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Tuesday, March 25, 2008

Everything RTs need to know about pneumonia

Normally, a person's lungs are sterile, or completely free of bacteria, viruses, fungi, or any other little particles that might cause harm to them. However, on occasion, something might make it's way into the lungs and cause what is commonly known as pneumonia.

Simply put, pneumonia is inflammation of the lung parenchyma. The most common cause of pneumonia is bacteria, although it can also be caused by viruses or fungi.

It's the single most common diagnosis of all the patients that I take care of, mainly becasue it's the most reimbursible. Thus, if a doctor thinks a patient is sick enough to be admitted yet doesn't know exactly what's wrong yet, pneumonia is often written in the chart.

Pneumonia Statistics: That in mind, I'm certain that some pneumonia statistics might be altered. According to Medicine.net, . "over 3 million people develop pneumonia each year in the United States. Over a half a million of these people are admitted to a hospital for treatment. Although most of these people recover, approximately 5% will die from pneumonia.

It's the sixth leading cause of death in the United States." According to mayoclinic.com, that 5% comes to about 60,000 Americans who die of pneumonia in any given year, most of these patients were compromised in one way or another, be it that they were elderly or had some disease such as cancer, COPD or other chronic illness. It's also the leading cause of death in children.

It can be deadly, but it can also be treated.

Signs and symptoms of pneumonia: Two common types of pneumonia are either viral or bacterial. Here are the signs of symptoms: 1. Shortness of breath 2. Rapid, shallow breathing 3. Auscultation

  • Crackles isolated to one lobe is usually bacterial
  • Crackles/ rhonchi in bases or throughout is usually viral

4. SpO2 levels decreasing below patient normal value

5. Cough: either dry or productive (green, brown, yellow and/or bloody secretions if bacterial, and clear to white if viral)

6. Chest pain that worsens with deep breath or when coughing

7. Fever, shaking, chills

8. Lab values: Increased WBC and/or increased neutrophils (if bacterial)


9. X-Ray shows dense white patch in infected lobe (bacterial). Viral pneumonias produces faint, widely scattered white streaks or patches

10. Sputum sample: lab may isolate bacteria if caused by bacteria (According to Merck.com, the organism is not isolated in 50% of patients.)

11. Patient may be pale, dusky, blue


12. Patient may be Diaphoretic, loss of appetite, fatigue, and (in elderly) confusion

13. With bacterial pneumonia, elderly patients may even have a decreased temp

Diagnosis of pneumonia:

Aside from a good sputum sample, a good history from the patient or patient's family can help you determine which type of pneumonia the patient has. If the symptoms occurred all of a sudden, then it may be bacterial or mycoplasma. On the other hand, if symptoms occurred following a bout of flu like symptoms, than a virus is probably the culprit.

Was the patient drinking? He may have aspiration pneumonia. Is he immunocompromised? Perhaps he has Pneumocystis carinii. Is it community acquired? It's probably gram-positive bacterium Streptococcus pneumoniae. Was it hospital acquired? Then it's probably Staphylococcus aureus or a gram-negative bacterium such as Klebsiella pneumoniae or Pseudomonas aeruginosa.

A third type of pneumonia is called walking pneumonia, so called because most patients develop mild flu like symptoms and are usually not sick enough to seek medical help. This type of pneumonia is caused my Mycoplasma, and is rarely seen in hospitals.

However, this disease is very common among people who work or hang around where there are lots of other people, and it spreads easily. Walking pneumonia is treated the same way that bacterial pneumonia is treated, with the right anti bacterial.

Another type of pneumonia, which is rare, is fungal pneumonia, which is usually less severe, but can cause a prolonged dry cough that might last for months. Patients with severely compromised immune systems may develop Pneumocystis carinii. This is usually reserved to patients who have AIDS, are receiving chemotherapy, and chronic lungers.

Aspiration pneumonia is where a patient inhales a foreign object, such as vomit (sounds yummy, hey?) This is a major concern for our drug overdose patients or other patients who have lost their gag reflex. Likewise, a drunk, inebriated person who has passed out may also be at high risk of aspiration and, thus, aspiration pneumonia.

Okay, let's back up a second.

What is pneumonia?

Say a bacteria gets past the normal immune responses that keep the lungs sterile, and makes it's way into the lungs. It is inhaled, goes down the trachea, takes a right or left turn at the corina, goes through the bronchioles, and to the tiny microscopic air sacs at the end of the air passages.

Infections of this area cause inflammation of the tissue, which increases white blood cells to that area to fight the infection.

This results in edema, or fluid buildup in that area of the lung parynchema. This increases ventilation/ perfusion mismatching, thus making it difficult or impossible for oxygen to cross into the blood stream.

Lung compliance is reduced in affected region

Thus you can see why pneumonia may cause someone to become short of breath, and have a lower oxygen level. In essence, oxygen is shunted away from the infested area. And, if the pneumonia is untreated, or becomes large enough, can cause serious problems, and even death.

Anyone can get pneumonia, but normally it is reserved to patients who are compromised in one way or another. And, while it is normally treated on an outpatient basis, occasionally a person has to be admitted, and these are the people we see.

Who is at risk for pneumonia?

The following is a list of who is at risk:

  1. Chronic diseases such as COPD, AIDS, diabetes of whom are immunocompromised
  2. Person's who've had spleen removed
  3. Corticosteroids can impair the immune system
  4. People who smoke or COPD. These people destroy their cilia, which is one of the bodies prime mechanisms for keeping the lungs sterile. Without cilia, a smoker has a weakened ability to remove secretions, and if they are not removed they can cause pneumonia.
  5. People who drink too much
  6. People exposed to chemicals or pollutants.
  7. Post op patients who refuse to or are unable to take in a deep breath and cough up secretions (this is where scare tactics, cough and deep breathing exercises, incentive spirometers, CPT, and forcing the patient to go for a walk come in handy.)
  8. Hospital acquired. This may or may not go hand in hand with #6. Intubated patients are at high risk of ventilator acquired pneumonia.

  9. Patient's who's immune system is worn down by other illness, and this may also lead to nosocomial infections
  10. Heart failure
  11. broken ribs
  12. Very old and very young
  13. people who are debilitated, paralyzed, bedridden, unconscious

How to treat pneumonia:

What medicines or therapies to give the patient is up to the doctor. Usually all of these patients get an antibiotic, however an antibiotic will not benefit patient's with viral pneumonia. They will also get something to control fever such as Tylenol and nausea. Fluids are beneficial to help the patient hydrate and spit up phlegm

Bronchodilator breathing treatments are controversial for pneumonia, yet many doctors like to prescribe them due to some studies that show beta adrenergics, along with dilating bronchioles, may also help the patient produce and bring up phlegm.

Likewise, many hospitals have pneumonia order sets that include Albuterol to assure the patient meets Intensity of Service, or to make the Centers for Medicaid and Medicare Services (CMS) will reimburse the hospital. If a bronchodilator is ordered, this often assures Intensity of Service is met.

In my experience that first breathing treatment sometimes opens the patient up a bit because that fluid breaking up may cause bronchospam and a wheeze, especially in COPD and asthma patients.

Since nosocomial pneumonia is the most common infection acquired in hospitals, RTs and RNs have been given the responsibility of working together with patients to prevent pneumonia.

Further reading about pneumonia:

Click here to learn how to prevent pneumonia

Click here to learn about Ventilator Acquired pneumonia (VAP)

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