Tag: pneumonia pathophysiology

Pneumonia is an infection in the lung parenchyma, particularly in the bronchioles and alveoli, which is caused by pathogens such as bacteria, fungi and viruses. On the other hand, Pneumonitis is an inflammation in the lung tissue which increases the patient’s risk of developing pneumonia.

Community-Acquired Pneumonia – pneumonia acquired within the community or within the first 48 hours post hospitalisation or institutionalisation. Patient hospitalisation for pneumonia depends solely on the acquired pneumonia severity (may be treated at the patient’s home unless severe). CAUSES: Streptococcus Pneumoniae, Haemophilus Influenzae & Mycoplasma Pneumoniae.

Hospital-Acquired Pneumonia a.k.a. Nosocomial Pneumonia – pneumonia acquired more than 48 hours after hospital admission with no prior infection symptoms exhibited. This type of pneumonia carries a higher mortality rate. CAUSES: Staphylococcus Aureus, Impaired Host Defenses, Comorbid Conditions (eg. Asthma, COPD), Supine Positioning & Prolonged Hospitalisation.

Immunocompromised Patient Pneumonia – patients who are immunocompromised (have AIDS, Immune Disorders, Haematological Malignancies, or who make use of Corticosteroids, Chemotherapy or other immunosuppressive agents) can easily develop pneumonia from organisms of low virulence (organisms who don’t cause pneumonia in healthy individuals).

Aspiration Pneumonia – pneumonia acquired from entry of endogenous (bacteria from within the body aspirated in the lung such as gastric contents) or exogenous (bacteria from outside the body eg. from a drink causing aspiration or from chemical contents or irritation gases) substances into the lower respiratory tract. Aspirated substances impair the lung defenses (eg. removal of mucus, mucociliary escalator), cause inflammation changes which then lead to bacterial growth, causing pneumonia. This type of pneumonia happens within the community or hospital setting.

Pneumonia Pathophysiology

1. When pathogens enter the respiratory tract and descend into the sterile lower respiratory tract, an inflammation occurs.
2. Exudate (pus) is then produced, which in turn interferes with gases exchange within the alveoli. Instead, white blood cells migrate to the alveoli and fill the spaces which otherwise would have been filled with air.
3. Furthermore, the same inflammation causes the lining of the bronchioles to swell i.e. mucosal oedema. Additionally, the inflammation also causes the goblet cells to secrete even more mucus.
4. Both mucosal oedema and excessive secretions cause narrowing of the bronchioles, interfering with the diffusion of oxygen and carbon dioxide, causing hypoventilation, leading to hypoxia due to less oxygen perfusion within the body tissues.

Commonly used Terms

• Bronchopneumonia: patchy consolidated areas
• Consolidation: solidified tissue resulting from the infectious process
• Lobar Pneumonia: consolidated lobe/s

Prevention

• Promote Coughing Exercises in patients with excessive mucus production conditions such as COPD and Asthma. This helps clear mucus that if left there could lead to pneumonia.
• Promote Smoking Cessation in patients who smoke, as smoking disrupts mucociliary clearance and white blood cell activity, both of which increase the risk.
• Raise Head of Bed in unconscious patients since unconsciousness causes decrease in cough reflex and airway protection.
• Frequent Repositioning, Breathing and Coughing Exercises, Suctioning and Chest Physiotherapy can help prevent pneumonia in long-term immobile patients.
• Oral Hygiene, NGT Placement Check and Proper Patient Positioning can help prevent it in patients making use of an NGT.
• Nutritious Diet, Frequent Turning, Ambulation and Coughing Exercises help prevent it in older adults.
• Infection Control helps in the reduction of organism transmission by healthcare providers.
• Pneumococcal Vaccine should be encouraged.

Pneumonia can be spread by infected respiratory droplets in person to person contact, thus, normal infection control practices should be encouraged and adhered to by the patient and his/her family members, as well as by healthcare staff using recommended PPEs.

Complications

• Septic Shock – bacteria may end up in the bloodstream, leading to a septic shock.
• Respiratory Failure – hypoventilation causes the patient to compensate for lack of oxygen by increasing Respiratory Rate. This causes the patient’s breathing muscles to get tired, leading to respiratory failure.
• Pleural Effusion – may be caused by the fluid that is caused by the inflammatory process
• Confusion – may be caused due to hypoxia

Pneumonia Clinical Manifestations

• Rapidly Rising Fever is caused due to the infection of the lung parenchyma.
• Pleuritic Chest Pain is caused by deep breathing and coughing.
• Rapid Bounding Pulse is caused due to the body trying to compensate for the low oxygen perfusion in the body.
• Tachypnoea is caused due to the body trying to compensate for the low oxygen perfusion in the body.
• Bradypnoea is caused when the accessory muscles get tired.
• Increased Cough (productive or not productive in dehydrated patients)
• Purulent Sputum is caused by pus-filled sputum due to the infection in the lung parenchyma (greenish sputum).
• Percussion Dullness can be heard where there is consolidation in the lungs.
• Decreased Breath Sounds is caused by the narrowing of the lower respiratory tract leading to less movement of air.
• Whispering Pectoriloquy can be noted due to consolidation in the lungs.
• Crackles can be heard if there is pleural effusion.

A Chest X-ray can confirm the presence of pneumonia, since pneumonia’s symptoms are very similar to other chronic conditions such as Chronic Heart Failure and so it is difficult to identify its type based on the clinical manifestations only.

Pneumonia Patient Assessment and Diagnostics

• History of a recent respiratory tract infection as this predisposes the patient to pneumonia.
• Physical Examination to note clinical manifestations.
• Chest X-ray can confirm pneumonia.
• Blood Culture helps determine any bloodstream invasion of the pathogen.
• Sputum Examination helps identify the pathogen responsible for infection, test sensitivity of the pathogen and determine treatment.

Sputum Examination should be done on a sputum sample, for which the following steps are necessary:

1. Prior to being started on an antibiotic, instruct patient to rinse mouth with water so as to minimise contamination with oral microorganisms;
2. Ask the patient to breathe deeply for several times;
3. Ask the patient to cough deeply and expectorate the raised sputum into a sterile container;
4. Send sputum sample for microscopy, culture and sensitivity.

Pneumonia Medical Management

1. If suspected, start patient on a broad spectrum antibiotic eg. Tazobactam;
2. Assess patient after 72 hours based on his/her clinical condition, sputum sample and blood culture results;
3. Based on findings, continue same treatment or escalate treatment eg. Meropenem, or start on antiviral or antifungal medication if required.

Upon diagnosis:

• start patient on IV fluids since fever causes fluid loss
• administer antipyretic medications to control fever
• administer antitussive medications to control cough
• administer analgesia for pleural chest pain
• administer oxygen therapy for hypoxia

Pneumonia Nursing Care

1. Improve Airway Patency through secretion removal by deep breathing and coughing exercises, chest physiotherapy and frequent position changes; adequate hydration to help thin and loosen secretions; humidification through oxygen therapy to help loosen secretions and improve ventilation; suctioning (SPO2 monitoring is required during suctioning as it can cause hypoxia).
2. Promote Rest and Energy Conservation by encouraging avoidance of overexertion and symptom exacerbation; place in Semi Fowler’s Position to promote a comfortable position whilst improving breathing; changing positions frequently so as to promote secretion clearance, pulmonary ventilation and perfusion.
3. Promote Adequate Fluid Intake and Nutrition – fluid intake should be increased to at least 2L per day to replace fluid loss; fluids with electrolytes help provide fluid, calories and electrolytes; and nutrition enriched beverages help in restoring proper nutrition with less effort.
4. Monitor patient for changes in pulse and temperature, amount and colour of secretions, and chest x-rays to confirm whether or not patient condition is improving.

Pneumonia Patient Discharge Planning

• Teach proper administration and side effects of Antibiotic treatment
• Teach signs and symptoms of worsening condition
• Teach breathing and coughing exercises
• Follow-up with Chest X-ray to ensure recovery
• Warn patient that one episode of pneumonia leads to susceptibility of recurrent pneumonia episodes, thus, teach patient to avoid stress, fatigue, alcohol and smoking, all of which decrease the defense system of the lungs
• Advise patient about adequate nutrition as well as to rest and avoid excessive activity to avoid recurrent pneumonia episodes
• Encourage patient to take the yearly influenza vaccine to avoid getting influenza which can also lead to pneumonia

Below you can find a collection of videos that can help provide a more visual approach to Pneumonia Nursing Care.

Pneumonia – Animation

https://www.youtube.com/watch?v=aKduNgfePLU

Chest Percussion

Crackles

Special thanks to the creators of the featured videos on this post, specifically Youtube Channels Alila Medical Media, Stanford Medicine 25, Medicos Scientia and EMTprep.

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