Pneumonia

Pneumonia 150 150 Tony Guo

Pneumonia

  • Acute infection of lung parenchyma
  • Associated with significant morbidity and mortality rates
  • Pneumonia and influenza are 8th leading cause of death in the U.S.

 

Etiology

  • Likely to result when defense mechanisms become incompetent or overwhelmed
  • Decreased cough and epiglottal reflexes may allow aspiration
  • Mucociliary mechanism impaired 
    • Pollution
    • Cigarette smoking
    • Upper respiratory infections
    • Tracheal intubation 
    • Aging 
  • Chronic diseases suppress immune system
  • Chronic diseases suppress immune system
  • Three ways organisms reach lungs:
    • Aspiration from nasopharynx or oropharynx
    • Inhalation of microbes present in air
    • Hematogenous spread from primary infection elsewhere in body

Types of Pneumonia

  • Can be classified according to causative organism 
  • Clinical classification:
    • Community-acquired (CAP)
      • Occurs in patients who have not been hospitalized or resided in a long-term care facility within 14 days of the onset of symptoms
      • Can be treated at home or hospitalized dependent on patient condition
      • Empiric antibiotic therapy started ASAP
    • Hospital-acquired (HAP)
      • HAP: Occurs 48 hours or longer after hospitalization and not present at time of admission
      • Ventilator-associated  (VAP): Occurs more than 48 hours after endotracheal intubation
      • Associated with longer hospital stays, increased costs, sicker patients, and increased risk of morbidity and mortality
  • Multidrug-resistant (MDR) organisms are major problem in treatment
    • Staphylococcus aureus
    • Gram-negative bacilli
  • Risk factors
    • Advanced age
    • Immunosuppression
    • History of antibiotic use
    • Prolonged mechanical ventilation
    • Aspiration Pneumonia
      • Results from abnormal entry of secretions into lower airway
      • Major risk factors:
        • Decreased level of consciousness
        • Difficulty swallowing
        • Insertion of nasogastric tubes with or without tube feeding
      • Aspirated material triggers inflammatory response
      • Primary bacterial infection most common
      • Empiric therapy based on severity of illness, where infection acquired, and probable causative organism
      • Aspiration of acid gastric contents initially causes chemical (noninfectious) pneumonitis
    • Necrotizing Pneumonia
      • Rare complication of bacterial lung infection
      • Often results from CAP
      • Signs and symptoms
        • Immediate respiratory insufficiency and/or failure
        • Leukopenia
        • Bleeding into airways
    • Opportunistic Pneumonia
      • Patients at risk 
        • Severe protein-calorie malnutrition
        • Immunodeficiencies
        • Chemotherapy/radiation recipients
        • Long-term corticosteroid therapy
      • Caused by microorganisms that do not normally cause disease
    • Pneumocystis jiroveci pneumonia (PJP) 
      • Onset slow and subtle
      • Diffuse bilateral infiltrates to massive consolidation
      • Can be life threatening
      • Spread to other organs
      • Treat with trimethoprim/sulfamethoxazole IV or orally
    • Cytomegalovirus (CMV) pneumonia
      • Herpes virus
      • Asymptomatic and mild to severe disease
      • Life threatening in immunosuppressed person
      • Treat with antiviral medications and high-dose immunoglobulin

    Pathophysiology

    • Inflammatory response
      • Attraction of neutrophils
      • Release of inflammatory mediators
      • Accumulation of fibrinous exudates, red blood cells, and bacteria
    • As a result, the inflammatory process attracts more neutrophils, edema of the airways occurs, and fluid leaks from the capillaries and tissues into alveoli
      • Alveoli fill with fluid and debris (consolidation)
      • Increased production of mucus (airway obstruction)
    • Normal O2 transport is affected, leading to clinical manifestations of hypoxia (e.g., tachypnea, dyspnea, tachycardia)
    • Resolution of infection
      • Macrophages in alveoli ingest and remove debris
      • Normal lung tissue restored
      • Gas exchange returns to normal

    Risk factors

    • Abdominal or thoracic surgery
    • Age >65 yr.
    • Air pollution
    • Altered consciousness: alcoholism, head injury, seizures, anesthesia, drug overdose, stroke
    • Bed rest and prolonged immobility
    • Chronic diseases: chronic lung and liver disease, diabetes mellitus, heart disease, cancer, chronic kidney disease
    • Debilitating illness
    • Exposure to bats, birds, rabbits, farm animals
    • Immunosuppressive disease and/or therapy (corticosteroids, cancer chemotherapy, human immunodeficiency virus [HIV] infection, immunosuppressive therapy after organ transplant)
    • Inhalation or aspiration of noxious substances
    • Intestinal and gastric feedings via nasogastric or nasointestinal tubes
    • IV drug use
    • Malnutrition
    • Recent antibiotic therapy
    • Resident of a long-term care facility
    • Smoking
    • Tracheal intubation (endotracheal intubation, tracheostomy)
    • Upper respiratory tract infection

    Clinical manifestation

    • Most common
      • Cough
      • Fever, chills
      • Dyspnea, tachypnea
      • Pleuritic chest pain
      • Green, yellow, or rust-colored sputum
    • Change in mentation for older or debilitated patients
    • Nonspecific manifestations
    • Physical examination findings
      • Fine or coarse crackles
      • Bronchial breath sounds
      • Egophony
      • Increased fremitus
      • Dullness to percussion if pleural effusion present

    Complications

    • Atelectasis
      • (Collapsed, airless alveoli) of one or part of one lobe may occur. These areas may clear with effective deep breathing and coughing.
    • Pleurisy
      • Inflammation of the pleura
    • Pleural effusion 
      • Fluid in the pleural space
    • Bacteremia
      • (Bacterial infection in the blood) is more likely to occur in infections with Streptococcus pneumoniae and Haemophilus influenzae
    • Pneumothorax
      • Can occur when air collects in the pleural space, causing the lungs to collapse
    • Meningitis 
      • Can be caused by Streptococcus pneumoniae. 
      • The patient with pneumonia who is disoriented, confused, or drowsy may have a lumbar puncture to evaluate the possibility of meningitis.
    • Acute respiratory failure 
      • One of the leading causes of death in patients with severe pneumonia. 
      • Failure occurs when pneumonia damages the lungs’ ability to facilitate the exchange of O2 and CO2 across the alveolar-capillary membrane.
    • Sepsis/septic shock 
      • Can occur when bacteria within alveoli enter the bloodstream. Severe sepsis can lead to shock and multisystem organ dysfunction syndrome (MODS)
    • Lung abscess
      • Not a common complication of pneumonia.
      • It may occur with pneumonia caused by S. aureus and gram-negative organisms
    • Empyema
      • The accumulation of purulent exudate in the pleural cavity, occurs in less than 5% of cases and requires antibiotic therapy and drainage of the exudate by a chest tube or open surgical drainage

    Diagnostic tests

    • History and physical examination
    • Chest x-ray
    • Gram stain of sputum
    • Sputum culture and sensitivity test
    • Pulse oximetry or ABGs (if indicated)
    • Blood cultures
    • Thoracentesis
    • Bronchoscopy  with washings
    • Biologic markers to guide clinical decisions:
      • C-reactive protein (CRP)
      • Procalcitonin

    Interprofessional Care

    • Pneumococcal vaccine
      • To prevent Streptococcus pneumoniae
    • Prompt treatment with antibiotics is essential
      • Response generally occurs within 48-72 hr
        • Drop in temperature
        • Improved breathing
        • Decreased chest discomfort
      • Repeat chest x-ray in 6-8 weeks
    • Supportive care
      • Oxygen for hypoxemia
      • Analgesics for chest pain
      • Antipyretics
      • Individualize rest and activity
    • No definitive treatment for majority of viral pneumonias
    • Antivirals for influenza pneumonia

    Drug therapy

    • Start with empiric therapy 
      • Based on likely infecting organism and risk factors for MDR organisms
      • Varies with local patterns of antibiotic resistance
    • Should see improvement in 3-5 days
    • Start with IV and then switch to oral therapy as soon as patient stable

    Nutritional therapy

    • Adequate hydration
      • Prevent dehydration
      • Thin and loosen secretions
      • Adjust for older adults, patients with heart failure, those with preexisting respiratory conditions
    • High calorie, small, frequent meals
      • Monitor for weight loss

    Nursing assessment

    • Subjective Data
      • Important Health Information
        • Past health history: 
          • Lung cancer, COPD, diabetes mellitus, chronic debilitating disease, malnutrition, altered consciousness, immunosuppression, exposure to chemical toxins, dust, or allergens
        • Medications: 
          • Antibiotics, corticosteroids, chemotherapy, or any immunosuppressants
        • Surgery or other treatments: 
          • Recent abdominal or thoracic surgery, splenectomy, endotracheal intubation, or any surgery with general anesthesia. Tube feedings
      • Functional Health Patterns
        • Health perception–health management: 
          • Cigarette smoking, alcoholism; recent upper respiratory tract infection, malaise 
        • Nutritional-metabolic: 
          • Anorexia, nausea, vomiting. Chills
        • Activity-exercise: 
          • Prolonged bed rest or immobility. Fatigue, weakness. Dyspnea, cough (productive or nonproductive). Nasal congestion
        • Cognitive-perceptual: 
          • Pain with breathing, chest pain, sore throat, headache, abdominal pain, muscle aches
    • Objective Data
      • General
        • Fever
        • Restlessness or lethargy
        • Splinting affected area
      • Respiratory
        • Tachypnea
        • Asymmetric chest movements
        • Use of accessory muscles (neck and abdomen)
        • Crackles
        • Friction rub on auscultation
        • Dullness on percussion over consolidated areas
        • Increased tactile fremitus on palpation
        • Sputum amount and color (Pink, rusty, purulent, green, yellow, or white sputum [amount may be scant to copious])
      • Cardiovascular
        • Tachycardia
      • Neurologic
        • Changes in mental status
      • Possible Diagnostic Findings
        • Leukocytosis. 
        • Abnormal ABGs with decreased or normal PaO2, decreased or normal PaCO2, and increased or normal pH initially, and later decreased PaO2, increased PaCO2, and decreased pH. 
        • Positive sputum on Gram stain and culture. Patchy or diffuse infiltrates, abscesses, pleural effusion, or pneumothorax on chest x-ray

    Nursing Diagnoses

    • Impaired gas exchange
    • Ineffective breathing pattern related to inflammation and chest discomfort
    • Acute pain (chest) related to inflammation and ineffective pain management and/or comfort measures
    • Activity intolerance related to chest discomfort, inflammation, shortness of breath, generalized weakness

    Planning

    • Clear breath sounds
    • Normal breathing patterns
    • No signs of hypoxia
    • Normal chest x-ray
    • Normal white blood cell (WBC) count
    • Absence of complications related to pneumonia.

    Nursing implementation

    • Health Promotion
      • Teach hygiene, nutrition, rest, regular exercise to maintain natural resistance
      • Cough or sneeze into elbow, not hands
      • Avoid cigarette smoke
      • Prompt treatment of URIs
      • Influenza and pneumococcal vaccination
    • Prevent pneumonia in at risk patients
      • Proper positioning to prevent aspiration
      • Reposition patient every 2 hours
      • Strict adherence to ventilator bundle to prevent VAP
      • Elevate head-of-bed 30 degrees and have sit up for all meals
      • Assist with eating, drinking, taking meds as needed
      • Assess for gag reflex
      • Early mobilization
      • Incentive spirometry
      • Twice-daily oral hygiene
      • Pain management
      • Strict medical asepsis
      • Hand hygiene
      • Respiratory devices
      • Suctioning 
      • Avoid unnecessary antibiotic usage
    • Ambulatory care
      • Teach the patient about 
        • Importance of taking every dose of the prescribed antibiotic, any drug-drug and food-drug interactions for the prescribed antibiotic, and the need for adequate rest to facilitate recovery. 
        • Drink plenty of liquids (at least 6 to 10 glasses/day, unless contraindicated) and to avoid alcohol and smoking. 
        • A cool mist humidifier or warm bath may help the patient breathe easier.
        • Explain that a follow-up chest x-ray may be done in 6 to 8 weeks to evaluate resolution of pneumonia
        • Information about available influenza and pneumococcal vaccines.

    Evaluation

    • Effective respiratory rate, rhythm, and depth of respirations
    • Lungs clear to auscultation
    • Reports pain control
    • SpO2 ≥ 95
    • Free of adventitious breath sounds
    • Clear sputum from airway

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