10. Pneumonia Flashcards
Pneumonia is an __
acute inflammation of the lung parenchyma (caused by an infectious agent) that can lead to alveolar consolidation.
Causative agents include:
- bacterial
- viral
- fungal
- parasitic
Pneumonia may also be classified according to where it developed:
-Community-acquired pneumonia (CAP)
-Hospital-acquired pneumonia (HAP)
-Ventilator-associated pneumonia (VAP); now referred to as ventilator-associated event (VAE)
Community-acquired pneumonia (CAP)
-Outside the hospital
-Common pathogens: streptococcus pneumonia, Legionella pneumophila, klebsiella pneumoniae, haemophilus influenzae, staphylococcus aureus, mycoplasma pneumoniae, pseudomonas aeruginosa
Hospital-acquired pneumonia (HAP)
-Acute care
-Long-term care
-Nursing Home
VAP (VAE)
Ventilator-associated pneumonia (VAP); now referred to as ventilator-associated event (VAE)
-By definition, develops 48 hours or more after admission to hospital
-Common pathogens: P. aeruginosa, Escherichia coli., K. pneumoniae, Acinetobacter baumannili, Staphylococcus aureus (esp diabetes and head trauma), MRSA
-HAP has higher mortality than CAP.
Risk Factors for Pneumonia
Multiple Factors will increase the risk, including:
-age
-preexisting pulmonary disease
-smoking
-decreased level of consciousness (LOC)
-artificial airways
-chronic illness
-malnutrition
-immunocompromised
-increased secretions
-atelectasis
-immobility
-depressed cough or gag reflexes
-concurrent antibiotic therapy
-aspiration
-organisms spread from other site (gut, wound) to lungs
-multiple organ dysfunction syndrome (MODS)
Signs and symptoms of Pneumonia
-Chills, diaphoresis, fever, mailaise
-tachycardia, chest pain
-confusion (especially for the elderly)
-productive cough
-use of accessory muscles
-dehydration
-over area of consolidation on the chest:
-increased tactile fremitus
-dull to percussion
-bronchial breath sounds or diminished breath
sounds
-bronchophony (louder/clearer)
-egophony (“e” to “a”)
-whispered pectoriloquy (whisper heard better with
a stethoscope)
Diagnosis of Pneumonia
-CXR: consolidation or diffuse patchy infiltrates
-sputum culture with gram stain
-blood cultures
-WBC: high but may be normal or low in
immunocompromised or elderly people
-WBC differential: increased bands > 10%
-ABGs: hypoxemia
-Thoracentesis for effusions
Treatment of Pneumonia:
-Optimize oxygenation and ventilation
-Titrate FiO2
Positioning – GOOD lung DOWN
-bronchial hygiene, chest physiotherapy
- prone positioning for severe hypoxemia
-noninvasive ventilation or intubation/mechanical
ventilation as needed
-bronchoscophy (with lavage, if needed)
-mobilize, clear secretions
-ID organism
-sputum culture and sensitivity (C&S)
-blood cultures
-Antibiotic therapy
-System support
-Hydration
-fever management
-glucose control
-nutrition
-General preventative measures
-smoking cessation
-pneumonia vaccine for those who are 65 and older
-flu vaccine
Antibiotic therapy for pneumonia
-Empiric therapy: choice of agent is based on the likely
causative organism (as determine by a pt assmt and
the types of pneumonia seen in the community and in
the institution) and whether that organism may be
resistant to therapy.
-Timing: First dose within 4 hrs if pt first presents to the ED (and is later admitted to the hospital); the first antibiotic dose should be given in the ED; note that if the pt has sepsis, the antibiotic timing differs
-Organism - specific therapy: as soon as the C&S results are available
Prevention of Hospital-Acquired Pneumonia
-practice hand hygiene
-keep HOB elevated 30 degrees or >
-prevent bacterial translocation from GI tract: use the
gut, feed pt
-practice oral hygiene!
- provide education on common institution pathogens
and the rates of nosocomial pneumonia
-Use evidence-based confirmation of feeding tube placement.
-confirm with X-Ray prior to using for feeding
-Mark the exit site with an indelible marker for future
reference
-Assess latency q 4 h
-observe for a change in the length of the external
portion of the feeding tube (as determined by
movement of the marked portion of the tube).
-Review routine chest and abdominal X-ray reports
to look for notations about tube location
-observe for changes in volume of aspirate from
feeding tube.
- If pH strips are available, measure the pH of
feeding tube aspirates if feedings are
interrupted for more than a few hrs.
-Observe the appearance of feeding tube aspirates
if feedings are interrupted for more than a few
hours.
-obtain an x-ray to confirm tube position if there
is doubt about the tube’s location.
Prevention of Ventilator-Associated Pneumonia
Prevention involves all the interventions for preventing hospital-acquired pneumonia, plus:
-Drain accumulated condensate from tubing
-Prevent back flow of tubing condensate into the endotracheal tube (ETT).
-Change ventilator tubing only when it is contaminated.
-Mobilize the pt.
-Utilize aseptic technique for ETT, tracheostomy suctioning.
-Adhere to mouth care protocol, chlohexidine mouth rinse.
-Brush teeth to remove plaque.
-Keep ETT cuff inflated
-Perform subglottic suctioning prior to cuff deflation.
-Perform routine oropharyngeal suctioning.
