Pneumonia C. Unantenne RN, BSN, MS

What is Pneumonia Acute infection of the lung paranchyma Significan rate of death in > 65 years Basically, Pneumonia is an inflammation in the lungs, which can cause cough, mucus , fever, SOB, and chest pain. Normally, our protective mechanisms such as the cilia, and cough reflex prevent germs from entering the lungs. Pneumonia Symptoms Inflammation is found in the alveoli Alveoli end up filling with fluids which leads to impaired gas exchange. SOB also known as dyspnea. The inflammation and the immune responses causes the other symptoms of Pneumonia. Ex fever, chest pain, chills, yellow sputum. Chest pain What is walking Pneumonia? Atypical Pneumonia Shows different symptoms Happens gradually, often after being sick with something else Fever is lower, no chills, headache, body aches, joint pain, unproductive cough, tired and weak. You can still attend to daily activity.

Protective Mechanisms Air filtration Epiglottis Cough reflex Muccocilliary escalator mechanism Reflex bronchoconstriction Immune defense: immunoglobulin A&G, Macrophages

Patho Inflammatory Response Decreased Gas Exchange Attract Neutrophil Releases Inflammatory Mediators Accumulation of Exudate Inflammatory Response Alveoli fill with fluids and debris Increased mucus production Decreased Gas Exchange Resolution of Infection (1) Macrophage in alveoli ingest and remove debris (2) Normal lung tissue restored (3) Gas exchange returns to normal

Clinical Manifestations, Complications and Diagnosis Fever Cough Dyspnea Tachypnea Pleuritic chest pain Complications Pleurisy, atelectasis, lung abscesses, meningitis, sepsis, acute resp distress, pneumothorax Diagnosis H&P X ray Sputum and blood CX ABG

Treatment Oxygen Increase fluid Antipyretics Analgesics Antibiotics Rest Nutrition Pneumovax Vaccination >65 years, long term health issues Smokers, asthma, long term care facility

Transmission Toxic material. Fungi Most common – bacteria Streptococcus Pneumoniae, other types include H. Influenza, Chlamydia, Mycoplasm, and Legionella. How does the bacteria gets in the lung? Most common – aspiration, S pneumonia is a normal body flora found in the mouth, pharynx and the nose ( upper airway). Aspiration – fluids in the lungs, food, drinks and saliva Breathing infected air droplets. Blood stream ***** Vaccinations have decreased the number of cases over the years. ***** Core measures.

Who is at Risk People with chronic health problems ex DM People who are immunosuppressed. HIV, AIDS Other lung diseases – COPD, asthma Very young and very old >65 yrs Intubation URI Prolonged immobility Diagnosis Listening to lungs- rasping, crackles X – rays- cloudy ABG Sputum cultures Treatment Supportive care Antibiotics Oxygen therapy

Types of Pneumonia Bacterial, Viral, Mycoplasma organism, Fungi, Parasites, Chemical Opportunistic Pneumonia PCP- HIV Classification Community acquired – NOT HOSPITALIZED X 14 DAYS Medical- Care Associated HOSPITAL- > 48 hrs after hospitalization VENTILATOR- 48 hrs after intubation HEALTH CARE – acute care > 2 days within 90 days, resident of a long term facility, received antibiotics, wound care, chemo within 30 days, hemodialysis clinic

Pulmonary Disease Restrictive obstructive Impaired movement of chest wall and diaphragm obstructive Increased resistance to air flow EXTRAPULMONARY CNS- Head injury, opioids Neuromuscular- GB, SC, MS Chest wall- obesity, trauma (B) INTRAPULMONARY Pleural – Pleural effusion, pneumothorax Parenchymal- atelectasis, ARDS Asthma COPD CF

COPD COPD Can be divided into two clinical phenotypes: emphysema and chronic bronchitis. Bronchitis – hyper secretion of mucus and inflammation along the bronchioles, decreased mucocilliary clearance, this causes obstruction. Emphysema – damage to collagen and elastic fibers ( structural integrity of lungs), lung fibrosis and loss of elastic recoil. Structures along the bronchioles Columnar cells Goblet cells – produce mucus Cilia – clears mucus , smokers loose these cilia and looses the ability to clear mucus.

COPD is Characterized by ( 1 ) Progressive dyspnea – interferes with gas exchange : increased WOB/rate, air hunger, hypercapnia, hypoxemia. ***** can not reverse ***** How can we slow the progress of COPD Early diagnosis is important Decrease inflammation – steroids. Stop the initial insult – quit smoking ( 2 ) Chronic cough. ( 3 ) Chronic Tobacco use **** classification of COPD By spirometer

Diagnosis Pulmonary function test – flow and volume of breathing FEV1- force expiratory volume in one second. FVC – force vital capacity FEV1/FVC = 0.8 is normal

Treatment for COPD SMOKING CESSATION BRONCHODIALATORS : Beta 2 Agonist- short acting (Salbutamol) , long acting ( Salmetrol) CORTICOSTEROIDS OXYGEN PULMONARY REHABILITATION LUNG VOLUME REDUCTION SURGERY: REDUCES HYPERINFLATION, IMPROVES LUNG RECOIL

Asthma Hyper-reactivity of the air way which leads to Broncho constriction, air way inflammation, increased production of mucus. Triggers – allergens, smoke, cold air, stress, emotions, genetics Signs and symptoms Increased RR Prolonged expiration ( 1: 3- 4 ). Wheezing Cough – night and early morning Retractions, use of accessory muscles, nasal flaring. Unable to speak in complete sentences.

Treatment Everyone with asthma needs SABA Persistent asthma – needs SABA + ICS ( inhaled corticosteroids – Flovent) – this takes several days to kick in. First SABA then ICS Then oral Acute Exacerbation SABA Q 20 MTS X 3 ex Albuterol, Xoponex, Epi Oral corticosteroids ex Prednisone O2 if sats < 90% Severe Exacerbation Continuous SABA and add Atrovent Oral or IV corticosteroids q 4 – 6 hrs May need Heliox – lowers gas density **** do not give Theophylline, mucolytic, sedatives and antibiotics.

Treatment Chronic Bronchodilators - LABA - Servent - Methoxanthine – Theophyline – oral/IV - Anticholinergic – Atrovent - Corticosteroids – Flovent, pulmocort – mouth sores - Mass cell stabilizers – Cromlyn - Leukotriene Modifiers – Singular - tabs

Correct use of Drug Therapy MDI Can use a spacer Shake well before use Coordinate breaths with activation unless you use a spacer Hold breath for 10 sec Do not float them in water or shake them to see if they are empty DPI ( DRY POWDER INHALER) Simple to use Can not use a spacer Do not have to coordinate breaths with puffs Breathe in deeply and quickly Hold breaths x 10 sec Keep away from humidity, do not breathe into devise

Treatment Nebulizers Converts drug solution into mist ****inhalers work faster, decrease side effects compared to oral ***** Acute Interventions 2 – 4 breaths q 20 x 3 Increased louder wheezing may be heard and it’s a good sign ( air way open) Reduce anxiety Slow deep breaths, purse lip breathing, ask patient to breathe with you O2 sats improving – ssx of getting better

Ambulatory/Home Care Interventions Make every effort to remain symptom free Learn about your medicine Keep a diary Utilize a peak flow meter daily ( best of 3 blows) Follow a written asthma management plan - Green – 80-100% no change - yellow – 50 – 80% be more vigilant use SABA - Red – take SABA and ER

Nursing DX Impaired Gas Exchange Ineffective Airway Clearance - must have a Sao2 or Pao2 issue - interventions : purse lip breathing, peep, O2 Ineffective Airway Clearance - could be secretions, lack of cough effort, pain - Interventions : increase fluids and splinting Ineffective Breathing Pattern - could be hyperventilation or shallow breathing - Interventions : pain meds, anxiety control

How do I Know My Patient is Getting Worse Wheezing is an unreliable sign of severity of attack Increase work of breathing ex use of accessory muscles, nasal flaring, inability to speak in complete sentences. Decreased saturation RR > 30 Ominous changes Decreased HR and RR – IMPENDING RESP FAILURE Silent chest – NO BREATH SOUNDS Diagnosis PEAK FLOW PFTs Allergy testing – skin tests , RAST Chest X – Rays

Mild Moderate Severe Brittle Couple of times per week Greater than two times per week Very severe asthma Exercise induced Exercise may be a trigger Sleep disturbances Can be fatal Relieved with Broncho dialators Symptoms usually seen at night Frequent hospitalizations Needs medicine

Asthma Allergic ( extrinsic) Non Allergic(intrinsic) Causes Diagnosis Triggered by allergens Not related to allergens Allergens, History Common Triggered by stress, exercise , cold air, dry air, hyperventilation Respiratory infections PFT Cough, wheezing, SOB, chest tightness Immune system is not involved Weather X -ray Inhalation of dust, pet dander, pollen, mold Emotions Spirometry Medication ex Asprin Peak air flow

Anti inflammatory Anti cholinergics Leukotriene modifiers Beta adrenergic agonists methylxanthines Corticosteroids (A) Short Acting (A) Receptor Blockers (A) SABA IV - Aminophyline Solucortef Atrovent Accolate- oral tablets, Albuterol, Ventolin Oral - Theophyline Solumedrol Dry mouth Headaches, dizziness, abdomen pain Tremors, increase HR, BP Increase HR, BP, dysrhythmias, Cipro, Cimetadine, erythromycine will increase levels Prednisone (B) Long Acting Singular - tablets MONITOR CARDIAC PATIENTS Check Theophyline levels Side effects Spiriva (DPI)- Dry powder ( B) Inhibitors Xopanex Cushinoid appearance, osteoporosis, peptic ulcers, menistrial irregularities, Zileuton – tab May cause liver enzymes to go up, pain, headaches Less cardiac side effects Flovent, Pulmocort, beclomethasone (B) LABA Tapering, oral care, obesity Salmetrol – never by itself