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04/11/20231
Pneumonia
SOAP
Saeid kashefi2nd year post.baccNovember 12, 2011, has been
proclaimed World Pneumonia Day.
Every 20 seconds a child dies from pneumonia
2
Fluid and pus filled air space
contains bacteria
3
Who Gets Pneumonia?
• Anyone can get pneumonia, but some people are at a higher risk than
others.
• Risk factors include:
Cigarette smoking
Recent viral respiratory infection—a cold, laryngitis, influenza, etc.
Difficulty swallowing (due to stroke, dementia, Parkinson's disease, or other
neurological conditions)
Chronic lung disease such as COPD, bronchiectasis, or cystic fibrosis
Heart disease, liver cirrhosis, or diabetes
Living in a nursing facility
Impaired consciousness (loss of brain function due to dementia, stroke, or
other neurologic conditions)
Recent surgery or trauma
Having a weakened immune system due to illness, certain medications, and
autoimmune disorders
4
Community-acquired Pneumonia (CAP) was the 4th leading cause of death in the
world in 2012 according to the WHO and 6th leading cause of death in the U.S.
It’s a Inflammation of one or both lungs.
What Causes Pneumonia?
The infection may be bacterial, viral, fungal.
Pneumonia is extremely contagious
Pneumonia can be a serious and life-threatening infection. This is true especially in
the elderly, children, and those who have other serious medical problems, such as
COPD, heart disease, diabetes, and certain cancers.
Pneumonia
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Pneumonia confirmed by chest X-ray testing. (dense white patch)
CT scan
With pneumonia, sputum is sometimes bloody
Sputum Gram Stain and culture
Pulse oximetry
Routine lab testing –
CBC
BMP (basic metabolic panel)
LFTs
ABG (arterial blood gas)
Diagnosis of Pneumonia
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How do we classify pneumonia?
• Community AcquiredCAP
• Health Care Associated HCAP
• Hospital AcquiredHAP
• ICU AcquiredICUAP
• Ventilator AcquiredVAP
Nosocomial Pneumonias
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Treatment of Community Acquired Pneumonia (CAP)
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Table 116-8 Evidence-Based Empiric Antimicrobial Therapy for Pneumonia in AdultsClinical Setting Usual Pathogens Empiric Therapy
Outpatient/community acquired
•Previously healthy S. pneumoniae, M. pneumoniae, H influenza, C. pneumoniae, M. catarrhalis
Macrolide/azalide, or tetracycline
•Comorbidities (diabetes, heart/lung/liver/renal disease, alcoholism
Fluoroqinoloned or -lactam + macrolideb
•Elderly S. pneumoniae, Gram-negative bacilli Piperacillin/tazobactam or cephalosporine or carbapenemf
Inpatient/community acquired •Non-ICU S. pneumoniae, H. influenza, M.
pneumoniae, C. pneumoniae, Legionellasp. Fluoroquinoloned or -lactam + macrolideb
•ICU S. pneumoniae, S.aureus, Legionella sp, gram-negative bacilli, H. influenza
β-lactam + macrolide or fluoroquinolone; piperacillin/tazobactam
meropenem or cefepime + fluoroquinolone , β-lactam + AMG + azithromycin β-lactam + AMG + respiratory
fluoroquinoloneIf MRSA suspected Above + vancomycin or linezolid
Hospital acquired, ventilator associated, or healthcare associated
•No risk factors for MDR pathogens
S. pneumoniae, H. influenzae, MSSA enteric Gram-negative bacilli
Ceftriaxone or fluoroquinoloned or ampicillin/sulbactam or ertapenem or doripenem
•Risk factors for MDR pathogen
P. aeruginosa, K. pneumoniae (ESBL), Acinetobacter sp.,
Antipseudomonal cephalosporine or antipseudomonal carbapenem or -lactam/-lactamase + antipseudomonal fluoroquinoloned or AMG
If MRSA or Legionella sp. suspected Above + vancomycin or linezolid•Aspiration Mouth anaerobes, S. aereus, enteric Gram-
negative bacilli Penicillin or clindamycin or piperacillin/tazobactum + AMG
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SOAP
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*Bilateral pneumonia and ARDS
*Right sided pneumonia
*Septic shock
Problem List
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*C/O sudden onset breathlessness since morning (3 AM)
*Associated with shivering, severe sweating
Subjective Evidence
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Physical Examination:
*RR-35/min
*SpO2-60% ( 95-100%)
*RS : Right B/L basal creps+
Objective Evidence
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*WBC: 22.0 x103 cells/mm3
*N: 90.9 (35-75)%
* L: 4.9 (20-45)%
Routine Biochemical Investigation
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*Bilateral pneumonia and ARDS
*Right sided pneumonia
*Septic shock
FINAL DIAGNOSIS
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ETIOLOGY
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Table 116-6 Pneumonia Classifications and Risk Factors
Type of Pneumonia Definition Risk FactorsCommunity
acquired (CAP)Pneumonia developing in patients with no contact to
a medical facility
•Age >65 years •Diabetes Mellitus •Asplenia •Chronic cardiovascular, pulmonary, renal and/or liver disease •Smoking and/or alcohol abuse
Healthcare associated (HCAP)
Pneumonia developing in patients not in medical facility but two or more risk factors for MDR pathogens
•Recent hospitalization 2 days within past 90 days •Nursing home or long-term care facility resident •Recent (past 30 days) antibiotic use, chemotherapy, wound care or infusion therapy either at a healthcare facility or home •Hemodialysis patients •Contact with a family member with infection caused by MDR pathogen
Hospital-acquired (HAP)
Pneumonia developing >48 hours after hospital admission
•Witnessed aspiration •COPD, ARDS, or coma •Administration of antacids or H2-antagonists •Supine position •Enteral nutrition, nasogastric tube •Reintubation, tracheostomy, or patient transport •Prior antibiotic exposure •Head trauma, ICP monitoring •Age >60 years •See healthcare associated for MDR risk factors •Same as hospital acquired
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*Yes, therapy is indicated to Reduce morbidity and mortality
Prevent complications and Improve quality of life.
Assessment if therapy is indicated?
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Drug with Dose & Route 12/10
13/10
14/10
15/10
16/10
Generic Name Dosage form
Brand Name 1ICU
2ICU
3ICU
4 5
Piperacillin/Tazobactam
Inj. Tazillin 4.5 g IV
Stat in 50 ml of NS over 1 hrs
Over 30min
Methylprednisolone Inj. Solumedrol 40 mg
in 40 ml NS Q8H
Dopamine Inj. Dopamine 6 ml/hr
Ipratropium (20mcg/1puff)Levosalbutamol (50mcg)
Neb. Duolin Q6H
Pantoprazole Tab. Pan 40mg 1-0-0 (b/f)
Paracetamol Tab. Dolo 650mg SOS
Chlorpheniramine Inj Avil IV 1amp SOS
Ondansetron Inj. Emeset 4mg IV SOS
NA Inf Na
Montelukast Tab Montair Stat-1
Salbutamol (100ml) Neb Asthalin Stat
Chlorpheniramine (4mg/5mL)/ Dextromethorphan (10mg)
Syp Aerodil 2tsp 1-0-1
Cap Becelac forte 1-1-1
21
22
Assessment of
Current Therapy
23
*Class: Piperacillin : extended-spectrum beta-lactam antibiotic of the ureidopenicillin class.
Tazobactam: β-lactamase inhibitor.
*MOA: Piperacillin inhibits bacterial cell wall synthesis.
Tazobactum inhibits the action of bacterial β-lactamases.
*Indication: is indicated for Community-acquired pneumonia (moderate severity only),
Nosocomial pneumonia (moderate to severe)
*Justification: It is correctly indicated according to the Infectious Diseases Society of American Guidelines on the Management of CAP in Adults.
*Dose, dosage and schedule were found to be correct.
*ADR: Prolongation of bleeding time, anaphylaxis, nausea,
vomiting, diarrhea.
Inj. Tazillin 4.5 g IV (Piperacillin/Tazobactam) Stat in 50 ml of NS over 1 hrs Days 1-5
24
*Class: Corticosteroid drug
*MOA: It inhibit the potent mediators of inflammation such as prostaglandins and
leukotrienes.
*Indication: It is indicated for breathlessness
*Justification: It is correctly indicated as patient was having breathlessness as
symptoms of pneumonia
*Dose, dosage and schedule were found to be correct.
*ADR: Hypercalciuria, hypokalemic alkalosis, CHF, PUC, HTN, viral infections,
itching, allergic skin reactions.
Inj. Solu medrol 40 mg (Methylprednisolone) in 40 ml NS Q8H DAY 1
25
*MOA: increases blood pressure by acting on both α and β-1 receptors.
*Indication: It is given for the treatment of severe hypotension and septic shock
*Justification: It is correctly indicated as the patient had hypotension on day 1 and septic shock
*Dose, dosage and schedule were found to be correct.
*ADR: nervousness, headache, dysrhythmias, palpitations, chest pain, dyspnea,
nausea, and vomiting.
INJ. Dopamine 6 ml/hr DAY 1
26
*Class: anticholinergic agent/Stimulates β- receptors
*MOA: Ipratropium bromide: decreased contractility of smooth muscle/
Levosalbutamol: Stimulates β-receptors
*Indication: breathlessness.
*Justification: It is indicated correctly because patient had breathlessness from day 1
*Dose, dosage and schedule were found to be correct.
*ADR: tremor, tachycardia, leg cramps, dizziness, vomiting
Neb. Duolin (Ipratropium (20 mcg/1puff)Levo-salbutamol (50 mcg)) Q6H DAYS 1-3
27
Class: proton pump inhibitor (PPI)
MOA: Pantoprazole inhibit H+/K+ - ATPase enzyme
Indication: for prevention of gastric irritation
Justification: It is indicated to prevent gastric irritation due to poly pharmacy
Dose, dosage and schedule were found to be correct.
ADR: Weakness, dizziness, nausea, vomiting, anxiety, dyspnea, pain, pharyngitis, cough,
arthralgia, rhinitis, chest pain, bronchitis, backache, urinary frequency, UTI, hyperlipidemia.
Tab. Pan 40 mg (Pantoprazole) 1-0-0 (b/f) Day 1-5
28
*Class: NSAIDs (antipyretic and analgesic)
*Indication: for chills (as symptoms of pneumonia) as well as RA.
*Justification: It is indicated correctly because the patient had chills on day 1 and RA
according to medical history. (Patient has been taking paracetamol)
*Dose, dosage and schedule were found to be correct.
*ADR: Bronchospasm, blood dyscrasias, centribular necrosis, liver damage,
hypoglycemic coma, hepatic necrosis, liver failure, skin rashes, GI adverse effects.
Tab. Dolo 650mg (Paracetamol) SOS DAYS
29
*Class: first-generation alkylamine antihistamine
*MOA: it is H1-receptor antagonist
*Indication: cough, running nose (since 4 days back)
*Justification: It is correctly indicated as the patient had cough
*Dose, dosage and schedule were found to be correct.
*ADR: Blurred vision, dry eyes, mydriasis, drowsiness, constipation, fatigue, headache, dizziness, psychomotor impairment, dry mouth, gastrointestinal disturbances.
Inj. Avil IV (Chlorpheniramine) 1amp SOS
30
Inj. Emeset 4mg IV (Ondansetron) S.O.S. days 1-2
Class: prevent nausea and vomiting caused by cancer chemotherapy, radiation therapy, and surgery.
MOA: serotonin (5HT3) antagonist
Indication: given for vomiting
Justification: It is given due to patient suffering from vomiting.
Dose, dosage and schedule were found to be correct.
ADR: Headache, dizziness, drowsiness, tiredness, or constipation may occur.
31
*Class: catecholamine (adrenergic agonists)
*MOA: norepinephrine stimulates cardiac contractility.
*Indication: hypotensive states, septicaemia
*Justification: It is correctly indicated as the patient had hypotension and septic
shock. (Norepinephrine is used to treat shock, because it increases vascular resistance and, therefore,
increases blood pressure. Other actions of norepinephrine are not considered to be clinically significant.)
*Dose, dosage and schedule were found to be correct.
*ADR: ausea, stomach upset, skin rash, acute toxicity.
Inf. NA (Noradrenaline) day-2
32
*Class: leukotriene receptor antagonist
*MOA: Montelukast selectively antagonizes LTD4, preventing smooth muscle
contraction.
*Indication: breathlessness
*Justification: This reduces the bronchoconstriction caused by the leukotriene, and
results in less inflammation
*Dose, dosage and schedule were found to be correct.
*ADR: Angioedema, headache, restlessness, abdominal pain, agitation, oedema,
allergy anaphylaxis.
Tab. Montair (Montelukast) Stat-1 DAY- 1
33
*Class: β2-agonist
*MOA: direct-acting sympathomimetic which producing bronchodilating effects.
*Indication: breathlessness
*Justification: It is given correctly as the patient complained of breathlessness
*Dose, dosage and schedule were found to be correct.
*ADR: Fine skeletal muscle tremor especially hands, tachycardia, palpitations, muscle
cramps, headache, angioedema, urticaria, hypotension and collapse.
Neb. Asthalin (Salbutamol (100ml)) Stat
34
*Class: Lactobacillus acidophilus 2000lacs, Folic acid 1.5 mg, Vit.B12 15 mcg ,Niacinamide 100 mg, Calcium pantothenate 50 mg, Biotin 100mcg.
*MOA: It helps to prevent harmful bacterial growth.
*Indication: Used For vitamins and minerals deficiency due to diarreha.
*Justification: It is given correctly as in cases of mild Antibiotic induced diarrhea.
*Dose, dosage and schedule were found to be correct.
Cap Becelac forte 1-1-1 day 4-5
35
*Class: Antitussive agent
*MOA: Chlorpheniramine is an H1-antagonist. Dextromethorphan acts as
antagonist to the NMDA glutamatergic receptor
*Indications: used for treatment and prevention of cough.
*Justification: correctly indicated as patient suffered from cough.
*Dose, dosage and schedule were found to be correct.
*ADR: Dependency, dizziness, drowsiness, vomiting, restlessness, mental confusion,
excitation
Syrp. Aerodil (Chlorpheniramine (4mg/5mL)/ Dextromethorphan (10mg)) 2 tsp 1-0-1 day 4
36
PLANNING
37
* Eradication of the offending organism through selection of the
appropriate antibiotic and complete clinical cure
*To decrease morbidity and mortality
*To prevent complications
*To relieve patient symptoms
*To improve quality of life
Goals of Therapy
Monitoring Parameters
Therapeutic Monitoring Toxicity Monitoring
vitals, RR, SpO2-
chest Xray
RS :B/L basal creps+,
WBC:
plateleate
Electrolytes
Heart rate
Fatiguability
Pedal edema
Jaundice
Input/output
38
39
*Patient having high TSH which indicated for hypothyroidism.
*Blood urea nitrogen level
*Ondansetron is not for preventing nausea or vomiting that is caused by factors other than cancer treatment or surgery.
Points to Physician
40
Points to the patient:
You have infection in your lung and it can be treated if you adhere to your therapy.
It is contagious which can be spread easily.
Hence care must be taken.
Points to Patient
41
How to Strengthen Your Lungs After Having Pneumonia
Method 1: Performing Breathing Exercises
1-Practice deep breathing.
2-Do pursed-lip breathing.
3-Try breathing from your diaphragm
4-Practice huff-cough breathing.
Life Style Modification
42
At Home
*Rest as much as possible to help speed your recovery.
*Drink plenty of fluids throughout the day.
*Take the entire course of any prescribed medications.
*Get enough vitamins and minerals.
43
Tab pan 40 mg 1-0-0
Tab tazillin 4.5 gm Q8h
Syr aerodil 2tsp 1-0-1
Tab dolo 650mg sos
Points to Patient on Discharge Medication
44
*It is antibiotic which is indicated for treatment of pneumonia.
*It should be taken one tablet each every 8 hours.
*You may have nausea, vomiting and diarrhea as side effects.
Tab tazillin 4.5 gm Q8h
Tab pan 40 mg 1-0-0
*It is indicated to prevent gastric irritation due to multi drugs.
*One tablet should be taken 30 min. before breakfast.
*You may have weakness, dizziness, nausea, vomiting or anxiety as side effects.
45
*It is indicated to reduce your cough.
*It should be taken 2 tea spoon each 12hours.
*You may have dizziness, drowsiness, vomiting, restlessness as side effects.
Syr aerodil 2tsp 1-0-1
Tab dolo 650mg sos
It is indicated for your Rheumatoid Arthritis.
You should take it whenever there is pain in your joints.
You may have nausea, vomiting and diarrhea as side effects.
46
*To review SOS
Follow up/Review
47
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