation techniques such as meditation or deep breathing exercises can be beneficial.

How can MS patients incorporate these lifestyle changes effectively? Start by setting small, achievable goals and gradually building up to more significant changes. Work with your healthcare team to create a personalized plan that takes into account your specific MS symptoms and overall health status.

Preventing Respiratory Complications in MS

Proactive measures can significantly reduce the risk of developing serious respiratory complications in MS patients. Here are some key preventive strategies:

1. Regular Check-ups

Scheduling regular appointments with your healthcare provider allows for early detection and management of potential respiratory issues.

2. Vaccination

Staying up-to-date with vaccinations, particularly against influenza and pneumococcal disease, can help prevent respiratory infections.

3. Proper Nutrition

A balanced diet rich in nutrients supports overall health and can help maintain the strength of respiratory muscles.

4. Hydration

Adequate fluid intake helps keep mucus thin and easier to clear from the airways.

5. Swallowing Precautions

For those with swallowing difficulties, following recommendations from a speech-language pathologist can help prevent aspiration.

What are the signs of respiratory distress that MS patients should watch for? Key warning signs include:

Increased breathing rate
Difficulty speaking in full sentences
Bluish tinge to lips or fingernails
Use of accessory muscles for breathing
Chest pain or discomfort

If you experience any of these symptoms, seek medical attention immediately.

The Role of Caregivers in Managing Respiratory Issues in MS

Caregivers play a crucial role in supporting MS patients with respiratory challenges. Here are some ways caregivers can help:

1. Assistance with Exercises

Caregivers can help patients perform prescribed breathing exercises and ensure they’re done correctly.

2. Monitoring Symptoms

Keeping track of any changes in breathing patterns or new respiratory symptoms can help in early intervention.

3. Medication Management

Assisting with proper administration of medications and monitoring for any side effects that may affect breathing.

4. Environmental Control

Maintaining a clean, dust-free environment and ensuring good air quality can help prevent respiratory irritation.

5. Emergency Preparedness

Knowing the signs of respiratory distress and having an emergency plan in place is crucial.

How can caregivers balance providing support while promoting independence? It’s important to encourage MS patients to do as much as they can independently while being ready to assist when needed. Open communication about the patient’s needs and preferences is key to striking this balance.

Research and Future Directions in MS Respiratory Care

Ongoing research continues to shed light on the relationship between MS and respiratory function, paving the way for improved treatments and management strategies. Some areas of current research include:

Development of more targeted respiratory muscle training programs
Investigation of new medications to support respiratory function in MS
Exploration of advanced assistive technologies for breathing support
Studies on the impact of MS disease-modifying therapies on respiratory health
Research into the potential benefits of alternative therapies such as yoga and mindfulness for respiratory symptoms

What promising developments are on the horizon for MS respiratory care? While it’s difficult to predict specific breakthroughs, the increasing focus on this aspect of MS care is likely to lead to more targeted and effective interventions in the future. Staying informed about the latest research and clinical trials can help patients and caregivers access cutting-edge treatments as they become available.

In conclusion, while respiratory complications are not the most common symptoms of multiple sclerosis, they can significantly impact a patient’s quality of life when they do occur. Understanding the potential respiratory challenges, recognizing early signs of problems, and working closely with healthcare providers to implement appropriate management strategies can help MS patients maintain optimal respiratory health. With ongoing research and advancements in treatment, the outlook for managing respiratory issues in MS continues to improve, offering hope for enhanced quality of life for those living with this complex condition.

Breathing Problems and MS | National Multiple Sclerosis Society

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In this article

Respiration problems from multiple sclerosis

Note: If breathing problems occur suddenly, see a healthcare provider immediately or go to the emergency room. Signs of respiratory distress requiring immediate attention include increased breathing rate, grunting when exhaling, nose flaring, sweating, wheezing, chest retractions (chest appears to sink in with each breath), leaning forward while sitting to help take deeper breaths, or bluish color around the mouth, on the inside of the lips, or on the fingernails.

Respiration — or breathing — is primarily under the control of the autonomic or “automatic” nervous system. This is the part of the central nervous system that controls vital functions such as heartbeat and respiration without conscious thought. It is unusual for multiple sclerosis to affect the autonomic nervous system. For this reason, it’s uncommon for breathing problems to occur in MS as a direct result of loss of autonomic control.

In MS, the most common cause of respiratory problems is loss of muscle strength and endurance. Just as a person can experience muscle weakness in the arms or legs, weakness can occur in the muscles of the chest and abdomen that are involved in breathing. And like weakness in other parts of the body, weakness of the muscles related to proper breathing and lung function can begin to occur early in the disease course and gradually worsen over time. People with weakened breathing muscles have to work harder to inhale and exhale. This extra effort can be quite tiring, particularly for people who already experience a significant amount of MS fatigue.

Respiratory problems can also interfere with speech. It can be much more difficult and tiring for people to carry on a conversation or speak loudly enough to be heard. A speech/language pathologist can recommend exercises and tools to enhance speech and communication. Learn more about MS-related speech symptoms.

Does MS cause shortness of breath?

No. Shortness of breath is not usually a direct symptom of MS. If you are experiencing shortness of breath, go to the emergency room.

Breathing problems that occur with MS present differently than what you might call shortness of breath. People with MS experience a tightening of the chest called an MS hug (dysesthesia). Read more about the symptoms of an MS hug and how to manage it in Momentum Magazine.

Treatment for MS breathing problems

Evaluations of breathing problems are most often done by a healthcare provider with special training in this area. If your respiratory function becomes affected, a therapy program including breathing exercises may be recommended to strengthen the muscles that support your lungs and breathing.

Everyone living with MS can benefit from adding breathing exercises into their regular wellness routine. Once you have consulted with your healthcare provider on what exercise program might be best for you, consider viewing our Breathing Tips for MS video for guided breathing exercises.

Breathing assistance devices

Some studies have determined that respiratory muscle training may help strengthen breathing muscles, improve respiratory function, clear airways, decrease fatigue and increase quality of life. This muscle training may include use of a device, such as a positive expiratory pressure (PEP) device or an acapella device (sometimes called a green pickle), to assist you in clearing your lungs and keeping airways open. Discuss the use of a device with your doctor and your rehabilitation care team.

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Why Multiple Sclerosis Can Affect Your Breathing

Multiple sclerosis can negatively affect multiple processes that control or modulate breathing. Here’s what you can do to improve your respiratory function.

By Madeline R. Vann, MPHMedically Reviewed by Jason Paul Chua, MD, PhD

Reviewed: May 24, 2021

Medically Reviewed

MS can make it difficult to cough effectively, which can lead to a higher risk of respiratory infections like pneumonia. Alamy

Among the many possible complications of multiple sclerosis (MS) is a reduction in your ability to exhale fully and to cough effectively enough to clear secretions or food from your airway, says Anthony Reder, MD, a multiple sclerosis specialist and professor of neurology at the University of Chicago. A serious consequence of these changes is a higher risk of respiratory infections like pneumonia. Changes in breathing function can also cause fatigue, as you work harder to breathe and supply your body with the oxygen it needs.

How MS Can Affect Your Breathing

There are a number of ways that MS can lead to breathing problems, including the following:

Lesions in the Brain

As multiple sclerosis progresses, lesions in your brain and spine can affect almost every aspect of your physical functioning. It’s possible that brain lesions could change your respiratory function, says Zulma Hernandez-Peraza, MD, a neurologist at the University of Illinois Hospital and Health Sciences System in Chicago.

Lesions that disrupt the signals from the brain to the lungs can result in a condition known as central sleep apnea, in which breathing stops and restarts repeatedly during sleep, notes Dr. Reder. Symptoms of central sleep apnea include waking up abruptly with shortness of breath, having shortness of breath that improves with sitting up, insomnia, daytime sleepiness, and chest pain at night.

A more common form of sleep apnea, where the upper airway becomes intermittently obstructed, can also occur in people with MS if the muscles that normally keep the airway open become slack due to lesions in the brain, adds Reder. Obstructive sleep apnea is associated with snoring and obesity.

Spinal Lesions

These can cause weakness of the breathing muscles and also restrict your ability to get air in and out of the lungs, says neurologist Staley Brod, MD, professor of neurology at the Medical College of Wisconsin in Milwaukee. “Weakness can affect breathing,” says Dr. Brod. Spasticity in the muscles that help with inhaling and exhaling could also contribute to the problem.

“A lesion in the cervical spine creates the ‘MS hug’ sensation, which can cause the feeling of shortness of breath,” adds Dr. Hernandez-Peraza. “This is usually just an unpleasant perception. When tested, the oxygen levels in your blood should be normal.”

Medication

One of the side effects of the MS disease-modifying drug Gilenya (fingolimod) is a reduction in some measures of breathing function, says Reder. Some types of medication, such as tranquilizers, muscle relaxants, and opioids, can also slow or reduce breathing.

In 2019, the U.S. Food and Drug Administration (FDA) issued a warning that serious breathing difficulties may occur in people who have respiratory risk factors who are taking gabapentin (Neurontin, Gralise, Horizant) or pregabalin (Lyrica, Lyrica CR). According to the National Multiple Sclerosis Society, these pain medications (known as gabapentinoids) are sometimes prescribed for people who have multiple sclerosis. Talk to your doctor if you have respiratory risk factors including (but not limited to) chronic obstructive pulmonary disease (COPD) or older age and you have been prescribed these medications, especially at high doses, notes Reder.

What You Can Do When MS Attacks Your Breathing Function

If you’re unable to cough normally or you’re feeling short of breath, dizzy, or even faint, don’t just write off these symptoms as an expected part of life with MS. Taking the following steps can help you manage the problem and prevent it from getting worse, says Reder.

See your doctor. Your doctor will ask you about your symptoms and do a physical exam to look for the cause of the problem. They may conduct tests of your lung function or refer you to a pulmonologist for pulmonary function tests. Lung function tests are painless and noninvasive, and they allow your doctor to see how much air is moving in and out of your lungs, how forcefully you can exhale after inhaling, and how quickly you can force air out of your lungs.

Go to pulmonary rehabilitation. Depending on the cause of your breathing problems, your doctor may refer you for pulmonary rehabilitation, where you’ll learn exercises and techniques to improve your breathing. You may be instructed to spend several minutes a day using a handheld device to build your breathing muscles and increase your lung volume. You may also work with a physical therapist or pulmonary rehabilitation specialist on exercises to strengthen your upper body.

A study published in October 2020 in Multiple Sclerosis and Related Disorders found that 12 weeks of inspiratory muscle training with low resistance (like breathing in and out through a wide straw) was more effective than conventional respiratory exercises to improve respiratory strength and labored breathing in people who have MS.

Additionally, a review published in December 2017 in the Cochrane Library found some evidence that inspiratory muscle training with a resistive device is moderately effective at improving respiratory muscle strength in people who have mild to moderate MS.

Aim for a healthy weight. Being overweight and having a thick neck can lead to sleep apnea, says Brod. To maintain a healthy weight, you may have to battle the fatigue that often comes with MS, notes Reder. “Many patients with MS are tired, fatigued, and weak from deconditioning and the MS,” he says, adding that it’s important to “fight” these symptoms and try your best to exercise regularly and eat a healthy diet.

Stop smoking. “It is known that smoking is bad for a person with MS,” points out Brod. It’s also bad for your lungs. If you smoke and have multiple sclerosis, you’re increasing the burden on your lungs.

Use oxygen if it’s prescribed. Supplemental oxygen is rarely needed for MS unless you have another medical condition that affects your lungs, such as COPD. But if oxygen is prescribed, it can help you feel better and function better.

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Community-acquired pneumonia (not caused by Covid-19) – Diagnostic approach

During a pandemic, all patients with cough, fever or other suspicious symptoms should be considered as having COVID-19 until proven otherwise.

The patient’s history and physical examination are important components of the diagnosis and may indicate symptoms that are consistent with CAP, immune dysfunction, and/or potential exposure to specific pathogens. However, a definitive diagnosis of pneumonia requires confirmation of the presence of a new infiltrate on a chest x-ray.

History

The purpose of the history is to identify symptoms consistent with CAP, immune dysfunction, and possible exposure to specific pathogens.

Risk factors include age over 65 years, institutionalization, COPD, HIV infection, exposure to cigarette smoke, alcohol abuse, poor oral hygiene, contact with children, and use of certain drugs (eg, acid-lowering drugs, inhaled corticosteroids, antipsychotics, antidiabetic drugs, opioids). Diabetes mellitus and chronic liver or kidney disease are also associated with PFS.

Typically present with clinical signs and symptoms of infection (fever or chills and leukocytosis) and respiratory symptoms (including cough, often with increased sputum production, dyspnea, pleural pain, and hemoptysis). There may be complaints of non-specific symptoms such as myalgia and arthralgia. In elderly, chronically ill, and immunocompromised patients, the signs and symptoms of a lung infection may be less severe, and pneumonia may not be recognized due to the presence of non-respiratory symptoms.

Some causes of pneumonia (eg, legionellosis) may have a specific history. Legionellosis may present with headache, confusion, digestive disturbances such as diarrhea, and clinical manifestations of hyponatremia.

Mycoplasma pneumoniae infection is most common in younger patients and patients treated with antibiotics prior to current presentation for pneumonia. It can present with extrapulmonary manifestations such as myringitis, encephalitis, uveitis, iritis, and myocarditis. [20]Torres A, Barberán J, Falguera M, et al. Multidisciplinary guidelines for the management of community-acquired pneumonia [in Spanish]. Med Clin (Barc). 2013 Mar 2;140(5):223.e1-223.e19.
http://www.ncbi.nlm.nih.gov/pubmed/23276610?tool=bestpractice.com

CVD is more severe in men than in women, resulting in higher mortality among men in general and especially among older men.[71]Barbagelata E, Cillóniz C, Dominedò C, et al. Gender differences in community-acquired pneumonia. Minerva Med. 2020 Apr;111(2):153-65.
http://www.ncbi.nlm.nih.gov/pubmed/32166931?tool=bestpractice.com

Physical examination

Perform a physical examination. The patient may have fever, tachycardia, and dyspnea at rest. Auscultation of the chest may reveal moist rales, rales or bronchial breathing, dullness of percussion sound or weakening of voice trembling may be determined.

Imaging methods

Chest x-rays should be ordered as soon as possible in all patients hospitalized with suspected NGP to confirm or rule out the diagnosis. In general, a chest x-ray is not mandatory for outpatients with suspected NGP. Direct and oblique lateral projections increase the likelihood of diagnosing pneumonia and are useful in establishing the severity of the disease.

The benefit of chest x-ray in the diagnosis of CAP has been questioned by studies using lung ultrasound and computed tomography (CT) of the chest. Lung ultrasonography should be considered if the chest x-ray is negative and the patient is elderly and frail, or clinical suspicion is uncertain.[72] Niederman MS. Imaging for the management of community-acquired pneumonia: what to do if the chest radiograph is clear. Chest. 2018 Mar;153(3):583-5.
http://www.ncbi.nlm.nih.gov/pubmed/29519296?tool=bestpractice.com
The American College of Physicians recommends bedside ultrasound in patients with acute dyspnea in case of diagnostic uncertainty.[73]Qaseem A, Etxeandia-Ikobaltzeta I, Mustafa RA, et al. Appropriate use of point-of-careultrasonography in patients with acute dyspnea in emergency department or inpatientsettings: a clinical guideline from the American College of Physicians. Ann Intern Med. 2021Jul;174(7):985-93.
https://www.doi.org/10.7326/M20-7844

http://www.ncbi.nlm.nih.gov/pubmed/33

2?tool=bestpractice.com
Chest CT scan should be considered in patients with an indeterminate diagnosis after chest x-ray and ultrasonography.[72]Niederman MS. Imaging for the management of community-acquired pneumonia: what to do if the chest radiograph is clear. Chest. 2018 Mar;153(3):583-5.
http://www.ncbi.nlm.nih.gov/pubmed/29519296?tool=bestpractice.com

Ultrasound of the lungs is a simple and affordable method for diagnosing CAP. It does not involve radiation and its use is especially valuable if chest x-ray is not available. Diagnosis of CAP by bedside ultrasound of the lungs mainly depends on the detection of induration. However, densification is not always seen in CAP, as the pneumonia may be interstitial or present as diffuse lung infiltration.[74] Reissig A, Gramegna A, Aliberti S. pneumonia. Eur J Intern Med. 2012 Jul;23(5):391-7.
http://www.ncbi.nlm. nih.gov/pubmed/22726366?tool=bestpractice.com
Evidence demonstrates that lung ultrasonography can accurately diagnose pneumonia in adults, including in the emergency department.[75]Llamas-Álvarez AM, Tenza-Lozano EM, Latour-Pérez J. the diagnosis of pneumonia in adults: systematic review and meta-analysis. Chest. 2017 Feb;151(2):374-82.
http://www.ncbi.nlm.nih.gov/pubmed/27818332?tool=bestpractice.com
[76] Orso D, Guglielmo N, Copetti R. Lung ultrasound in diagnosing pneumonia in the emergency department: a systematic review and meta-analysis. Eur J Emerg Med. 2018 Oct;25(5):312-21.
http://www.ncbi.nlm.nih.gov/pubmed/29189351?tool=bestpractice.com
[77] Gartlehner G, Wagner G, Affengruber L, et al. Point-of-care ultrasonography in patients with acute dyspnea: an evidence report for a clinical practice guideline by the American College of Physicians. Ann Intern Med. 2021 Jul;174(7):967-76.
https://www.doi.org/10.7326/M20-5504

http://www.ncbi.nlm.nih.gov/pubmed/33

8?tool=bestpractice.com

Chest CT may improve the diagnosis of NGP because chest x-ray can lead to a misdiagnosis. Chest CT provides detailed information about the condition of the parenchyma and lungs, as well as the mediastinum. However, major limitations include exposure to radiation, high cost, and the inability to perform bedside examinations. One study showed that in patients presenting to emergency departments with suspected NGP, early CT scan results, if CT is used as an adjunct to chest x-ray, significantly affect both diagnosis and clinical management.[ 78] Claessens YE, Debray MP, Tubach F, et al. Early chest computed tomography scan to assist diagnosis and guide treatment decision for suspected community-acquired pneumonia. Am J Respir Crit Care Med. 2015 Oct 15;192(8):974-82.
http://www.ncbi.nlm.nih.gov/pubmed/26168322?tool=bestpractice.com

These alternative imaging modalities may prove useful in diagnosing CAP as the availability of CT in emergency and emergency departments increases in parallel with the ability to perform scans as quickly as chest x-rays with equivalent radiation dose. [30] Wunderink RG, Waterer G. Advances in the causes and management of community acquired pneumonia in adults. BMJ. 2017 Jul 10;358:j2471.
http://www.ncbi.nlm.nih.gov/pubmed/28694251?tool=bestpractice.com

Microbiology

Initial antibiotic treatment is empiric in most cases. Determination of microbial etiology reduces the wastage of broad-spectrum antibiotics and helps ensure appropriate antibiotic therapy, which is an important factor in reducing mortality. It also identifies resistant pathogens and pathogens that may have public health implications (eg Legionella).

Sputum and blood culture:

Prior to treatment, Gram stain and culture of lower respiratory secretions and blood culture should be performed in the following patients in a hospital setting:[19]Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019Oct 1;200(7):e45-e67.
https://www.atsjournals.org/doi/full/10.1164/rccm.201908-1581ST
http://www.ncbi.nlm.nih.gov/pubmed/31573350?tool=bestpractice.com
- Patients with severe CAP as defined by the American Thoracic Society (ATS) or the Infectious Diseases Society of America (IDSA) criteria for severe CAP (see Diagnostic Criteria section), especially if these patients are intubated
- Patients receiving empiric treatment for methicillin-resistant Staphylococcus aureus (MRSA) or Pseudomonas aeruginosa
- Patients previously infected with MRSA or P. aeruginosa, especially those who have had respiratory tract infections
- Patients with hospitalization and parenteral antibiotic therapy within the last 90 days.
These studies are generally not recommended for other inpatients, nor are they recommended for outpatient use. Consideration should be given to local protocols for rational antimicrobial therapy, local etiological factors, and the clinical picture when deciding whether to conduct these studies. [19]Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-e67.
https://www.atsjournals.org/doi/full/10.1164/rccm.201908-1581ST
http://www.ncbi.nlm.nih.gov/pubmed/31573350?tool=bestpractice.com
Sputum Gram stain is a sensitive and highly specific method for the detection of pathogens in patients with NGP. In a meta-analysis, this study was found to be highly specific for Streptococcus pneumoniae, Haemophilus influenzae, S. aureus, and Gram-negative bacilli. However, the false negative rate ranged from 22% (for H. influenzae) to 44% (for S. pneumoniae), indicating that a negative result is not definitive confirmation of the absence of causative pathogens, and antibiotic therapy should not necessarily be stopped. based on a negative sputum Gram stain.[79]Del Rio-Pertuz G, Gutierrez JF, Triana AJ, et al. Usefulness of sputum gram stain for etiologic diagnosis in community-acquired pneumonia: a systematic review and meta-analysis. BMC Infect Dis. 2019 May 10;19(1):403.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6509769
http://www.ncbi.nlm.nih.gov/pubmed/31077143?tool=bestpractice.com

Urinalysis for pneumococcal and Legionella antigens:

Patients with severe LPH should have a urine test for pneumococcal antigen. Urinalysis for Legionella antigen should be performed in patients with epidemiological factors (eg, association with a Legionella outbreak or recent travel) or in patients with severe NGP. In patients with severe NGP, lower respiratory secretions should be sampled simultaneously for bacteriological examination for Legionella or nucleic acid amplification. In large observational studies, urinalysis for antigens has been associated with a reduction in mortality and should be considered in settings where Legionella infections are on the rise, especially in critically ill patients. [19]]Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-e67.
https://www.atsjournals.org/doi/full/10.1164/rccm.201908-1581ST
http://www.ncbi.nlm.nih.gov/pubmed/31573350?tool=bestpractice.com

Influenza testing:

Rapid molecular testing (as opposed to antigen-based tests) for influenza virus testing should be performed while influenza viruses are circulating in the community. Studies during periods of low influenza activity are also being considered.[19] Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019Oct 1;200(7):e45-e67.
https://www. atsjournals.org/doi/full/10.1164/rccm.201908-1581ST
http://www.ncbi.nlm.nih.gov/pubmed/31573350?tool=bestpractice.com

Laboratory tests

In hospitalized patients, complete blood count, blood glucose, serum electrolytes, urea, and liver function tests should be ordered. An elevated white blood cell count indicates infection Chronic kidney and liver disease are risk factors for death and complications in patients hospitalized with CAP.

Arterial blood gases should be measured in critically ill or hospitalized patients. Oximetry is non-invasive and can be used continuously.

Biomarker tests such as C-reactive protein (CRP) and procalcitonin should be considered. These biomarkers are useful in predicting a deficient host response. High levels of CRP or procalcitonin at first visit are risk factors for poor host response,[80] Menéndez R, Cavalcanti M, Reyes S, et al. Markers of treatment failure in hospitalized community acquired pneumonia. Thorax. 2008 May;63(5):447-52.
http://thorax.bmj.com/content/63/5/447.long

http://www.ncbi.nlm.nih.gov/pubmed/18245147?tool=bestpractice.com
while low levels are protective. In patients with suspected pneumonia, a CRP level >100 mg/l suggests the possibility of pneumonia.[81] Woodhead M. New guidelines for the management of adult lower respiratory tract infections. Eur Respir J. 2011 Dec;38(6):1250-1.
http://erj.ersjournals.com/content/38/6/1250.long

http://www.ncbi.nlm.nih.gov/pubmed/22130759?tool=bestpractice.com
Increased PCT values correlate with bacterial pneumonia, while low values correlate with viral and SARS. PCT is especially elevated in cases of pneumococcal pneumonia.[82] Menéndez R, Sahuquillo-Arce JM, Reyes S, et al. Cytokine activation patterns and biomarkers are influenced by microorganisms in community-acquired pneumonia. Chest. 2012 Jun;141(6):1537-45.
http://www.ncbi.nlm.nih.gov/pubmed/22194589?tool=bestpractice.com
[83] Ugajin M, Yamaki K, Hirasawa N, et al. Predictive values of semi-quantitative procalcitonin test and common biomarkers for the clinical outcomes of community-acquired pneumonia. Respiratory care. 2014 Apr;59(4):564-73.
http://rc.rcjournal.com/content/59/4/564.full

http://www.ncbi.nlm.nih.gov/pubmed/24170911?tool=bestpractice.com
Initial empiric antibiotic therapy should be initiated in patients with clinical suspicion and radiological confirmation of CAP, regardless of initial procalcitonin levels.[19] Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019Oct 1;200(7):e45-e67.
https://www.atsjournals.org/doi/full/10.1164/rccm.201908-1581ST

http://www.ncbi.nlm.nih.gov/pubmed/31573350?tool=bestpractice.com

In all patients with pleural effusion, aspiration and culture of the pleural fluid should be considered. Parapneumonic effusions – exudates; positive Gram staining of the pleural fluid indicates empyema.

Bronchoscopy

Bronchoscopy should be considered in immunosuppressed patients, in patients with severe AHP, and in cases of treatment failure. The most common sampling methods are bronchoalveolar lavage (BAL) and brush biopsy. A threshold value of 10⁴ colony forming units (CFU)/ml in BAL samples indicates the presence of infection. For brush biopsy, a threshold of 10³ cfu/mL is recommended to distinguish colonization from infection.[84]Sirvent JM, Vidaur L, Gonzalez S, et al. Microscopic examination of intracellular organisms in protected bronchoalveolar mini-lavage fluid for the diagnosis of ventilator-associated pneumonia. Chest. 2003 Feb;123(2):518-23.
http://www.ncbi.nlm.nih.gov/pubmed/12576375?tool=bestpractice.com

Molecular Techniques

Conventional plating is too time consuming and not feasible from a treatment perspective. Nucleic acid amplification techniques such as polymerase chain reaction have improved diagnostic accuracy in NGP. Molecular methods provide high sensitivity and specificity in the diagnosis of mono- or polymicrobial infections and can help detect antimicrobial resistance (as may occur in the presence of Staphylococcus aureus, non-fermenting gram-negative rods, and enterobacteria) associated with severe AHP. [85] Murdoch D.R. How recent advances in molecular tests could impact the diagnosis of pneumonia. Expert Rev Mol Diagn. 2016;16(5):533-40.
http://www.ncbi.nlm.nih.gov/pubmed/26891612?tool=bestpractice.com

The American Thoracic Society recommends that nucleic acid tests be used to analyze respiratory specimens for viral pathogens other than influenza only in hospitalized patients with suspected AHP who have either severe AHP or are immunocompromised. The routine use of nucleic acid-based tests in outpatients with suspected NGP is not recommended.[86]Evans SE, Jennerich AL, Azar MM, et al. Nucleic acid-based testing for noninfluenza viral pathogens in adults with suspected community-acquired pneumonia. An official American Thoracic Society clinical practice guideline. Am J Respir Crit Care Med. 2021 May 1;203(9):1070-87.
https://www.doi.org/10.1164/rccm.202102-0498ST

http://www.ncbi.nlm.nih.gov/pubmed/33929301?tool=bestpractice.com

Animation of venipuncture and phlebotomy

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