How to diagnose a potential lung infection in a 96-year-old bedbound female patient with a history of Gastroesophageal Reflux Disease (GERD) who is on hospice care and presenting with yellow oral secretions?

From the Guidelines

For a 96-year-old bedbound hospice patient with GERD who has yellow secretions from her mouth, a focused physical examination and assessment of vital signs, including oxygen saturation, respiratory rate, and temperature, are the most appropriate initial steps to evaluate for a possible lung infection, as they can help identify signs of respiratory distress or infection without causing undue discomfort or stress to the patient 1. Given the patient's advanced age and hospice status, the primary goal is symptom management rather than definitive diagnosis or life prolongation.

• A comprehensive medical history and physical examination can help define the severity of the condition and exclude other potential sources of infection, as recommended by guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia 1.
• The yellow secretions could represent infected respiratory secretions, but could also be related to her GERD with regurgitated stomach contents mixed with saliva, highlighting the importance of considering the patient's underlying conditions in the diagnostic approach 1.
• Limited diagnostic testing, such as pulse oximetry or a portable chest X-ray, may be considered if consistent with hospice goals and if the results would meaningfully change management to improve comfort, as the primary goal for hospice patients is symptom management rather than definitive diagnosis or life prolongation.
• Sputum culture of the secretions could identify specific pathogens, but this should be balanced against the potential discomfort and stress caused to the patient, and should only be done if the results would guide changes in management that would improve the patient's comfort and quality of life 1.
• Blood tests, such as a complete blood count, may be considered if aligned with care goals, but should be used judiciously and only if the results would inform changes in management that would improve the patient's comfort and quality of life.

From the Research

Diagnostic Approach

To diagnose a lung infection in a 96-year-old female patient with a history of GERD, who is bedbound and on hospice, the following steps can be taken:

• Take a comprehensive patient history, including the patient's symptoms, medical history, and current medications, as outlined in 2
• Perform a physical examination to assess the patient's overall condition and look for signs of lung infection, such as cough, sputum production, and shortness of breath
• Use diagnostic testing, such as chest X-rays or blood tests, to support the diagnosis, but only if the test is medically appropriate and aligned with the patient's values and preferences, as discussed in 3

Treatment Considerations

If a lung infection is diagnosed, treatment options may include antibiotics, such as piperacillin-tazobactam, which has been shown to be effective in treating pneumonia in patients with COPD, as demonstrated in 4

• However, the effectiveness of piperacillin-tazobactam in critically ill patients may be limited by its pulmonary penetration, as noted in 5
• High-frequency chest-wall oscillation (HFCWO) may be used to help remove sputum and improve lung function, as described in 4

Patient-Centered Care

It is essential to involve the patient and their family in the decision-making process, taking into account their values, preferences, and goals of care, as emphasized in 3

• The patient's bedbound status and hospice care should be considered when developing a treatment plan, with a focus on comfort and symptom management
• The patient's history of GERD should also be taken into account, as it may impact their respiratory symptoms and treatment options