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Conversations in Pulmonary, Critical Care and Sleep Medicine by the American Thoracic Society
non: [00:00:00] You are listening to the ATS Breathe Easy podcast, brought to you by the American Thoracic Society.
Eddie: Hello and welcome. You're listening to a ATS Breathe Easy Podcast with me, your host, Dr. Eddie Chan, also the host of the ICUN and podcast. Each Tuesday, the ATS will welcome guests who will share the latest news in pulmonary critical care and sleep medicine. Whether you're a patient, patient advocate, or healthcare professional, the ATS Breathe Easy podcast is for you today on the eve of World Pneumonia Awareness Day.
Joining me is Dr. Ramirez, who will discuss the, diagnosis and management of community acquired pneumonia. Welcome, Dr. Ramirez.
Dr. Ramirez: Thank you. Thank you for the invitation.
Eddie: Absolutely. Absolutely. So I think we should, we should probably jump right into it. And I, and I'll say, you know, on the, on the critical care side, one of the things [00:01:00] I've been looking forward to is the, well, I guess maybe, maybe not looking forward to, but watching out for, is the surviving sepsis campaign guidelines.
And, you know, this document I'm preparing for like 200, 300 pages. but one of the thing that first strikes me about this, this update to the guidelines I recently put out is. Is it's more focused. why, why did, why did we decide to do an do an update before we kind of jump into all the things that y'all focused on?
Dr. Ramirez: Yes. I think that, yes, you just e essentially bring the point that, that, that if we want to be, comprehensive in any topic of medicine, in just in a couple of years that you. From the prior guidelines, there's so much new information, and it's so much nuance, that, that we'll have to, we want to make a guidelines for the full management of acquired pneumonia.
We are going to end it with 200 pages, but more important, [00:02:00] this, we are going to take probably three years to go, three, four years to go through. All the evidence. Then, and then we all recognize that we spend three years, four years for a publication. It's already, useless the way that we move in medicine.
Then the, the ATS now decided that, that, that in the new guidelines for pneumonia, the first thing that they committed did was, okay, what are three or four questions that based on our experience has moved? To the point that we need to have some update. They still having a comprehensive update of every management of acquired pneumonia.
We said, well, site of care where the patients should be managed, in the hospital, ambulatory. What patients should be in the intensive care unit? Well, we have not evolved to much. From the prior, then why reviewing things that we are going to come out probably with the same recommendations and essentially moving forward, this is going to be focus, update.
this is why [00:03:00] we, in this guidance, it's only four questions that we, address. and the goal is, okay, instead of waiting another five years, probably one or two years, another three or four questions, then you keep moving. With more, frequent guidelines with whatever we consider is the, the area in this case of mutual pneumonia with more, e evolution based on the, on the evidence that we have.
Eddie: Yeah, so that makes a lot of sense. I, I think that makes a lot of sense. And so based off of what I'm hearing, we should be expecting more of these smaller updates, at least for the community acquired pneumonia guidelines. At, at what, at what frequency do you guys anticipate having these kind of updates out?
It's okay if you don't know that now.
Dr. Ramirez: Yeah. No, I, I don't know that now I know that the, the goal is to have every two, three years to have an update and, okay. What happened the last two, three years? In what area? What, another thing that was, interesting, for instance, is that, that, that one of [00:04:00] the questions that we have this time, that was the role of, ultrasound in the diagnosis of cobi pneumonia.
In the last guidelines, there was only a discussion. Because this is an area of medicine that has evolved so quickly. ultrasound, I mean, you being in critical care, I mean, this is part of your everyday life. They, they did so much, because, remember in the past they were just very specialized and they, the instrument had moved so quickly, they so portable.
Now this is part of training, not initially where the, the pulmonary fellow, but now he's even training of the medical students. Yeah, yeah, sure. Then all of a sudden, and the way that medicine is moving. it's going to be very interesting to see what is new in the last two, three years, and just to move very quickly with these updates.
Eddie: I'm a, I'm a big fan of ultrasound, as you already pointed out, as a critical care provider. You know, there's, there's discussions about should we replace the stethoscope with a, with an [00:05:00] ultrasound? You know, I'm not quite there yet. but yeah, it, it really has moved really quickly. But yeah, I guess that's a good segue into that first recommendation.
But just looking at lung ultrasound versus a chest x-ray at a diagnosed community acquired pneumonia, where the guideline where this update says, for adults with suspected community acquired pneumonia, we suggest. Lung ultrasound is an acceptable alternative for chest x-ray in medical centers where appropriate clinical expertise exists.
So, so, so this is interesting. So you mentioned, you know, we didn't have this question even discussed in the last iteration of guidelines. What, what changed, what happened that made you and the committee think that we need to make a comment on this?
Dr. Ramirez: As I, partially alluded, a technology that evolved very quickly, a technology that is, that is, available and also the, the recognition that these, guidelines, even though.
They are the, the ATS, IDSA [00:06:00] guidelines focused on the, in the US practice, but the recognition that we'll go globally because these guidelines are used globally, and a sign in significant number of places having an x-ray, a chest x-ray machine is not even there. then the, the ultrasound, they will say, well, the ultrasound may resolve a lot of, issues when we're having the, in the diagnosis of pneumonia.
We all recognize that, that that. I mean, the, the problem with pneumonia is a syndrome. No, we don't have a test to say, okay, you have pneumonia. You don't have pneumonia. the patient has signs and symptoms. We listen to the chest, but again, the stethoscope listen to the chest. Then we always say, well, the only way to, to more or less know is the patient has their virlar inflammation, the local inflammatory response.
We need to have a chest rate to see the. The white blood cells in the lung, then you have the pulmonary infiltrator. Okay, I have ural inflammation. but if the chest rate is not [00:07:00] there, then it may be a lot of, overuse or underuse of antibiotic because of poor diagnosis. Now, the ultrasound may resolve this problem in areas where chest rate is not, too, available, then, but the, the challenge that we have is that, that.
We look at the literature and the literature is there, but it was not all these recommendations been it say we suggest because we didn't, we couldn't find an article, say, okay, these patient were managed with ultrasound, these were managed with chest xray. What up with the outcomes really is the ultrasound is as good as the, the, the, the, the studies were, this is an ultrasound, this HS grade, and now I'm going to get a CT scan because I.
Because there's something and then compare with CT scan. Then there was, there were not too many, we couldn't find an article looking at, at clinical outcomes in [00:08:00] patient management with ultrasound. But I think that was enough for us to say that, that, that if the chest grade is not, available, or you are in an ER and you have the ultrasound, and the ultrasound is positive, don't wait for the chest rate.
The patient fulfilled the criteria. If you define a local inflammatory response, this is iCal pneumonia. Go ahead and manage the patient as iCal pneumonia.
Eddie: No, I think this is also very pertinent because, yeah, I wanna come back to one of the points you made that, you know, there, there are places where the chest x-ray isn't readily available, but if you have an ultrasound machine, you can always go ahead and do it.
That's why we call it point of care. Even, even in my own practice, and I've done all my practice here in the, in the United States, that sometimes it takes a while. We have the chest exert machine, but. For, for various reasons. Sometimes a portable chest x-ray can take a while depending on how busy the emergency department is or the hospital is.
what I, what I really appreciated about the guidelines was that if you dive a [00:09:00] little bit deeper into the text, they, you also give us what kind of things we should be looking for. And so these are things that I. I'm teaching medical students and, and residents about when, when I'm looking about lung ultrasound, be it consolidations or irregular contours, air broncho grams, air trapping B lines, the presence of pleural effusion.
So I personally, I really do appreciate how the guidelines really, were a little bit more specific other than just lung ultrasound. Yes. As a general term. The, the, the next several questions there are, they, they're kind of split into different recommendations between whether you're inpatient or outpatient and whether you have severe versus non-severe pneumonia, inpatient versus outpatient.
I think a lot of people already understand, but, but how, how do you want clinicians to determine severe versus not severe? As we talk through the next several questions.
Dr. Ramirez: This is a very [00:10:00] important, factor. I may say that, that for, for, clinicians now that, that seems to be in the medical literature that we tend to, to characterize patients in different groups.
and in the case of Cobi Jaqua pneumonia, where we say, well, there is. Is mild, moderate, and severe. the problem is very simple to say, oh, these mild, moderate. The question is, what is the definition? Yeah. Then, but we tend to agree that, that a mild pneumonia outpatient management. Moderate, admitted to the hospital, to the ward severe, admitted to the hospital, to the ICU.
Then you can say that the, the, the location, the site of care more or less can define if you are mild, moderate, severe. Then, as a general rule, we may say that, well, if the patient. Pneumonia, you are evaluating the patient and sick enough to be in the ICU. This patient qualifies severe, [00:11:00] acquired pneumonia.
again, cy of care based on, on severity. but, but in reality. in, for this, consideration, the, the severe comput upon pneumonia, we, we mention in this guidelines, we apply the same criteria that the prior guidelines use for the, are the A-T-S-I-D-S-A criteria for severe comput point pneumonia.
Then, the, the major criteria that will be you have respiratory failure to the point that, that you, let me, let me put it this way. Uh. From the host response. See, we are discussing with clinicians from the host response. We know that, that the diagnosis is basically this, a local inflammatory response.
This is a systemic inflammatory response. Okay? Local inflammatory response cough, which has chest red, post ultrasound, systemic fever, leukocytosis. This VQ is match. This is hypoxemia. This is. What happened there? Now we know that if the patient is going to have severe pneumonia, [00:12:00] is going to move into a dysregulated inflammatory response or a hyper inflammatory response.
Now the question is how do we recognize this dysregulated inflammatory response? And it's going to go into organ dysfunction. Organ failure, if we all the way to organ failure, or life is simple. You already have respiratory failure. You need to be on a ventilator. Well, this is severe pneumonia. Or you have hypotension.
It doesn't respond to IV fluid. You need based suppressors. Well, this pneumonia, you have septic shock. Then in these two you have you needle mechanical ventilation, needle based suppressors, respiratory failure, septic shocks, you have severe pneumonia. The question is, how do identify the patient with organ dysfunction?
They still does have failure, and in this regard, we still consider that the minor criteria that were described by the A-T-S-I-D-S-A before then. And then for the clinician, it is almost like a, another way to look at this is, okay, [00:13:00] the patient doesn't have respiratory failure. That that doesn't need mechanical ventilation, but the puffy is getting worse, the oxygenation is getting worse.
Then this moving to severe pneumonia. It's not. Doesn't need base suppressor, but I need to get fluids to maintain blood pressure. Is, is hypertension. Move to severe pneumonia from the CNS. The patient is confused, is moving into severe pneumonia. Confusion for hematological failure. The patient has thrombocytopenia.
Is moving into severe pneumonia from the hematological failure. If the patient has increased, lactic acid is moving into severe pneumonia from the renal failure. If the creatinine start moving up, the patient is moving into severe pneumonia. Then it is all these quote unquote minor criteria where you have two or three of these.
This patient, we can define he's having severe pneumonia. then I may say that it's a matter of the clinician looking at the patient and, and understanding the, the pathophysiology is this patient is having a dysregulated [00:14:00] inflammatory response. This patient is moving into organ failure. And then you define, severe acute one pneumonia.
Eddie: Yeah, no, it makes sense. And, and, and it's helpful for me as a critical care provider and doing a lot of research that a lot of these overlap with the, the SOFA criteria, the sequential organ failure assess assessment, which we use in the sepsis three definition to determine sepsis and see, there's a lot of overlap, seemingly
Dr. Ramirez: No, I, I, I agree.
If you were to be doing. SOFA scores. Again, this is not part of the acquired pneumonia, but, but, but still it is, is to me, it's a very good way to be looking at. Okay. How is that the organs is are moving then the deterioration of the SOFA score will be also considered the patient moving into severe acquired pneumonia.
Yes.
Speaker 4: Yeah, absolutely.
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Eddie: So the next question from the guidelines is. Talking about antibacterial therapy for patients who also test positive for a respiratory virus, which I think to summarize, and please correct me if I'm wrong, if, if you have an adult outpatient without comorbidities that you think has community acquired pneumonia and they test positive for respiratory virus, that the, the committee suggests not prescribing empiric antibiotics.
But if you are an inpatient or you have an outpatient with comorbidities, then that you suggest prescribing empiric antibiotics. Is, is that correct? And how did you guys land on that
Dr. Ramirez: exactly? The, the, because this is a little [00:16:00] also different from the prior guide because, with COVID-19, with the pandemic, PCR for virus became more.
Standard then, and nowadays, we start recognizing more and more patient with pneumonia. They have a post PCR for sars, COV two, for influenza, for RSV. And with these panels that we tend to do multiple, viruses, then, then the question is what to do with these patient with RSV. Post PCR that the patient has RSB pneumonia or has RSB pneumonia Plus Pneumococcal pneumonia, it is just a viral pneumonia or it's a viral bacterial coinfection that we have been always The issue with influenza, is this just influenza, or it's influenza plus staph plus.
And then the question is, is when the, when the risk for viral bacteria coinfection is low enough that you're going to say, I feel confident. Not to give antibiotics, [00:17:00] and the only place that we feel confident not to give antibiotics is that you have pneumonia. I going to send you home because you're going to be treated at home and you don't have any comorbidity.
You are almost a, a healthy person. And I have influencer RSB. even no ranvir, well, this probably is just a viral pneumonia. I don't give, I don't need to give you antibiotic. This is a big difference from the last guidelines that, that in the last guidelines, we say, well, whenever we have a virus, since we never know who may have a bacteria, we give antibiotics to everybody.
Now we have a group that if this person is healthy, no comorbidities, you have an influenza, and of course you get an x-ray, you have a big al infiltrate, you're still going to give antibiotic. This is why there is a table in the guidelines table one that will say, what favor these recommendation? Not. [00:18:00] Then you have.
No. 40-year-old, no COPD, no. Diabetes. He's healthy. Yes, he has an influenza and you get an x-ray and there's a big alur infiltrate. Well, this is influenza plus meco, and we're not going to say send this patient home without antibiotics. You have to look at the patient. But, but if you have, you know, the, the, the classical.
Sar Cov two, you get an X-ray, little bit of gland graft opacity. The patient is fine. The white blood cell count, you get what cell count is no, 11,000. Don't give antibiotic. This patient has just a viral pneumonia. Now, once you get admitted to a hospital, you have comorbidities. We still say that, that we decided to give antibiotics and then do the, the workup.
And in 24, 48 hours, blood cultures are negative. Procal C is normal. And then you start, you start coming with. Putting the case together to see is this a viral pneumonia only or a viral plus bacterial pneumonia. You may discontinue [00:19:00] antibiotics or not. But empirically we think that we don't have enough, laboratory of clinical data in a hospital space that can tell me, oh, this a viral pneumonia, and I'm not concerned that he may have a bacterial coinfection.
Eddie: No, I think this is, this is really interesting to me. In fact, if I take a step back away from community choir in a million or otherwise, it seems like historically there's been this push for antibiotics and early antibiotics in particular. But as we, as we do this more and more, there's pushes both on the, well, maybe not everybody needs antibiotics.
And antibiotics are medicines and drugs just like anything else. And everything has their side effects. And so if they're not a benefit, then they're just represent risks without a benefit. But then the other side of it, which is actually the the third guideline question, unintentional segue is can we shorten that duration of antibiotics?
Do we need that longer duration of antibiotics? I remember. Through, through I, my training and through all [00:20:00] the, the board exams and test taking, we have to memorize, oh, for this infection, we need this length of an antibiotics. And for this infection we need this length. And it's five days, seven days, 10 days, 14 days, six weeks for some things, eight weeks for some things.
And it's just a whole, whole big soup. But we're challenging that now.
Dr. Ramirez: No, exactly. I think that we challenge this for, for, for the logical reason, and this is why in these guidelines, there've been a lot of emphasis of, of phenotyping. The patient with, with the, have the idea that, that we need to, we need to tailor therapy.
And of course, in retrospect now we say that, how could it be that, that for pneumococcal pneumonia, you, you cannot have a fixed number of days for any infection. You're going to depend on the pathogen, the virulence, the, the bacterial load, the immune system of the patient, how the immune system is going to respond.
I will give them the appropriate antibiotics. Then, duration of therapy needs to be individualized. The, the question here was [00:21:00] what would be in a patient that is responding very well that you hit the right antibiotics, that the patient is not critically ill, what would be the minimal duration of therapy?
And here is that when we say, okay, how short can we go? this is different from the prior gala. The prior guide, we say, well, a minimum of five days because probably it will give less than five days. Some patient are going to relapse or, or they going to have a recurring pneumonia. But now there are not too many studies, just a handful of studies indicated that the patient is not sick.
Of course, we're not discussing severe acute upon pneumonia, but the patient has pneumonia. And doesn't have too much of a comorbidities, and it has a very good clinical response. Probably, three days of antibiotics. Is sufficient for patients that we don't have any evidence. Uh uh and again, any, and here we separate some pathogens.
[00:22:00] Staphylococcus Oreos may take longer. Pseudomonas is going to take longer, and there are some pathogens that definitely going to take longer. But the streptococcal pneumonia, helo influenza. The patient is doing fine. Very rapid clinical improvement. probably three days is so that you need. Now the question is how many days do we need to sterilize the alveolar of the patient?
But of course we don't know. uh. But the, but another concept there is that you are health what relatively healthy. Probably in three days I decrease the bacteria load in your lung to either you don't have anymore. Helo influenza or whatever is there, your macrophages are going to take care of this.
They were not saying that in three days everybody is going to have an sterile lung, but probably in three days we flip things around and, and the patient has rapid clinical improvement. Three days is going to [00:23:00] be, or what is necessary for a significant number of patients. Now, at no point we say. A patient with pneumonia use three days?
No. No. We need to look at the patient and say, if the patient is stable, does it have any complication? Of course, there's no ple effusion, there's no, lung, because you can get better, but you have, there's no bacteremia. This, I mean, everything looks good. Then three days is all that you need.
Eddie: Yeah. No, that makes sense.
And especially since there is a, disclaimer in early in the guidelines to say that, that these guidelines weren't meant for those who are immune compromised. Exactly. That if you, you get to this point, you're talking about like the, there's sterilization of alveoli, but, but you don't, you don't need that.
Right. So you can get to the point where our immune systems can take back over, as you said. So that, that, that makes a lot of sense to me. I think when I, when I talk with. With patients about this too. It's, you know, you don't need to take antibiotics until you feel back to a hundred percent right? And I think that's a, that's an important part of [00:24:00] an expectation setting.
After three days, you, you, you probably, hopefully will be feeling a little bit better, but you might not be feeling all the way better and that's okay. as far as the natural prog natural progression of this disease, agree. So, we'll end this antibiotic duration section. I think, you know, two, two of these, recommendations are, or suggestions are, are pretty straightforward for adult outpatients.
With a community-acquired pneumonia who reach clinical stability, we would suggest less than five days, at least three days of duration. And then for adult inpatients with severe community-acquired pneumonia, we suggest five or more days of antibiotics. But this middle one, at least just by pure percentages, seem to have the most.
I don't know, controversy might be a strong word, but the most disagreement within the committee where for adult in patients with non-severe community-acquired pneumonia who reach clinical stability, we suggest less than five days of antibiotics, minimum of three days duration rather than five or more days of antibiotics.
And [00:25:00] said 69% of committee members voted in favor of this section. Can, can you, are you privy to taking me behind it? Oh,
Dr. Ramirez: no, no. Yeah, yeah, yeah. But this, this, this was, uh. This was a yes, a, a critical issue. Because, because here, the, the, the, there is some data suggesting that, that that three days may be enough in the studies with a lot of exclusion criteria, a lot of exclusion criteria, and, and there was, and they're looking at, at mortality.
And there was one patient in the short course therapy. That die because the patient hasor bacteremia and receive, three days. And as we discussed, you knowOr bacteremia for three days. Then, then the question here is the patient is hospitalized. Um. Well, let me, I, I don't want to bring my bias. [00:26:00]
Eddie: No, this, this is your, this is your time to shine,
Speaker 4: right?
Well, no, but, but because I was, I was, I was part of the, the, the negative boat. Yeah.
Eddie: Good. That's, that's perfect. That's exactly, that's
Dr. Ramirez: hospitalized. This is hospitalized. We have, you know, five, 6% mortality, and, and the difference between three days. And, and five days is, is not such, to me, not such a, a big deal in this patient.
Then I would say, the, the problem is that, that this is a, for a very, very selective group of patients, and I'm concerned that, that, that with so much. if we just said hospitalized, patient can be treated with three days, someone may miss the ance sta or this is, or the patient has, you know, plural fluid and because I've seen so many patients with computer pneumonia.[00:27:00]
When we review our EMPAA cases at our VA hospital, a lot were patients with co pneumonia treated with short duration of therapy. But essentially we miss that there was a collection of fluid there that require more. I mean, and I, I wanted to be a little more conservative. In the, in the hospitalized patients.
but the majority, but this is why it's interesting that you pick up on this 69%. This was a very controversial recommendation, okay. To, to give three days for the person that was sick enough to be hospitalized because this another thing, because this are thing, oh, the patient is hospitalized, but who is hospitalized?
If you are very liberal, everybody get hospitalized, but at least. In, in, in the United States. Now to be hospitalized, you have to be sick. You're not going to get into a hospital with a, with a moderate [00:28:00] pneumonia. You have then, I was considering that, that that probably is better to maintain the five days for the hospitalized patient, but it was a big discuss.
Eddie: Yeah. No, it, it, it's good. I think, you know, it's guidelines can, can be considered so, so black and white?
Dr. Ramirez: No, I, I, this is, you pick up on this, this is why we decided that it was very important. To put the percentage of people that vote one way or the other because then, because otherwise the guy recommend this and then you are there and say, well, I tend to disagree.
But then you can figure out, okay, what was the agreement when you have, because there were nine ATS members and nine IDSA members. Then you can say, well, this 100% agreement. Then you can say, well, you know, most likely, again, we don't have a good. But at least these 18 people are doing the same with the evidence that we have.
But when you [00:29:00] have, disagreement among the committee members, after one year of discussion, you may say, well, I still can, I can follow this recommendation or not, because it's not agreement among the quote unquote experts.
Eddie: Yeah. I, I really, I personally, as a clinician, I really appreciate it because I think it is important to highlight these gray areas where it's, it's not as black and white.
Some of some of these are pretty easy, but if it was easy, that's, that's not what I need the guidelines for, right? I, I need, I need the advice and the expert recommendations for these gray areas, and so. I've really appreciated that and I think a lot of people do too. But the last question I think is, was a little bit more clear, talking about like a hundred percent agreement, with some of the committee members.
And it's talking about, corticosteroids for community acquired pneumonia. and, and this, this, I, this, this was recommendation was pretty straightforward and had a lot of agreement. For inpatients with non-severe community-acquired pneumonia, we recommend not administering systemic [00:30:00] corticosteroids.
And then for adult inpatients with severe community-acquired pneumonia, we suggest systemic corticosteroids. And there was near a hundred percent on both of these, for agreement. Why, why was this something that you thought the committee needed to comment on? and take me, take me a little bit behind the scenes on some of this.
Dr. Ramirez: Yes. Well, again, this was, in the prior guidelines, the recommendation was not to give steroids because, but, but then since the last guidelines had been a couple of very good, prospective is still one very good prospective started done at the our VA hospitals here across the us That was negative.
Steroids didn't decrease mortality. One very good, study done in intensive care units in France that showed that steroids decreased mortality. Then it's, doesn't mean that, that, the new evidence is [00:31:00] all very clear, but, but it was a discussion looking at the designs of the studies, and what happened and, and then, the, and then of course looking at, at, at other studies.
And meta-analysis. and there was a, a consideration that even adding the negative studies were more in favor of steroids, decreasing, mortality. The, the, the question still is in severe compute according then in when we separate. Non-severe and severe in, in non-severe acute cord pneumonia. There is no decreased mortality, then probably non-severe.
We can gain the, the, the toxicity or adverse events without any clinical benefit. The non-severe was simple, but in the severe. Then there were some studies. Positive, some negative, but in the meta-analysis, I think there was, you need to treat, 18 patients or 17 patients to [00:32:00] get one decreased, mortality.
and, and at this moment we thought that that until more evidence. Is, generated, probably if we, we need to make a decision now. And people say, well, based on this, what would you do in your institution? Well, Athena, we recommend steroids for severe computer pneumonia. The, the retrospective data on influenza acquired pneumonia.
again, this is not prospective randomized, but retrospective data has been that steroids may even. Deteriorate outcomes. Then the studies, for instance, the French study decided to exclude a patient with influenza. This is why we say that in influenza, probably we don't recommend steroids because retrospective data, but who knows?
The pro, when we get prospective studies, we need to figure out. But then for, for influenza, for aspergillus, we don't recommend steroids, but for, for the classical bacteria, [00:33:00] pneumonia, severe pneumonia, probably steroids. The, the challenge is. That we all recognize is, is, is the patient has the quote unquote cytokine storm or the, the hyper inflammation, probably ster may be.
Good. But the problem is that it's difficult to identify these patient I we go back to, to, your Eddie. Your first question, what is severe al pneumonia? Right? 'cause this is, we still don't know then if I were to know for sure that these patient has severe AL pneumonia due to hyper inflammation and due to cyro and storm, well probably steroids are going to be good.
But then there are so many other reasons why the patient may deteriorate clinically and the patient may have hypoxemia. this is an acute mi. That develop because of the pneumonia and the hypoxemia has nothing to do with cyro storm. It's because, because of congest failure, then, we're still, trying to, this is [00:34:00] why we discussed that, that looking at the, at the, looking at the clinical phenotype, we say, well, the patient needs to have severe pneumonia, some form of organ dysfunction, looking at the inflammatory phenotype, ideally want to see.
Very high elevated CRP that is telling me that now I have a little bit of organ dysfunction, but I all have, even though the CRP, that is a reflections we know of the inter level of interleukin six that goes to the liver and, and favored production of of CRP. Well, if I have elevated CRP. But now that we are going to be able to measure more cytokines, but, but we still have to define the, the, the patient that is hyper inflammation that will benefit the most from, from steroids.
And this is part of what we mentioned, no future research better, better biomarkers to define, the patient that will benefit better for steroids.
Eddie: Yeah, no, you, you already pointed it out and it, [00:35:00] it is a little bit full circle for this conversation for me too. You know, I'm a, I'm a intensivist, so I can keep things a little bit simple for myself to make it easy.
But if, if I think that the problem is inflammation, then the anti inflammatory medicine like steroids seems like a reasonable choice here. So when you get into, you were talking earlier in this conversation about. Severe community acquired a million, you're talking about this dysregulated, systemic host response to inflammation.
And maybe that's where the problem is that this makes a lot of sense. But yes, o of course, you know, I'm, I'm very active in some of the research talking about like, you know, different patients who present the same, might have different etiologies, whether it's AFL inflammatory phenotype or, or whatever.
So, so there's, there's a lot of what you say about future research that resonates with me personally here. I, I think, you know, so that, that, those were the four questions that we talked about for the, for the guidelines. In addition to the recommendations that were made, is there anything that [00:36:00] you would wanna share with clinicians as it pertains to the treatment of community acquired pneumonia?
Dr. Ramirez: Well, I may say that one of the channel that we have is that as we learn more. I, it is interesting in pneumonia, I may say that I've been doing research in pneumonia for years. what we said is a balance between the, the pathogen virulence and the immune response, not the immune protection. Uh and in the past we give a lot of emphasis to the pathogen and the right antibiotic, but now we are learning more and more.
The pro, the host response is. It's critical. and as you alluded, this, this type of, the modulating the horse response, we are going to be having more and more, ways to modulate the horse response. then steroid is another thing. Steroid is a big thing that, that downplay the full immune system.
That probably this is a very, is a very broad spectrum. We need to be [00:37:00] a little more, specific. I would learn. To modulate the, the host response. And this go back to the, the, that's happened all across medicine. We want to do personalized medicine. We need to do better, phenotyping, and, and as. And we need to do also, I mean, phenotyping for the clinician that will be know the pneumonia is not a simple group of patients.
We can sub classify the patients, and this is important. Now I see a patient with pneumonia. It is severe pneumonia. No severe pneumonia is inflammation. No inflammation. These are characteristics. I need to classify the patient. But now in, in, in research, we know that the endot typing of patient trying to, to define at the molecular level what is the pathogenesis or the, that is happening Then, then we have no considerations, like, like proteomics or metabolomics, transcriptomics.
And then we see these very nice articles that show the patient is admitted with pneumonia, and now I have all these. Hundred genes and these genes are [00:38:00] elevated. These are all inflammatory genes. These are, and then I say, wow, I can figure out at the genetic level. And then I want to know the patient has a bacteria pneumonia.
A viral pneumonia. This is inflammation. Well, this is in the future, but I, I don't know. I don't know how. How far in the future now with artificial intelligence? I don't know in the future, maybe tomorrow, but, but, but again, we are moving from phenotyping to genotyping and this can be a, a totally different way that then we can definitely do personalized medicine in computer one pneumonia.
Eddie: Yeah. No, that, that makes, that makes a lot of sense. That makes a lot of sense for me overall. And, and I'll, and I'll point out that you mentioned artificial intelligence, not me. I think that's come up on every single episode that I've, I've recorded here with the, with the breathe easy. is there anything else that you wanna talk, do you wanna talk about today, Dr.
Ro? Oh, no, I
Speaker 4: think that, I think that we, we covered, we did a, a big overview. Great.
Eddie: Great. Well, well thank you so much for your time and thank you to everyone listening for joining us [00:39:00] for today's ATS Breathe Easy episode. Please subscribe and share this episode with your colleagues. Put it, put it on your calendar to register for the ATS International Conference in Orlando in May.
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