COMMUNITY ACQUIRED PNEUMONIA

VII.     DISCHARGE PLANNING:

·                  Demonstrate hand-washing techniques.

·                  Instruct the patient and family to use an antibacterial soap for hand washing after toileting.

·                  Drinking fluids is very important because fever causes the body to lose fluid faster.

·                  Avoid exposure to irritants. Proper protection in the workplace is vital to preventing exposure.

·                  Avoiding long exposure to air pollution from heavy traffic may help prevent bronchitis.

·                  Teach the patient to continue the medications for the full length of therapy.

·                  Instruct him or her to space the medication evenly around the clock; take with a full glass of water; and report symptoms of difficulty of breathing, bleeding, or other new symptoms.

MEDICAL DIAGNOSIS:

Community Acquired Pneumonia

Community-acquired pneumonia (CAP) is one of the most common infectious diseases addressed by clinicians. CAP is an important cause of mortality and morbidity worldwide. Community-acquired pneumonia refers to pneumonia acquired outside of hospitals or extended-care facilities. It is a term used to describe one of several diseases in which individuals who have not recently been hospitalized develop an infection of the lungs (pneumonia). CAP is a common illness and can affect people of all ages. CAP often causes problems like difficulty in breathing, fever, chest pains, and a cough. CAP occurs because the areas of the lung which absorb oxygen (alveoli) from the atmosphere become filled with fluid and cannot work effectively.

CAP occurs throughout the world and is a leading cause of illness and death. Causes of CAP include bacteria, viruses, fungi, and parasites. CAP can be diagnosed by symptoms and physical examination alone, though x-rays, examination of the sputum, and other tests are often used. Individuals with CAP sometimes require treatment in a hospital. CAP is primarily treated with antibiotic medication. Some forms of CAP can be prevented by vaccination.

Signs and symptoms

§  problems breathing

§  coughing that produces greenish or yellow sputum

§  a high fever that may be accompanied with sweating, chills, and uncontrollable shaking

§  sharp or stabbing chest pain

§  rapid, shallow breathing that is often painful

Less common symptoms include:

§  the coughing up of blood (hemoptysis)

§  headaches (including migraine headaches)

§  loss of appetite

§  excessive fatigue

§  blueness of the skin (cyanosis)

§  nausea

§  vomiting

§  diarrhea

§  joint pain (arthralgia)

§  muscle aches (myalgia)

The manifestations of pneumonia, like those for many conditions, might not be typical in older people. They might instead experience:

§  new or worsening confusion

§  hypothermia

§  falls

Additional symptoms for infants could include:

§  being overly sleepy

§  yellowing of the skin (jaundice)

§  difficulties feeding

 

Risk factors

Some people have an underlying problem which increases their risk of getting an infection. Some important situations are covered below:

Obstruction

When part of the airway (bronchi) leading to the alveoli is obstructed, the lung is not able to clear fluid when it accumulates. This can lead to infection of the fluid resulting in CAP. One cause of obstruction, especially in young children, is inhalation of a foreign object such as a marble or toy. The object is lodged in the small airways and pneumonia can form in the trapped areas of lung. Another cause of obstruction is lung cancer, which can grow into the airways block the flow of air.

Lung disease

People with underlying lung disease are more likely to develop CAP. Diseases such as emphysema or habits such as smoking result in more frequent and more severe bouts of CAP. In children, recurrent episodes of CAP may be the first clue to diseases such as cystic fibrosis or pulmonary sequestration.

Immune problems

People who have immune system problems are more likely to get CAP. People who have AIDS are much more likely to develop CAP. Other immune problems range from severe immune deficiencies of childhood such as Wiskott-Aldrich syndrome to less severe deficiencies such as common variable immunodeficiency.

Treatment

CAP is treated by administering an antibiotic which is effective in killing the offending microorganism as well as managing any complications of the infection. If the causative microorganism is unidentified, different antibiotics are tested in the laboratory in order to identify which medication will be most effective. Often, however, no microorganism is ever identified. Also, since laboratory testing can take several days, there is some delay until an organism is identified. In both cases, a person's risk factors for different organisms must be remembered when choosing the initial antibiotics (called empiric therapy). Additional consideration must be given to the setting in which the individual will be treated. Most people will be fully treated after taking oral pills while other people need to be hospitalized for intravenous antibiotics and, possibly, intensive care. In general, all therapies in older children and adults will include treatment for atypical bacteria. Typically this is a macrolide antibiotic such as azithromycin or clarithromycin although a fluoroquinolone such as levofloxacin can substitute. Doxycycline is now the antibiotic of choice in the UK for complete coverage of the atypical bacteria. This is due to increased levels of clostridium difficile seen in hospital patients being linked to the increased use of clarithromycin.

 Prevention

Immunization against influenza and increasingly resistant pneumococci can play a critical role in preventing pneumonia, particularly in immunocompromised and older adults. The influenza vaccine is formulated and administered annually. The Centers for Disease Control and Prevention (CDC) recommends that vaccines be offered to persons older than 50 years, residents of extended-care facilities, and patients who have chronic heart and lung disorders, chronic metabolic diseases (including diabetes mellitus), renal dysfunction, hemoglobinopathies, or immunosuppression.

 The pneumococcal vaccine has been shown to be 60% to 70% effective in immunocompetent patients. Side effects are rarely serious and consist of local pain and erythema, which occur in up to 50% of recipients. The CDC recommends that vaccines be offered to all persons 65 years of age or older, those at increased risk for illness and death from pneumococcal disease because of chronic illness, those with functional or anatomic asplenia, and immunocompromised persons.¹⁶ Patients who are immunosuppressed by chronic disease or treatment might not have sustained titers of protective antibody and should be considered for revaccination after 6 years.

Residual immunity against Bordetella pertussis wanes over time, leading to transmission from older adults to other adults and infants. Because secondary bacterial pneumonia occurs in a significant number of cases of pertussis, the ACIP (Advisory Committee on Immunization Practices) has recommended that the tetanus-diphtheria-acellular pertussis (Tdap) vaccine replace the tetanus-diphtheria (Td) vaccine in the adult immunization schedule.

 The emergence of SARS, with significant spread in hospitals, forced an extensive reassessment of respiratory infection control in many institutions. Measures to prevent the spread of SARS-associated coronavirus include close attention to cough hygiene, hand hygiene, contact precautions, and respiratory droplet precautions.

Anatomy and Physiology of the Lungs

The lungs are the primary organs of the respiratory system. The main function of the human respiratory system is to transport oxygen from the atmosphere into the blood, and to expel carbon dioxide from the body. Healthy levels of oxygen are absolutely crucial for the human body, as oxygen gives our cells energy and helps them regenerate.

The Anatomy of the Lung

Each lung is divided into lobes. The right lung, which has three lobes, is slightly larger than the left, which has two. The lungs are housed in the chest cavity, or thoracic cavity, and covered by a protective membrane called the pleura. The diaphragm, the primary muscle involved in respiration, separates the lungs from the abdominal cavity.

The pulmonary arteries carry de-oxygenated blood from the right ventricle of the heart to the lungs. The pulmonary veins, on the other hand, carry oxygenated blood from the lungs to the heart, so it can be pumped to the rest of the body. 

How the Lungs Work

The lungs expand upon inhalation, or inspiration, and fill with air. They then return to their resting volume and push air out upon exhalation, or expiration. These two movements make up the process of breathing, or respiration.

The respiratory system contains several structures. When you breathe, the lungs facilitate this process:

1. Air comes in through the mouth and/or nose, and travels down through the trachea, or "windpipe." This air travels down the trachea into two bronchi, one leading to each lung. The bronchi then subdivide into smaller tubes called bronchioles. The air finally fills the alveoli, which are the small air sacs at the ends of the bronchioles.
2. In the alveoli, the lungs facilitate the exchange of oxygen and carbon dioxide to and from the blood. Adult lungs have hundreds of alveoli, which increase the lungs' surface area and speed this process. Oxygen travels across the membranes of the alveoli and into the blood in the tiny capillaries surrounding them.
3. Oxygen molecules bind to hemoglobin in the blood and are carried throughout the body. This oxygenated blood can then be pumped to the body by the heart.
4. The blood also carries the waste product carbon dioxide back to the lungs, where it is transferred into the alveoli in the lungs to be expelled through exhalation.

Smoking can damage the alveoli and make breathing labor intensive, resulting in emphysema or lung cancer.

Types of Respiration

Two types of respiration exist:

·         Quiet respiration happens when the body is at rest. During quiet respiration, the diaphragm contracts and pulls down, lowering the pressure in the lungs and causing air to enter the lungs through the mouth and nose to equalize the pressure. When the diaphragm relaxes, it moves back up, pushing air back out of the lungs. The lungs and chest walls also return to their resting positions. This also reduces the size of the chest cavity and helps to push air out of the lungs.

·         Active respiration occurs when the body is active and requires higher levels of oxygen to the blood than when resting. During active respiration, the muscles around the ribs raise and push out the ribs and sternum, which increases thoracic volume, helping the lungs take in more air. During exhalation, the intercostals force the ribs to contract, and the abdominal muscles contract, forcing the diaphragm to rise. Both these movements make the thoracic cavity contract, and help push air out of the lungs.

The Lungs' Protections

Several lung parts and functions act as protective mechanisms to keep out irritants and foreign particles. The hairs and mucus in the nose prevent foreign particles from entering the respiratory system.

The breathing tubes in the lungs secrete mucus, which also helps protect the lungs from foreign particles. This mucus is naturally pushed up toward the epiglottis, where is passed into the esophagus and swallowed. Coughing up any of this mucus is usually an indication of a respiratory infection, or a condition such as bronchitis or chronic obstructive pulmonary disease (COPD). Irritants can also cause bronchospasm, in which the muscles around the bronchial tubes constrict in order to keep out irritants. Asthma involves inflammation and constriction of the bronchial tubes, and is often triggered by environmental irritants. Bronchial constriction causes breathing difficulties.

About Breathing Difficulties

Damage to any part of the respiratory pathway can also cause breathing difficulties. Understanding human lung anatomy and physiology makes clear how the different lung parts are affected in disease.

In people with bronchitis, the bronchial tubes become inflamed and irritated. They produce mucus, resulting in a cough. Bronchitis can be acute, with a sudden onset and quick recovery, or chronic, and last much longer.

Chronic obstructive pulmonary disease (COPD) involves symptoms of both chronic bronchitis and emphysema. Blockage in the bronchioles and alveoli make it difficult to exhale. This traps air in the lungs and in turn makes proper inhalation difficult.

Interstitial lung disease, including pulmonary fibrosis, causes a buildup of scar tissue in the lungs and reduces lung function. Any of these conditions affect not only the lungs, but the entire body, as the healthy respiration is required to supply oxygen to the body and its organs.

MEDICAL MANAGEMENT

Medical Care

Therapeutic principles in community-acquired pneumonia

• Pathogens
• Single pathogens almost always cause community-acquired pneumonia (CAP). Multiple pathogens rarely, if ever, cause CAP.
• CAP is almost never caused by more than one typical or two atypical organisms or multiple typical/atypical organisms. Studies that report multiple pathogens are flawed and demonstrate one organism microbiologically with serologic evidence of prior exposure to the other pathogen. Clinical experience has demonstrated this principle for decades.
• The only cause of multiple-pathogen pneumonia is aspiration pneumonia.
• Comorbid conditions
• Comorbid conditions do not affect selection of antimicrobial therapy.
• Monotherapy is as effective as multidrug therapy.
• The addition and/or change of antibiotics based on severity of illness and/or comorbidities is irrational.
• Antimicrobial therapy is directed against the pathogen rather than against the comorbid factors.
• Comorbidity is an important prognostic factor and contributes to the severity index but has no place in antibiotic selection.
• Severity
• The severity of CAP is determined by underlying conditions of the lungs, heart, and spleen.
• Do not change antibiotics or use additional antibiotics to treat severe CAP.
• Additional antibiotics do not affect the pulmonary, cardiac, or splenic dysfunction that determines clinical severity.
• CAP that presents with hypotension and/or shock is due to underlying lung disease, cardiac disease, acute myocardial infarction, or an exacerbation of CHF.
• Antibiotic monotherapy is the same for mild, moderate, or severe CAP.
• Rapid cavitation is not a typical feature of CAP. CA-MRSA CAP presents as a fulminant CAP with rapid cavitation and necrotizing pneumonia caused by CA-MRSA (SCC mec IV) with the PVL gene, which follows influenza.
• Appropriate empiric coverage
• In normal hosts, therapy does not need to cover S aureus, Klebsiella species, or P aeruginosa in CAP. (Most CAP regimens include K pneumoniae coverage.) S aureus coverage should be included in patients with influenza who have focal infiltrates.
• Most antibiotics used to treat community-acquired aspiration pneumonia (eg, doxycycline, respiratory quinolones, beta-lactams) are highly effective against oral anaerobes. Metronidazole and clindamycin are usually unnecessary. For aerobic lung abscesses, clindamycin or moxifloxacin is preferable.
• Coverage should include the typical (S pneumoniae, H influenzae, M catarrhalis) and atypical (Legionella and Mycoplasma species, C pneumoniae) pathogens.
• Therapeutic considerations
• Monotherapy coverage of both typical and atypical pathogens in CAP is preferred over double-drug therapy.
• Monotherapy is less expensive and as effective as double-drug regimens.
• Avoid empiric macrolide monotherapy because approximately 25% of S pneumoniae strains are naturally resistant to all macrolides.
• Preferred monotherapy for CAP includes doxycycline or a respiratory quinolone.
• This is the least expensive way to optimally treat CAP.
• No increased resistance is noted with extensive use.
• No serious adverse effects are noted.
• It is well tolerated in both oral and intravenous forms.
• It is ideal for intravenous-to-oral switch monotherapy in terms of patient compliance, safety, and cost.
• In patients with CAP who are able to take oral medication, switch from intravenous to oral administration after 48 hours, using an antibiotic with the appropriate spectrum, high bioavailability, minimal adverse gastrointestinal effect profile, little or no resistance potential, and relatively low cost such as doxycycline or a respiratory quinolone.
• Most penicillin resistance is relative resistance and is readily treatable with penicillin and/or beta-lactams.
• Most highly penicillin-resistant S pneumoniae infections (minimum inhibitory concentration [MIC] >2 µg/mL) may also be treated with beta-lactams. Alternately, doxycycline or respiratory quinolones may be used. Vancomycin is rarely, if ever, needed.
• Very highly penicillin-resistant S pneumoniae (MIC 6 µg/mL) strains are a rare cause of CAP but remain susceptible to ceftriaxone.

Discharge Planning

M- Medication

            Instruct the patient that the medication is very important to continue depending on the duration the doctor ordered for the total recovery of the patient.

E- xercise

Exercise should be promoted in a way by stretching hand and feet every morning and exercise burping every after bottle feeding.

T- Treatment

            Tell the patient to relax in order to recover in his condition. Instruct the patient to minimize from exposure to an open environment such as dusty and smoky area, which airborne microorganisms are present that can be a high risk that may cause severity of his condition.

H- Health

            Encourage and explain to the patient that it is important to maintain proper hygiene to prevent further infection. Instruct the patient to take a bath everyday and explain that bathing early in the morning is not a factor or cause of having pneumonia. Instruct to increase fluid intake of the patient.

O- Out Patient Follow Up

            Regular consultation to the physician can be factor for recovery and to asses and monitor patient’s condition.

D- Diet

            Instruct the patient that nutrition is very important in order to meet his nutritional needs and to boost his immunity.