Pneumonia
Pneumonia: Excerpt from Handbook of Diseases
An acute infection of the lung paren-chyma, pneumonia often impairs gas exchange. The prognosis is generally good for people with normal lungs and adequate host defenses before the onset of pneumonia. However, pneumonia is the seventh leading cause of death in the United States, and in 2003, severe acute respiratory syndrome, a new, deadly type of pneumonia, emerged. (See SARS.)
Causes
Pneumonia can be classified in several ways:
❑ Microbiologic etiology — Pneumonia can be viral, bacterial, fungal, protozoal, mycobacterial, mycoplasmal, or rickettsial in origin.
❑ Location — Bronchopneumonia involves distal airways and alveoli; lobular pneumonia, part of a lobe; and lobar pneumonia, an entire lobe.
❑ Type — Primary pneumonia results from inhalation or aspiration of a pathogen; it includes pneumococcal and viral pneumonia. Secondary pneumonia may follow initial lung damage from a noxious chemical or other insult (superinfection), or may result from hematogenous spread of bacteria from a distant focus. (See Types of pneumonia, pages 650 to 653.)
Predisposing factors
Predisposing factors for bacterial and viral pneumonia include chronic illness and debilitation, cancer (particularly lung cancer), abdominal and thoracic surgery, atelectasis, common colds or other viral respiratory tract infections, chronic respiratory disease (chronic obstructive pulmonary disease [COPD], asthma, bronchiectasis, cystic fibrosis), influenza, smoking, malnutrition, alcoholism, sickle cell disease, tracheostomy, exposure to noxious gases, aspiration, and immunosuppressant therapy.
Predisposing factors for aspiration pneumonia include old age, debilitation, nasogastric (NG) tube feedings, impaired gag reflex, poor oral hygiene, and decreased level of consciousness.
Signs and symptoms
The five cardinal signs and symptoms of early bacterial pneumonia are coughing, sputum production, pleuritic chest pain, shaking chills, and fever. Physical signs vary widely, ranging from diffuse, fine crackles to signs of localized or extensive consolidation and pleural effusion.
Complications include hypoxemia, respiratory failure, pleural effusion, empyema, lung abscess, and bacteremia, with the spread of infection to other parts of the body resulting in meningitis, endocarditis, and pericarditis.
Diagnosis
Clinical features, chest X-ray film showing infiltrates, and sputum smear demonstrating acute inflammatory cells support this diagnosis. Positive blood cultures in patients with pulmonary infiltrates strongly suggest pneumonia produced by the organisms isolated from the blood cultures.
Pleural effusions, if present, should be tapped and the fluid analyzed for evidence of infection in the pleural space. Occasionally, a transtracheal aspirate of tracheobronchial secretions or bronchoscopy with brushings or washings may be done to obtain material for smear and culture. The patient’s response to antimicrobial therapy also provides important evidence of the presence of pneumonia.
Treatment
Antimicrobial therapy varies with the causative agent. Therapy should be reevaluated early in the course of treatment.
Supportive measures include humidified oxygen therapy for hypoxia, mechanical ventilation for respiratory failure, a high-calorie diet and adequate fluid intake, bed rest, and an analgesic to relieve pleuritic chest pain. Patients with severe pneumonia on mechanical ventilation may require positive end-expiratory pressure to facilitate adequate oxygenation.
Special considerations
Correct supportive care can increase patient comfort, prevent complications, and speed recovery.
Throughout the illness:
❑ Maintain a patent airway and adequate oxygenation. Measure arterial blood gas levels, especially in hypoxic patients. Administer supplemental oxygen if partial pressure of arterial oxygen is less than 60 mm Hg. Patients with underlying chronic lung disease should be given oxygen cautiously.
❑ Teach the patient how to cough and perform deep-breathing exercises to clear secretions, and encourage him to do so often.
❑ For severe pneumonia that requires endotracheal intubation or tracheostomy with or without mechanical ventilation, provide thorough respiratory care and suction often, using sterile technique, to remove secretions.
❑ Obtain sputum specimens by suction if the patient can’t produce specimens independently. Collect specimens in a sterile container and deliver them promptly to the microbiology laboratory.
❑ Administer antibiotics as necessary and pain medication as needed; record the patient’s response to medications. Fever and dehydration may require I.V. fluids and electrolyte replacement.
❑ Maintain adequate nutrition to offset high caloric utilization secondary to infection. Ask the dietary department to provide a high-calorie, high-protein diet consisting of soft, easy-to-eat foods. Encourage the patient to eat.
❑ Supplement oral feedings with NG tube feedings or parenteral nutrition as necessary. Monitor fluid intake and output.
❑ Provide a quiet, calm environment for the patient, with frequent rest periods.
❑ To control the spread of infection, dispose of secretions properly. Tell the patient to sneeze and cough into a disposable tissue; tape a waxed bag to the side of the bed for used tissues.
To prevent pneumonia:
❑ Advise the patient to avoid using antibiotics indiscriminately during minor viral infections because this may result in upper airway colonization with antibiotic-resistant bacteria. If the patient then develops pneumonia, the organisms producing the pneumonia may require treatment with more toxic antibiotics.
❑ Encourage annual influenza vaccination and Pneumovax for high-risk patients, such as those with COPD, chronic heart disease, or sickle cell disease.
❑ Urge all bedridden and postoperative patients to perform deep-breathing and coughing exercises frequently. Position such patients properly to promote full aeration and drainage of secretions.
CLINICAL TIP: To prevent aspiration during NG tube feedings, elevate the patient’s head, check the tube’s position, and administer the formula slowly. Don’t give large volumes at one time; this could cause vomiting. If the patient has an endotracheal tube, inflate the tube cuff. Keep the patient’s head elevated for at least 30 minutes after the feeding. Check for residual formula at 4- to 6-hour intervals.
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Book Source Details
- Book Title: Handbook of Diseases
- Author(s): Springhouse
- Year of Publication: 2003
- Copyright Details: Handbook of Diseases, Copyright © 2003 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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More About This Book:
Title: Handbook of Diseases
Authors: Springhouse
Publisher: Lippincott Williams & Wilkins
Copyright: 2003
ISBN: 1-58255-266-5
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