Pneumonia

[ResTech]

When it comes to assessing lung sounds of a pneumonia patient, crackles are mostly heard from the exudates, inflammation, and resulting fluid which I understand. But what is typically heard when the patient actually has an area of consolidation?

With consolidation, I understand it to be an area of infection that has basically solidified and is no longer taking part in the gas exchange process. So to me the area of consolidation would have very little to no air movement, correct?

So I guess my actual question is, is it to be expected to have a focal absence of breath sounds in the portion of the lung that has become consolidated?

And how long does it usually take for a pneumonia to progress to consolidation?

Is consolidation something that will normally present in the pre-hospital field or are most pneumonia patients who call 911 still early enough in the infection process to only display with the crackles and sometimes wheezes?

All replies are greatly appreciated.

 

[daedalus]

If you can't hear normal sounds in a localized area, I suppose you could percuss. Consolidation would not produce the normal resonance, and would probably be a "flat" sound. Than again, large solid tumor vs consolidation is something you might have to consider. You could also try to auscultate for bronchophony.

On a prehospital run, this patient would likely have impaired diffusion, so your treatment would be aimed at correcting oxygen levels and relieving symptoms.

My 2 cents, I am sure that Vent or someone else can give you much better information.

 

[VentMedic]

And how long does it usually take for a pneumonia to progress to consolidation?

That would depend on which of the many different types of the PNA the patient has, how many lobes are involved, cardiac disorders, lung condition, liver diseases and their over all health.

Some delay calling 911 because they write it off as a "little bronchitis, a touch of asthma or a little cold coming on". Some may think the pain in some lung region is from coughing too hard. Thus, if the patient says they have been feeling a little sickly for several days even if it sounds like nothing, they had more than enough time to have a consolidated area(s).

Some may have been seen earlier in the ED or clinic but did not have radiographic evidence of PNA at that time. They may have been sent home with some type of antibiotic but without a sputum specimen, the antibiotic may not provide the right coverage. Sometimes a bronchoscopy is required to get the right specimen to determine what the right treatment. This is particularly true with PCP. There are other infections that also mimic PNA with consolidation. There are conditions that result from poorly treated PNA from a prior time or that area of the lung may have been damaged by some type of PNA such as a necrotizing bacterial type.

The other thing to consider is atelectasis from hypoventialtion, injury, disease states that restrict air flow, conditions within the abdomen that hamper diaphragmatic excursion such as ascites, obesity or pregnancy.

 

[ResTech]

Thanks for the info... so when auscultating breath sounds of a patient with pneumonia like presentation, if you hear air movement in all fields except for an area say in the right apice, that could very well be consolidation and where the infection is?

 

[VentMedic]

One also has to look at the body shape when noting the apex part of the lung. Scoliosis? Kyphosis? Any rotation of apical vertebra?

What about a hx of CA (breast or oropharyngeal) that required radiation? Pneumo? COPD or marijuana smoker? Bullae? Surgical removal of bullae?

 

[ResTech]

Say in a patient that is 80 years old, no medical history, normal body shape, not a weed smoker, is presenting with pneumonia S/S.... lung sounds reveal some crackles and than you get to a certain area of the lung and nothing... no air movement... would it be accurate to suspect an area of consolidation and a pneumonia that has been brewing for at least a few days?. Or would the consolidated area be altered in pitch.

 

[VentMedic]

Say in a patient that is 80 years old, no medical history, normal body shape, not a weed smoker, is presenting with pneumonia S/S.... lung sounds reveal some crackles and than you get to a certain area of the lung and nothing... no air movement... would it be accurate to suspect an area of consolidation and a pneumonia that has been brewing for at least a few days?. Or would the consolidated area be altered in pitch.

By s/s do you mean she has a temp? A cough? Productive? Flu like symptoms?

By altered in pitch, do you mean decreased? Rub? Tracheal? Bronchial? Vesicular? Bronchovesicular?

Discomfort on inspiration or expiration? Bronchophony? Egophony? Fremitus?

Other things to consider when assessing the lungs:
Aspiration? Recent dental work? Taking amiordarone? Pneumonitis?

PNA can be a catch all diagnosis until other differentials can be examined. In the field you may just have to treat the signs and symptoms. If you want to call it PNA for your treatment pathway, you should be okay. However, if dealing with a complex patient such as those in a nursing home or even this healthy appearing elderly person, the obvious won't always be the primary cause. Some hear the crackles and assume something without looking further for other conditions.