RTPP 03 - Pneumonia

Viral Pneumonias

+ 50% of pneumonias; antibiotics not effective + Influenza "flu" viruses - causing many viral illnesses and upper respiratory infections + Respiratory Syncytial Virus (RSV) - serious pneumonia in infants, particularly preemies + Adenoviruses - serious pneumonias in children during flu season + Severe Acute Respiratory Syndrome (SARS) - severe viral pneumonia requiring ventilator support in 10% of patients

Radiologic Findings

+ Chest Radiograph Increased density (from consolidation and atelectasis) Air bronchograms Pleural effusions + Computed Tomography (CT) Scan Alveolar consolidation Air bronchograms

The Physical Examination

+ Chest pain/decreased chest expansion + Cyanosis ( does not indicate hypoxemia, hypoxia) + Cough, sputum production - possible hemoptysis, and hemoptysis + Increased tactile and vocal fremitus + Dull percussion note + Bronchial breath sounds + Crackles + Pleural friction rub --- if process extends to pleural surface + Whispered pectoriloquy// sound louder when you whisper

Pneumocystis Carinii Pneumonia (PCP)

+ Now referred to as Pneumocystis jiroveci + Atypical pneumonia caused by mycobacterium organism + Only infects immunosuppressed individuals --AIDS patients --Transplant patients + Prophylaxis with Pentamadine(Nebupent)via inhalation + Treatment with same drugs if infection develops

Nosocomial Pneumonia

+ Pneumonia developing in a patient 2 days or more after hospital admission. (HAP) + Commonly associated with intubated patients on the ventilator due to loss of normal airway protection mechanisms (VAP)- develops 48-72 hours AFTER intubation + Hospitals are NOT reimbursed for nosocomial infection + Additional procedures such as use of specialized tubes is now standard to prevent Ventilator Acquired Pneumonia (VAP)

Community Pneumonias

+ Streptococcus pneumonia - 80% of all pneumonias + Haemophilus influenza - common in pulmonary patients and children **Staphylococcal pneumonia** - immunosuppressed patients and children, HAP, resistant pneumonias like MRSA + Mycoplasmal - walking pneumonia common in schools, day cares, etc. + Legionella - infection comes from soil or stored water

Severe Acute Respiratory Syndrome

+ coronavirus + droplet transmission by coughing and sneezing. +The incubation period for SARS is typically 2 to 7 days. Initially, the patient usually develops a fever (>100.4 °F or >38.0 °C), followed by chills, headaches, general feeling of discomfort, and body aches. Toward the end of the incuba- tion period, the patient with SARS usually develops a dry, nonproductive cough, shortness of breath, and malaise. In severe causes hypoxemia develops.

walking pneumonia"

+ has no clinical significance, it is often used to describe a mild case of pneumonia. For example, patients infected with Mycoplasma pneumoniae, who gener- ally have mild symptoms and remain ambulatory, are some- times told that they have "walking pneumonia."

Community-Acquired Atypical Pneumonia

+ respiratory symptoms such as cough plus headache, general fatigue, or diarrhea); a cough that tends to come in violent attacks, producing only a small amount of white mucus. Some patients experi- ence nausea or vomiting. In some cases, the patients may experience a profound weakness that lasts for a long time. + mycoplasma organism is the most common cause + Mycoplasma pneumonia is commonly seen among children and young adults. This type of pneumonia spreads easily in areas where people congregate, such as child-care centers, schools, and homeless shelters.

Why does VAP occur?

1- endotracheal tube ( ET) // pa can close, and cough on their own 2- impaired natural protection/ clearance System // put bacteria in lung 3-

Prevention of VAP

1- using proper sterile technique 2- proper hand washing 3- isolation contagious patient 4- elevating the patient HOB at least 4 5 5- limiting patient sedation 6- weaning patient from mechanical ventilation as soon as possible

clinical manifestations result from the pathophysiologic mechanisms caused (or activated) by

1. Alveolar Consolidation 2. Increased Alveolar-Capillary Membrane 3. Thickness 4. Atelectasis 5. Excessive Bronchial Secretions During the resolution stage of pneumonia

Respiratory Care Treatment Protocols

1. Oxygen therapy protocol 2. Lung expansion therapy protocol ( breathing technique, cough, IPPB, spirometer) 3. Bronchopulmonary hygiene therapy( vet, deep breathing, cough, turning them)

Cross-sectional view of alveolar consolidation in pneumonia.

AC=alveolar consolidation,// bleeding L=lymphocyte, RBC = red blood cell, M=macrophage

Abnormal Laboratory Tests and Procedures

Abnormal sputum examination ==> decide pneumonia (see Figure 16-1 and Overview page 262)

bronchopneumonia

Bronchopneumonia is limited to the segmental bronchi and surrounding lung parenchyma

VAP

Commonly associated with intubated patients on the ventilator due to loss of normal airway protection mechanisms- develops 48-72 hours AFTER intubation

Pulmonary Function Test Findings (Restrictive Lung Pathophysiology)// Forced Expiratory Volume and Flow Rate Findings

FVC FEVT FEV1/FVC ratio FEF25%-75 ↓ N or ↓ N or ↑ N or ↓ FEF50% FEF200-1200 PEFR MVV N or ↓ N or ↓ N or ↓ N or ↓

Thoracentesis

For diagnostic and therapeutic purposes, thoracentesis may be used if a pleural effusion is present. From a diagnostic standpoint, fluid samples may be examined for the following: Color Odor RBC count Protein Glucose Lactic dehydrogenase (LDH) Amylase pH Wright's, Gram, and acid-fast bacillus (AFB) stains Aerobic, anaerobic, tuberculosis, and fungal cultures Cytology

Pneumonia developing in a patient 2 days or more after hospital admission.

HAP

Pneumonia Causing Bugs in Chronic Pulmonary Patients // top 3 bacteria in COPD pa

Haemophilus Influenza // oral secretion Klebsiella pneumonia // age 40 above - smoke and drink Pseudomonas aeruginosa // burn pa, GI tract, green smelly sputum Chronic pulmonary patients with lots of secretions are usually colonized with a gram negative bacteria. When stressed, the colonization becomes an acute infection.

Vital Signs

Increased values that indicate: + Tachypnea + Fever (bacteria >100° F and viral < 101° F) + Tachycardia + Hypertension // high BP

Anatomic Alterations of the Lungs

Inflammation of the alveoli Alveolar consolidation Atelectasis (e.g., aspiration pneumonia)

interstitial pneumonia

Interstitial pneumonia is usually diffuse and is commonly associated with infections with Mycoplasma pneumonia or viruses.

lobar pneumonia

Lobar pneumonia is a widespread or diffuse alveolar inflammation and consolidation. Lobar pneumonia is often the end result of severe broncho- pneumonia in which the infection spreads from one lung segment to another until the entire lung lobe is involved.

Etiology

Pneumonia and influenza combined are the 8th leading cause of death among Americans and the 6th leading cause of death over the age of 65. Approximately 50,000 Americans die of pneumonia each year. Pneumonia and influenza are especially life-threatening in individuals whose lungs are already damaged by chronic obstructive pulmonary disease (COPD), asthma, or smoking.

Aspiration Pneumonia

Pneumonia as a result of aspiration of oropharyngeal contents and gastric contents including stomach acid. Severe pneumonia often progressing to acute respiratory distress syndrome (ARDS) and requiring mechanical ventilation in the ICU At-risk for aspiration pneumonia: --Swallowing impairment (dysphagia)// MMS pa, ALS, stroke pa --Esophageal reflux // GERD --Neurologic impairment // ALS, --Absence of gag reflex // brain dead pa

General Management of Pneumonia

The treatment of pneumonia is based on: The specific etiology of the pneumonia, and The severity of symptoms demonstrated by the patient.

Respiratory Syncytial Virus (RSV)

Treatment --Antiviral therapy // relate to mump --Oxygen therapy --Airway clearance --Mechanical ventilation if needed --Use of Virazole (ribavirin) by special nebulizer is sometimes used; outcomes are variable

Pulmonary Function Test Findings (Restrictive Lung Pathophysiology)// Lung Volume and Capacity Findings

VT IRV ERV RV VC N or ↓ ↓ ↓ ↓ ↓ IC FRC TLC RV/TLC ratio ↓ ↓ ↓ N

Causes of pneumonia include

bacteria, viruses, fungi, protozoa, parasites, tuberculosis, anaerobic organisms, aspiration, and the inhalation of irritating chemicals such as chlorine.

Influenza "flu" viruses -

causing many viral illnesses and upper respiratory infections

When both lungs are involved, the condition is sometimes called double pneumonia by laypersons.

double pneumonia

The risk of death from pneumonia or influenza is also higher among people with

heart disease, diabetes, or a weakened immune system.

IVAC - Infection- related Ventilator - Associated Complication

if the patient cultures are positive, and their sputum become purulent or PVAP

pneumonia

inflammation of the lung parenchyma usually caused by infection, bacteria, and some virus

Importance of VAP

it hold a mortality rate of 24% in younger patients and up to 60 % in those 85 years of age and above

Mycoplasma pneumoniae

no cell wall around it + in daycare, school

Arterial Blood Gases Pneumonia // Mild to Moderate Stages: Acute Alveolar Hyperventilation with Hypoxemia (Acute Respiratory Alkalosis)

pH PaCO2 HCO3− PaO2 SaO2/SpO2 ↑ ↓ ↓ ↓ ↓ (but normal)

Arterial Blood Gases Pneumonia // Severe Stage: Acute Ventilatory Failure with Hypoxemia (Acute Respiratory Acidosis)

pHPaCO2 HCO3− PaO2 SaO2/SpO2 ↓ ↑ ↑ ↓ ↓ (but normal)

Nosocomial Pneumonia

pneumonia acquired in the hospital 9 may causes by gram - negative organism which are often resistant to therapy

VAP - ventilator Acquired Pneumonia

pneumonia develop more than 48-72 hours after incubation and ventilation\ 4 definitions associated with pneumonia incidences in a mechanically ventilated patient + VAE +VAC +IVAC +PVAP

CAP - community Acquired Pneumonia

pneumonia that is acquired outside of the hospital

Community-acquired pneumonia (CAP)

refers to a pneumonia acquired from normal social contact (i.e., in the community) as opposed to being acquired while in hospitals or extended-care facilities (e.g., nursing homes)

Respiratory Syncytial Virus (RSV) -

serious pneumonia in infants, particularly preemies

+ Adenoviruses

serious pneumonias in children during flu season

+ Severe Acute Respiratory Syndrome (SARS) -

severe viral pneumonia requiring ventilator support in 10% of patients -- happenned China

Aerobic - Anaerobic Aspiration pneumonia Lobar pneumonia "Double" pneumonia "Walking" pneumonia Ventilator acquired pneumonia (VAP) Hospital acquired pneumonia (HAP)

terminology

The terms bronchopneumonia, lobar pneumonia or interstitial pneumonia often refer to the anatomic location of the inflammation.

the anatomic location of the inflammation.

PVAP - Possible VEntilator- Associated Pneumonia

this mean that patient meets the criteria for VAC, and a causative pathogens has been determine

VAE - ventilator associated Event

when pa suffers a deterioration after a period of stability on the ventilator can lead to VAC

VAC - Ventilator Associated COndition

within 2 days after the deterioration period. The patient tempt or WBC increase and an antibiotic is started . can lead to IVAC