Pneumonia Pneumonia (pneumonitis), an acute infection, causes an inflammatory process in the lung parenchyma usually associated with a marked

increase in intestinal and alveolar fluid which commonly impairs gas exchange. The prognosis is generally good for people who have normal lungs and adequate host defenses before the onset of pneumonia; however, pneumonia is the sixth leading cause of death in the United States. Advances in antibiotic therapy have led to the perception that pneumonia is no longer a major health problem in the United States. Among all nosocomial infections (hospital-acquired), pneumonia is the second most common, but has the highest mortality. Etiology and Risk Factors There are many causes of pneumonia, including bacteria, viruses, mycoplasmas, fungal agents, and protozoa. Pneumonia may also result from aspiration of food, fluids, or vomitus or from inhalation of toxic or caustic chemicals, smoke, dusts, or gases. Pneumonia may complicate immobility and chronic illnesses. Pneumonia often follows influenza and together they rank as the seventh leading cause of death in the United States, and are the fifth leading cause in people older than 65. Pneumonia can be classified in several ways: Microbiologic etiology Pneumonia can be viral, bacterial, fungal, protozoan, mycrobacterial, mycoplasmal, or rickettsial in origin. Location Bronchopneumonia involves distal airways and alveoli; lobular pneumonia, part of a lobe; and lobar pneumonia, an entire lobe. Type Primary pneumonia results from inhalation or aspiration of a pathogen; it includes pneumococcal and viral pneumonia. Secondary pneumonia may follow initial lung damage from a noxious chemical or other insult (superinfection), or may result from hematogenous spread or bacteria from a distant focus.

Predisposing factors for bacterial and viral pneumonia include chronic illness and debilitation, cancer (particularly lung cancer), abdominal and thoracic surgery, atelectasis, common colds or other viral respiratory infections, such as acquired immunodeficiency syndrome, chronic respiratory disease (chronic obstructive pulmonary disease [COPD], asthma, bronchiectasis, and cystic fibrosis), influenza, smoking, malnutrition, alcoholism, sickle cell disease, tracheostomy, exposure to noxious gases, aspiration, and immunosuppressive therapy. Predisposing factors for aspiration pneumonia include old age, debilitation, artificial airway use, nasogastric (NG) tube feedings, impaired gas reflex, poor oral hygiene, and decreased level of consciousness. In elderly patients and patients who are debilitated, bacterial pneumonia may follow influenza or a common cold. Respiratory pneumonia in children ages 2 to 3. In school-age children, mycoplasma pneumonia is more common. Major risk factors for pneumonia include the following: o o o o o o o o o o o Advanced age History of smoking Upper respiratory tract infection Tracheal intubation Prolonged immobility Immunosuppressive therapy A nonfunctional immune system Malnutrition Dehydration Homelessness Chronic disease states (such as diabetes, heart disease, chronic lung disease, renal disease, and cancer) Additional risk factors are dysphagia; exposure to air pollution; altered consciousness (from alcoholism, drug overdose, general anesthesia, or a seizure disorder); inhalation of noxious substances; aspiration of food, liquid, or foreign or gastric

material; and residence in institutional settings, where transmission of the disease is more likely. Pathophysiology Streptococcus pneumoniae, a major cause of bacterial pneumonia, generally resides in the nasopharynx and is carried asymptomatically in approximately 20%-50% of healthy individuals. It is the most common type of community-acquired pneumonia. Viral infections increase attachment of S. pneumoniae to the receptors on respiratory epithelium. Once inhaled into the alveolus, pneumococci infect type II alveolar cells. They multiply in the alveolus and invade alveolar epithelium. Pneumococci spread from alveolus to alveolus through pores of Kohn, thereby producing inflammation and consolidation along lobar compartments. Inflamed and fluid-filled alveolar sacs cannot exchange oxygen and carbon dioxide effectively. Alveolar exudate tends to consolidate, so it is increasingly difficult to expectorate. Bacterial pneumonia may be classified associated with significant ventilation-perfusion mismatch as the infection grows. Signs and Symptoms The main symptoms of pneumonia are coughing, sputum production, pleuritic chest pain, shaking chills, shortness of breath, rapid shallow breathing, and fever. Physical signs vary widely, ranging from diffuse, fine crackles to signs of localized or extensive consolidation and pleural effusion. There may also be associated symptoms of headache, sweating, loss of appetite, excess fatigue, and confusion (in older people). Complications include hypoxemia, respiratory failure, pleural effusion, empyema, lung abscess, and bacteremia, with spread of infection to other parts of the body, resulting in meningitis, endocarditis, and pericarditis. Complications Septic shock Hypoxemia Respiratory failure Empyema Lung abscess Bacteremia

Endocarditis

Pericarditis

Meningitis

Diagnosis Clinical features, chest X-ray showing infiltrates, and sputum smear

demonstrating acute inflammatory cells support the diagnosis. Gram stain and sputum culture may identify the organism. Positive blood cultures in the patient with pulmonary infiltrates strongly suggest pneumonia produced by the organisms isolated from the blood cultures. Pleural effusions, if present, should be tapped and fluid analyzed for evidence of infection in the pleural space. Occasionally, a transtracheal aspirate of tracheobronchial secretions or bronchoscopy with brushings or washings may be done to obtain material for smear and culture. The patients response to antimicrobial therapy also provides important evidence of the presence of pneumonia. Treatment Antimicrobial therapy varies with the causative agent. Therapy should be reevaluated early in the course of treatment. Supportive measures include humidified oxygen therapy for hypoxemia, mechanical ventilation for respiratory failure, a highcalorie diet and adequate fluid intake, bed rest, and an analgesic to relieve pleuritic chest pain. Patients with severe pneumonia on mechanical ventilation may require positive end-expiratory pressure to facilitate adequate oxygenation. Special considerations Correct supportive care can increase patient comfort, avoid complications, and speed recovery. The following protocol should be observed throughout the illness: 1. Maintain a patent airway and adequate oxygenation. 2. Monitor pulse oximetry. 3. Measure arterial blood gas levels, especially in hypoxemia patients. 4. Administer supplemental oxygen if the partial pressure of arterial oxygen is less than 55 to 60 mmHg.

5. Patients with underlying chronic lung disease should be given oxygen cautiously. 6. Teach client how to cough and perform deep-breathing exercises to clear secretions; encourage client to do so often. 7. In severe pneumonia that requires endotracheal intubation or tracheostomy (with or without mechanical ventilation), provide thorough respiratory care. 8. Suction often, using sterile technique, to remove secretions. 9. Obtain sputum specimens as needed, by suction if the patient cant produce specimens independently. Collect specimens in a sterile container and deliver them promptly to the microbiology laboratory. 10. Administer antibiotics as ordered and pain medication as needed; record the patients response to medications. Fever and dehydration may require I.V. fluids and electrolyte replacement. 11. Maintain adequate nutrition to offset hypermetabolic state secondary to infection. Ask the dietary department to provide a high-calorie, high-protein diet consisting of soft, easy-to-eat foods. Encourage patient to eat. As necessary, supplement oral feedings with NG tube feedings or parenteral nutrition. Monitor fluid intake and output. Consider limiting use of milk products as they may increase sputum production. 12. Provide a quiet, calm environment for the patient, with frequent rest periods. 13. Give emotional support by explaining all procedures (especially intubation and suctioning) to the patient and his family. Encourage family visits. Provide diversionary activities appropriate to the patients age. 14. To control the spread of infection, dispose of secretions properly. Tell the patient to sneeze and cough into a disposable tissue; taped a line bag to the side of the bed for used tissues. Pneumonia can be prevented as follows: 1. Advise the patient to avoid antibiotics indiscriminately during minor viral infections because this may result in upper airway colonization with antibioticresistant bacteria. If the patient then develops pneumonia, the organisms producing the pneumonia may require treatment with more toxic antibiotics.

2. Encourage pneumovax and annual influenza vaccination for high-risk patients, such as those with COPD, chronic heart disease, or sickle cell disease. 3. Urge all bedridden and post-operative patients to perform deep-brathing and coughing exercises frequently. Reposition such patients often to promote full aeration and drainage of secretions. Encourage early ambulation in postoperative patients. 4. To prevent aspiration during Ng tube feedings, elevate the patients head, check the tubes position, and administer the formula slowly. Dont give large volumes at one time; this could cause vomiting. Keep the patients head elevated for at least 30 minutes after the feeding. Check for residual formula at 4- to 6-hour intervals. Prevention Wash hands frequently to prevent infections. Advise patients to avoid taking antibiotics indiscriminately during viral infection.

Bibliography Books: Kluwer, W. (2009). Professional guide to diseases (9th Ed).Philadelphia: Lippincott Williams & Wilkins Black, J & Hawks, J. (2009). Medical-surgical nursing: clinical management for positive outcomes Vol.2 (8th Ed). Singapore: Saunders & Elsevier