PNEUMONIA

Pneumonia
- Is an infection of the
parenchyma of one or both
lungs caused by various
microorganisms, including
bacteria, viruses, fungi, and
chemical irritants. It is
characterized by inflammation
and fluid accumulation in the
air sacs.
PNEUMONITIS
-Is the general term that refers
to swelling and irritation, also
called the inflammation of the
lung tissue.
PREVALENCE
Pneumonia is a common respiratory infection,
affecting approximately 450 million people a year and
occurring in all parts of the world. It is a major cause of
death among all age groups, resulting in 1.4 million deaths
in 2010 (7% of the world's yearly total) and 3.0 million
deaths in 2016 (the 4th leading cause of death in the world).
According to WHO, pneumonia resulted in 808,000 deaths
of children under the age of 5 in 2017, accounting for 15%
of all deaths in this age group. In 2019, pneumonia led to
the deaths of 740,180 children under the age of 5,
accounting to 14% of all deaths in this age group.
 TYPES OF
PNEUMONIA
According to what caused it.
 Bacterial Pneumonia: The most common bacterial
cause is Streptococcus pneumoniae (pneumococcal
pneumonia), which can affect people of all ages,
especially those with weakened immune systems.
- Streptococcus pneumoniae or pneumococcus, is
a gram-positive, spherical bacteria, alpha-hemolytic
member of the genus streptococcus.
 Viral Pneumonia: Viral pneumonia can be caused by
various viruses, including the flu (influenza) and
respiratory syncytial virus (RSV), and is responsible for
about one-third of all pneumonia cases.
- Respiratory syncytial virus (RSV), also called human
respiratory syncytial virus (hRSV)and human
orthopneumovirus, is a contagious virus that causes
infections of the respiratory tract. It is a negative-sense,
single-stranded RNA virus. Its name is derived from the
large cells known as syncytia that form when infected cells
fuse.
 Fungal Pneumonia: Fungal pneumonia can
results from conditions such as valley fever,
caused by the Coccidioides fungus.

 Walking Pneumonia: Is a milder case of

pneumonia. People with walking pneumonia may
not even know they have pneumonia. Their
symptoms may feel more like a mild respiratory
infection than pneumonia.
TYPES OF PNEUMONIA
According to the areas of the lung involved/affected:
 Bronchopneumonia (Lobular or Catarrhal pneumonia):
This is the most common type of pneumonia. Infection
usually start from the bronchus and the bronchioles and
spreads to the alveoli of the periphery. The lobules are
inflamed and consolidated. Sometimes these lobules are not
inflamed but are collapsed due to mucopurulent plugging of
the bronchioles which supply them. This pneumonia is
caused by pneumococcus, Klebsiela pneumoniae, and
Hemophilus influenzae. The onset of this type on pneumonia
is slow and the fever is lower. The period of communicability
remains unknown, however, it is believed that the disease
remains infectious while the exciting agent is given off in the
discharges from the nose and throat.
Lobar Pneumonia (Croupous
pneumonia): This is a consolidation
of the entire lobe. It is manifested by
chills, chest pain on breathing, and
cough with blood-streaked sputum
(prune juice or rusty). As the disease
progresses, the prune-juice color of
the sputum maybe replaced by
thinner or yellowish color.
Four Stages of Untreated Lobar
Pneumonia
Stage 1: Congestion
 Occurs within 24 hours of infection.
 The lung is heavy.
 The lung is dark red in color.
 The lung is pits upon pressure with finger.
 The lung exudes a bubbly, blood-tinged froth.
Stage 2: Red hepatization
 Occurs after 48 to 72 hours and lasts
for about 2 to 4 days.
 The affected lung becomes more
dry, granular and airless and
resembles the consistency of liver.
 It looks like a piece of red granite.
Stage 3: Grey hepatization
 Occurs on day 4 to 6 and continues for 4 to 8
days.
 The red color changes to gray.
 It is softer and tears more easily
 When pressed, it exudes a purulent fluid.

Stage 4: Resolution
 Occurs between 8 to10 days.
 The inflammatory exudate is either absorbed
by the blood stream or expectorated.
TYPES OF PNEUMONIA
Depending on the setting or environment where it is
acquired:
 Community-Acquired Pneumonia (CAP): This refers
to pneumonia that is acquired outside of a medical or
institutional setting. Common causes include bacteria
like streptococcus pneumoniae, Haemophilus influenzae,
and atypical pathogens like Mycoplasma pneumoniae
and Chlamydia pneumoniae.

Streptococcus Haemophilus Mycoplasma Chlamydia

Pneumoniae Influenzae Pneumoniae Pneumoniae
 Hospital-Acquired Pneumonia (HAP): This
type of pneumonia develops 48 hours or more
after hospital admission following an illness or a
procedure and is often caused by more antibiotic-
resistant pathogens like Staphylococcus aureus,
Pseudomonas aeruginosa, and Klebsiella
pneumoniae. This type of pneumonia can be fatal
and hard to treat.

Staphylococcus Pseudomonas Klebsiella

Aureus Aeruginosa Pneumoniae
 Ventilator-Associated Pneumonia (VAP):
This type of pneumonia is acquired more than
48 hours after endotracheal intubation and
mechanical ventilation. The pathogens are
similar to those causing HAP but also include
Acinetobacter species.

Acinetobacter species
 Healthcare-Associated Pneumonia (HCAP):
HCAP is acquired when residing in an extended-
stay outpatient clinic or a long-term care
facility (such as a nursing home). Similar to
pneumonia obtained in a hospital, antibiotic-
resistant bacteria are typically the main cause.
 Aspiration Pneumonia: This type of
pneumonia is caused by the ingestion of gastric
contents, solid food, or liquid that enters the
throat and goes directly to the lungs. This
condition is often seen in patients with
impaired gag reflexes and people with
swallowing difficulties.
CURB 65
CURB-65, also known as the CURB
criteria, is a clinical prediction rule that has
been validated for predicting mortality in
community-acquired pneumonia. The CURB-
65 is based on the earlier CURB score and is
recommended by the British Thoracic Society
for the assessment of severity of pneumonia.
It was developed in 2002 at the University of
Nottingham by Dr. W.S. Lim et al.
The score is an acronym for each of the risk
factors measured. Each risk factor scores one
point, for a maximum score of 5:
• Confusion of new onset (defined as an AMTS of 8
or less)
• Blood Urea nitrogen greater than 7 mmol/L (19
mg/dL)
• Respiratory rate of 30 breaths per minute or
greater
• Blood pressure less than 90 mmHg systolic or
diastolic blood pressure 60 mmHg or less
• Age 65 or older
The CURB-65 is used as a means of
deciding the action that is needed to be
taken for that patient.
 0-1: Treat as an outpatient
 2:
Consider a short stay in hospital or
watch very closely as an outpatient
 3-5:Requires hospitalization with
consideration as to whether they need
to be in the intensive care unit
RISK FACTORS
 Young children (5 years old and below)
 Older adults (60 years old and above)
 People with underlying health conditions
(e.g., cystic fibrosis, chronic obstructive
pulmonary disease (COPD) and asthma)
 People diagnosed with impaired immune
systems
 Smokers and heavy drinkers
 PATHOPHYSIOLOGY OF PNEUMONIA
PREDISPOSING FACTORS PRECIPITATING FACTORS
Age (5 yr. below and 65yr. above) Smoking Alcohol use
Individual with underlying respiratory conditions Poor hygiene Crowded living
Weakened immune system

PATHOGEN ENTRY
PATHP
Organism reach the upper respiratory airway

Ineffective defense mechanism

Proliferation of the microbe in lower airways and alveoli

Local and systemic defense mechanism are disturbed

Systemic inflammatory Local response by alveolar epithelial cells release

response chemokines
Systemic cytokine release
Inflammatory response
Fever Chills/Rigor
LOBAR INTERSTITIAL

Thickening of alveolar Irritated alveolar

Irritation and attempted white opacity on Blocked
walls walls
clearance of airways plain film at site of alveolar sacs
fluid buildup
↓ Exchange of CO2 and O2 Dry Cough
Phlegm production
Consolidation
on CHR
Hypoxemia/Hypercarbia Triggers peripheral and Dyspne
Productive Cough
central chemoreceptors a
SIGN & SYMPTOMS
SYMPTOMS SIGNS

 Rapid or difficult breathing  Inspection

 Cough - tachypnea
 Fever - chest recession
 Chills - nasal flaring
 Poor feeding  Palpations
 Wheezing (more common in viral - reduced vocal fremitus
infections)  Percussions
 In severe pneumonia, children - dull to percussion May be
may experience recession (usually in lobar pneumonia)
absent
 Auscultation
in
- reduced breath sounds
infant
- bronchial breath sound
- coarse crepitation
- pleural rub
DIAGNOSTIC TEST
• Chest X-ray
• Physical exam
• Sputum test
• Blood tests
• Pleural fluid test
NURSING DIAGNOSIS
 Impaired gas exchange
 Ineffective airway clearance
 Activity intolerance
 Sleep pattern disturbance
 High risk for infection
 Altered tissue perfusion
 Altered nutrition: less than body requirement
 Altered body temperature
MEDICAL MANAGEMENT
Antimicrobial therapy varies with each agent
 Pen G Na is still the drug of choice.

Causative Agent Antibiotic of Choice Alternative Antibiotics

Streptoccocus Penicillin G or Penicillin V, Macrolide antibiotic such as

Pneumonia or amoxicillin clavulanate azithromycin (Zithromax) or
(Augmentin), Trimethoprim clarithromycin (Biaxin); doxycycline;
sulfamethoxazole (TMP- oral beta lactams such as cefuroxime
SMZ). (Ceftin), Linozolid.
Staphyloccocus Aureus Penicillin Cephalosporins; vancomycin
(Vancocin) for methicillin-resistant S.
aureus.
Haemophilus Influenza 2nd /3rd generation Azithromycin, TMP-SMZ
cephalosphorins, β lactam-
β-lactamase inhibitor,
doxycycline.
 Causative Agent Antibiotic of Choice Alternative Antibiotics

Mycoplasma Doxycycline, macrolides,

Pneumonia Fluoroquinolone

Klebsiella Pneumonia 3rd generation Aztreonam, β lactam-β-

cephalosporin with or lactamase inhibitor,
without aminoglycoside, fluoroquinolone
carbapenams
Legionella Pneumonia Macrolide + rifampin, Doxycycline + rifampin
fluoroquinolone

Pneumocystis TMP-SMZ, pentamidine + Dapsone + trimethoprim

prednisone + Clindamycin +
primaquine +
Trimetrexate
SURGICAL MANAGEMENT
 Thoracotomy: Which involves an
incision to open the chest and view the
lungs so that dead and damaged lung
tissue can be removed.
 Lobectomy: Removing a part of
the lung affected by pneumonia.
 Pneumonectomy: Is defined as
the surgical removal of the entire
lung.
 Chest Tube: Is a surgical drain that is
inserted through the chest wall and
into the pleural space or mediastinum.
NURSING MANAGEMENT
 Maintain the patient’s airway and adequate
oxygenation.
 Teach the patient how to cough and perform
deep breathing exercises to clear secretions
and advise him to do this often.
 Obtain sputum specimen as needed, and teach
the correct collection of specimen.
 Maintain adequate nutrition to offset high-
calorie utilization.
 Provide a calm environment as the patient
needs rest.
 Control the spread of infection by disposing
secretions properly.
 Control temperature by doing cooling measures.
 Monitor vital signs closely and watch for danger
signs like:
- marked dyspnea
- thready, small irregular pulse,
- delirium with extreme restlessness,
- cold moist skin, and
- cyanosis and exhaustion.
Prognosis
With treatment, most types of bacterial
pneumonia will stabilize in 3-6 days. It
often takes a few weeks before most
symptoms resolved. X-ray findings typically
clear within four weeks and mortality is low
(less than 1%). In persons requiring
hospitalization, mortality may be as high as
10%, and in those requiring intensive care
it may reach 30-50%.
PREVENTION
• Get vaccinated
NAME BRAND NAME What Is it for?
Pneumococcal 13-valent Prevnar 13® - Children as part of their
Conjugate Vaccine regular immunization
(PCV13) schedule at 2, 4, 6, and 12-
15 months
- Older adults who need it
Pneumococcal 15-valent Vaxneuvance® - Adults
Conjugate Vaccine
(PCV15)
Pneumococcal 20-valent Prevnar 20® - Adults
Conjugate Vaccine
(PCV20)

Pneumococcal Vaccine Pneumovax 23® - Children 2-18 who need it

Polyvalent (PPSV23) - Adults who receive PCV15
or who have received
PCV13
• Practice good hygiene
• Wash your hands regularly
• Maintain a healthy diet
• Get regular exercise
• Don’t smoke/quit smoking
COMPLICATIONS
 Empyema: Infection of the space between the
membranes surrounding the lungs and chest
cavity.
 Pericarditis: Inflammation of the sac
surrounding the heart.
 Endobronchial obstruction: Blockage of the
airway that allows air into the lungs.
 Atelectasis: Collapse of an entire lung or an
area within the lung.
 Lung Abscess: Collection of pus in the lungs.
 Pleurisy: Inflammation of the thin membranes
between the lungs and ribcage.
 Septicemia: Infection in the blood that
originated elsewhere in the body.
 Sepsis: A life-threatening immune reaction to
septicemia.
 Worsened chronic conditions: Pneumonia can
exacerbate conditions like congestive hearts
failure and emphysema.
 Death: In severe cases, pneumonia can be fatal,
especially in vulnerable populations like young
children and older adults.