management of Pneumonia

1. MR.GOPAL ,..MSC (N),
ASSISTANT PROFESSOR
MEDICAL SURGICAL NURSING
GANGA COLLEGE OF NURSING
COIMBATORE

3. CONTENT OVERVIEW
• Introduction
• Anatomy & physiology
• Incidence
• Definition
• Types of Pneumonia
• Risk factors
• Pathophysiology
• Clinical manifestations
• Diagnostic evaluation
• Complications
• Management

4. INTRODUCTION
• Pneumonia is an inflammatory condition of the lung
that is caused by a microbial agent.
• It is the leading cause of death from the infectious
disease.
• “Pneumonitis” is a general term that describes an
inflammatory process in the lung tissue that may
predispose a patient to or place a patient at risk for
microbial invasion.

5. ANATOMY & PHYSIOLOGY

6. DEFINITION
Pneumonia is an inflammation of the lung
parenchyma (i.e. alveoli rather than the bronchi) of
infective origin.

7. INCIDENCE
• Pneumonia accounts for 15% of all deaths of
children under 5 years old, killing 808 694 children
in 2017.
• In developed nations, pneumonia is a serious
concern in adults over age 65. In the United States
in 2010, approximately 1.1 million patients were
hospitalized for pneumonia and the average length
of hospital stay was 5.2 days.

8. TYPES OF PNEUMONIA
According to the areas of the lung involved
/affected:
• Lobar pneumonia
• Multi-lobar pneumonia
• Bronchial pneumonia
• Interstitial pneumonia
• Alveolar (acinar) pneumonia
• Necrotizing pneumonia

9. TYPES OF PNEUMONIA cont..
According to the environment
• Community-acquired pneumonia.
• Hospital acquired pneumonia.
• Pneumonia in the immuno-compromised host.
• Ventilator acquired Pneumonia (VAP)

10. According to the cause
• Eosinophilic pneumonia : occur in response to
infection with parasite.
• Chemical pneumonia
• Aspiration pneumonia
• Dust pneumonia
• Bilateral pneumonia.
TYPES OF PNEUMONIA cont..

11. LOBAR PNEUMONIA
Lobar pneumonia is acute bacterial infection
of a part of lobe the entire lobe, or even two lobes of
one or both the lungs.

12. MULTI-LOBAR PNEUMONIA
Multi-lobar pneumonia, as the name
suggests, is a lobar pneumonia affecting multiple
lobes. Patients with community-acquired multilobar
pneumonia have a worse prognosis with longer
admissions, more need for ventilatory support and
more frequent treatment failure.

13. BRONCHO PNEUMONIA
Bronchopneumonia is infection of the
terminal bronchioles that extends into the
surrounding alveoli resulting in patchy
consolidation of the lung.

14. INTERSTITIAL PNEUMONIA
Interstitial pneumonia is a disease in which the
mesh-like walls of the alveoli become inflamed. The
pleura (a thin covering that protects and cushions the
lungs and the individual lobes of the lungs) might
become inflamed as well.

15. ALVEOLAR PNEUMONIA
The infection causes the lungs' air sacs (alveoli)
to become inflamed and fill up with fluid or pus. That
can make it hard for the oxygen you breathe in to get
into your bloodstream.
The symptoms of pneumonia can range from
mild to severe, and include cough, fever, chills, and
trouble breathing.

16. NECROTIZING PNEUMONIA (NP)
Necrotizing pneumonia (NP) is an uncommon,
severe complication of pneumonia. It is characterized
by destruction of the underlying lung parenchyma
resulting in multiple small, thin-walled cavities and is
often accompanied by empyema and bronchopleural
fistulae.

17. COMMUNITY-ACQUIRED PNEUMONIA
Pneumonia that is acquired outside
the hospital, nursing home or other healthcare
center.
The most commonly identified pathogens are
Streptococcus pneumoniae, Haemophilus influenzae,
atypical bacteria (ie, Chlamydia pneumoniae,
Mycoplasma pneumoniae, Legionella species), and
viruses.

18. HOSPITAL ACQUIRED PNEUMONIA
This type of bacterial pneumonia is
acquired during a hospital stay. It can be more
serious than other types, because the bacteria
involved may be more resistant to antibiotics.

19. IMMUNOCOMPROMISED HOST
Pneumonia in the immuno-compromised host
is a complex infection and inflammation of the lower
respiratory tract, complicated by widespread multi-
drug antibiotic resistance.
The major immuno-compromised host groups are:
• HIV/AIDS
• Malignancy on chemotherapy or radiation therapy
• Autoimmune diseases
• Acquired immunodeficiencies: asplenia, long-term steroid
use

20. VENTILATOR-ASSOCIATED PNEUMONIA
Ventilator-associated pneumonia is a lung
infection that develops in a person who is on
a ventilator. It occur 48-72 hours after intubation.
A ventilator is a machine that is used to help a
patient breathe by giving oxygen through a tube
placed in a patient's mouth or nose, or through a hole
in the front of the neck.
An infection may occur if germs enter through
the tube and get into the patient’s lungs.

21. RISK FACTORS
• Age 60 or older
• Smoking & Air pollution
• Altered consciousness : Alcoholism, head injury,
anaesthesia, drug overdose
• Tracheal intubation
• Upper Respiratory Tract Infection
• Chronic Disease : Chronic lung disease, Diabetes
mellitus, heart disease, cancer

22. RISK FACTORS
• Immunosuppression.
• Malnutrition & Fatigue
• Inhalation of noxious substances.
• Prolonged Bed rest and immobility
• Aspiration of fluid, liquid, foreign or gastric content.
• Prolonged hospital stay.
• Residence in institutional areas/setting where
transmission is prone.

23. CAUSATIVE ORGANISMS
BACTERIA:-
• Pneumococcal pneumonia caused by
Streptococcus pneumonia
• Staphylococcal pneumonia caused by
Staphylococcus aureus
• Influenzal pneumonia caused by
Haemophilus influenza
• Gram-negative bacterial pneumonia caused by
Klebsiella pneumonia
• Anaerobic bacterial pneumonia caused by
normal oral flora.

24. VIRUS :-
• Rhinovirus, coronaviruses, influenza virus,
respiratory sncytial virus(RSV) and adenovirus.
• Herpes simplex virus rarely causes pneumonia in
newborns, persons with cancer, transplant
recipients, and people with significant burns.
• People following organ transplantation or immuno
compromised present high rates of cytomegalovirus
pneumonia.
CAUSATIVE ORGANISMS

25. FUNGAL :-
• Fungal pneumonia caused by histoplasmosis ,
blastomycosis, coccidioidomycosis, aspergillosis,
candidiasis.
PARASITIC :-
• Parasitic pneumonia (caused by protozoa,
nematodes, platyhelminthes); common organism is
Pneumocystis (carinii) firoveci
CAUSATIVE ORGANISMS

26. PAPTHOPHYSIOLOGY
Enters the organism
Inflammatory response initiated.
Lose defense mechanisms of the lungs.
Allow organisms to penetrate the sterile LRT.
Develop inflammation.

27. Disruption of the mechanical defenses
Colonization of the lungs.
Inflamed & fluid-filled alveolar sacs.
Alveolar exudates tends to consolidate.
Alveoli & respiratory bronchioles fill with serous
exudate, blood cells, fibrin and bacteria
Consolidation of lung tissues

28. COMMON SIGNS AND SYMPTOMS

29. DIAGNOSTIC EVALUATION
• History collection
– Medical history
• Physical examination
– Chest expansion
– Crackling sounds over affected area
– Dullness on percussion on affected area
– Decrease in breath sounds
– Unequal chest expansion

30. • Laboratory test:
– Sputum Gram stain and/or culture
– Blood cultures & Serum sodium level
– Serum transaminase levels
– Lactic acid level & C-reactive protein (CRP)
– Lactate dehydrogenase (LDH)
– Molecular diagnostics, ie, polymerase chain reaction
(PCR) testing
– Urinary antigen testing for Legionella species
DIAGNOSTIC EVALUATION

31. Laboratory test:
– Complete blood cell (CBC) count with differential
– Serum blood urea nitrogen (BUN) and creatinine
levels
– Creatine phosphokinase (CPK)
– Serum phosphorus level
Imaging test:
– Chest x-ray & CT-scan
DIAGNOSTIC EVALUATION

32. COMPLICATION
• Pleural effusion - When fluid accumulates between the
pleura and the chest wall due to the large amount of fluid
already present in the lungs. As a result of the
Pneumonia, a pleural effusion may develop which could
lead to the collapse of the lungs if not treated
appropriately.
• Empyema - Pus may be present in the lungs due to the
infection. Thus pockets of pus may develop in the cavity
between the pleura and the chest wall, or in the lung
itself which is otherwise known as empyema.

33. • Lung abscess - A lung abscess develops when the
infection has destroyed lung tissue and a cavity
filled with pus is formed.
• Bacteremia - This occurs when the infection is no
longer contained within the lungs and moves into
the bloodstream, thus the blood is infected.
• Meningitis - The infection may spread to the
meninges that cover the brain and spinal cord,
leading to meningitis.

34. • Septicemia - When bacteremia occurs septicemia can
follow, as this is an infection that is spread throughout
the body. The infected blood is the best way for the
infection to manifest in other parts of the body.
• Septic arthritis - When bacteremia has occurred septic
arthritis is also a danger, as the bacteria manifests in
the joints through which blood passes.
• Endocarditis or pericarditis - As blood is also
circulated through the heart muscles and the
pericardium, the risk of developing an infection there is
very high if bacteremia is present.

35. MANAGEMENT
• General management
• Pharmacological management
• Surgical management
• Nursing management

36. GENERAL MANAGEMENT
• Fowlers/ semi fowlers position
• Oxygen administration
• Incentive spirometry exercise
• Deep breathing & Pursed-lip breathing
• Administer humidification - to mobilize secretions
• Mobilization of the patient - done to increase air entry,
increase chest expansion, and to loosen secretions
• Postural drainage - this allows gravity to drain
secretions from specific segments of the lungs

37. PHARMACOLOGICAL MANAGEMENT
• Streptococcus Pneumonia :
– Penicillin G or Penicillin V, or amoxicillin clavulanate
(Augmentin), Trimethoprim sulfamethoxazole
• Staphylococcus Aureus :
– Penicillin. Cephalosporins; vancomycin (Vancocin)
for methicillin- resistant S. aureus.
• Haemophilus Influenza :
– 2nd/3rdgeneration cephalosporins, β lactam- β-
lactamase inhibitor, doxycycline. Azithromycin.

38. • Mycoplasma Pneumonia :
– Doxycycline, macrolides, Fluoroquinolone
• Klebsiella Pneumonia :
– 3rd generation cephalosporin with or without
aminiglycoside, carbapenams.
• Legionella Pneumonia :
– Macrolide + rifampin, fluoroquinolone Doxycycline +
rifampin
• Pneumocystis :
– Pentamidine + prednisone.

39. SURGICAL MANAGEMENT

40. NURSING DIAGNOSIS
• Impaired gas exchange related to inflammatory
pulmonary infection, Alveolar-capillary
membrane changes Ventilation-perfusion
imbalance as evidenced by presence of retained
secretions, Changes in respiratory rate
diminished/adventitious breath sounds,
dyspnea, cyanosis Ineffective cough.

41. • Ineffective airway clearance related to copius
secretions evidenced by presence of retained
secretions, changes in respiratory rate
diminished/adventitious breath sounds, dyspnea,
cyanosis ineffective cough
• Activity intolerance related to imbalance between
oxygen supply and demand, general weakness,
possibly evidenced by report of weakness ,fatigue,
exertional dyspnea, tachypnea, abnormal heart rate
response to activity.

42. • Acute pain on chest related to increased effort
of breath as evidenced by pain scale
• Impaired tissue perfusion related to v/q
mismatch, hypoxia as evidenced by delayed
capillary refills
• Disturbed sleeping pattern related to breathing
difficulty as evidenced by redness of eyes.

43. • Lewis & dirksen, (2015) textbook of medical –
surgical nursing, 2nd South asian edition,
elsevier publication.
• Brunner & suddarth’s, (2014) textbook of
medical – surgical nursing, 13th edition, wolters
kluwer publications.
REFERENCE

44. REFERENCE
• Black .J.M and Jacobs. Medical surgical nursing.
7th edition. India : Elsevier, a division of Reed
Elsevier; 2009.
• John Sterny. Respiratory physiology and chest
physiotherapy techniques : A self-learning
exercise for physiotherapy students. 5th edition.
Hong Kong: The Hong Kong Lui Press; 2010.
• Gerene .S, Bauldoffetal. Breathing disorders:
your complete exercise; 2009.