Community Acquired Pneumonia (CAD) is
CAP
a disease in which individuals who have
not recently been hospitalized develop an
infection of the lungs. It is an acute
inflammatory condition that’s result from
aspiration of oropharyngeal secretions or
stomach contents in the lungs.
Unstable vital signs:
- RR > 30 breaths/min - PR >125
beats/min
- SBP < 90 mmHg - DBP < 60 mmHg
- Temperature < 36°C or > 40°C
Altered mental state of acute onset
Suspected aspiration
Unstable / Decompensated comorbid
condition
-uncontrolled diabetes mellitus, active
malignancies, neurologic disease in
evolution,
congestive heart failure (CHF) Class II-IV,
unstable coronary artery disease, renal
failure on
dialysis, uncompensated COPD,
decompensated
liver disease
Chest X-ray:
- multilobar infiltrates
- (+) pleurai effusion or abscess
HIGH RISK CAP
Any of the clinical feature of Moderate risk
CAP plus any of the following:
Severe Sepsis and Septic Shock
OR
Need for mechanical ventilation
Several Microbes can cause
CAP
The most commonly
identified pathogensare
Streptococcus
pneumoniae,
Haemophilus
influenzae, and
atypical organisms
Pathophysiology
CAP is usually acquired via inhalation or
aspiration of pulmonary pathogenic
organisms into a lung segment or lobe.
Less commonly, CA P results from
secondary bacteraemia from a distant
source, such as Escherichia coli urinary
tract infection and/or bacteraemia.
due to aspiration of Oropharyngeal
contents is the only form of CAP involving
multiple pathogens
Symptoms and Signs
Symptoms include malaise, cough,
dyspnea, and chest pain. Cough typically
is productive in older children and adults
and dry in infants, young children, and the
elderly. Dyspnea usually is mild and
exertional and is rarely present at rest.
Chest pain is pleuritic and is adjacent to
the infected area. Pneumonia may
manifest as upper abdominal pain when
lower lobe infection irritates the
diaphragm. Symptoms become variable at
the extremes of age; infection in infants
may manifest as nonspecific irritability
and restlessness; in the elderly, as
confusion and obtundation.
Signs include fever, tachypnea,
tachycardia, crackles, bronchial breath
sounds, egophony, and dullness to
percussion. Signs of pleural effusion may
also be present (see Mediastinal and
Pleural Disorders: Symptoms and Signs).
Nasal flaring, use of accessory muscles,
and cyanosis are common in infants. Fever
is frequently absent in the elderly.
Symptoms and signs were previously
thought to differ by type of pathogen, but
presentations overlap considerably. In
addition, no single symptom or sign is
sensitive or specific enough to predict the
organism. Symptoms are even similar for
noninfective lung diseases such as
pulmonary embolism, pulmonary
malignancy, and other inflammatory lung
diseases.
INEFFECTIVE AIRWAY CLEARANCE
Definition: The inability to clear secretions
or obstruction of the respiratory tract to
maintain the cleanliness of the airway.
defining Characteristics:
- Dispneu, Decreased breath sounds
- Orthopneu
- Cyanosis
- Abnormal breath sounds (rales,
wheezing)
- Difficulty speaking
- Cough, not efektif or no
- Eyes widened
- Production of sputum
- Fidget
- Changes in the frequency and rhythm of
the breath
Related factors:
- Environment: smoking, inhaling cigarette
smoke, passive smoking-POK, infections
- Physiological: neuromuscular
dysfunction, bronchial wall hyperplasia,
airway allergy, asthma.
- Obstruction of the airway: airway spasm,
secretion detained, the number of mucus,
the presence of artificial airway, bronchial
secretions, the presence of exudate in the
alveoli, the presence of foreign bodies in
the airway.
Tracheobronchial secretion
Tracheobronchial secretions are formed by
mucous glands and goblet cells in man
and many experimental animals; there is
also an undetermined amount of
transudation from serum. Estimates of the
volume of the secretions in a normal
human adult range from 10 to 100 cc/day.
The secretions are composed of about 95
per cent water and 1 per cent each of
carbohydrate, protein, lipid and inorganic
material. The physical properties of the
secretions are largely due to several
locally produced, as yet poorly
characterized glycoproteins. Also present
are secretory IgA, bronchial lactoferrin,
bronchial lysozyme and some serum
proteins.
Enhancing Airway Clearance
1. Obtain freshly expectorated sputum for
Gram’s stain and culture, as directed.
Instruct the patient as follows:
a. Rinse mouth with water to
minimize contamination by normal flora.
b. Breathe deeply several times.
c. Cough deeply and expectorate
raised sputum into sterile container.
2. Encourage patient to cough—retained
secretions interfere with gas exchange.
Suction as necessary.
3. Encourage increased fluid intake, unless
contraindicated, to thin mucus and
promote expectoration and replace fluid
losses due to fever, diaphoresis,
dehydration, and dyspnea.
4. Humidify air or oxygen therapy to
loosen secretions and improve ventilation.
5. Employ chest wall percussion and
postural drainage when appropriate to
loosen and mobilize secretions.
6. Auscultate the chest for crackles.
7. Administer cough suppressants when
coughing is nonproductive, debilitating,
and when coughing paroxysms cause
serious hypoxemia.
hacking cough a short, frequent,
shallow and feeble cough.
productive cough cough with
expectoration of material from the
bronchi.
Crackles are discontinuous, explosive,
"popping" sounds that originate within the
airways. They are heard when an
obstructed airway suddenly opens and the
pressures on either side of the obstruction
suddenly equilibrates resulting in
transient, distinct vibrations in the airway
wall. The dynamic airway obstruction can
be caused by either accumulation of
secretions within the airway lumen or by
airway collapse caused by pressure from
inflammation or edema in surrounding
pulmonary tissue. Crackles can be heard
during inspiration when intrathoracic
negative pressure results in opening of the
airways or on expiration when thoracic
positive pressure forces collapsed or
blocked airways open. Crackles are heard
more commonly during inspiration than
expiration. They are significant as they
imply either accumulation of fluid
secretions or exudate within airways or
inflammation and edema in the pulmonary
tissue.
chest x--ray Diagnosis of CAP