Pulmonology – ClinCaseQuest https://clincasequest.hospital Medical education in clinical cases Wed, 15 Dec 2021 19:02:17 +0000 en-US hourly 1 https://wordpress.org/?v=6.2.13 https://clincasequest.hospital/wp-content/uploads/sites/7/2020/02/logo-ru-project-90x90.png Pulmonology – ClinCaseQuest https://clincasequest.hospital 32 32 CURB-65 Score for Pneumonia Severity https://clincasequest.hospital/curb65-score-pneumonia-severity/ Wed, 15 Dec 2021 02:51:00 +0000 https://clincasequest.hospital/?p=31908 Estimates mortality of community-acquired pneumonia to help determine inpatient vs. outpatient treatment. The CURB-65 calculator also can be used in the emergency department setting to…

Сообщение CURB-65 Score for Pneumonia Severity появились сначала на ClinCaseQuest.

]]> Estimates mortality of community-acquired pneumonia to help determine inpatient vs. outpatient treatment. The CURB-65 calculator also can be used in the emergency department setting to risk stratify a patient’s community acquired pneumonia.

Confusion:
Yes
No

BUN ( blood urea nitrogen) > 19 mg/dl(> 7 mmol/L):
Yes
No

Respiratory Rate ≥30:
Yes
No

Systolic BP < 90 mmHg or Diastolic BP ≤ 60 mmHg:
Yes
No

Age ≥ 65:
Yes
No

Is this a COVID-19 patient?
Confirmed Positive
Suspected
Unlikely
Confirmed Negative




CURB-65
score		 30-day
Mortality Risk		 Recommendation per Derivation Study
0 0 0

The CURB-65 scores range from 0 to 5. Assign points as in the table based on confusion status, urea level, respiratory rate, blood pressure, and age. Clinical management decisions can be made based on the score based on the addition of the selected points:

ParametersPoints
Confusion+1
BUN > 19 mg/dl (> 7 mmol/L)+1
Respiratory Rate ≥ 30+1
Systolic BP < 90 mmHg or Diastolic BP ≤ 60 mmHg+1
Age ≥ 65+1

While many pneumonias are viral in nature, typical practice is to provide a course of antibiotics given the pneumonia may be bacterial.

Disposition (inpatient vs. outpatient) often dictates further care and management — including lab testing, blood cultures, etc.

For patients scoring high on CURB-65, it would be prudent to ensure initial triage has not missed the presence of sepsis. Evaluation of SIRS criteria should be considered.

Score interpretation (as per derivation study):

CURB-65 score30-day Mortality RiskRecommendation per Derivation Study
00.60%Low risk; consider home treatment
12.70%Low risk; consider home treatment
26.80%Short inpatient hospitalization or closely supervised outpatient treatment
314.00%Severe pneumonia; hospitalize and consider admitting to intensive care
4 or 527.80%Severe pneumonia; hospitalize and consider admitting to intensive care

The original study was a retrospective review of three prospective studies of CAP in the UK, New Zealand, and the Netherlands. It included a total of 1068 patients. A five-point score based on confusion, urea, respiratory rate, blood pressure, and age was developed to stratify patients into different treatment group based on mortality risk. The validation study was done in India and included 150 patients.

The CURB-65 Score includes points for confusion and blood urea nitrogen, which in the acutely ill elderly patient, could be due to a variety of factors. An alternative scoring system, SOAR, circumvents those two parameters. It uses low systolic BP and poor oxygenation, advancing age, high respiratory rate.

CURB-65’s original study including co-morbidity variables like chronic lung disease, chronic liver disease, CHF, CVD, and DM, and these were controlled for when developing the relevant criteria for the risk stratification that ultimately led to CURB-65’s risk factors.

Several other more recent validation studies in several different countries show increasing mortality and even need for intubation with increasing CURB-65 scores, ranging from 0-1.1% (CURB-65 score = 0) to 17-60% (CURB-65 score = 5), with over 3100 patients in these studies when combined.

Сonclusions

CURB-65 is fast to compute, requires likely already-available patient information, and provides an excellent risk stratification of community acquired pneumonia. It can facilitate better utilization of resources and treatment initiation.

In comparison to the pneumonia severity index, CURB-65 offers equal sensitivity of mortality prediction due to community acquired pneumonia. Notably, CURB-65 (74.6%) has a higher specificity than pneumonia severity index (52.2%).

Register on our website right now to have access to more learning materials!

Subscribe to our pages:

References:

  1. Lim WS, van der Eerden MM, Laing R, et al. Defining community acquired pneumonia severity on presentation to hospital: an international derivation and validation study. Thorax. 2003;58(5):377-382. doi:10.1136/thorax.58.5.377 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1746657/?tool=pmcentrez
  2. Aujesky D, Auble TE, Yealy DM, Stone RA, Obrosky DS, Meehan TP, Graff LG, Fine JM, Fine MJ. Prospective comparison of three validated prediction rules for prognosis in community-acquired pneumonia. Am J Med. 2005 Apr;118(4):384-92. doi: 10.1016/j.amjmed.2005.01.006. PMID: 15808136. https://pubmed.ncbi.nlm.nih.gov/15808136/
  3. Shah BA, et. al. Validity of Pneumonia Severity Index and CURB-65 Severity Scoring Systems in Community Acquired Pneumonia in an Indian Setting. The Indian Journal of Chest Diseases & Allied Sciences. 2010;Vol.52.
  4. British Thoracic Society, Myint PK, Kamath AV, Vowler SL, Maisey DN, Harrison BD. Severity assessment criteria recommended by the British Thoracic Society (BTS) for community-acquired pneumonia (CAP) and older patients. Should SOAR (systolic blood pressure, oxygenation, age and respiratory rate) criteria be used in older people? A compilation study of two prospective cohorts. Age Ageing. 2006 May;35(3):286-91. doi: 10.1093/ageing/afj081. PMID: 16638769. https://pubmed.ncbi.nlm.nih.gov/16638769/
  5. Capelastegui A, España PP, Quintana JM, Areitio I, Gorordo I, Egurrola M, Bilbao A. Validation of a predictive rule for the management of community-acquired pneumonia. Eur Respir J. 2006 Jan;27(1):151-7. doi: 10.1183/09031936.06.00062505. PMID: 16387948. https://pubmed.ncbi.nlm.nih.gov/16387948/

Charlson Comorbidity Index (CCI) Online Calculator

Charlson Comorbidity Index predicts 10-year survival in patients with multiple comorbidities.

Loading...

History of definite or probable MI (EKG changes and/or enzyme changes)

Exertional or paroxysmal nocturnal dyspnea and has responded to digitalis, diuretics, or afterload reducing agents

Intermittent claudication or past bypass for chronic arterial insufficiency, history of gangrene or acute arterial insufficiency, or untreated thoracic or abdominal aneurysm (≥6 cm)

History of a cerebrovascular accident with minor or no residua and transient ischemic attacks

Chronic cognitive deficit

Any history of treatment for ulcer disease or history of ulcer bleeding

Severe = cirrhosis and portal hypertension with variceal bleeding history, moderate = cirrhosis and portal hypertension but no variceal bleeding history, mild = chronic hepatitis (or cirrhosis without portal hypertension)

Severe = on dialysis, status post kidney transplant, uremia, moderate = creatinine >3 mg/dL (0.27 mmol/L)

* Required
VariablePointsAge <50…
Read More

Multiple Myeloma Diagnostic Criteria – Online Calculator

Loading...

≥1 of the following (A or B)

≥1 myeloma defining event (C1 or C2)

* Required
For Multiple Myeloma Diagnostic Criteria assessment necessary to provide selection of the…
Read More

Сообщение CURB-65 Score for Pneumonia Severity появились сначала на ClinCaseQuest.

]]> RESP (Respiratory ECMO Survival Prediction) Score online calculator https://clincasequest.hospital/resp-online-calculator/ Mon, 29 Nov 2021 06:11:00 +0000 https://clincasequest.hospital/?p=31641 Predicts in-hospital survival in adult patients after ECMO for acute respiratory failure. RESP Score should be used in patients receiving venovenous (VV) and veno-arterial (VA)…

Сообщение RESP (Respiratory ECMO Survival Prediction) Score online calculator появились сначала на ClinCaseQuest.

]]> Predicts in-hospital survival in adult patients after ECMO for acute respiratory failure.

RESP Score should be used in patients receiving venovenous (VV) and veno-arterial (VA) extracorporeal membrane oxygenation (ECMO) for acute respiratory failure. NB! Do not use in patients receiving VA ECMO for cardiogenic shock (see SAVE Score).

Age, years
18-49
50-59
≥60

Immunocompromised status at time of ECMO
Any malignancy, solid organ transplant, HIV, or cirrhosis:
Yes
No

Mechanically ventilated before ECMO initiated:
48 hours to 7 days
<48 hours

Diagnosis:
Viral pneumonia
Bacterial pneumonia
Asthma
Trauma or burn
Aspiration pneumonitis
Other acute respiratory diagnosis
Nonrespiratory or chronic respiratory diagnosis

History of central nervous system dysfunction
Neurotrauma, stroke, encephalopathy, cerebral embolism, or seizure/epilepsy:
Yes
No

Acute associated nonpulmonary infection
Any other bacterial, viral, parasitic, or fungal infection not involving the lung:
Yes
No

Neuromuscular blockade before ECMO:
Yes
No

Nitric oxide before ECMO:
Yes
No

Bicarbonate infusion before ECMO:
Yes
No

Cardiac arrest before ECMO:
Yes
No

PaCO₂ ≥75 mmHg (≥10 kPa):
Yes
No

Peak inspiratory pressure ≥42 cm H₂O (≥4.1 kPa):
Yes
No




Patient’s score RESP Score Risk class In-hospital survival
0 0 0 0

ECMO is a resource-intensive endeavor with high morbidity, and patients should be selected carefully. Survival estimates may aid the decision process.

Addition of the selected points:

Age, years18-490
 50-59-2
 ≥60-3
Immunocompromised status at time of ECMO
Any malignancy, solid organ transplant, HIV, or cirrhosis		No0
 Yes-2
Mechanically ventilated before ECMO initiated>7 days0
 48 hours to 7 days+1
 <48 hours+3
DiagnosisViral pneumonia+3
 Bacterial pneumonia+3
 Asthma+11
 Trauma or burn+3
 Aspiration pneumonitis+5
 Another acute respiratory diagnosis+1
 Nonrespiratory or chronic respiratory diagnosis0
History of central nervous system dysfunction
Neurotrauma, stroke, encephalopathy, cerebral embolism, or seizure/epilepsy		No0
 Yes-7
Acute associated nonpulmonary infection
Any other bacterial, viral, parasitic, or fungal infection not involving the lung		No0
 Yes-3
Neuromuscular blockade before ECMONo0
 Yes+1
Nitric oxide before ECMONo0
 Yes-1
Bicarbonate infusion before ECMONo0
 Yes-2
Cardiac arrest before ECMONo0
 Yes-2
PaCO₂ ≥75 mmHg (≥10 kPa)No0
 Yes-1
Peak inspiratory pressure ≥42 cm H₂O (≥4.1 kPa)No0
 Yes-1

Interpretation:

RESP ScoreRisk classIn-hospital survival
≥6I92%
3-5II76%
-1 to 2III57%
-5 to -2IV33%
≤-6V18%

Other factors may contribute to the decision to initiate ECMO (e.g. life expectancy, quality of life, resource availability).

The RESP Score only predicts survival before hospital discharge and does not predict neurologic function or functional status, that may be important considerations. The score was derived from a cohort of patients who were placed on ECMO, and likely excluded many patients who may have had different survival rates.

RESP Score Assessment can be useful in survival prediction and may be incorporated into the decision to initiate VA ECMO.

Prone positioning was not included in the derivation of the RESP Score, and its effect on the predictive value of the score is unknown.

The RESP Score was derived in a retrospective cohort study by Schmidt et al (2014), which included 2,355 patients in the Extracorporeal Life Support Organization (ELSO) registry who received ECMO for acute respiratory failure. Patients receiving ECMO for indications other than acute respiratory failure (e.g. cardiogenic shock) were excluded. Predictive variables with p-values ≤0.05 were included to derive the final score.

The score was prospectively validated in 140 patients (included in initial publication) (c = 0.92, CI 0.89-0.97). In a small retrospective study of 41 patients (Brunet 2017), the score was found to have low predictive value for mortality (c-index 0.60).

Comprehensive decision-making should not be based solely on one prediction rule, and the threshold to initiate ECMO may vary by institution.

Predicts chances of mortality after on ECMO in COVID-19 patients, performing better in validations than PRESET Score.

SAVE (Survival After Veno-Arterial ECMO) Score

Register on our website right now to have access to more learning materials!

Literature:
1. Schmidt M, Bailey M, Sheldrake J, et al. Predicting survival after extracorporeal membrane oxygenation for severe acute respiratory failure. The Respiratory Extracorporeal Membrane Oxygenation Survival Prediction (RESP) score. Am J Respir Crit Care Med. 2014;189(11):1374-82. https://pubmed.ncbi.nlm.nih.gov/24693864/
2. Brunet J, Valette X, Buklas D, et al. Predicting Survival After Extracorporeal Membrane Oxygenation for ARDS: An External Validation of RESP and PRESERVE Scores. Respir Care. 2017;62(7):912-919. https://pubmed.ncbi.nlm.nih.gov/28536282/

Charlson Comorbidity Index (CCI) Online Calculator

Charlson Comorbidity Index predicts 10-year survival in patients with multiple comorbidities.

History of definite or probable MI (EKG changes and/or enzyme changes)

Exertional or paroxysmal nocturnal dyspnea and has responded to digitalis, diuretics, or afterload reducing agents

Intermittent claudication or past bypass for chronic arterial insufficiency, history of gangrene or acute arterial insufficiency, or untreated thoracic or abdominal aneurysm (≥6 cm)

History of a cerebrovascular accident with minor or no residua and transient ischemic attacks

Chronic cognitive deficit

Any history of treatment for ulcer disease or history of ulcer bleeding

Severe = cirrhosis and portal hypertension with variceal bleeding history, moderate = cirrhosis and portal hypertension but no variceal bleeding history, mild = chronic hepatitis (or cirrhosis without portal hypertension)

Severe = on dialysis, status post kidney transplant, uremia, moderate = creatinine >3 mg/dL (0.27 mmol/L)

VariablePointsAge <50…
Read More

Multiple Myeloma Diagnostic Criteria – Online Calculator

≥1 of the following (A or B)

≥1 myeloma defining event (C1 or C2)

For Multiple Myeloma Diagnostic Criteria assessment necessary to provide selection of the…
Read More

Сообщение RESP (Respiratory ECMO Survival Prediction) Score online calculator появились сначала на ClinCaseQuest.

]]>