1. Pneumonia
C. Unantenne RN, BSN, MS

2. 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.

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

6. 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

7. 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

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

9. 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.

10. 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

11. 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

12. 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

13. 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.

18. 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

19. 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

21. 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

22. 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.

24. 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.

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

26. 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

27. 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

28. 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 – % no change
- yellow – 50 – 80% be more vigilant use SABA
- Red – take SABA and ER

29. 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

30. 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

31. 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

32. 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

34. 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