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Pneumonia

Pneumonia. Jen Denno RN, BSN, CEN. Pneumonia . Vaccination Percent of adults 65 years and over who had ever received a pneumococcal vaccination: 59% Health Care Use Hospital inpatient care Number of discharges: 1.1 million Average length of stay: 5.2 days Nursing home care

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Pneumonia

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  1. Pneumonia Jen Denno RN, BSN, CEN

  2. Pneumonia • Vaccination • Percent of adults 65 years and over who had ever received a pneumococcal vaccination: 59% • Health Care Use • Hospital inpatient care • Number of discharges: 1.1 million • Average length of stay: 5.2 days • Nursing home care • Number of residents with pneumonia: 33,700 • Percent of residents with pneumonia: 2.3% • Mortality • Number of deaths: 50,774 • Deaths per 100,000 population: 16.5

  3. CURB-65 • CURB-65 is a scoring system developed from a multivariate analysis of 1068 patients that identified various factors that appeared to play a role in patient mortality.[32] One point is given for the presence of each of the following: • •C onfusion – Altered mental status • •U remia – Blood urea nitrogen (BUN) level greater than 20 mg/dL • •R espiratory rate –30 breaths or more per minute • •B lood pressure – Systolic pressure less than 90 mm Hg or diastolic pressure less than 60 mm Hg • •Age older than 65 years • Current guidelines suggest that patients may be treated in an outpatient setting or may require hospitalization according to their CURB-65 score, as follows: • •Score of 0-1 – Outpatient treatment • •Score of 2 – Admission to medical ward • •Score of 3 or higher – Admission to intensive care unit (ICU)

  4. AHRQ: Pneumonia Severity Index • •Age, men – Starting point value is age in years • •Age, women – Starting point value is age in years minus 10 points • •Nursing home resident – Add 10 points • Coexisting illnesses are scored as follows: • •Neoplasia – Add 30 points • •Liver disease – Add 20 points • •Congestive heart failure, cerebrovascular disease, renal disease – Add 10 points for each • Physical examination findings are scored as follows: • •Altered mental status – Add 20 points • •Respiratory rate of 30 breaths or more per minute – Add 20 points • •Systolic blood pressure less than 90 mmHg – Add 20 points • •Temperature less than 35°C or that is 40°C or higher – Add 15 points • •Pulse greater than 125 bpm – Add 10 points • Laboratory and radiographic findings are scored as follows:

  5. PSI • •Arterial pH less than 7.35 – Add 30 points • •BUN value of 30 mg/dL or greater – Add 20 points • •Sodium level less than 130 mmol/L – Add 20 points • •Glucose level of 250 mg/dL or greater – Add 10 points • •Hematocrit value less than 30% – Add 10 points • •Partial arterial pressure (PaO2) less than 60 mm Hg or peripheral oxygen saturation (SpO2) less than 90% – Add 10 points • •Pleural effusion – Add 10 points • The combined total points make up the risk score, which stratifies patients into 5 PSI mortality risk classes, as follows: • •0-50 points = Class I (0.1% mortality) • •51-70 points = Class II (0.6% mortality) • •71-90 points = Class III (0.9% mortality) • •91-130 points = Class IV (9.3% mortality) • •More than 130 points = Class V (27% mortality)

  6. Sputum production • •S pneumoniae is classically associated with a cough productive of rust-colored sputum. • •Pseudomonas, Haemophilus, and pneumococcal species may produce green sputum. • •Klebsiella species pneumonia is classically associated with a cough productive of red currant-jelly sputum. • •Anaerobic infections often produce foul-smelling or bad-tasting sputum.

  7. Black Lungs v. White Lungs • On an x-ray, lungs can show up as either black or white. If the lung appears black, it is perfectly healthy, as black indicates that the x-ray passed through air. If the lung appears white on the x-ray image, the same color as bones and solid objects, it indicates that the lung is full of fluid. This is the case with an infected pneumonia lung.

  8. In the case of bacterial pneumonia, bacteria invade alveoli air sacs and elicit an immune response. White blood cells called neutrophils arrive and engulf bacteria • In the case of viral pneumonia, viruses attack alveolar cells, which die or self destruct. This too triggers an immune response, this time by lymphocyte white blood cells. The lymphocytes release cytokines that cause fluid to leak into the alveoli

  9. Viral vs Bacterial • Interstitial infiltrates on chest radiographs are generally believed to suggesta viral cause of pneumonia and alveolar infiltrates to indicate a bacterial cause

  10. VIRAL • Viral infections are characterized by the accumulation of mono- nuclear cells in the submucosa and perivascular space, resulting in partial obstruction of the airway. Patients with these infections present with wheezing and crackles.

  11. VIRAL • Disease progresses when the alveolar type II cells lose their structural integrity and surfactant production is diminished, a hyaline membrane forms, and pulmonary edema develops.

  12. Do we treat viral pneumonia with antibiotics? • The influenza pandemic of 1918 was responsible for the deaths of approximately 40-50 million people worldwide (>600,000 deaths in the United States), many of which were likely ultimately due to secondary bacterial infection. • With the 2009 H1N1 influenza A pandemic, the US Centers for Disease Control and Prevention (CDC) mortality estimates range from 8,800 to 18,000 between April 2009 and April 2010. The vast majority of deaths occurred in individuals younger than 65 years. Evaluation of 77 postmortem lung specimens by the CDC revealed that 29% of those that died also had evidence of bacterial coinfection.

  13. Bacterial • In bacterial infections, the alveoli fill with proteinaceous fluid, which triggers a brisk influx of red blood cells (RBCs) and polymorphonuclear (PMN) cells (red hepatization) followed by the deposition of fibrin and the degradation of inflammatory cells (gray hepatization). During resolution, intra-alveolar debris is ingested and removed by the alveolar macrophages. This consolidation leads to decreased air entry and dullness to percussion; inflammation in the small airways leads to crackles.

  14. Four stages of lobar pneumonia have been described. • Stage 1 • In the first stage, which occurs within 24 hours of infection, the lung is characterized microscopically by vascular congestion and alveolar edema. Many bacteria and few neutrophils are present. • What are the signs and symptoms of a new pneumonia?

  15. Stage 2 • The stage of red hepatization (2-3 d), so called because of its similarity to the consistency of liver, is characterized by the presence of many erythrocytes, neutrophils, desquamated epithelial cells, and fibrin within the alveoli. • What do you think the patient looks like during this stage?

  16. Stage 3 • In the stage of gray hepatization (2-3 d), the lung is gray-brown to yellow because of fibrinopurulent exudate, disintegration of RBCs, and hemosiderin. • What complications would you anticipate in a patient during this stage?

  17. Stage 4 • The final stage of resolution is characterized by resorption and restoration of the pulmonary architecture. Fibrinous inflammation may lead to resolution or to organization and pleural adhesions. • What co-morbidities could cause this stage to last a long time?

  18. What stage is coughing most present? • 1 • 2 • 3 • 4

  19. What nursing interventions are important during the stages with coughing?

  20. Klebsiella How do you get it? eating unwashed vegetables and drinking contaminated water.

  21. Most of the time, a Klebsiella pneumoniae infection is very common in patients with underlying diseases like diabetes, chronic lung diseases, chronic alcoholics, etc. It is mostly a nosocomial infection that occurs in hospitalized patients with weakened immune system.

  22. Once Klebsiella pneumoniae enters the lungs, it causes many destructive changes in the lungs. It leads to necrosis, inflammation, hemorrhage, etc. of the lung tissues. This leads to production of a very thick, jelly like mucus that is called 'currant jelly sputum'. The rapid destruction of the lung tissues is the distinguishing factor for Klebsiella pneumoniae infection. Initially, Klebsiella pneumoniae will cause a sudden high fever. This fever is generally more than 103ºF. The fever is accompanied by other symptoms like chills and dizziness. The patient will also cough up the thick currant jelly sputum. This sputum may show streaks of blood.

  23. As the condition spreads, it leads to formation of abscess. These abscesses are dead tissue pockets that contain millions of Klebsiella pneumoniae bacteria. Formation of abscesses cause the lungs to stick with the connective tissues surrounding them. This may lead to collapsed lungs in some patients. Soon, the infection spreads to the upper respiratory tract. When the infection spreads, it causes severe airway congestion. This leads to a foul-smelling nasal discharge.

  24. Other common pneumonias • Strep • Pseudomonas CORE MEASURES Order sets

  25. Current research • The 3-steps of the critical pathway involved, first, the early mobilization of patients, followed by the use of objective criteria for switching to oral antibiotic therapy, and then the use of predefined criteria for deciding on hospital discharge. • The median LOS was significantly shorter in the 3-step group than in the usual care group (3.9 days vs 6.0 days, respectively; P < .001). Likewise, the median duration of IV antibiotics use was shorter, at 2.0 days vs 4.0 days for the 2 groups, respectively (P < .001). • http://www.medscape.com/viewarticle/764917

  26. Lung U/S to diagnose • LUS correctly diagnosed CAP in 211 of 226 patients with confirmed CAP, for a sensitivity of 93.4%. • Chest x-ray alone was slightly less sensitive (199/215, 92.6%) and slightly more specific (122/122, 100%) than LUS for diagnosing CAP. • LUS offers several different applications, especially if chest X-ray is not available (in point-of-care ultrasonography, in emergency units, in a general practitioner practice) or not applicable," said Dr. Angela Reissig, whose findings were published online June 14 in Chest. • "In cases with sonographic evidence of pneumonia, the diagnosis can be established and the therapy can start immediately," Dr. Reissig http://www.medscape.com/viewarticle/767288

  27. Case study • A 44-year-old Caucasian man presented to our hospital for hyperpyrexia (over 39°C) for about a week, with general weakness and strong headaches; he had been treated by his general practitioner with amoxicillin orally with no improvement. • His case history revealed that he was a smoker (20 packs/year). No other pathologies or trips abroad had been registered in the last 6 months.

  28. On admission, he had hyperpyrexia (38.9°C), headache, dry cough, diarrhea, general weakness and sinus tachycardia (100 beats/minute); his oxygen saturation was 95% (no oxygen supplement). • Our patient began treatment with intravenous piperacillin and tazobactam (13.5 g/day) and clarithromycin orally (1 g/day). On the third day the results of his urinary antigen test were found to be positive for Legionella serogroup 1, so clarithromycin was suspended and substituted with intravenous levofloxacin (750 mg/day). We maintained the piperacillin and tazobactam treatment to help prevent secondary infection from other Gram-positive and Gram-negative bacteria.

  29. On the sixth day, his clinical condition worsened. After consultation with an infectious disease specialist, we added rifampicin (900 mg/day) to support the levofloxacin action against Legionella pneumonia. • On the ninth day he showed respiratory distress (40 breaths/minute). An Arterial Blood Gas analysis in room air gave the following results: partial O2 pressure (pO2) of 50 mmHg, partial CO2 pressure (pCO2) of 30 mmHg, pH 7.50 and oxygen saturation (SaO2) of 86%. • A computed tomography (CT) scan of his chest revealed multiple areas of parenchymal consolidation in the entire upper left pulmonary lobe, mixed with ground-glass areas and abundant pleural effusion. In the right lung, in the dorsal and basal regions, there were ground-glass areas mixed with consolidation areas

  30. What does his ABG show?pH 7.50(pO2) of 50 mmHg(pCO2) of 30 mmHg(SaO2) of 86%.

  31. Based on the CT and CXR report, what nursing interventions would be appropriate?

  32. On the 10th day PaO2/fraction of inspired O2 (FiO2) ratio was 101 and he was moved to our intensive care unit. Here he was placed on a ventilator on continuous positive airway pressure modality, with noticeable improvement of the respiratory parameters (PaO2/FiO2 ratio of 254). On the 17th day, levofloxacin was suspended in order to allow wash-out and taking of further blood cultures. On the 19th day levofloxacin was resumed; after advice from an infectious diseases specialist intravenous levofloxacin 1500 mg per day together with intravenous fluconazole 800 mg per day were given

  33. What is a bad P/F ratio?

  34. On the 21st day, after an initial improvement, he showed respiratory distress. A CT scan showed increased parenchymal consolidation with left pneumothorax • On the 22nd day, because of the unexpected occurrence of muscular exhaustion, orotracheal intubation was performed and he was placed on a mechanical ventilator in synchronized intermittent mandatory ventilation mode associated with appropriate kinetic therapy on a reclining bed

  35. On the 23rd day, methylprednisolone (120 mg/day intravenously) was added to the therapy. • On the 26th day, he underwent another bronchoscopy, in the basal segments of the lower right lobe, which revealed a histological condition compatible with acute eosinophilic pneumonia This confirmed the presence of eosinophils 28%, macrophages 57%, lymphocytes 15%, neutrophilic granulocytes 2% and a CD4/CD8 ratio of 1. Incidental findings showed masses of finely pigmented macrophages (due to our patient's smoking habit).

  36. What is the methylprednisolone for? What are the complications of steroid treatment? • What is eosinophilic pneumonia?

  37. Eosinophilic pneumonia has been linked to more than 80 drugs, although only 20 of these (for the most part NSAIDs and antibiotics) can be considered as common causes of this pathology.All the drugs administered in the weeks prior to the appearance of eosinophilic infiltrate should be suspected as a possible cause of the pathology. Iatrogenic eosinophilic infiltrates usually develop progressively, with dyspnea, cough and fever in subjects who have taken certain drugs for weeks or months.

  38. On the 27th day, his steroid therapy was increased (methylprednisolone 1 g/day) while levofloxacin was suspended. His response to steroid therapy was rapid, with a general improvement starting from the fifth day of treatment (the 32nd day overall), associated with accompanying improvement of respiratory exchange and subsequent return to spontaneous breathing on the 41st day (PaO2/FiO2 ratio of 357). • On the 51st day, a chest X-ray showed that the pneumonia bilateral consolidation had completely resolved

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