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Pneumonia (pneumonitis)-Acute inflammation of the lung
Lower respiratory tract
Incidence: 4,000,000 cases in the U.S. per year. Attack rate of 12 per 1000 adults.
Continues to be a major health problem in the U.S.
-Seventh leading cause of death (CDC, 2003)
Classifications: CAP-Community Acquired Pneumonia
Onset in the community or first two days in the hospital
Four categories based on severity
Classifications: HAP-Hospital Acquired Pneumonia
Nosocomial pneumonia that occurs 48 hours or more after admission to hospital
Three groups based on severity and risk factors
Risk Factors
#1 SMOKING
Air Pollution
Altered consciousness - aspiration
Tracheal intubation
Upper respiratory tract infections
Chronic diseases
Immunosuppression, (HIV, immunosuppressive drugs)
Malnutrition
Inhalation or aspiration of substances
Debilitating illness
Bedrest/Prolonged immobility
Altered oropharyngeal flora
Intestinal and gastric feedings (aspiration)
Types of Pneumonia
Community Acquired
Organism identified only 50% of the time
Hospital Acquired
Usually bacterial
2nd most common hospital acquired infection
Etiology Infectious agent (organisms)
Aspiration of foreign matter
Inhalation of infected aerosols, chemicals, gas
Hematogenous spread from a primary infection (ie. Staph aureus)
Fungal
Increasing in incidence, very ill, immunosuppressed
Opportunistic
Pneumocystis Carinii
CMV
Pathophysiology
Congestion
Red hepatization
Gray hepatization
Resolution
Causative Agents
Bacterial
Gram+: Pneumococcus (most common community acquired pneumonia), Staphylococcus, Enterococcus
Gram-: E. Coli, Pseudomonas, Enterobacter, Klebsiella
Viral
CMV (cytomegalovirus-1/2 of all viral pneumonias), Influenza
Note: same causative agents 2 names: pneumococcus=streptococcus pneumoni
Detailed Pathophysiology
Aspiration of S. pneumoniae
Release of bacterial endotoxin
Inflammatory Response: Attraction of neutrophils; release of inflammatory mediators; accumulation of fibrinous exudate, red blood cells, and bacteria
Red hepatization and consolidation of lung parenchyma
Leukocyte infiltration (neutrophils and macrophages)
Gray hepatization and deposition of fibrin on pleural surfaces; phagocytosis in alveoli
Resolution of infection: macrophages in alveoli ingest and remove degenerated neutrophils, fibrin, and bacteria
Causative Agents: Fungal
Fungal
Aspergillas
Candida
PCP (Pneumocystis Carinii)
Mycoplasma (walking pneumonia)
characteristics of both bacteria and viruses (treated like a bacteria with antibiotics)
Manifestations
May have one or more of the following:
Fever, chills, sweats
Pleuritic chest pain vs Cardiac pain take a deep breath if it hurts rule out cardiac
Sputum: hemoptysis or purulent green/yellow sputum
Headache, weakness, malaise
Dyspnea, tachycardia, tachypnea
Older Adults may only show signs of Altered Mental Status fatigue and purulent sputum
CAP (nonbacterial): may have only a severe, dry hacking cough and fine rales on auscultation
"Typical" Clinical Pattern (usually bacterial)
Sudden onset - rigor (shaking chills, febrile, bacteremia
fever
productive cough
leukocytosis
pleuritic pain
Usually bacterial
Legionella can have either a typical or atypical pattern
"Atypicals" Clinical Pattern (generally viral)
Mycoplasma, Chlamydia, Legionella, viral
VIRAL-LIKE ILLNESS - fevers (usually without rigors), myalgias and headache
URI symptoms but appear less ill (dry cough)
dry nonproductive cough, minimal adventitious lung sounds
Little elevation in white blood cell count
Diagnostic Studies
History and Physical Exam
Sputum for gram Stain and C&S
CXR
ABG's
CBC
Blood cultures
SaO2
Prompt Treatment
Prompt initiation of effective antibiotics decreases mortality (treat within 4 hours)
90% of admitted patients respond promptly to empiric therapy (based on experience not scientific evidence)
Treatment must include therapy against "atypical organisms".
PORT: Patient Outcome Research Team
This is how antibiotic is chosen and how long hospital stay will be
Study 1991 38,000 inpatients
Collaborative Care
Antibiotics
Increased fluid intake (3 liters)
Limited activity and rest
Antipyretics
Analgesics
Oxygen
Management: CAP
Macrolide Antibiotics or Doxycycline
Management: HAP
Cyclosporins
Aminoglycosides
Management
Treatments (suction, chest PT)
Medications (IV Fluids, Antibiotics)
Consultations: Respiratory, Nutritional
Monitoring: VS, I&O, WBC
Nutrition: 1500 kcal
Safety: elevate HOB 30°
Teaching: TCDB, frequent rest periods
Things to remember
Clinical improvement should be seen within 72 hours
If not consider: CHF, PE, Ca, airway obstruction, ARDS, hemorrhage, drug reaction, interstitial disease, resistant organism, TB, inadequate host response
Change to PO antibiotics when patient has clinically improved within 72 hours
CXR's clear VERY SLOWLY-it takes weeks to months. Wait 6 weeks for follow-up CXR unless there is clinical deterioration.
Complications
Pleurisy: inflammation of the pleura
Pleural effusion (1 to 2 weeks to go away)
Atelectasis: clear with effective cough and deep breathing
Delayed resolution: 3-4 weeks
Lung abscess: very uncommon
Complications
Empyema: fluid/pus in the pleural space
Pericarditis
Arthritis: organism spreads to joints, treatment with antibiotics should resolve
Meningitis
Endocarditis
Risk factors for a complicated course (consider hospitalization)
*age >65 yrs
Comorbid Disease: COPD, bronchiectasis, diabetes, cancer, renal failure, CHF, chronic liver disease, ETOH abuse, malnutrition, hospitalization in the prior year, splenectomy
Prevention (<65 yrs recovering from chronic illness)
Pneumococcal Vaccine: lifetime immunity. However, booster may be given q 5 years for immunosuppressed clients.
Guideline:
Over 65 years old
Chronic illness such as heart or lung disease and DM
Recovering from severe illness
Lives in nursing home or long-term care facility