Pneumonia Lecture Hcortez

Harold Haze S. Cortez, Harold Haze S. Cortez, RN, MANRN, MAN

IUDMCIUDMC

D R O E RD R O E R

IntroductiIntroductionon Pneumonia is defined as the

inflammation of lung tissue caused by an infectious agent that results in acute respiratory signs and symptoms.

Causative agents include: bacteria (S. pneumoniae), virus (H. influenzae), fungi (P. jirovecii)

TOP KILLERTOP KILLER

Pneumonia is the most common presentation of IPD in children.

Most commonly affects the very young Pneumonia is the top killer of Filipino

children <5 years old, accounts for 34% of deaths

Pneumonia remains to be a major cause of Pneumonia remains to be a major cause of morbidity and mortality among Filipino morbidity and mortality among Filipino

children.children.

Region I: 400Region II: 600

Region III: 250

Region IV-A: 700

Region IV-B: 350

Region V: 3200

Region VI: 900Region VII: 800

Region VIII: 1400

Region IX: 650

Region X: 600

Region XI: 1300

Region XII: 1200

NCR: 450

CAR: 1750

CARAGA: 450

ARMM:

Pneumonia Morbidity Rate by RegionRate per 100,000 population

2008

TypesTypes Community-acquired pneumonia (CAP)

Onset in community or during 1st 2 days of hospitalization (Strep. pneumoniae most common) 75%

Hospital-acquired Pneumonia(HAP)Occurring 48 hrs or longer after

hospitalization Aspiration pneumonia Pneumonia caused by opportunistic

organismsPneumocystis Carinii

DIAGNODIAGNOSTICSSTICS

ASSESSMENTASSESSMENT

TAKE IT OFF???!!TAKE IT OFF???!!

ASSESSMENTASSESSMENT Fevers, chills,

anorexia Pleuritic chest pain SOB Crackles/wheezes Cough, sputum

production Tachypnea

Chest Chest RetractionsRetractions

Seen in severe pneumonia

Bacterial vs. Bacterial vs. ViralViral

Features Bacterial Viral

Fever T>38.5°C T<38.5°C

Wheeze Absent Present

Alveolar infiltrates in Chest Xray or an elevated white cell count favors bacterial pathogen

DIAGNOSTICSDIAGNOSTICS Pulse Oximetry Chest X-Ray Computed Tomography (CT scan) Bronchoscopy Thoracentesis Pulmonary Function Tests Sputum Specimen and Cultures

PULSE PULSE OXYMETRYOXYMETRY Measures arterial oxygen

saturation Pulse oximetry probe on

forehead, ears, nose, finger, toes,

False readings Intermittent or continuous

monitoring Ideal values: 95-100% When to Notify MD

< 91%86% (Medical Emergency)

CHEST X-RAYCHEST X-RAYScreen, diagnose,

evaluate treatment

Instructions: No metals/jewelry

NORMAL CHESTNORMAL CHEST

Lateral ViewLateral View

Bronchial Bronchial PneumoniaPneumonia

Lobar Lobar PneumoniaPneumonia

SPUTUM SPUTUM SPECIMENSPECIMEN To diagnose; evaluate

treatment Specimen: ID organisms or

abnormal cellsCulture & Sensitivity (C&S)CytologyGram stains

○ (e.g. Acid Fast Bacilli)

Computed Computed Tomography Tomography (CT)(CT) Images in cross-section

view

Uses contrast agents

Instructions:

BronchoscopyBronchoscopy Diagnose problems and

assess changes in bronchi/bronchioles

Performed to remove foreign body, secretions, or to obtain specimens of tissue or mucus for further study

Procedure Care/InstructionsProcedure Care/Instructions::NPO 6 -8 hrs priorNPO 6 -8 hrs priorSedation during procedureSedation during procedurePost Procedure:Post Procedure:HOB elevatedHOB elevatedObserve for hemorrhageObserve for hemorrhageNPO until gag reflex returnsNPO until gag reflex returns

Pulmonary Pulmonary Function Function Test(PFTs)Test(PFTs) Evaluate lung function

Observe for increased dyspnea or bronchospasm

Instructions: No bronchodilators 6

hours prior

ThoracentesisThoracentesis Specimen from pleural

fluid Treat pleural effusion Assess for

complicationsPost-Procedure care: CXR after procedurePositionsPositions

•Sitting on side of bed over Sitting on side of bed over bedside table chestbedside table chest elevatedelevated•Lying on affected sideLying on affected side•Straddling a chairStraddling a chair

HEMATOLOGYHEMATOLOGY WHITE BLOOD CELL COUNT ESR / CRP

MICROBIOLOGYMICROBIOLOGYBlood C/SPlueral fluid C/STracheal aspiration C/SSputum C/S

Who shall be Who shall be considered as considered as

having having community-community-

acquired acquired Pneumonia?Pneumonia?

For ages 3 months to 5 years are tachypnea and/or chest indrawing

For ages 5 to 12 years are fever, tachypnea, and crackles

Who shall be Who shall be considered as considered as

having having community-community-

acquired acquired Pneumonia?Pneumonia?

Beyond 12 years of ages are the presence of the following features:Fever, tachypnea, and tachycardiaAt least one abnormal chest findings of

diminished breathing sounds, ronchi, crackles or wheezes

Tachypnea is still the best predictor of pneumonia

Who will Who will require require

admission?admission? A patient who is at moderate to high risk to develop pneumonia-related mortality should be admitted

A patient who is minimal to low risk can be managed on an outpatient basis

Risk Risk Classification of Classification of

PneumoniaPneumoniaVariables PCAP A Minimal risk

PCAP BLow risk

PCAP CModerate risk

PCAP DHigh risk

Co-morbid illness None Present Present Present

Compliant caregiver Yes Yes No No

Ability to follow up Possible Possible Not possible Not possible

Presence of dehydration None Mild Moderate Severe

Ability to feed Able Able Unable Unable

Age >11 mos >11 mos <11 mos <11 mos

Respiratory rate 2-12mos 1-5years >5 years

≥50/min≥40/min≥30/min

>50/min>40/min>30/min



RESPIRATORY RESPIRATORY RATE CRITIARATE CRITIA

Variables PCAP A Minimal

risk

PCAP BLow risk

PCAP CModerat

e risk

PCAP DHigh risk

Respiratory rate 2-12mos 1-5years >5 years

≥50/min≥40/min≥30/min




Risk Risk Classification of Classification of

PneumoniaPneumoniaVariables PCAP A Minimal risk

PCAP BLow risk

PCAP CModerate risk

PCAP DHigh risk

Signs of respiratory failure a. Retraction b. Head bobbing c. Cyanosis d. Grunting e. Apnea f. Sensorium

NoneNoneNoneNoneNone

Awake

NoneNoneNoneNoneNone

Awake

Intercostal/SubcostalPresentPresentNoneNone

Irritable

Supraclavicular/Intercostal/Subcostal

PresentPresentPresentPresent

Lethargic/Stuporous/Comatose

Complication(effusion, pneumothorax)

None None Present Present

Action Plan OPD follow up at end of treatment

OPD follow up after 3 days

Admit to regular ward Admit to ICURefer to specialist

RHONCHIThese are low

pitched, snore-like sounds.

They are caused by airway secretions and airway narrowing.

They usually clear after coughing.

HEAD BOBBING

The presence of retraction on admission was the best single predictor of death

Inability to cry, head nodding and a respiratory rate of >60/min were the best predictors of hypoxemia

What diagnostic What diagnostic aids are requested aids are requested

for a patient for a patient classified as PCAP classified as PCAP

A or PCAP B?A or PCAP B? No diagnostic aids are initially requested for a patient classified as either PCAP A or PCAP B who is being managed in an ambulatory setting

What diagnostic What diagnostic aids are initially aids are initially requested for a requested for a

patient classified as patient classified as either PCAP C or either PCAP C or

PCAP D?PCAP D? The following should be routinely requested:

Chest x-ray PA-lateralWhite blood cell countCulture and sensitivity of

○ Blood for PCAP D○ Pleural fluid○ Tracheal aspirate upon initial intubation○ Blood gas and/or pulse oximetry

When is When is antibiotic antibiotic

recommended?recommended? For a patient classified as either PCAP A or B and is:Beyond 2 years of ageHaving high grade fever without wheeze

For a patient classified as PCAP C and is:Beyond 2 years of ageHaving high grade fever without wheezeHaving alveolar consolidation in the CXRHaving WBC > 15,000

For a patient classified as PCAP D

EtiologyEtiology First 2 years: viruses

As age increases bacterial pathogens become more prevalent

INTERVENTION/INTERVENTION/TREATMENTTREATMENT Treatment

Antibiotics → choose based on age, suspected cause & immune status

Supportive care → IV fluids, supplemental oxygen therapy, respiratory monitoring, cough enhancement

*may take 6-8 weeks for CXR to normalize

MEDICATION MEDICATION (BACTERIAL)(BACTERIAL) For a patient classified as PCAP A

or B without previous antibiotic, oral Amoxicillin (40-50mg/kg/day in 3 divided doses) is the DOC

For a patient classified as PCAP C without previous antibiotic who has completed primary immunization against H.Influenza type b, Penicillin G (100,000units/kg/day in 4 divided doses) is the DOC

MEDICATION MEDICATION (BACTERIAL)(BACTERIAL)If a primary immunization againts Hib has not been completed, intravenous Ampicillin (100mg/kg/day in 4 divided doses) should be given

For a patient classified as PCAP D, a specialist should be consulted

DURATION OF DURATION OF TREATMENTTREATMENT

5 -7 days - outpatients 7-10 days – inpatients, S.

pneumoniae 10-14 days – Mycoplasma,

Chlamydia, Legionella 14+ days - chronic steroid users

MANAGEMENT MANAGEMENT (VIRAL ETIOLOGY)(VIRAL ETIOLOGY)

Ancillary treatment should be given

Oseltamivir (2mg/kg/dose BID for 5 days) or Amantadine (4.4-8.8mg/kg/day for 3-5days) may be given for influenza that is either confirmed by laboratory or occurring as an outbreak

When can a When can a patient be patient be

considered as considered as RESPONDING TO RESPONDING TO

THE CURRENT THE CURRENT ANTIBIOTIC?ANTIBIOTIC?

Decrease in respiratory signs (particularly tachypnea) and defervescence within 72hours after initiation of antibiotic

Persistence of symptoms beyond 72 hours after initiation of antibiotics requires reevaluation

End of treatment CXR, WBC, ESR or CRP should not be done to assess therapeutic response to antibiotic

What What should be should be done if a done if a patient is patient is

NOT NOT RESPONDIRESPONDI

NG NG to to current current

antibiotic antibiotic therapy?therapy?

PCAP A or BPCAP A or B If an outpatient classified as either

PCAP A or B is not responding within 72hours, consider any one of the following:Change the initial antibiotic Start an oral macrolideReevaluate diagnosis

PCAP CPCAP C If an inpatient classified as PCAP C is

not responding within 72hours, consider consultation with a specialist because of the following possibilities:Penicillin resistant Streptococcus

pneumoniaePresence of complication (pulmonary or

extrapulmonary)Other diagnosis

PCAP DPCAP D If an inpatient classified as

PCAP D is not responding within 72hours, consider IMMEDIATE re-consultation with a specialist

IV to Oral IV to Oral AntibioticsAntibiotics

Switch from intravenous antibiotic administration to oral from 2-3 days after initiation is recommended in a patient who:

Is responding to the initial antibiotic therapy

Is able to feed with intact gastrointestinal absorption

Does not have any pulmonary or extra pulmonary complication

NURSING ACTIONS: NURSING ACTIONS: Ancillary TreamentAncillary Treament Among inpatient, oxygen and

hydration should be given if needed Cough preparations, chest

physiotherapy, bronchial hygiene, nebulization using normal saline solution, steam inhalation, topical solution, bronchodilators and

In the presence of wheezing, a bronchodilator may be administered

herbal herbal medicines medicines are are not not routinely routinely given given in in community-community-acquired acquired pneumoniapneumonia

COMPLICATIONSCOMPLICATIONSHypoxemia

Pleural effusion

Atelectasis

Pleurisy

AtelectasisPleurisy

Pleural EffusionPleural Effusion

PREVENTIONPREVENTION Influenza vaccine Pneumococcal Vaccine

PREVENTION PREVENTION (ICU Patients)(ICU Patients)

Isolation of patients with resistant respiratory tract infections

Enteral nutrition Choice of GI prophylaxis Subglottic secretion removal

HIGLY CONTAGIOUS

STAY HEALTHYSTAY HEALTHY

Any Questions?

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Pneumonia Lecture Hcortez