PNEUMONIA

A. DESCRIPTION

– is an inflammatory process involving the respiratory bronchioles, alveolar space and walls, and lobes, caused primarily by chemical irritants or by specific bacterial, viral, fungal, mycoplasmal, or parasitic organisms

– “Pneumonitis” is a more general term that describes an inflammatory process in the lung tissue that may predispose or place the patient at risk for microbial invasion

B. ETIOLOGY

Classification:

1. Community-Acquired Pneumonia

Ø Occurs either in the community setting or within the first 48 hours after hospitalization or institutionalization

1. Pneumonia caused by Streptococcus pneumoniae

Ø Most common CAP in people younger than 60 years of age and above

Ø A gram-positive, capsulated, non-motile coccus that resides naturally in the respiratory tract

Ø May occur as a lobar or bronchopneumonic form in patients of any age and may follow a recent respiratory illness

b. Mycoplasma pneumonia

Ø Occurs most often in older children and young adults and is spread by infected respiratory droplets through

Ø person-to-person contact

Ø Spreads throughout the entire respiratory tract, including the bronchioles, and has the characteristics of a bronchopneumonia

c. Haemophilus influenzae (type B)

Ø Frequently affects elderly people and those with comorbid illnesses (eg. COPD, alcoholism,diabetes mellitus)

Ø The presentation is indistinguishable from that of other forms of bacterial CAP and may be subacute, with cough or low-grade fever for weeks before diagnosis

Ø Chest x-rays may reveal multilobar, patchy bronchopneumonia or areas of consolidation (tissue that solidifies as a result of collapsed alveoli or pneumonia)

d. Viruses

Ø The most common cause of pneumonia in infants and children but are relatively uncommon causes of CAP in adults

Ø In immunocompetent adults, the chief causes of viral pneumonia are influenza viruses types A and B, adenovirus, parainfluenza virus, coronavirus, and varicella-zoster virus

Ø In immunocompressed adults, cytomegalovirus is the most common viral pathogen, followed by herpes simplex virus, adenovirus, and respiratory synctial virus

Ø Acute stage of a viral respiratory infection occurs within the ciliated cells of the airways. This is followed by infiltration of the tracheobronchial tree

B.Hospital-Acquired Pneumonia

Ø Also known as nosocomial pneumonia

Ø Defined as the onset of pneumonia symptoms more than 48 hours after admission in patients with no evidence of infection at the time of admission

Occurs when at least one of three conditions exists:

Ø host defenses are impaired

Ø an inoculum of organisms reaches the lower respiratory tract and overwhelms the host’s defenses

Ø a highly virulent organism is present

Ø The common organisms responsible for HAP include the pathogens Enterobacter species, Escherichiacoli, H. influenzae, Klebsiella species, Proteus, Serratia marcescens,

P. aeruginosa, methicillin- sensitive or methicillin-resistant Staphylococcus aureus (MRSA), and S. pneumoniae

3. Pneumonia in the Immunocompromised Host

Ø Pneumocystis pneumonia (PCP), fungal pneumonias, and Mycobacterium tuberculosis

Ø Pneumocystis jiroveci causes PCP

Ø May be caused by the organisms also observed in CAP or HAP

Ø Rarely observed in immunocompetent hosts and is often an initial AIDS-defining complication

Ø Has a subtle onset, with progressive dyspnea, fever, and a non-productive cough

4. Aspiration Pneumonia

Ø Refers to the pulmonary consequences resulting from entry of endogenous or exogenous substances into the lower airway

Ø The most common form of aspiration pneumonia is bacterial infection from aspiration of bacteria that normally reside in the upper airways

Ø May occur in the community or hospital setting

Ø Common pathogens are S. pneumoniae, H. influenzae, and S. aureus

Ø Causes and contributing factors to pneumonia include:

a. Inability to move pulmonary secretions.

b. Aspiration pneumonia due to an abnormal swallowing mechanism or tube feedings

c. Immunosupressed clients

d. Frequent alcohol intoxication

e. Immobility

f. Cigarette smoking

D. INCUBATION PERIOD

• The incubation period for pneumonia varies, depending on the type of virus or bacteria causing the infection. Some common incubation periods are: respiratory syncytial virus, 4 to 6 days; influenza, 18 to 72 hours.

E. PERIOD OF COMMUNICABILITY

• Not known.

• It appears that transmission can occur as long as the organism remains in respiratory secretions.

F. MODE OF TRANSMISSION (Dependent on the infecting organism)

• Breathing in small droplets that contain the organisms that can cause pneumonia

• Sharing drinking glasses and eating utensils to the infected person

• Touching the used tissues or handkerchiefs of an infected person.

G. ASSESSMENT FINDINGS

a. Clinical Manifestations

• Dullness with consolidation on percussion of chest

• Bronchial breath sounds auscultated over consolidated lung fields; egophony “EE” to “AY”

• Sudden onset fever over 100 degrees Fahrenheit

• Shaking chills (with bacterial pneumonia)

• Chest pain aggravated by hacking cough

• Dyspnea, respiratory grunting, and nasal flaring

• Flushed cheeks; cyanotic lips and nail beds

• Purulent sputum

• Anxiety and confusion

• In the elderly, the only signs may be mental status' change and dehydration.

b. Laboratory Findings

• Sputum culture and sensitivity are positive for a specific causative organism.

• White blood cell (WBC) count is elevated in pneumonia of bacterial origin; WBC count is depressed in pneumonia of mycoplasmal or viral origin.

c. Diagnostic Findings

• Chest radiograph shows density changes, primarily in the lower lung fields.

• Cytologic findings - neutrophilic inflammation that may or may not be septic

• Bacterial culture - indicated to detect secondary infection

H. TREATMENT MODALITIES

• Bacterial pneumonia (caused by the streptococcus pneumonia bacteria) is often treated with penicillin, ampicillin-clavulanate (Augmentin) and erythromycin.

• Bacterial pneumonia (caused by the hemophilus influenza bacteria) is treated with antibiotics, such as cefuroxime (Ceftin), ampicillin-clavulanate (Augmentin), ofloxacin (Floxin), and trimethoprim-sulfanethoxazole (Bactrim and Septra).

• Bacterial pneumonia (caused by legionella pneumophilia and staphylococcus aureus bacteria) are treated with antibiotics, such as erythromycin.

• Mycoplasma pneumonia is often treated with antibiotics, such as erythromycin, clarithromycin (Biaxin), tetracycline or azithromycin (Zithromax).

• Bedrest

• Plenty of fluids

• Therapeutic coughing, breathing exercises

• Proper diet

• Cough suppressants

• Pain relievers and fever reducers, such as aspirin (not for children) or acetaminophen

• In severe cases, oxygen therapy and artificial ventilation may be required.

I. NURSING MANAGEMENT

• Administer prescribed medications, which may include antibiotics, mucolytics expectorants, or antitussive agents.

• Promote infection control measures, especially droplet precautions as indicated.

• Prevent aspiration pneumonia in a client receiving tube feedings. Keep the client in an upright position during feedings and for 30 minutes afterward. Check for residual gastric contents; if more than 100 mL, stop feeding and reevaluate.

• Pt will need to have breath sounds monitored q 4hr to determine if pneumonia is progressing.

• O2 saturation should be done regularly ( at least q4°during acute phase) to make sure that patient is getting adequate perfusion.

• Make sure to give all scheduled antibiotics on schedule so that therapeutic ranges are maintained.

• Any signs and symptoms of infection must be monitored and reported to the physician.

J. METHODS OF PREVENTION

• Practice good hygiene.

• Get a pneumonococcal vaccine.

• Practice good preventive measures by eating a proper diet, getting regular exercise and plenty of sleep.

• Stop smoking. Smoking makes it more likely you will get pneumonia.

• Avoid contact with people who have respiratory tract infections, such as colds and influenza (flu). Pneumonia may develop after these types of infections.

• If you have not had measles or chickenpox, avoid contact with people who have these infections. Pneumonia can be a complication of measles and chickenpox, so getting these infections can put you at risk for developing pneumonia.