3 Diagnosis and assessment

Diagnosing pneumonia

3.1 During the COVID‑19 pandemic, face to face examination of patients may not be possible. Advice on how to conduct a remote consultation can be found in BMJ guidance on COVID-19: a remote assessment in primary care, which includes a visual summary for remote consultations.

3.2 Where physical examination and other ways of making an objective diagnosis are not possible, the clinical diagnosis of community-acquired pneumonia of any cause in an adult can be informed by other clinical signs or symptoms such as:

3.3 Assessing shortness of breath (dyspnoea) is important, but may be difficult via remote consultation. Tools such as the Medical Research Council's dyspnoea scale or the CEBM's review of ways of assessing dyspnoea (breathlessness) by telephone or video can be useful.

Assessing severity

3.4 Use the following symptoms and signs to help identify patients with more severe illness to help make decisions about hospital admission:

  • severe shortness of breath at rest or difficulty breathing

  • coughing up blood

  • blue lips or face

  • feeling cold and clammy with pale or mottled skin

  • collapse or fainting (syncope)

  • new confusion

  • becoming difficult to rouse

  • little or no urine output.

Use of assessment tools

3.5 Be aware that the CRB65 tool has not been validated in people with COVID‑19. It also requires blood pressure measurement, which may be difficult or undesirable during the COVID‑19 pandemic and risks cross-contamination (see recommendation 1.4).

3.6 Where pulse oximetry is available use oxygen saturation levels below 92% (below 88% in people with COPD) on room air at rest to identify seriously ill patients. While the ROTH tool has been suggested as an alternative where pulse oximetry is not available, its use has not been validated in people with COVID‑19 and there are concerns that it may underestimate illness severity (see the CEBM's rapid review of the use of the Roth score in remote assessment).

3.7 Use of the NEWS2 tool in the community for predicting the risk of clinical deterioration may be useful. However, a face-to-face consultation should not be arranged solely to calculate a NEWS2 score.

Differentiating viral COVID-19 pneumonia from bacterial pneumonia

It is difficult to determine whether pneumonia has a COVID‑19 viral cause or a bacterial cause (either primary or secondary to COVID‑19) in primary care, particularly during remote consultations. However, as COVID‑19 becomes more prevalent in the community, patients presenting with pneumonia symptoms are more likely to have a COVID‑19 viral pneumonia than a community-acquired bacterial pneumonia.

3.8 COVID‑19 viral pneumonia may be more likely if the patient:

  • presents with a history of typical COVID‑19 symptoms for about a week

  • has severe muscle pain (myalgia)

  • has loss of sense of smell (anosmia)

  • is breathless but has no pleuritic pain

  • has a history of exposure to known or suspected COVID‑19, such as a household or workplace contact.

3.9 A bacterial cause of pneumonia may be more likely if the patient:

  • becomes rapidly unwell after only a few days of symptoms

  • does not have a history of typical COVID‑19 symptoms

  • has pleuritic pain

  • has purulent sputum.