What are the immediate management steps for a patient with atypical pneumonia, increased work of breathing, worsening cough, and hematemesis, currently receiving continuous albuterol?

Critical Questions and Assessment for 16-Year-Old with Atypical Pneumonia, Increased Work of Breathing, and Hematemesis

Immediate Life-Threatening Assessment

Stop continuous albuterol immediately and reassess the diagnosis—this patient likely does NOT have asthma or bronchospasm as the primary problem, and continuous albuterol is inappropriate for pneumonia without documented bronchospasm. 1, 2

Hematemesis Evaluation (URGENT)

• What is the volume and character of blood? Frank red blood vs. coffee-ground vs. blood-streaked sputum 3
• Is this true hematemesis (GI bleeding) or hemoptysis (pulmonary bleeding)? This distinction is critical—ask if blood came with coughing or vomiting 3
• When did hematemesis start relative to continuous albuterol? Albuterol can cause significant cardiovascular effects including tachycardia and hypertension that could precipitate bleeding 2
• Any history of recent forceful coughing or vomiting? Mallory-Weiss tear from severe cough is possible 3
• Current hemodynamic status: Heart rate, blood pressure, signs of hypovolemia or shock 1, 3

Respiratory Status Assessment

• Current oxygen saturation and FiO2: Target SpO2 >92% 1, 3, 4
• Arterial blood gas results: Essential to assess both oxygenation (PaO2 target >8 kPa) and CO2 retention 1, 3
• Respiratory rate and pattern: Tachypnea, use of accessory muscles, ability to speak in full sentences 1, 3
• Bilateral breath sounds: Crackles vs. wheezing vs. decreased air entry—wheezing should be minimal or absent in pure atypical pneumonia 5, 6, 7

Why Is This Patient on Continuous Albuterol?

This is the most critical question. Atypical pneumonia does NOT typically cause bronchospasm requiring continuous albuterol. 5, 6, 7

• Was there documented wheezing on exam or just increased work of breathing? Increased work of breathing from pneumonia does not equal bronchospasm 1, 3
• Does patient have underlying asthma? M. pneumoniae and C. pneumoniae can exacerbate asthma, which would justify bronchodilator use 6
• What was the response to albuterol? If no improvement in work of breathing, it should be discontinued 1, 2
• Any cardiac arrhythmias or tachycardia? Continuous albuterol can cause significant cardiovascular effects and arrhythmias 2

Pneumonia-Specific Assessment

Severity Markers (Determine if ICU-Level Care Needed)

• Mental status changes or confusion? 1, 3
• Systolic BP <90 mmHg or diastolic BP <60 mmHg? 1, 3
• Respiratory rate ≥30 breaths/minute? 1, 3
• Bilateral or multilobar infiltrates on chest X-ray? 1, 3
• Volume depletion status: Assess for need of IV fluid resuscitation 1, 3, 4

Diagnostic Workup Completion

• Has appropriate antibiotic therapy been initiated? Should be started within 1 hour of presentation for severe CAP 1, 3
• What antibiotics are being given? Atypical pneumonia requires macrolides, doxycycline, or fluoroquinolones—NOT beta-lactams alone 5, 6, 7
• Legionella urinary antigen testing done? Essential in severe CAP 1, 3
• Complete blood count, electrolytes, liver/renal function obtained? 3

Extrapulmonary Manifestations of Atypical Pneumonia

Atypical pneumonias are systemic diseases with characteristic extrapulmonary features that help differentiate the causative organism. 6

• Neurologic symptoms: Headache, confusion, encephalitis (common with M. pneumoniae) 6
• Dermatologic findings: Rash, erythema multiforme (M. pneumoniae) 6
• GI symptoms: Diarrhea, abdominal pain (Legionella) 6
• Hepatic involvement: Elevated transaminases (Q fever, Legionella) 6
• Cardiac manifestations: Myocarditis, pericarditis (M. pneumoniae) 6

Monitoring Parameters (Must Be Done at Least Twice Daily)

• Temperature, respiratory rate, pulse, blood pressure 1, 3, 4
• Mental status 1, 3, 4
• Oxygen saturation and inspired oxygen concentration 1, 3, 4
• Hemoglobin/hematocrit if ongoing bleeding 3

Critical Pitfalls to Avoid

• Do not continue bronchodilators without documented bronchospasm—this wastes resources and causes unnecessary side effects 1, 2
• Do not use beta-lactam antibiotics alone for atypical pneumonia—they are completely ineffective 5, 6, 7
• Do not delay oxygen assessment beyond 3 hours—this is an independent risk factor for death 3
• Do not assume hematemesis is minor—assess volume status and consider GI consultation if true hematemesis 3
• Do not delay ICU transfer if severity criteria are met—delayed ICU admission increases mortality 3