Pneumonia

 Pneumonia is an inflammation of the lung parenchyma

usually caused by various microorganism such as:
 bacteria

 Fungi

 Viruses

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 Causes

Gram-positive bacteria Gram-negative bacteria

 Strept pneumoniae  Haemophilus influenzae

 Staphylococcus aureus  Klebsiella pneumoniae

 Streptococcus agalactie  Escherichia coli

 Pseudomonas aeruginosa

 Moraxella catarrhalis

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Viruses Fungi
 Influenza virus,
 Histoplasma capsulatum,
 Respiratory syncytial
 Blastomyces,
virus
 Cryptococcus neoformans,
 Adenovirus,
 Pneumocystis jiroveci
 Herpes simplex virus,

 Cytomegalovirus (CMV)
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Parasites Atypical" bacteria

 Chlamydophila
 Toxoplasma gondii

 Strongyloides  Mycoplasma pneumoniae

 Ascariasis  Legionella pneumophila

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 Mode of transmission

Aspiration
- transmitted from the oropharynx & GIT to the lungs

by direct-contact
- is common cause of bacterial pneumonia (nosocomial

pneumonias )
 Causes
- patients with NG-tube
- unconscious patients
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 Inhalation (Airdroplets)
- suspended droplet spread in to the air with coughing,
sneezing & talking.
 Circulatory spread (hematogenous )
- pathogens are transmitted through the circulatory system
to lung from pre-existing infection. e.g. septicemia,
endocarditis.

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 Risk Factors
 Alcoholism

 Cigarette smoking

 Underlying diseases such as Heart failure, COPD, cancer

 Age extremes (>65)

 Immunosuppressive therapy and disorders

 Decreased consciousness, comma , seizure

 Surgery

 Instrument insertion (Endotracheal tube, NG tube)

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 Pathophysiology

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 Classification of pneumonia
It can be classified into four types:
community-acquired pneumonia (CAP)

Hospital acquired pneumonia (HAP)

Ventilator-associated pneumonia (VAP)

Other subcategories are those in the immunocompromised host and

aspiration pneumonia

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 Community-acquired pneumonia (CAP)
 Pneumonia that occurs either in the community setting or within the
first 48 hours of hospitalization.

Causes:

S. pneumoniae (pneumococcus)

• It is the most common cause of CAP

• Gram-positive organism that resides naturally in the upper

respiratory tract

• It may occur as a lobar or bronchopneumonic form in patients of

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any age and may follow a recent respiratory illness 10
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H. influenzae

• It causes a type of CAP that frequently affects older adults and

those with comorbid illnesses

• The presentation is indistinguishable from that of other forms

of bacterial CAP

• It may be subacute, with cough or low-grade fever for weeks

before diagnosis

Mycoplasma pneumonia

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• It is caused by M. pneumonia 11
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• It is spread by infected respiratory droplets through person-to person contact
• The inflammatory infiltrate is primarily interstitial rather than alveolar

 Viruses

• They are the most common cause of pneumonia in infants and children but
are relatively uncommon causes of CAP in adults

• The acute stage of a viral respiratory infection occurs within the ciliated cells
of the airways, followed by infiltration of the tracheobronchial tree

• With pneumonia, the inflammatory process extends into the alveolar area,
resulting in edema and exudation

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 Hospital-acquired pneumonia (HAP)

 HAP develops 48 hours or more after admission and does

not appear to be incubating at the time of admission.
Which was caused by
 Escherichia coli
 Klebsiella pneumoniae

 Pseudomonas aeruginosa

 Methicillin-sensitive or Methicillin-resistant staphylococcus aureus

(MRSA)
 S. pneumoniae

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 Clinical manifestation
• The usual presentation of HAP is a new pulmonary infiltrate on
chest x ray combined with evidence of infection such as fever,
respiratory symptoms, purulent sputum, or leukocytosis

• Pneumonias from Klebsiella or other gram-negative

organisms (E. coli)

They are characterized by the destruction of lung structure and

alveolar walls, consolidation (tissue that solidifies as a result of
collapsed alveoli or infectious process such as pneumonia)

Bacteremia
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• Development of a cough or increased cough and sputum

production are common presentations, along with low-grade
fever and general malaise

• In debilitated or dehydrated patients

• sputum production may be minimal or absent

• Pleural effusion, high fever, and tachycardia are common

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 Ventilator-Associated Pneumonia
• It is a subtype of HAP; however, in such cases, the patient has been endo-
tracheally intubated and has received mechanical ventilator support for at least 48
hours

• The etiologic bacteriologic agents associated with VAP typically differ based on
the timing of the occurrence of the infection relative to the start of mechanical
ventilation

 within 96 hours of the onset of mechanical ventilation is usually due to antibiotic-

sensitive bacteria that colonize the patient prior to hospital admission

 VAP developing after 96 hours of ventilator support is more often associated with
MDR bacteria

• Prevention remains the key to reducing the burden of VAP

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 Pneumonia in the Immunocompromised
Pneumonia in immunocompromised hosts includes Pneumocystis pneumonia
(PCP), fungal pneumonias, and Mycobacterium tuberculosis.

The organism that causes PCP is now known as Pneumocystis jiroveci

Pneumonia occurring in patients with low immunity

Immunity may be suppressed by

Corticosteroids,

Chemotherapy,

Nutritional Depletion,

AIDS

The use of broad spectrum antimicrobial agents

Genetic immune disorders

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• Pneumonia in immunocompromised hosts may be caused by the
organisms also observed in CAP or HAP (S. pneumoniae, S.
aureus, H. influenzae, P. aeruginosa, M. tuberculosis)

• PCP is rarely observed in immunocompetent hosts and is often an

initial AIDS-defining complication

• Cytomegalovirus is the most common viral pathogen, followed by

herpes simplex virus, adenovirus, and respiratory syncytial virus

• PCP has a subtle onset, with progressive dyspnea, fever, and a

nonproductive cough

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 Aspiration Pneumonia

• Group 2

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 Assessment and Diagnostic Findings

• The diagnosis of pneumonia is made by:

history (particularly of a recent respiratory tract infection)

physical examination

chest x-ray

blood culture (bloodstream invasion [bacteremia] occurs

frequently)
sputum examination

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• The sputum sample is obtained by having patients do the following:

rinse the mouth with water to minimize contamination by normal

oral flora
breathe deeply several times

cough deeply

expectorate the raised sputum into a sterile container

 More invasive procedures may be used to collect specimens

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 Prevention
 Pneumococcal vaccination

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 Medical Management

• The treatment of pneumonia includes administration of the appropriate

antibiotic as determined by the results of a culture and sensitivity

• Inpatients should be switched from intravenous (IV) to oral therapy

when they are hemodynamically stable, are improving clinically, are able

to take medications/fluids by mouth, and have a normally functioning

gastrointestinal tract

• As soon as patients are clinically stable, have no medical problems, and

have a safe environment for continued care, they should be discharged

from the hospital

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• In suspected HAP, treatment is usually initiated with a broad-spectrum IV antibiotic and may be
monotherapy or combination therapy

patients with no known multidrug resistance

monotherapy with ceftriaxone (Rocephin), ampicillin/sulbactam (Unasyn), levofloxacin

(Levaquin), or ertapenem (Invanz) is used

Patient with known multidrug resistance

a three-drug combination therapy may be used; this drug regimen may include an
antipseudomonal cephalosporin or ceftazidime (Fortaz) or antipseudomonal carbapenem or
piperacillin/tazobactam (Zosyn) plus antipseudomonal fluoroquinolone or aminoglycoside plus
linezolid (Zyvox) or vancomycin (Vancocin)
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• The patient’s status must be assessed 72 hours after the initiation of therapy, and
antibiotics should be discontinued or modified based on the culture results

• Education of clinicians about the use of evidence-based guidelines in the

treatment of respiratory infection is important, and some institutions have
implemented algorithms to assist clinicians in choosing the appropriate antibiotics

• Antibiotics are ineffective in viral upper respiratory tract infections and

pneumonia, and their use may be associated with adverse effects

• Treatment of viral pneumonia is primarily supportive

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 Complications
 Shock and Respiratory Failure

 Pleural Effusion

• A pleural effusion is an accumulation of pleural fluid in the pleural space

• A parapneumonic effusion is any pleural effusion associated with bacterial

pneumonia, lung abscess, or bronchiectasis

• After the pleural effusion is detected on a chest x-ray, a thoracentesis may

be performed to remove the fluid, which is sent to the laboratory for
analysis

• There are three stages of parapneumonic pleural effusions based on

pathogenesis: uncomplicated, complicated, and thoracic empyema
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Nursing diagnosis
 Ineffective Airway Clearance related to thicker and increased amounts of
respiratory secretions
 Risk for deficient fluid volume related to fever and a rapid respiratory rate

 Fatigue and activity intolerance related to impaired respiratory function

 Deficient knowledge about the treatment regimen and preventive measures

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 Nursing management
 Achieving airway clearance

 Improving breathing patterns

 Improving activity tolerance

 Monitoring and managing potential complications

 Promoting home and community-based care

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