Running Head: PNEUMONIA

Pneumonia Krista Switzer, RN, FNP-S State University of New York Institute of Technology NUR 652

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Definition Community acquired pneumonia is defined as an infection of the lung parenchyma that is acquired outside of a healthcare facility or that develops more than 48 hours after admission to a healthcare facility. (Richman 2013) The lung tissue, in pneumonia, usually becomes consolidated as alveoli become filled with exudate and gas exchange may be impaired as blood is shunted around nonfunctional alveoli. It can be confined to a lobe, a segment of a lobe, the interstitial tissue, or alveolar/bronchial. It can be viral, bacterial or a combination of both. It can also be fungal or from a parasite, which is less common. When the pathogen enters the lower respiratory tract in sufficient number or with sufficient virulence to overwhelm defenses, the inflammatory response is set in motion. This increases capillary permeability and attracts neutrophils, lymphocytes, platelets, and fibrinogen to the site of infection. As this progresses, cellular debris accumulates, impeding flow from alveoli. The spongy consistency of lung tissue becomes fluid filled and infiltrated by several lineages of white blood cells. The area of change is considered a consolidation focus which is typically dull to percussion on physical exam. (Dunphy 2011) Etiology/Incidence In adults with community acquired pneumonia (CAP), streptococcus pneumonia is the most common pathogen. The other common pathogens responsible for CAP are staphylococcus aureus, Moraxella catarrhalis, and haemophilus pnuemoniae. Some atypical pathogens can be mycoplasma pneumoniae (#2 most common), legionella, chlamydia pneumonia, other fungi and viruses. ( ATS 2001) In children the most common cause for pneumonia is viral. Buckley and Schub (2013) report that 90% of pediatric pneumonia is viral. Viral pneumonia can be caused by Influenza A, B or C (most common in adults), H5N1 and H1N1; RSV (most common in infants and young children), parainfluenza, adenovirus,

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cytomegalovirus, varicella-zoster virus, herpes-simplex virus, rubeola, enteroviruses, coronaviruses, Epstein-barr virus, and hanta virus. (Buckley & Schub 2013) Primary viral pneumonia is recognized as the most severe pulmonary manifestation of influenza. (Rello 2009) In pediatrics, ages 4 months-4 years, the most common cause is also streptococcus pneumonia. In the United States, pneumonia is the sixth leading cause of death and the number one cause of death from infectious disease. 5.6 million cases of CAP occur annually and approximately 1.1 million of these require hospitalization. (ATS 2001) In the outpatient setting, the mortality rate remains low, in the range of less than 1-5%, but among patients with CAP that require hospitalization, the mortality rate averages 12%. This increases in specific populations, such as those with bacteremia, and those from nursing home settings, and approaches 40% in those who are most ill and require admission to the ICU. (ATS 2001) Screening The approach to a testing decision in patients suspected of having pneumonia should be driven by the probability of disease, the sensitivity and specificity of the diagnostic test, the cost and the harms of the test, and the treatment threshold. (Metlay 2003) Some of the important history questions that should be asked are: When did the cough start? Did it come on suddenly or gradually? Are you bringing up any sputum? Any associated fever? Any shortness of breath? Wheezing? Any other associated symptoms? Where do they reside, in their own home, nursing home, with children, any other family members? Anyone at home or work that is sick with similar symptoms? These are just a few of the many history questions needed to evaluate thoroughly and to assist with the decision making process.

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Risk Factors Dunphy (2011) reports that risk Factors that increase someones chance of getting pneumonia are as follows: Infants <6 months old Infants <5 yrs. old Smokers ETOH Residents in nursing homes Young adults living in close quarters (military, college housing) Any patient with impaired swallowing or coughing reflex Adults >65 yrs. old HIV/immunocompromised Recent antibiotic therapy or resistance Asthma/COPD CAD/CHF Chronic renal failure Liver disease Diabetes Neoplasm

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Clinical Findings There are a broad range of clinical findings in a patient with pneumonia depending on the pathogen such as viral, bacterial ,fungal or parasite. The diagnosis of pneumonia should be considered in any patient with newly acquired respiratory symptoms (cough, sputum production, and/or dyspnea), especially if accompanied by a fever and ausculatory findings of abnormal breath sounds such as crackles. In a patient with advanced age or inadequate immune response, pneumonia may present with non-respiratory symptoms such as confusion, failure to thrive, worsening of an underlying chronic disease or falling down (when previous was not unstable.) In these patients, fever may be absent, but tachypnea is usually present along with abnormal physical exam of the lungs. (ATS 2001) Domino (2014) reports some general findings consistent with most pneumonia are as follows: Fever >100.4 Tachypnea Tachycardia Rales/crackles/rhonchi Egophony Increase fremitus Bronchial breath sounds Dullness of percussion Asymmetrical breath sounds Abdominal tenderness Chest pain

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Differential Diagnosis Differential diagnosis for a patient that comes in with similar symptoms are: bronchitis, asthma exacerbation, pulmonary edema, lung cancer, tuberculosis, pneumonitis, bronchiolitis, croup, CHF, SARS, atelectasis, pulmonary embolus/infarction, lymphoma, collagen vascular disease, sarcoidosis, eosinophilic pneumonitis, and pulmonary fibrosis. (Cunha 2013) Labs and Testing All patients with suspected CAP should have a chest x-ray to establish diagnosis and the presence of complications. All patients should have careful assessment of disease severity, but gram stain and sputum culture is not required (and not always easily accessible in the outpatient setting). To assess severity of illness, you need to look at all your tools. The history, physical exam (respiratory rate, blood pressure, signs of dehydration, and mental status), chest x-ray,(multi-lobar pneumonia, pleural effusion), patient picture. If the patient has underlying chronic lung or heart disease, then the assessment of oxygenation by pulse oximetry may define the need for hospitalization and supplemental oxygen. Routine lab tests (cbc, electrolytes, hepatics enzymes, renal function) are of little value in determining the etiology of the pneumonia, but they may have prognostic significance and influence the decision to hospitalize. They should be considered in patient over age 65 or with coexisting illness. (ATS 2001) The proportion of patient with an increase in WBCs (> 15) or increased ESR (>30) was similar in bacterial and viral pneumonia. (Virkki 2002)

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All inpatients should have an assessment of gas exchange (oximetry or arterial blood gas), routine chemistry and blood counts, and a collection of two sets of blood cultures. If atypical or drug resistant pathogen is suspected, then sputum culture should be obtained. (ATS 2001) Management/Treatment Guidelines Some outpatient management and treatment guidelines are as follows: Increase fluids Analgesia for pain Decrease activity/rest in acute phase Deep breathing to expand lungs Antibiotic if determine its bacterial Mucolytic (to thin mucous to expel) Sometimes a cough suppressant (you dont always want to suppress the cough reflex because you would want to cough up the sputum) (Dunphy 2011) Antibiotic Treatment The decision to start antibiotic treatment is based on assessment and clinical findings and the choice of drug is based on knowledge of the distribution of the most likely pathogens and their resistance patterns in the patient population and your community. (Holm 2006) The American Thoracic Society (2001) reports that because of the increase in resistant streptococcus pneumoniae (DRSP) and because all patients could potentially be infected with Chlamydia pneumonia, Mycoplasma pneumoniae, or

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Legionella (the atypical pathogens), either alone or as part of a mixed infection, all patients should be treated to account for this possibility. This would be with a Macrolide (or tetracycline) alone in healthy patients, or an IV macrolide in patients who have no risk factors for DRSP, gram negatives or aspiration. For out-patients or non ICU patients, with risk factors for these organisms, therapy should be either with a beta-lactam/macrolide combination or a fluroquinolone alone. (ATS 2001 & Caballero 2011) Examples of macrolides are azithromycin and clarithromycin. Examples of quinolones are moxifloxacin, levofloxacin, ciprofloxacin. Several outcome studies show that both inpatient and outpatients have a less complicated clinical course if a macrolide is used as part of the therapy regime or a quinolone is used alone. (ATS 2001) Complications Some complications of pneumonia are as follows: Metastatic infections Arthritis Endocarditis Pericarditis Peritonitis Empyema Renal failure/heart failure Pulmonary embolism Acute MI

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Sepsis ARDS (acute resp. distress syndrome) Death Social/Environmental Considerations

For the development of pneumonia: 1) Occupational workers (workers can develop berylliosis, which is a chronic allergic type lung disease when exposed to chemicals such as ceramics, high technology electronics, and alloy manufacturing). Farmers due to exposure to moldy hay (farmers lung). 2) Lifestyle (college students, military housing, nursing home) increase risks due to close living quarters. 3) SARS- people who travel abroad a lot to areas of known transmission of SARS For people already diagnosed with pneumonia: 1) The absence of a caregiver in a stable home situation is a strong indication for hospitalization, at least for observation purposes 2) A clean, safe home environment for the person such as avoidance of mold, second hair cigarette smoke, stairs (in someone elderly and weak). (ATS 2001 & Dunphy 2011) Counseling/Education/Referral/Follow up Educate people that are previously healthy that a fever can last 2-4 days, crackles in the lungs can last beyond 7 days in 20-40% of patients. If patients have a chronic illness, COPD or are a smoker, resolution

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of symptoms can last much longer. Smokers need to be advised to quit and given tools to assist them. Education regarding pneumonia and influenza vaccines need to be given to patients as a preventative measure. Follow up is depending on the severity of illness and patient status. It can be a phone call home in 24-48 hours, a follow up visit in a week and another in 4-6 weeks to repeat chest x-ray to confirm resolution is required. Referral may be required for people with chronic recurrent pneumonia or COPD to a pulmonologist. (Domino 2014, Hollier 2011, & ATS 2001)

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References American Thoracic Society. (2001) Guidelines for the management of adults with community acquired pneumonia. American Journal of Respiratory Critical Care Medicine. 163, 1730-1754. Andrews, C., Coalson, J., Smith, J.& Johanson, W. (1981) Diagnosis of nosocomial bacterial pneumonia in acute, diffuse lung injury. American College of Chest Physicians. 80(3), 254-258. Buckley, L. & Schub, T. (2013) Quick lesson about viral pneumonia. Cinahl Information Systems. Retrieved from CINAHL plus with full text. Cao, B. (2010) Viral and mycoplasma pneumonia community acquired pneumonia and novel clinical outcome evaluation in ambulatory adult patients in china. The European Journal of Clinical Microbiology& Infectious Diseases. 29, 1443-1448. Cunha, B. (2013) Community acquired pneumonia: a clinical diagnostic approach. Consultant. 53(5), 325334. Ebell, M. (2007) Predicting pneumonia in adults with respiratory illness. American Family Physician. 76(4), 560-562. Falsey, A. & Walsh, E. (2006) Viral pneumonia in older adults. Aging and Infectious Disease. 42, 518-524. Figueiredo, L. (2009) Viral pneumonia: epidemiological, clinical, pathophysiological and therapeutic aspects. Pneumologia E Tisilogia. 35(9), 899-906. a De

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File, T. (2010) Recommendations for treatment of hospital acquired and ventilator-associated pneumonia: Review of recent international guidelines. Clinical Infectious Diseases. 51 (S1) S42S47. Fine, M., Auble, T., Yealy, D., Hanusa, B., Weissfeld, L., () Kapoor, W. (1997) A prediction rule to identify low-risk patients with community acquired pneumonia. The New England Journal of Medicine. 336(4), 243-250. Gallagher, J. (2012) Implementation of ventilator-associated pneumonia clinical guideline (bundle). The Journal for Nurse Practitioners. 8(5), 377-382. Griffin, M., Zhu, Y., Moore, M., Whitney, C.& Grijalva, C. (2013) U.S. hospitalizations for pneumonia after a decade of pneumococcal vaccination. The New England Journal of Medicine. 369, 155-163. Holm, A., Nexoe, J., Bistrup, L., Pedersen, S., Obel, N., Nielson, L., & Pedersen, C. (2007) Aetiology and prediction of pneumonia in lower respiratory tract infection in primary care. British Journal of General Practice. 57 (540), 547-554. Ito, T., Iijima, M. & Takano, T. (2008). Pediatric pneumonia death caused by community-acquired methicillin-resistant staphylococcus aureus, Japan. Emerging Infectious Disease. 14(8), 13121314. Khawaja, A., Zubairi, A., Durrani, F. & Zafar, A. (2013) Etiology and outcome of severe community acquired pneumonia in immunocompetent adults. BMC Infectious Diseases. 13, 94.

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Mandell, L., Wunderink, R., Anzueto, A., Bartlett, J., Campbell, D., Dean, N. (.)Whitney, C. (2007) Infectious diseases society of America/American thoracic society consensus guidelines on the management of community- acquired pneumonia in adults. Clinical Infectious Diseases. 44, S2772. Metlay, J. & Fine, M. (2003) Testing strategies in the initial management of patients with community acquired pneumonia. Annals of Internal Medicine. 138, 109-118. Metlay, J., Kapoor, W. & Fine, M. (1997) Does this patient have community-acquired pneumonia? Diagnosing pneumonia by history and physical examination. Journal of American Medical Association. 278 (17), 1440-1445. Rello, J. & Pop-Vicas, A. (2009) Clinical review: primary influenza viral pneumonia. Critical Care. 13, 235. Richards, S .& Schub, T. (2013) Quick lesson about bacterial pneumonia. Cinahl Information Systems. Retrieved from CINAHL plus with full text. Richman, S. & Schub, T. (2013) Quick lesson about community-associated pneumonia. Cinahl Information Systems. Retrieved from CINAHL plus with full text. Roblin, P. & Hammerschlag, M. (1998) Microbiologic efficacy of azithromycin and susceptibilities to azithromycin of isolates of chlamydia pneumonia from adults and children with communityacquired pneumonia. Antimicrobial Agents and Chemotherapy. 42(1), 194-196.

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Shapiro, E., Berg, A., Austrian, R., Schroeder, D., Parcells, V, (..) Clemens, J. (1991) The protective efficacy of polyvalent pneumococcal polysaccharide vaccine. The New England Journal of Medicine. 325(21), 1454-1460. Virkki, R., Juven, T., Rikalainen, H., Svedstrom, E., Mertsola, J. & Ruuskanen, O. (2002) Differentiation of bacterial and viral pneumonia in children. British Medical Journal. 57, 438-441. Wilson, Mary. (2012) Not pneumonia? Hold the antibiotics. Journal Watch Infectious Diseases. Retrieved from http://www.jwatch.org/id201301090000006/2013/01/09/not-pneumonia-hold-antibiotics.