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Chapter 15

Pneumonia

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Figure 15-1. Cross-sectional view of alveolar consolidation in pneumonia.

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Inflammation of the alveoli

Alveolar consolidation

Atelectasis (e.g., aspiration pneumonia)

Anatomic Alterations of the Lungs

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Lobar pneumonia: Involvement of the entire

lung lobe

Double pneumonia: Involvement of both lungs

Walking pneumonia: Mild case of pneumonia.

Patient remains ambulatory

Etiology

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Box 15-1 Causes of Pneumonia and

Classifications

Bacterial Causes

Gram-positive organisms Streptococcus

Staphylococcus

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Figure 15-2. The Streptococcus organism is a gram-positive, nonmotile coccus that occurs singly, in pairs, and in short chains.

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Figure 15-3. The Staphylococcus organism is a gram-positive, nonmotile coccus that is found singly, in pairs, and in irregular clusters.

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Box 15-1 Causes of Pneumonia and

Classifications (Cont’d)

Gram-negative organisms

Haemophilus influenzae

Klebsiella

Pseudomonas aeruginosa

Moraxella catarrhalis

Escherichia coli

Serratia species

Enterobacter species

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Figure 15-4. The bacilli are rod-shaped microorganisms and are the major gram-negative organisms responsible for pneumonia.

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Atypical organisms

Mycoplasma pneumoniae

Legionella pneumophila

Chlamydia psittaci

Chlamydia pneumoniae

Box 15-1 Causes of Pneumonia and

Classifications (Cont’d)

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Anaerobic bacterial infections

Peptostreptococcus species

Bacteroides melaninogenicus

Fusobacterium necrophorum

Bacteroides asaccharolyticus

Porphyromonas endodontalis

Porphyromonas gingivalis

Box 15-1 Causes of Pneumonia and

Classifications (Cont’d)

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Viral causes

Influenzavirus

Respiratory syncytial virus

Parainfluenza virus

Adenovirus

Coronavirus (SARS)

Box 15-1 Causes of Pneumonia and

Classifications (Cont’d)

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Other causes Rickettsial infections Varicella Rubella Aspiration pneumonitis Lipoid pneumonitis Pneumocystis carinii Cytomegalovirus Tuberculosis Fungal infections Avian Influenza A

Box 15-1 Causes of Pneumonia and

Classifications (Cont’d)

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Acquired pneumonia classification

Community-acquired pneumonia (CAP)

Nursing home–acquired pneumonia

Hospital-acquired pneumonia

Ventilator-associated pneumonia

Box 15-1 Causes of Pneumonia and

Classifications (Cont’d)

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Acquired pneumonia classification

Community-acquired pneumonia (CAP)

Nursing home–acquired pneumonia

Hospital-acquired pneumonia

Ventilator-associated pneumonia

Etiology

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Overview

of the Cardiopulmonary Clinical Manifestations

Associated with

Pneumonia

The following clinical manifestations result from the

pathophysiologic mechanisms caused (or activated)

by Alveolar Consolidation

Increased Alveolar-Capillary Membrane Thickness

Atelectasis

Excessive Bronchial Secretions• During the resolution stage of pneumonia

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Clinical Data Obtained at the

Patient’s Bedside

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The Physical Examination

Vital Signs Increased

• Respiratory rate (Tachypnea)

• Heart rate (pulse)

• Blood pressure

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The Physical Examination (Cont’d)

Chest pain/decreased chest expansion

Cyanosis

Cough, sputum production, and hemoptysis

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The Physical Examination (Cont’d)

Chest Assessment Findings

Increased tactile and vocal fremitus

Dull percussion note

Bronchial breath sounds

Crackles and rhonchi

Pleural friction rub • if process extends to pleural surface

Whispered pectoriloquy

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Clinical Data Obtained from

Laboratory Tests and Special

Procedures

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Pulmonary Function Test FindingsModerate to Severe

(Restrictive Lung Pathophysiology)

Forced Expiratory Flow Rate Findings

FVC FEVT FEV1/FVC ratio FEF25%-75

N or N or N or

FEF50% FEF200-1200 PEFR MVV

N or N or N or N or

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Pulmonary Function Test FindingsModerate to Severe

(Restrictive Lung Pathophysiology)

Lung Volume & Capacity Findings

VT IRV ERV RV VC

N or

IC FRC TLC RV/TLC ratio

N

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Arterial Blood GasesPneumonia

Mild to Moderate Stages

Acute Alveolar Hyperventilation with Hypoxemia (Acute Respiratory Alkalosis)

pH PaC02 HCO3 Pa02

(slightly)

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PaO2 and PaCO2 trends during acute alveolar hyperventilation.

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Arterial Blood GasesPneumonia

Severe Stage

Acute Ventilatory Failure with Hypoxemia (Acute Respiratory Acidosis)

pH PaC02 HCO3 Pa02

(Slightly)

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PaO2 and PaCO2 trends during acute or chronic ventilatory failure.

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Oxygenation Indices

QS/QT D02 V02 C(a-v)02 02ER Sv02

N N

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Abnormal Laboratory Tests and Procedures

Abnormal sputum examination (see Box 15-1)

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Radiologic Findings

Chest Radiograph Increased density (from consolidation and

atelectasis)

Air bronchograms

Pleural effusions

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Figure 15-5. Chest X-ray film of a 20-year-old woman with

severe pneumonia of the left lung and patchy pneumonia in the

right middle and lower lobes.

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Figure 15-6. Air bronchogram. The branching linear lucencies within the consolidation in the right lower lobe

are particularly well demonstrated in this example of staphylococcal pneumonia.

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Radiologic Findings (Cont’d)

CT Scan Alveolar consolidation

Air bronchograms

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Figure 15-7. Air bronchogram shown by CT in a patient with pneumonia.

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General Management of

Pneumonia

The treatment of pneumonia is based on:

1. The specific etiology of the pneumonia, and

2. The severity of symptoms demonstrated by

the patient.

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Table 15-1

Commonly Encountered Organisms Responsible for Pneumonia

and the Therapeutic Agents Used to Treat Them

Organism Responsible for

Pneumonia

Common Treatment Choices

Gram-Positive Organisms

Staphylococcus aureus

Methicillin-susceptible strains: nafcillin or

oxacillin with or without rifampin

Methicillin-resistant strains: vancomycin

with or without rifampin

Alternative choice: cephalosporins,

clindamycin,

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Table 15-1

Commonly Encountered Organisms Responsible for Pneumonia

and the Therapeutic Agents Used to Treat Them (Cont’d)

Organism Responsible for

Pneumonia

Common Treatment Choices

Streptococcus Penicillins: procaine penicillin G or aqueous

penicillin G, amoxicillin

Alternative choice: macrolides,

cephalosporins, doxycycline, quinolones

cefotaxime or ceftriaxone; antipseudomonal

fluoroquinolones (levofloxacin, gatifloxacin,

moxifloxacin).

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Table 15-1

Commonly Encountered Organisms Responsible for Pneumonia

and the Therapeutic Agents Used to Treat Them (Cont’d)

Organism Responsible for

Pneumonia

Common Treatment Choices

Gram-Negative OrganismsHaemophilus influenzae

Ampicillin, third-or fourth-generation

cephalosporin, macrolides (azithromycin,

clarithromycin), fluoroquinolones

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Table 15-1

Commonly Encountered Organisms Responsible for Pneumonia

and the Therapeutic Agents Used to Treat Them (Cont’d)

Organism Responsible for

Pneumonia

Common Treatment Choices

Gram-Negative OrganismsKlebsiella pneumoniae

Third-and/or fourth-generation

cephalosporins (cefotaxime, ceftriaxone)

plus aminoglycoside, antipseudomonal

penicillin, monobactam (aztreonam), or

quinolone

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Table 15-1

Commonly Encountered Organisms Responsible for Pneumonia

and the Therapeutic Agents Used to Treat Them (Cont’d)

Organism Responsible for

Pneumonia

Common Treatment Choices

Gram-Negative OrganismsPseudomonas aeruginosa

Tobramycin (TOBI), Aminoglycoside and

antipseudomonal agents (ticarcillin,

piperacillin, mezlocillin, ceftazidine)

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Organism Responsible for

Pneumonia

Common Treatment Choices

Atypical OrganismsMycoplasma pneumoniae

Doxycycline, macrolides or fluoro-

quinolones

Legionella pneumophila Erythromycin +/- rifampin (in severely

compromised patient) or clarithromycin, or a

macrolide (azithromycin), or a fluoro-

quinolone (ofloxacin, levofloxacin,

sparfloxacin)

Chlamydia pneumoniae Tetracycline, erythromycin, macrolide,

quinolone.

Table 15-1

Commonly Encountered Organisms Responsible for Pneumonia

and the Therapeutic Agents Used to Treat Them (Cont’d)

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Organism Responsible for

Pneumonia

Common Treatment Choices

Anaerobic bacterial infectionsPeptostreptococcus species

Bacteroides melaninogenica

Fusobacterium necrophorum

Bacteroides asaccharolyticus

Porphyromonas endodontalis

Porphyromonas gingivalis

Most of these organisms are oral

contaminants. For anaerobic coverage use

metronidazole (Flagyl) or clindamycin; or

Metronidazole + ceftriaxone; or penicillin +

amoxicillin. Infections respond slowly. 4-6

weeks of therapy is generally

recommended.

Most of the problem with aspiration

pneumonia is secondary to the acid present

in stomach contents, causing a chemical

pneumonia. Quinolones, penicillins are also

useful.

Table 15-1

Commonly Encountered Organisms Responsible for Pneumonia

and the Therapeutic Agents Used to Treat Them (Cont’d)

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Organism Responsible for

Pneumonia

Common Treatment Choices

Anaerobic bacterial infectionsPeptostreptococcus species

Bacteroides melaninogenica

Fusobacterium necrophorum

Bacteroides asaccharolyticus

Porphyromonas endodontalis

Porphyromonas gingivalis

Aspiration fluid should be cultured

immediately (even with bronchoscopy and

special culture) then patient started on

coverage medication while awaiting culture

results. If the culture is negative, stop the

antibiotics. Then reculture if CXR, or patient,

gets worse. Monitor closely for

superinfections such as candida, other

yeasts. May add vancomycin and Diflucan

to cover nosocomial suprainfections.

Table 15-1

Commonly Encountered Organisms Responsible for Pneumonia

and the Therapeutic Agents Used to Treat Them (Cont’d)

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Organism Responsible for

Pneumonia

Common Treatment Choices

Viral Causes Influenza virus

Respiratory syncytial virus

Type A: amantadine and rimantadine

Type A/B: zanamivir, oseltamivir phosphate

Ribavirin (Virazole), palivizumab (Synagis)

Table 15-1

Commonly Encountered Organisms Responsible for Pneumonia

and the Therapeutic Agents Used to Treat Them (Cont’d)

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Organism Responsible for

Pneumonia

Common Treatment Choices

Other Common CausesPneumocystis carintii

Fungal infections

Tuberculosis

(mycobacterium tuberculosis)

Pentamidine (NebuPent), Trimethoprim-

sulfamethoxazole (TMP-SMZ), dapsone-

trimethoprim, primaquine plus clindamycin

Amphotericin B, itraconazole, fluconazole,

ketoconazole

Isoniazid (INH), rifampin, pyrazinamide,

ethambutol, streptomycin

Table 15-1

Commonly Encountered Organisms Responsible for Pneumonia

and the Therapeutic Agents Used to Treat Them (Cont’d)

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Respiratory Care Treatment

Protocols

Oxygen Therapy Protocol

Bronchopulmonary Hygiene Therapy Protocol

Lung Expansion Therapy Protocol