PNEUMONIA Flashcards
Pneumonia
is an acute infection of the lung parenchyma.
Pneumonia Etiology
Pneumonia is more likely to occur when defense mechanisms become incompetent or are overwhelmed by the virulence or quantity of infectious agents.
Mechanisms that create a mechanical barrier to microorganisms
air filtration, epiglottis closure over the trachea, cough reflex, mucociliary escalator mechanism, and reflex bronchoconstriction
Immune defense mechanisms include
secretion of immunoglobulins A and G and alveolar macrophages.
Pneumonia is more likely to occur when defense mechanisms become
incompetent or are overwhelmed by the virulence or quantity of infectious agents.
Decreased consciousness
weakens the cough and epiglottal reflexes, which may allow aspiration of oropharyngeal contents into the lungs.
Tracheal intubation
bypasses normal filtration processes and interferes with the cough reflex and mucociliary escalator mechanism.
What changes that occur with aging also impair the mucociliary mechanism?
Air pollution, cigarette smoking, viral URIs, and normal changes that occur with aging can also impair the mucociliary mechanism.
Chronic diseases
can suppress the immune system’s ability to inhibit bacterial growth.
Risk Factors for Pneumonia
- Abdominal or thoracic surgery
- Age >65 yr
- Air pollution
- Altered consciousness: alcoholism, head injury, seizures, anesthesia, drug overdose, stroke
- Bed rest and prolonged immobility
- Chronic diseases: chronic lung and liver disease, diabetes mellitus, heart disease, cancer, chronic kidney disease
- Debilitating illness
- Exposure to bats, birds, rabbits, farm animals
- Immunosuppressive disease and/or therapy (corticosteroids, cancer chemotherapy, human immunodeficiency virus [HIV] infection, immunosuppressive therapy after organ transplant)
- Inhalation or aspiration of noxious substances
- Intestinal and gastric feedings via nasogastric or nasointestinal tubes
- IV drug use
- Malnutrition
- Recent antibiotic therapy
- Resident of a long-term care facility
- Smoking
- Tracheal intubation (endotracheal intubation, tracheostomy)
- Upper respiratory tract infection
Organisms that cause pneumonia reach the lung by three ways:
- Aspiration of normal flora from the nasopharynx or oropharynx. Many organisms that cause pneumonia are normal inhabitants of the pharynx in healthy adults.
- Inhalation of microbes present in the air. Examples include Mycoplasma pneumoniae and fungal pneumonias.
- Hematogenous spread from a primary infection elsewhere in the body. Examples are streptococci and Staphylococcus aureus from infective endocarditis.
Types of Pneumonia
community-acquired or hospital-acquired pneumonia.
Potential causes of pneumonia
Bacteria, viruses, Mycoplasma organisms, fungi, parasites, and chemicals
Organisms Causing Pneumonia -
Community-Acquired Pneumonia
- Streptococcus pneumoniae*
- Mycoplasma pneumoniae
- Haemophilus influenzae
- Respiratory viruses
- Chlamydophila pneumoniae
- Chlamydophila psittaci
- Coxiella burnettii
- Legionella pneumophila
- Oral anaerobes
- Moraxella catarrhalis
- Staphylococcus aureus
- Pseudomonas aeruginosa
- Enteric aerobic gram-negative bacteria (e.g., Klebsiella species)
- Fungi
- Mycobacterium tuberculosis
Organisms Causing Pneumonia
Hospital-Acquired Pneumonia
- Pseudomonas aeruginosa†
- Escherichia coli†
- Klebsiella pneumoniae†
- Acinetobacter species†
- Haemophilus influenzae
- Staphylococcus aureus
- Streptococcus pneumoniae
- Proteus species
- Enterobacter species
- Oral anaerobes
Community-acquired pneumonia (CAP)
is an acute infection of the lung occurring in patients who have not been hospitalized or resided in a long-term care facility within 14 days of the onset of symptoms.
(CAP) The decision to treat the patient at home or admit him or her to the hospital is based on several factors
patient’s age, vital signs, mental status, presence of co-morbid conditions, and current physiologic condition
Assessing Pneumonia Using CURB-65
may be used as a supplement to clinical judgment to determine the severity of pneumonia and if patients need to be hospitalized.
The CURB-65 scale - Identifying the Level of Risk
Patients receive 1 point for each of the following indicators:
- C: Confusion (compared to baseline)
- U: BUN >20 mg/dL
- R: Respiratory rate ≥30 breaths/min
- B: Systolic blood pressure <90 mm Hg or diastolic blood pressure ≤60 mm Hg
- 65: ≥Age 65 yr
CURB-65 scale - Scoring and Decision Making
0 Treat at home
1-2 Consider hospital admission
3 or more Hospital admission
4-5 Consider admission to intensive care unit
Empiric antibiotic therapy
the initiation of treatment before a definitive diagnosis or causative agent is confirmed, should be started as soon as CAP is suspected.
Hospital-acquired pneumonia (HAP)
pneumonia in a non intubated patient that begins 48 hours or longer after admission to hospital and was not present at the time of admission.
Ventilator-associated pneumonia (VAP)
type of HAP, refers to pneumonia that occurs more than 48 hours after endotracheal intubation.
Once the diagnosis of HAP or VAP is made treatment of pneumonia is initiated based on
known risk factors, early versus late onset, and probable organism. Antibiotic therapy can be adjusted once the results of sputum cultures identify the exact pathogen.
Both HAP and VAP are associated with
longer hospital stays, increased associated costs, sicker patients, and increased risk of morbidity and mortality.
A major problem in treating pneumonia today is
development of multidrug-resistant (MDR) organisms.
- methicillin-resistant Staphylococcus aureus and
- gram-negative bacilli.
Risk factors for development of multidrug-resistant MDR pneumonia include
advanced age, immunosuppression, history of antibiotic use, and prolonged mechanical ventilation.
MDR organisms also increase
the morbidity and mortality risks associated with pneumonia.
Aspiration pneumonia
the abnormal entry of material from the mouth or stomach into the trachea and lungs.
Conditions that increase the risk of aspiration
decreased level of consciousness (e.g., seizure, anesthesia, head injury, stroke, alcohol intake), difficulty swallowing, and insertion of nasogastric tubes with or without tube feeding.
The aspirated material (food, water, vomitus, or oropharyngeal secretions) triggers
an inflammatory response.
The most common form of aspiration pneumonia
primary bacterial infection
Until cultures are completed and results obtained, initial antibiotic therapy is based on
an assessment of probable causative organism, severity of illness, patient factors (e.g., malnutrition, current use of antibiotic therapy), and ability to treat common community-acquired organisms.
For patients who aspirate in hospitals, appropriate antibiotics should include
coverage for both gram-negative organisms and MRSA.
aspiration of acidic gastric contents causes
chemical (noninfectious) pneumonitis, which may not require antibiotic therapy.
However, secondary bacterial infection can occur 48 to 72 hours later.
Necrotizing pneumonia
rare complication of bacterial lung infection.
It is characterized by liquefaction and, in some situations, cavitation of lung tissue. Often occurs as a result (CAP)
Signs and symptoms of necrotizing pneumonia include
immediate respiratory insufficiency and/or failure, leukopenia, and bleeding into the airways. Lung abscesses commonly occur.
Treatment often includes long-term antibiotic therapy and possible surgery.
Opportunistic pneumonia
inflammation and infection of the lower respiratory tract in immunocompromised patients.
Individuals at risk for opportunistic pneumonia include
those with altered immune responses: severe protein-calorie malnutrition or immunodeficiencies (e.g., human immunodeficiency virus [HIV] infection) and those receiving radiation therapy, chemotherapy, and any immunosuppressive therapy, including long-term corticosteroid therapy.
P. jiroveci pneumonia (PJP)
symptoms of fever, tachypnea, tachycardia, dyspnea, nonproductive cough, and hypoxemia. The chest x-ray usually shows diffuse bilateral infiltrates. lungs have massive consolidation.
cytomegalovirus (CMV)
can cause viral pneumonia. asymptomatic or mild, but severe disease can occur in people with an impaired immune response
cytomegalovirus (CMV) treatment.
Antiviral medications (e.g., ganciclovir [Cytovene], foscarnet [Foscavir], cidofovir) and high-dose immunoglobulin are used for treatment.
pneumonia pathophysiologic changes
trigger an inflammatory response in the lungs w/ch attracts more neutrophils, edema of the airways occurs, and fluid leaks from the capillaries and tissues into alveoli. leading to hypoxia (e.g., tachypnea, dyspnea, tachycardia)
Consolidation
occurs when the normally air-filled alveoli become filled with fluid and debris. Mucus production also increases, which can potentially obstruct airflow and impair gas exchange even further.
symptoms of pneumonia
cough/may or may not be productive, fever, chills, dyspnea, tachypnea, and pleuritic chest pain. Sputum may appear green, yellow, or even rust colored (bloody).
Viral pneumonia may initially be seen as
influenza, with respiratory symptoms appearing and/or worsening 12 to 36 hours after onset.
pneumonia - aging
The older or debilitated patient may not have classic symptoms of pneumonia. Confusion or stupor (possibly related to hypoxia) may be the only finding.
pneumonia - aging symptoms
Hypothermia, rather than fever, may also be noted with the older patient. Nonspecific clinical manifestations include diaphoresis, anorexia, fatigue, myalgias, and headache.
pneumonia on physical examination
fine or coarse crackles may be auscultated over the affected region. If consolidation is present, bronchial breath sounds, egophony (a change in the sound of the voice of the patient), and increased fremitus (vibration of the chest wall produced by vocalization) may be noted. Patients with pleural effusion may exhibit dullness to percussion over the affected area.
Complications of pneumonia
more frequently in older individuals and those with underlying chronic diseases.
Complications of pneumonia types
Atelectasis, Pleurisy, Bacteremia, Pneumothorax, Meningitis, Acute respiratory failure, Sepsis/septic shock, Lung abscess is not a common complication of pneumonia.
Lung abscess
may occur with pneumonia caused by S. aureus and gram-negative organisms.
Empyema
the accumulation of purulent exudate in the pleural cavity, occurs in less than 5% of cases and requires antibiotic therapy and drainage of the exudate by a chest tube or open surgical drainage
diagnostic measures for pneumonia
History, physical examination, and chest x-ray often provide enough clinical information to make decisions about early treatment.
Other diagnostic measures for pneumonia
X-ray may also show pleural effusions. A thoracentesis and/or bronchoscopy with washings may be used to obtain fluid samples from patients not responding to initial therapy.
Interprofessional Care Pneumonia
- Diagnostic Assessment 2. Management 3. Drug Therapy
Pneumonia Diagnostic Assessment
• History and physical examination • Chest x-ray • Gram stain of sputum • Sputum culture and sensitivity test • Pulse oximetry or ABGs (if indicated) • Complete blood count, WBC differential, and routine blood chemistries (if indicated) • Blood cultures (if indicated)
Pneumonia Management
• Increased fluid intake (at least 3 L/day) • Balance between activity and rest • O2 therapy (if indicated)
Pneumonia Drug Therapy
• Appropriate antibiotic therapy • Antipyretics • Analgesics
Beginning antibiotic therapy
- Ideally, a sputum specimen for culture and Gram stain to identify the organism are obtained.
- However, antibiotic administration should not be delayed if a specimen cannot be readily obtained.
- Delays in antibiotic therapy can increase the risk of morbidity and mortality.
Diagnostic tests for pneumonia
Blood cultures are done for patients who are seriously ill. Arterial blood gases (ABGs) may be obtained to assess for hypoxemia (partial pressure of O2 in arterial blood [PaO2] less than 80 mm Hg), hypercapnia (partial pressure of carbon dioxide in arterial blood [PaCO2] greater than 45 mm Hg), and acidosis (pH <7.35). Leukocytosis occurs in the majority of patients with bacterial pneumonia; the white blood cell (WBC) count is usually greater than 15,000/µL (15 × 109/L) with the presence of bands (immature neutrophils).
Arterial blood gases (ABGs)
obtained to assess for hypoxemia (partial pressure of O2 in arterial blood [PaO2] less than 80 mm Hg)
hypercapnia
(partial pressure of carbon dioxide in arterial blood [PaCO2] greater than 45 mm Hg)
acidosis
(pH <7.35)
Leukocytosis
the white blood cell (WBC) count is usually greater than 15,000/µL (15 × 109/L) with the presence of bands (immature neutrophils).
Pneumococcal vaccine is used to prevent
Streptococcus pneumoniae
Antibiotics are highly effective for both bacterial and mycoplasma pneumonia.
The patient responds to drug therapy within
48 to 72 hours.
Pneumococcal vaccine Indications
decreased temperature, improved breathing, and reduced chest discomfort.
-Abnormal physical findings can last more than 7 days.
Pneumonia therapy follow up
A repeat chest x-ray may be obtained in 6 to 8 weeks to assess for resolution.
Pneumococcal conjugate vaccine (PCV13, Prevnar 13)
• All children <5 yr • All adults ≥65 yr • Anyone 2-64 yr old with certain medical conditions (e.g., sickle cell disease, asplenia, immunodeficiencies, HIV infection, chronic renal failure, leukemia, generalized malignancy, long-term immunosuppressive therapy, cerebrospinal fluid leaks, cochlear implant[s])
Pneumococcal polysaccharide vaccine (PPSV23, Pneumovax 23)
• All adults ≥65 yr • Anyone 2-64 yr old with certain long-term health problems (e.g., heart disease, lung disease, diabetes mellitus, alcoholism, cirrhosis, sickle cell disease, leaks of cerebrospinal fluid, cochlear implant) • Anyone 2-64 yr with a disease or condition that weakens the immune system or taking drugs that lowers body’s resistance to infection (e.g., HIV infection; lymphoma or leukemia; kidney failure; damaged or no spleen; multiple myeloma; receiving immunosuppressive chemotherapy, radiation therapy, or long-term corticosteroids; after organ or bone marrow transplantation) • Adults 19-64 yr who smoke cigarettes or have asthma
Pneumonia supportive measures
O2 therapy to treat hypoxemia, analgesics to relieve chest pain, and antipyretics (e.g., aspirin, acetaminophen) for elevated temperature. Although cough suppressants, mucolytics, bronchodilators, and corticosteroids are often prescribed as adjunctive therapy, the use of these drugs is controversial.
Pneumonia activity treatment
Individualize rest and activity to each patient’s tolerance. Benefits of mobility include improved diaphragm movement and chest expansion, mobilization of secretions, and prevention of venous stasis.
Viral pneumonia treatment
No definitive treatment exists. care is generally supportive. In most circumstances, viral pneumonia is self-limiting and will often resolve in 3 to 4 days.
Drug Therapy Outpatient Previously healthy
Bacterial Community-Acquired Pneumonia
Macrolide OR doxycycline
No recent antibiotic therapy in past 3 mo and no risk for drug-resistant Staphylococcus pneumoniae (DRSP)
Drug Therapy Outpatient
Bacterial Community-A Pneumonia
Respiratory fluoroquinolone
OR β-Lactam plus macrolide (doxycycline may be substituted for macrolide)
Co-morbidities (e.g., COPD; diabetes; chronic heart, liver, lung, or renal disease; malignancy; use of antibiotics in past 3 mo)
Bacterial Community-Acquired Pneumonia
Outpatient Respiratory Drug Therapy
fluoroquinolone OR β-Lactam plus macrolide
Regions with ≥25% macrolide-resistant S. pneumoniae
Inpatient Medical unit Drug Therapy
Bacterial Community-Acquired Pneumonia
Respiratory fluoroquinolone OR β-Lactam plus macrolide
Bacterial Community-Acquired Pneumonia
ICU Drug Therapy
β-Lactam plus either azithromycin or respiratory fluoroquinolone
Types of Antibiotics
Macrolides
erythromycin, azithromycin (Zithromax), clarithromycin (Biaxin)
Types of Antibiotics - Fluoroquinolones
moxifloxacin (Avelox, Vigamox), levofloxacin (Levaquin), gemifloxacin (Factive)
Types of Antibiotics - β-Lactams
High-dose amoxicillin, amoxicillin/clavulanate (Augmentin), cefpodoxime, ceftriaxone (Rocephin), cefuroxime (Ceftin)
Types of Antibiotics - Antipneumococcal, antipseudomonal β-lactams
imipenem/cilastatin (Primaxin), meropenem (Merrem), cefepime (Maxipime), piperacillin/tazobactam (Zosyn)
The prevalence and resistance patterns of MDR pathogens vary among localities and institutions. Therefore
the antibiotic regimen must be adapted to local patterns of antibiotic resistance.
Initially include antibiotics that are effective against both types
resistant gram-negative and resistant gram-positive organisms.
Clinical antibiotic improvement usually occurs in
3 to 5 days.
Patients who deteriorate or fail to respond to therapy require aggressive reevaluation to assess for
Noninfectious etiologies, complications, coexisting infectious processes, or pneumonia caused by a drug-resistant pathogen.
IV antibiotic therapy should be switched to
Oral therapy as soon as the patient is hemodynamically stable, is improving clinically, is able to ingest oral medication, and has a functioning gastrointestinal tract.
Total treatment time for patients with CAP should be
a minimum of 5 days, and the patient should be afebrile for 48 to 72 hours before stopping treatment.
CAP pt teaching
Emphasize the importance of completing the full course of antibiotic treatment.
Hydration is important in the supportive treatment of pneumonia to prevent
Dehydration and to thin and loosen secretions.
-Older adult, has heart failure, or has a known preexisting respiratory condition, IV administration of fluids and electrolytes may be necessary.
Weight loss may occur in patients with pneumonia because of
Increased metabolic needs and difficulty eating due to nonspecific abdominal complaints or shortness of breath.
- Small, frequent meals are easier for dyspneic patients to tolerate.
- Offer foods high in calories and nutrients.
Nursing Assessment Pneumonia - Subjective Data
Important Health Information
= Past health history: Lung cancer, COPD, diabetes mellitus, chronic debilitating disease, malnutrition, altered consciousness, immunosuppression, exposure to chemical toxins, dust, or allergens
= Medications: Antibiotics, corticosteroids, chemotherapy, or any immunosuppressants
= Surgery or other treatments: Recent abdominal or thoracic surgery, splenectomy, endotracheal intubation, or any surgery with general anesthesia. Tube feedings
Nursing Assessment Pneumonia - Subjective Data Functional Health Patterns
=Health perception–health management: Cigarette smoking, alcoholism; recent upper respiratory tract infection, malaise
=Nutritional-metabolic: Anorexia, nausea, vomiting. Chills
=Activity-exercise: Prolonged bed rest or immobility. Fatigue, weakness. Dyspnea, cough (productive or nonproductive). Nasal congestion
=Cognitive-perceptual: Pain with breathing, chest pain, sore throat, headache, abdominal pain, muscle aches
Nursing Assessment Pneumonia - Objective Data General
Fever, restlessness or lethargy. Splinting of affected area
Nursing Assessment Pneumonia - Objective Data Respiratory
Tachypnea, pharyngitis, asymmetric chest movements or retraction, decreased excursion, nasal flaring. Use of accessory muscles (neck, abdomen). Crackles, friction rub on auscultation, dullness on percussion over consolidated areas, increased tactile fremitus on palpation. Pink, rusty, purulent, green, yellow, or white sputum (amount may be scant to copious)
Nursing Assessment Pneumonia - Objective Data
Cardiovascular
Tachycardia
Nursing Assessment Pneumonia - Objective Data
Neurologic
Changes in mental status, ranging from confusion to delirium
Nursing Assessment Pneumonia - Objective Data
Possible Diagnostic Findings
Leukocytosis. Abnormal ABGs with ↓ or normal PaO2, ↓ or normal PaCO2, and ↑ or normal pH initially, and later ↓ PaO2, ↑ PaCO2, and ↓ pH. Positive sputum on Gram stain and culture. Patchy or diffuse infiltrates, abscesses, pleural effusion, or pneumothorax on chest x-ray
Blood gases* • Arterial pH
7.35-7.45 Alkalosis OR Acidosis
Blood gases PaCO2
35-45 mm Hg (4.66-5.98 kPa)
Compensated metabolic alkalosis
Compensated metabolic acidosis
Blood gases PaO2
80-100 mm Hg (10.6-13.33 kPa)
=Administration of high concentration of oxygen
=Chronic lung disease, decreased cardiac output
Blood gases CO2
23-29 mEq/L
Nursing diagnoses for the patient with pneumonia may include, but are not limited to, the following:
- Impaired gas exchange related to fluid and exudate accumulation within the alveoli and surrounding lung tissue
- Ineffective breathing pattern related to inflammation and chest discomfort
- Acute pain (chest) related to inflammation and ineffective pain management and/or comfort measures • Activity intolerance related to chest discomfort, inflammation, shortness of breath, generalized weakness
The overall goals are that the patient with pneumonia will have
(1) clear breath sounds, (2) normal breathing patterns, (3) no signs of hypoxia, (4) normal chest x-ray, (5) normal white blood cell (WBC) count, and (6) absence of complications related to pneumonia.
Health Promotion. To reduce the risk of pneumonia
frequent hand washing, proper nutrition, adequate rest, regular exercise, and coughing or sneezing into the elbow rather than hands. Avoidance of cigarette smoke
avoid exposure to people with URIs >7 days, the person should seek medical care. Encourage both influenza and pneumococcal vaccines for pts at risk.
Health Promotion pneumonia
acute care setting
Place the patient with altered consciousness in positions (e.g., side-lying, upright) that will prevent or minimize the risk of aspiration.
Turn and reposition the patient at least every 2 hours to facilitate adequate lung expansion and mobilization of secretions.
Encourage and assist with ambulation and positioning into a chair. In the ICU, strict adherence to all aspects of the ventilator bundle, a group of interventions aimed at reducing the risk of VAP, has been shown to significantly reduce VAP.
Health Promotion pneumonia
acute care setting difficulty swallowing
Assistance in eating, drinking, and taking medication to prevent aspiration, elevate the patient’s head-of-bed to at least 30 degrees and have the patient sit up for all meals.
Assess for a gag reflex before giving food or fluids. nasogastric tubes are at risk for aspiration pneumonia
How to reduce the incidence of health care–associated infection (HAI)
Practice strict medical asepsis and adherence to infection control guidelines
Health Promotion pneumonia Ambulatory Care.
=Teach the patient about the importance of taking every dose of the prescribed antibiotic, any drug-drug and food-drug interactions for the prescribed antibiotic, and the need for adequate rest to facilitate recovery. =Instruct the patient to drink plenty of liquids (at least 6 to 10 glasses/day, unless contraindicated) and to avoid alcohol and smoking.
=A cool mist humidifier or warm bath may help the patient breathe easier.
=Tell patients that it may be several weeks before their usual vigor and sense of well-being return.
=Explain that a follow-up chest x-ray may be done in 6 to 8 weeks to evaluate resolution of pneumonia.
Evaluation
The expected outcomes are that the patient with pneumonia will have
- Effective respiratory rate, rhythm, and depth of respirations
- Lungs clear to auscultation
Manifestations of Inadequate Oxygenation CNS
Unexplained apprehension
Unexplained restlessness or irritability
Unexplained confusion or lethargy
LATE = Combativeness Coma
Manifestations of Inadequate Oxygenation Respiratory
Tachypnea Dyspnea on exertion LATE- Dyspnea at rest Use of accessory muscles Retraction of interspaces on inspiration Pause for breath between sentences, words
Manifestations of Inadequate Oxygenation Cardiovascular
Tachycardia Mild hypertension Dysrhythmias EARLY AND LATE LATE- Hypotension Cyanosis Cool, clammy skin
Manifestations of Inadequate Oxygenation Other
EARLY AND LATE-
Diaphoresis
Decreased urine output
Unexplained fatigue
Normal and Critical Values for PaO2
=80-100 Normal value Asymptomatic • Routine assessment of patient
=60-79 Mild hypoxemia Restlessness, tachycardia, dysrhythmias, dyspnea, hypertension • Assess patient condition as necessary • Supplemental O2 may be required
=40-59 Moderate hypoxemia Confusion, lethargy, dysrhythmias, hypotension, respiratory distress, accessory muscle use • O2 required • Escalate level of care. Obtain critical care consult • Monitor frequently for sudden deterioration in condition
<40 Severe hypoxemia Cyanosis, coma, respiratory and/or cardiac arrest possible • High FIO2, intubation, mechanical ventilation • Continuous patient assessment and evaluation
Normal and Critical Values for SpO2
≥94 Normal value Asymptomatic• Routine assessment of patient
=90 Mild hypoxemia Restlessness, tachycardia, dysrhythmias, dyspnea, hypertension • Assess patient condition as necessary • Supplemental O2 may be required
=88 Moderate hypoxemia Confusion, lethargy, dysrhythmias, hypotension, respiratory distress, accessory muscle use • O2 required • Escalate level of care. Obtain critical care consult • Monitor frequently for sudden deterioration in condition
=75 Severe hypoxemia Cyanosis, coma, respiratory and/or cardiac arrest possible • High FIO2, intubation, mechanical ventilation • Continuous patient assessment and evaluation
