Pneumonia

Pneumonia is an inflammatory illness of the lung. Frequently, it is described

as lung parenchyma/alveolar inflammation and abnormal alveolar filling with
fluid (consolidation and exudation).

The alveoli are microscopic air-filled sacs in the lungs responsible for
absorbing oxygen. Pneumonia can result from a variety of causes, including
infection with bacteria, viruses, fungi, or parasites, and chemical or physical
injury to the lungs. Its cause may also be officially described as idiopathic—
that is, unknown—when infectious causes have been excluded.

Typical symptoms associated with pneumonia include cough, chest pain,

fever, and difficulty in breathing. Diagnostic tools include x-rays and
examination of the sputum. Treatment depends on the cause of pneumonia;
bacterial pneumonia is treated with antibiotics.

Pneumonia is a common illness which occurs in all age groups, and is a

leading cause of death among the elderly and people who are chronically and
terminally ill. Additionally, it is the leading cause of death in children under
five years old worldwide.[3] Vaccines to prevent certain types of pneumonia
are available. The prognosis depends on the type of pneumonia, the
appropriate treatment, any complications, and the person's underlying
health.

General Classification of Pneumonia

Typical Pneumonia

Typical pneumonia is usually acquired by bronchogenic spread of the

pathogen. The organism may also manifest itself as a suprainfection in
patients previously infected by an upper or lower respiratory viral infection.
There is no age-specific predisposition; however the incidence of infection
increases with advancing age.

Types:

• Bacterial Pneumonia

Bacterial pneumonia is caused by various bacteria. The Streptococcus

pneumoniae is the most common bacterium that causes bacterial
pneumonia. It usually occurs when the body is weakened in some way,
such as illness, malnutrition, old age, or impaired immunity, and the
bacteria are able to work their way into the lungs. Bacterial pneumonia
can affect all ages, but those at greater risk include persons who abuse
alcohol, persons who are debilitated, post-operative patients, persons with
respiratory diseases or viral infections, and persons who have weakened
immune systems.
 The symptoms of bacterial pneumonia include shaking, chills,
chattering teeth, severe chest pain, high temperature, heavy perspiring,
rapid pulse, rapid breathing, bluish color to lips and nail beds, confused
mental state or delirium, cough that produces rust-colored or greenish
mucus. Viral pneumonia is caused by various viruses, and is the cause of
half of all cases of pneumonia. Early symptoms of viral pneumonia are the
same as those of bacterial pneumonia, which may be followed by
increasing breathlessness and a worsening of the cough. Viral pneumonias
may make a person susceptible to bacterial pneumonia.

• Aspiration Pneumonia

Aspiration pneumonia is an inflammation of the lungs and bronchial

tubes caused by inhaling foreign material, usually food, drink, vomit, or
secretions from the mouth into the lungs. This may progress to form a
collection of pus in the lungs (lung abscess). Aspiration of foreign material
(often the stomach contents) into the lung can be a result of disorders
that affect normal swallowing, disorders of the esophagus (esophageal
stricture, gastroesophageal reflux), or decreased or absent gag reflex (in
unconscious, or semi-conscious individuals). Old age, dental problems, use
of sedative drugs, anesthesia, coma and excessive alcohol consumption
are also causal or contributing factors. The response of the lungs depends
upon the characteristics and amount of the aspirated substance. The
more acidic the material, the greater the degree of lung injury, although
this may not necessary lead to pneumonia.

• Hospital-Acquired Pneumonia

Hospital-acquired pneumonia is an infection of the lungs contracted

during a hospital stay. Pneumonia is a very common illness. It is caused
by many different organisms and can range in seriousness from mild to
life-threatening. Hospital-acquired pneumonia tends to be more serious
because defense mechanisms against infection are often impaired during
a hospital stay, and the kinds of infecting organisms are more dangerous
than those generally encountered in the community. Risk factors
predisposing people to hospital-acquired pneumonia are alcoholism, older
age, immunosuppression from medications or diseases, recent illness, and
risk of aspiration.

• Community-Acquired Pneumonia (CAP)

Community-acquired pneumonia (CAP) is a serious illness. It is the

fourth most common cause of death in the UK, and sixth in the USA. 85%
of cases of CAP are caused by the typical bacterial pathogens, namely,
Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella
catarrhalis. The remaining 15% are caused by atypical pathogens, namely
Mycoplasma pneumoniae, Chlamydia pneumoniae, and Legionella
species. Unusual aerobic gram-negative bacilli (for example,
Pseudomonas aeruginosa, Acinetobacter, Enterobacter) rarely cause CAP.
Atypical Pneumonia

Atypical pneumonia is a pneumonia that does not respond to the usual

antibiotic treatment. It can be caused by bacteria, in particular Mycoplasma
pneumoniae, Chlamydia pneumoniae, Legionella pneumophila and Bordatella
pertussis, or viruses including influenza and coronaviruses. Normally, these
infections are not as severe as typical pneumonia, but legionella causes
legionnaire’s disease, which kills up to 50% of its victims if left untreated.

Types:

• Mycoplasma Pneumonia

Mycoplasma pneumonia has somewhat different symptoms and

physical signs. It is caused by mycoplasmas, the smallest free-living
agents of disease in humankind, which have the characteristics of both
bacteria and viruses, but which are not classified as either. They generally
cause a mild, widespread pneumonia that affects all age groups.
Symptoms include a severe cough that may produce some mucus.
Mycoplasma pneumonia often affects younger people and may be
associated with symptoms outside of the lungs (such as anemia and
rashes), and neurological syndromes (such as meningitis, myelitis, and
encephalitis). Severe forms of Mycoplasma pneumonia have been
described in all age groups. Chlamydophila pneumonia occurs year round
and accounts for 5-15% of all pneumonias. It is usually mild with a low
mortality rate. In contrast, atypical pneumonia due to Legionella accounts
for 2-6% of pneumonias and has a higher mortality rate. Elderly
individuals, smokers, and people with chronic illnesses and weakened
immune systems are at higher risk for this type of pneumonia. Contact
with contaminated aerosol systems (like infected air conditioning systems)
has also been associated with pneumonia due to Legionella.

• Legionnaire's Disease

Legionnaire's disease is an acute respiratory infection caused by the

bacterium Legionella pneumophila, which can cause a broad spectrum of
disease from mild cough and fever to a serious pneumonia. The bacteria
that cause Legionnaire's disease have been found in water delivery
systems and can survive in the warm, moist, air conditioning systems of
large buildings including hospitals. The infection is transmitted through
the respiratory system. Person-to-person spread has not been proved.
From the onset of symptoms, the condition typically worsens during the
first 4 to 6 days, with improvement starting in another 4 to 5 days. Most
infection occurs in middle-aged or older people, although it has been
reported in children. Typically, the disease is less severe in children.

• Pneumocystis (Carinii) Jirovecii Pneumonia

 Pneumocystis carinii pneumonia is an infection of the lungs caused by
the fungus Pneumocystis carinii. PCP is a pneumonia caused by the fungal
organism Pneumocystis carinii, which is widespread in the environment,
and is not a pathogen (does not cause illness) in healthy individuals.
However, in individuals with weakened immune systems due to cancer,
HIV/AIDS, solid organ and/or bone marrow transplantation, as well as
individuals receiving chronic corticosteroids or other medications that
affect the immune system, Pneumocystis carinii may lead to a lung
infection. Individuals with advanced AIDS are of particular interest, since
PCP was a relatively rare infection prior to the AIDS epidemic. Before the
use of preventive antibiotics for PCP, up to 70% of individuals in the U.S.
with advanced AIDS would develop PCP.

Pneumonia in an immunocompromised host describes a lung infection

that occurs in a person whose infection-fighting mechanisms are
significantly impaired. People who are immunocompromised have a
defective immune response. Because of this, they are susceptible to
infections by microorganisms that are present everywhere, but do not
normally cause disease in healthy people. They are also more susceptible
to the usual causes of pneumonia, which can affect anyone.
Immunosuppression can be caused by HIV infection, leukemia, organ
transplantation, bone marrow transplant, and medications to treat cancer.

Viral pneumonia is an inflammation (irritation and swelling) of the

lungs caused by infection with a virus. Pneumonia is an infection of the
lung that affects 1 out of 100 people annually. Viral pneumonia is caused
by one of several viruses, including influenza, parainfluenza, adenovirus,
rhinovirus, herpes simplex virus, respiratory syncytial virus, hantavirus,
and cytomegalovirus. Most cases of viral pneumonia are mild and get
better without treatment, but some cases are more serious and require
hospitalization. People at risk for more serious viral pneumonia typically
have impaired immune systems such as people with HIV, transplant
patients, young children (especially those with heart defects), the elderly,
and people taking medications to suppress their immune systems in the
treatment of autoimmune disorders.

• Severe Acute Respiratory Syndrome

Severe Acute Respiratory Syndrome (SARS) is a respiratory disease in

humans which is caused by the SARS coronavirus. There has been one
near pandemic to date, between the months of November 2002 and July
2003, with 8,096 known infected cases and 774 deaths (a case-fatality
rate of 9.6%) worldwide being listed in the World Health Organization's
(WHO) 21 April 2004 concluding report. Within a matter of weeks in early
2003, SARS spread from the Guangdong province of China to rapidly
infect individuals in some 37 countries around the world.

Mortality by age group as of 8 May 2003 is below 1% for people aged

24 or younger, 6% for those 25 to 44, 15% in those 45 to 64 and more
than 50% for those over 65. For comparison, the case fatality rate for
 influenza is usually around 0.6% (primarily among the elderly) but can rise
as high as 33% in locally severe epidemics of new strains. The mortality
rate of the primary viral pneumonia form is about 70%.

As of May 2006, the spread of SARS has been fully contained thanks to
the efforts of the WHO, with the last infected human case seen in June
2003 (disregarding a laboratory induced infection case in 2004). However,
SARS is not claimed to have been eradicated (unlike smallpox), as it may
still be present in its natural host reservoirs (animal populations) and may
potentially return into the human population in the future.

Risk Factors

The elderly (who tend to have diminished cough and gag reflexes and
faltering immune systems) and infants and young children (who have
immature immune systems and small airways) are at greater risk of
community-acquired pneumonia (CAP) than are young and middle-aged
adults.

Certain individuals, such as the elderly, the very young, and those with
chronic or severe medical conditions, are of course at higher risk of
community-acquired pneumonia (CAP). Hospitalized patients are particularly
vulnerable to gram-negative bacteria and staphylococci, which can be very
dangerous, particularly in people who are already ill.

People, especially the elderly, who have recently had surgery or

suffered a traumatic injury, are also more likely to develop pneumonia
because they are less able to breathe deeply, cough, and get rid of mucous.

Pneumonia is more likely to occur in people whose immune system is

weakened by an existing illness, such as the flu, cancer, or AIDS, and in
people with chronic conditions, such as sickle cell disease, heart disease,
diabetes, kidney disease, asthma, chronic bronchitis, chronic obstructive
pulmonary disease (COPD), emphysema, or cystic fibrosis.

Recruits on military bases and college students are at higher than

average risk for Mycoplasma Pneumonia, which is usually mild. These groups
are at lower risk, however, for more serious types of pneumonia.

Frequent exposure to cigarette smoke can affect the lungs in ways that
make a person more likely to develop pneumonia. The risk for pneumonia in
smokers of more than a pack a day is three times that of nonsmokers. Those
who are chronically exposed to cigarette smoke, which can injure airways
and damage the cilia, are also at risk. Toxic fumes, industrial smoke, and
other air pollutants may also damage cilia function, which is a defense again
bacteria in the lungs.

Alcohol or drug abuse is strongly associated with pneumonia. These

substances act as sedatives and can diminish the reflexes that trigger
coughing and sneezing. Alcohol also interferes with the actions of
macrophages, the white blood cells that destroy bacteria and other microbes.
Intravenous drug abusers are at risk for pneumonia from infections that
originate at the injection site and spread through the blood stream to the
lungs.

Signs and Symptoms

The most common symptoms of pneumonia are shortness of breath;

chest pain, especially when breathing in; coughing; shallow, rapid breathing;
and fever and chills. Coughs usually bring up mucus, also called sputum. The
sputum may even be streaked with blood or pus.

In serious cases, the patient's lips or nail bed will appear blue due to
lack of oxygen. Physical examination may detect tachypnea and signs of
consolidation, such as crackles with bronchial breath sounds. This syndrome
is commonly caused by bacteria, such as S. pneumoniae and H. influenzae.

People who have bacterial pneumonia usually are very sick. Symptoms
of bacterial pneumonia usually begin suddenly and often develop during or
after an upper respiratory infection, such as influenza or a cold. Symptoms of
viral pneumonia are often less obvious, less severe, and come on gradually.

Viral pneumonia often goes unrecognized because the person may not
appear very ill. The symptoms vary with age and whether the person has
other health problems. Pneumonia caused by anaerobic bacteria such as
Bacteroides can produce dangerous abscesses in the lungs. People with such
pneumonias may have prolonged fever and productive cough, frequently
showing blood in the sputum. Signs of blood may indicate dead lung tissue
(necrosis). About a third of these patients experience weight loss.

Older adults may have milder symptoms, such as a dry

(nonproductive) cough. Sometimes there may be no fever. A change in
mental status (confusion or delirium) or worsening of an underlying lung
disease may be the major sign of pneumonia in older adults.

Diagnosis

The diagnosis of pneumonia is usually made from a medical history, a

physical examination, a chest X-ray and chest thoracentesis.

Treatment

Treatment of pneumonia consists of respiratory support, including O2 if

indicated, and antibiotics, which are selected on the basis of Gram stain
results. If Gram stain is not performed or does not establish a diagnosis,
antibiotics are selected on the basis of probabilities according to patient age,
epidemiology, host risk factors, and severity of illness.
 Antibiotics are the main causal therapy for pneumonia. The antibiotics
that are used depend on the nature of the pneumonia and the immune status
of the patient. Amoxicillin is used as first-line therapy in the vast majority of
community patients, sometimes with added clarithromycin. In North America,
where the atypical forms of community acquired pneumonia are becoming
more common, clarithromycin, azithromycin, and the fluoroquinolones have
displaced the penicillin-derived drugs as first line therapy. In hospitalized
patients and immune deficient patients, local guidelines generally determine
which combination of (generally intravenous) antibiotics is used. When in the
hospital, respiratory treatments to remove secretions may be necessary.
Occasionally, steroid medications may be used to reduce wheezing if there is
an underlying lung disease.

Prevention

A very common method for transmitting a cold is by shaking hands.

Everyone should always wash his or her hands before eating and after going
outside. Ordinary soap is sufficient. Waterless hand cleaners that contain an
alcohol-based gel are also effective for every day use and may even kill cold
viruses. Daily diets should include foods such as fresh, dark-colored fruits and
vegetables, which are rich in antioxidants and other important food chemicals
that help boost the immune system.

Deep-breathing exercises and therapy to clear secretions help prevent

pneumonia in people at high risk, such as those who have had chest or
abdominal surgery and those who are debilitated. People with pneumonia
also need to clear secretions and benefit from deep-breathing exercises and
therapy as well. If people with pneumonia are short of breath or their blood is
low in oxygen, supplemental oxygen is provided. Although rest is an
important part of treatment, moving often and getting out of bed and into a
chair are encouraged.

Several types of pneumonia can be prevented with the use of vaccines.

Vaccines are available to protect against pneumococcal pneumonia,
pneumonia caused by the bacterium Haemophilus influenzae, and pneumonia
caused by the influenza virus, which also often leads to a secondary bacterial
pneumonia. People over age 65 and those in high-risk groups are advised to
receive the pneumonia vaccine. The vaccine is effective in approximately 80
percent of healthy young adults; however, it may be less effective in people
in high risk groups. Healthy older adults usually need only one shot for
lifetime protection. People with a chronic medical problem are encouraged to
have the vaccine every 5 to 6 years. Some health professionals recommend
that everyone over the age of 65 receive the vaccine every 5 years.

Nursing Intervention

Nursing interventions and responsibilities in caring for the patient with

pneumonia include administering oxygen and medications as prescribed and
monitoring for their effects. Monitoring vital signs including oxygen level,
monitoring lung sounds, watching for edema and patients feeling of
shortness of breath. It may also include doing chest physiotherapy, educating
on the use of incentive spirometry and flutter valve. If the patient is immobile
it is imperative that the patient be turned every two hours and encouraged to
cough and deep breathe. If the patient has a tracheotomy proper tract care
and suctioning after hyperoxygenating is also a responsibility.

Complication

Complications of pneumonia that may occur include buildup of fluid in

the space between the lung and chest wall (pleural effusion), pockets of pus
that form in the space between the lung and chest wall (empyema) or in the
lung itself (lung abscess), secondary bacterial lung infection after a viral
infection, secondary infection, such as a vaginal infection or infections of the
digestive system, because of antibiotic therapy, bacteria in the bloodstream
(bacteremia) or throughout the body (septicemia), infection caused by
swelling of the covering of the spinal cord (meningitis), infection of a joint
caused by spread of bacteria through the bloodstream (septic arthritis), and
infection of the heart muscle or the sac surrounding the heart (endocarditis
or pericarditis).
BASIC PATHOPHYSIOLOGY OF BACTERIAL PNEUMONIA

MODIFIABLE NON-
MODIFIABLE
IFESTYLE & ENVIRONMENT AGE

ENTRY OF PNEUMOCOCCI

INFLAMMATORY RXN

PRODUCTION OF EXUDATE MIGRATION OF WBC

TO AVEOLI
 EXUDATE INTERFERE WITH MORE SOLID STRACTURE OF
THE
MOVEMENT OR DIFFUSION AIR CONTAINING
SPACES
O2 & CO2 BECAME FILLED

DECREASED VENTILATION

BLOOD SHUNTING

HYPOXEMIA

BULACAN STATE UNIVERSITY

COLLEGE OF NURSING
CITY OF MALOLOS BULACAN

OUTPUT IN CLINICAL DUTY

(EMILIO G. PEREZ DISTRICT HOSPITAL)
SUBMITTED BY:
JOHN PHILIP M. LACAS
BSN 3D GROUP 3

SUBMITTED TO:
MARIBEL VALENCIA, R.N
CLINICAL INSTRUCTOR