Hospital-acquired (or nosocomial) pneumonia (HAP) (Box 63.1) is defined as a lower respiratory tractin fection occurring 48h or more after admission which was not incubating at the time of admission.

Consider hospital-acquired pneumonia in a patient with:

• New cough productive of purulent sputum or purulent tracheal secretions
• Acute breathlessness (Chapter 10)
• Increased oxygen requirement/respiratory failure (Chapter 11)
• New delirium
• Core temperature >38 or <36°C

Make a rapid but systematic assessment using the ABCDE approach (Chapter 1).

Airway: ensure a clear airway (Chapters 59 and 112). If the airway is compromised, seek urgent help from an anaesthetist.

Breathing: maintain adequate oxygenation. Give supplemental oxygen as needed to maintain oxygen saturation at 94–96% (88–92% if known chronic obstructive pulmonary disease and at risk of CO₂ retention).

Circulation: maintain adequate cardiac output/systemic blood pressure:

• Volume-replacement with IV crystalloid if dehydrated.
• Correct major arrhythmia (Chapter 39). Rate-control if fast atrial fibrillation (Chapter 43).

While doing this, collect information about the patient, the current problem, the context and comorbidities.

Establish what has been decided regarding the ceiling of care and resuscitation status of the patient.