Assessment of CAP Severity

by Pneumonia Scores

Gamal Rabie Agmy, MD, FCCP Professor of Chest Diseases , Assiut University

Pneumonia

Scores

Clinical prediction rule recommended

by the British Thoracic Society that has

been validated for predicting mortality

in community acquired pneumonia and

therefore helps predict inpatient vs

outpatient treatment.

CURB-65

Each risk factor scores one point with a

maximum score of 5.

Confusion of new onset

Urea > 7 mmol/L

Respiratory rate >30/min or greater

Blood pressure <90 mmHg systolic or <65

mmHg diastolic

Age >65 years

CURB-65

The risk of death at 30 days increases as

the score increases:

0 - 0.7%

1 - 3.2%

2 - 13.0%

3 - 17.0%

4 - 41.5%

5 - 57.0%

CURB-65

Disposition recommendations based on

score:

0-1: Treat as an outpatient

2-3: Consider a short stay in hospital or

watch very closely as an outpatient

4-5: Requires hospitalization, consider ICU

admission

CURB-65

7

CURB 65 Rule – Management of CAP

CURB 65

Confusion

BUN > 30

RR > 30

BP SBP <90

DBP <60

Age > 65

CURB 0 or 1 Home Rx

CURB 2 Short Hosp

CURB 3 Medical Ward

CURB 4 or 5 ICU care

Each risk factor scores one point with a

maximum score of 4.

Confusion of new onset

Respiratory rate >30/min or greater

Blood pressure <90 mmHg systolic or <65

mmHg diastolic

Age >65 years

CRB-65

9

CRB 65 Rule – Management of CAP

CRB 65

Confusion

RR > 30

BP SBP <90

DBP <60

Age > 65

CRB 0 or 1 Home Rx

CRB 2 Short Hosp

CRB 3 Medical

Ward

CRB 4 ICU care

Each risk factor scores one point with a

maximum score of 8.

Confusion of new onset

Urea > 7 mmol/L

Respiratory rate >30/min or greater

Blood pressure <90 mmHg systolic or <65

mmHg diastolic

Age >65 years

LDH > 230 u/L

Albumin <3.5 g/dL

Platelet count <100 × 109/L

Expanded CURB-65

The expanded-CURB-65 score was

categorized into three classes as follows:

0–2 as low risk, 3–4 intermediate risk, and

5–8 high risk. Accordingly, patients with

one of three tiers of scores should be

treated either as outpatient, or inpatients in

hospital ward or ICU, respectively.

Expanded CURB-65

0–2  2.57% mortality

3–4 14.89% mortality

5–8 41.76% mortality

Expanded CURB-65

This is a more complex scoring system

which stratifies patients into low, moderate

or high risk, advocating outpatient

treatment for those in the low risk group.

Pneumonia Severity Index (PSI)

A patient can only be in the low risk group if they

satisfy the following criteria:

1-Age >50,

2-No malignancy, CCF, cerebrovascular, renal or

liver disease,

3-Normal mental state,

4-Satisfactory vital signs: HR<125, RR <30,

systolic BP >90 mmHg, temp 35-40C

Pneumonia Severity Index (PSI)

15

PORT Scoring – PSI

Clinical Parameter Scoring

Age in years Example

For Men (Age in yrs) 50

For Women (Age -10) (50-10)

NH Resident 10 points

Co-morbid Illnesses

Neoplasia 30 points

Liver Disease 20 points

CHF 10 points

CVD 10 points

Renal Disease (CKD) 10 points

Clinical Parameter Scoring

Clinical Findings

Altered Sensorium 20 points

Respiratory Rate > 30 20 points

SBP < 90 mm 20 points

Temp < 350 C or > 400 C 15 points

Pulse > 125 per min 10 points

Investigation Findings

Arterial pH < 7.35 30 points

BUN > 30 20 points

Serum Na < 130 20 points

Hematocrit < 30% 10 points

Blood Glucose > 250 10 points

Pa O2 10 points

X Ray e/o Pleural Effusion 10 points

Pneumonia Patient Outcomes

Research Team (PORT)

16

Classification of Severity - PORT

Predictors Absent

Class I

70

Class II

71 – 90

Class III

91 - 130

Class IV

> 130

Class V

17

CAP – Management based on PSI Score

PORT Class PSI Score Mortality % Treatment Strategy

Class I No RF 0.1 – 0.4 Out patient

Class II 70 0.6 – 0.7 Out patient

Class III 71 - 90 0.9 – 2.8 Brief hospitalization

Class IV 91 - 130 8.5 – 9.3 Inpatient

Class V > 130 27 – 31.1 IP - ICU

Recent Australian studies have developed

severity scoring systems (eg CORB,

SMART-COP) that are based on predictors

of requirement for intensive respiratory or

inotrope support, in addition to

mortality. The CORB score is simpler and

does not rely on investigation results

however it is less sensitive than SMART-

COP.

CORB and SMART-COP

Confusion (acute)

Oxygen saturation 90% or less

Respiratory rate > 30 breaths per minute

Blood pressure < 90 mm Hg (systolic) or <

60 mm Hg (diastolic)

'Severe CAP' is defined as the presence

of at least two of these features and has a

sensitivity of 81% and specificity of 68%

for predicting need for IRVS.

CORB

SMART-COP

SMART-COP

Interpretation of SMART-COP score:

0 to 2 points—low risk of needing intensive

respiratory or vasopressor support (IRVS)

3 to 4 points—moderate risk (1 in 8) of needing

IRVS

5 to 6 points—high risk (1 in 3) of needing

IRVS

7 or more points—very high risk (2 in 3) of

needing IRVS

Severe CAP = a SMART-COP score of 5 or

more points

SMART-COP

0–2  5.48 % mortality

3–4 22.75 % mortality

5–8 60.87 % mortality

A-DROP

It was developed in Japan

Age, Dehydration, Respiratory failure,

Orientation disturbance, Systolic blood

pressure.

0-1 Low risk Home treatment

2 Intermediate risk Hospitalization

3-5 High risk ICU admission

A-DROP

0–1  4.76 % mortality

2 16.07 % mortality

3-5 41.77 % mortality

Indications for admitting CAP patients to ICU

Major Criteria(1/2 sufficient)

• Acute respiratory failure(mechanical ventilation)

• Severe sepsis or septic shock(need of vasopressors)

Minor Criteria (ICU admission

recommended if ≥3) • Respiration rate ≥ 30/min • Multi lobar involvement

• PaO2:FiO2 ≤250 +/-SaO2 <90% with 6 L O2

• Confusion/ disorientation • Uremia BUN ≥20 mg/dl

• Leukopenia WBC < 4 x 109/L

• Thrombocytopenia Tc < 100.000 / mm3

• Hypothermia core temp< 36°

• Hypotension requiring aggressive fluid resuscitation