NUR 652 Family Primary Care Health 1 Krista Switzer, RN, FNP-S

Pathophysiology: The lung tissue usually becomes consolidated as alveoli fill 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/bronchi. It can be viral, bacterial or a combination or both. It can also be fungal or from a parasite, which is less common. When they enter the lower respiratory track 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, & 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 WBCs. The area of this change is referred to as a consolidation focus which is typically dull to percussion on physical exam. (Dunphy 2011)

In adults with CAP, streptococcus pneumoniae is the most common pathogen. The other common pathogens responsible for pneumonia can be staph. aureus, m. catarrhalis & H. influenzae. Some atypical pathogens can be mycoplasma (#2 most common) legionella, chlamydia pnumoniae, fungi and viruses. (ATS 2001) In children, the most common cause for pneumonia is viral. Buckley and Schub (2013) report that approx. 90%of peds pneumonia is viral. VP 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, cytomegalovirus, varicella-zoster virus, herpes simplex virus, rubeola, enteroviruses, coronaviruses, epsteinbarr virus, and hantavirus. (Buckley & Schub 2013) Primary viral pneumonia is recognized as the most severe pulmonary manifestation of influenza.( Rello 2009) In peds, (ages 4 mos.-4 yrs) the most common bacterial cause is s. pnuemoniae. 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 pneumonia occur annually and as many as 1.1 million of these require hospitalization. (ATS 2001)

In the outpatient setting, the mortality rate remains low, in the range of <1-5%, but among patients with CAP who require hospitalization, the mortality rate averages 12% overall but 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 who require admission to ICU. (ATS 2001) Screening and Risk Factors

The approach to a testing decision in patients suspected of having CAP should be driven by the probability of disease, the sensitivity and specificity of the diagnostic test, the cost, and the harms of the diagnostic test, and the treatment threshold. (Metlay 2003) *When did the cough start? Did it come on suddenly or start gradually? Have you had a fever? Any shortness of breath? Wheezing? Any associated symptoms? Where do they reside? Anyone around them sick with anything? (just to name a few)

Risk Factors *infants < 6mos *children < 5yrs *smokers *ETOH *residents in nursing homes *young adults living in close quarters (military, college) *any patient with impaired swallowing or cough reflex *adults >65 yrs *HIV/immunocompromised *recent abx therapy/resistance *asthma or COPD *CAD *chronic renal failure *CHF *DM *liver disease *neoplasms (Dunphy 2011)

*Broad range depending on bacterial, viral, fungal, etc. The diagnosis of pneumonia should be considered in any patient who has newly acquired respiratory symptoms ( cough, sputum production and/or dyspnea), especially if accompanied by fever, and ausculatory findings of abnormal breath sounds and 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 illness or falling down. In these patients, fever may be absent, but tachypnea is usually present, along with abnormal physical exam of the lungs. (ATS 2001)

Normal CXR, LLL pneumonia, RML pneumonia

*Some general findings consistent with most pneumonia are as follows: 1) Fever >100.4 2) Tachypnea 3) Tachycardia 4) Rales 5) Rhonchi 6) Egophony 7) Increase fremitus 8) Bronchial breath sounds 9) Dullness to percussion 10) Asymmetric breath sounds 11) Abdominal tenderness 12) Chest pain (Domino 2014)

Bronchitis Asthma exacerbation Pulmonary edema Lung cancer Tuberculosis Pneumonitis Bronchiolitis Croup CHF SARS Atelectasis Pulmonary embolus/infarction Lymphoma Collagen vascular disease Sarcoidosis Eosinophilic pneumonitis Pulmonary fibrosis (Cunha 2013)

All patients with suspected CAP should have a chest xray to establish diagnosis and the presence of complications. All patients should have a careful assessment of disease severity, but grams stain and sputum culture are not required (and not always easily available in the out patient setting.) (ATS 2001)

All admitted patients should have as assessment of gas exchange (oximetry or arterial blood gas), routine blood chemistry and blood counts, and a collection of two sets of blood cultures. If atypical or drug resistance pathogen is suspected, then sputum culture should be obtained. (ATS 2001)
(OUT-PATIENT) In addition, it is necessary to assess severity of illness, relying on radiographic findings (mulitlobar pneumonia, pleural effusion), and physical findings (respiratory rate, systolic and diastolic blood pressure, signs of dehydration, and mental status). If the patient has underlying chronic heart or lung disease, then assessment of oxygenation by pulse oximetry my define the need for hospitalization and supplemental oxygen. Routine lab tests (cbc, electrolytes, hepatic enzymes, renal function) are of little value in determining the etiology of pneumonia, but may have prognostic significance and influence the decision to hospitalize. They should be considered in patients who may need hospitalization, and in patients > 65yrs or with coexisting illness. (ATS 2001) The proportion of patients with an increased WBC (>15) or increased ESR (>30) was similar in bacterial and viral pneumonia. (Virkki 2002)

Non-pharmacologic Increase fluids Analgesia for pain Decrease activity/rest in acute phase Deep breathing to expand lungs

Pharmacologic Antibiotics (if determined bacterial) Mucolytic (to thin mucous) Sometimes cough suppressant (dont always want to completely suppress cough because they need to express the sputum) (Dunphy 2011)

The decision to initiate antibiotic treatment relies on clinical assessment, and the choice of drug relies on the knowledge of the distribution of the most likely pathogens and their resistance patterns in the patient population. (Holm 2006) The American Thoracic Society (2001) reports that because of the increase in drug resistant Streptococcus pnumoniae (DRSP) and because all patients could potentially be infected with Chlamydia pneumoniae, Mycoplasma pneumonia and 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 outpatients, or an IV macrolide alone in inpatients who have no risk factors for DRSP, gram negatives or aspiration. For outpatients or non-ICU inpatients with risk factors for these other organisms, therapy should be with either a B-lactam/macrolide combination or an antipneumococcal fluroquinolone alone. (ATS 2001 & Caballero 2011) Examples of macrolides are azithromycin and clarithromycin; examples of quinolones are moxifloxacin, levofloxacin and ciprofloxacin Several outcome studies show that both inpatients and outpatients have a less complicated clinical course if a macrolide is used as part of the therapy regime, or if a quinolone is used alone. (ATS 2001)

Metastatic infections Arthritis Endocarditis Pericarditis Peritonitis Empyema (lung abscess) Renal failure Heart failure Pulmonary embolus Acute MI Sepsis ARDS (acute resp. distress syndrome) Death (ATS 2001)

For development of pneumonia Occupational (workers who 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) Lifestyle (college students, military housing, nursing home; increase risks due to close quarters) SARS-people who travel abroad to area of known transmission of SARS For people already diagnosed with pneumonia The absence of a caregiver in a stable home situation is a strong indication for hospitalization, at least for observation purposes. A clean, safe home environment for the person such as mold, second hand cigarette smoke, stairs (in someone elderly and weak) (Dunphy 2011 & ATS 2001)

Educate people that are previously healthy that the fever can last for 2-4 days, crackles in the lungs can last beyond 7 days in 20-40% of patients. If patients have chronic illness, COPD or smokers, resolution of sxs can last much longer. Smokers need to be advised to quit and given options Education regarding pneumonia vaccines and influenza vaccines need to be given to patients as a preventive measure Follow up is depending on the severity of illness and patient status. It can be a phone call home in 1-2 days and office visit in a week. A 4-6 week appt. for a repeat chest xray to confirm resolution is required. (Domino 2014, Hollier 2011 & ATS 2001) Referral may be required for people with chronic recurrent pneumonia to a pulmonologist

1) Whats the most common bacterial pathogen that causes community acquired pneumonia in an adult?
a) b) c)

M. pneumoniae Streptococcal pneumoniae Pseudomonas

2) What the most common reason for CAP in a child?

a) b) c)

Viral Bacterial Mycoplasma

3) What is the most common bacterial pathogen in peds CAP?

a) b) c)

E. coli S. pneumoniae Chlamydia trachomatis

4) What is the most common atypical pathogen in CAP in an adult?

a) b) c)

Mycoplasma E. coli Listeria

5) What factors make you at higher risk of developing pneumonia? (more than one)
a)
b) c)

Obesity Smokers Hypertension

d) >65 yrs old e) <5 yrs old f) hx of DVT

6) When do patients need a repeat chest x-ray to confirm clearing of pneumonia?

a) b) c)

2 weeks 6 weeks 12 weeks

7) What are some treatment options for CAP in a healthy person with no recent illness?
a)

b)
c)

Amoxicillin Zithromax Omnicef

d) Biaxin e) Cipro

8) What situation requires hospitalization?

a) b) c)

45 yr old diagnosed with pneumonia, fever 100.6, mild SOB, no regular meds, decrease appetite 4 month old diagnosed with pneumonia, retractions, tachypnea, fever 100.4 2 year old diagnosed with pneumonia, fever 102, dry cough, playing with toys in exam room and eating and drinking normally

9) Which meds are contraindicated in pregnancy?

a) b) c)

Doxycycline Zithromax Augmentin

10) What are some complications from pneumonia? (more than one answer)
a) b) c) d) e)

Respiratory failure Hypertension Sepsis Death GERD

1) 2) 3) 4) 5) 6) 7) 8) 9) 10)

B A B A B,D,E B B,D B A A,C,D

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