Community Acquired Pneumonia Background Microsoft Images Lisa Bennett

Community Acquired Pneumonia (Background: Microsoft Images) Lisa Bennett RN, BSN MSN 621, Friday March 1, 2012

Community Acquired Pneumonia (CAP) is an acute infection of lung tissue that develops outside of the hospital setting. CAP is the leading cause of death from infection in the United States. The most common bacterial cause of CAP is streptococcus pneumoniae which will be the focus of this tutorial. (Cochrane 2009)

At the completion of this tutorial you will be able to : • Describe the pathophysiology of CAP • Identify the populations at risk for CAP • Recognize the common signs and symptoms of CAP • Determine which tests will help to diagnose CAP • Report the current guidelines for the management of CAP

Mr. Congestion Mr. C is a 70 year old male that presents to the primary care clinic where you work. He is accompanied by his daughter. Mr. C’s daughter states that Mr. C has a bad cold with a cough and that he has been confused. He fell as he was getting dressed this morning.

To understand CAP a review of the Inflammatory Response is needed: (Bowne 2012)

Four Stages of Pathologic Process of Pneumococcal Pneumonia Edema: Build up of fluid containing protein and bacteria accumulates in the air sacs of the lungs Red Hepatization: An excess of fluid in the capillaries of the air sacs causes an influx of many white and red blood cells Gray Hepatization: Macrophages come to the rescue engulfing the white blood cells, red blood cells and other cellular debris Resolution: Alveolar exudate is then removed and the lung gradually returns to normal (Porth 2009)

Bacteria commonly enter the respiratory tract, but do not normally cause pneumonia. When pneumonia does occur, it is the result of: 1. A very virulent microbe 2. A large “dose” of bacteria 3. An impaired host defense mechanism (Waterer et al 2010)

Factors that Interfere with Respiratory Defense Mechanisms Nose and throat defenses Function • • Ig. A protects again the multiplying of bacteria Sneezing removes bacteria from respiratory tract Factors That Impair • • Decreased Ig. A Nasal inflammation caused by allergies Common cold Trauma to the nose Cough reflexes Protect against aspiration Reduced cough reflex r/t • Stroke • neuromuscular diseases • sedation • anesthesia Muociliary clearance system Cilia remove bacteria from respiratory passages • • • Smoking Viruses Cold, dry air Alveolar macrophage Removes bacteria from alveoli • • Cold, dry air Alcohol use Smoking Obstruction Ig. G and Ig. M Help to remove bacteria from the blood • • Ig. G deficiency Ig. M deficiency (Porth 2009)

Back to Mr. C Past Medical History: • 20 year smoking history • Coronary Artery Disease • Recovering alcoholic • History of asthma (currently tapering off corticosteroids for recent exacerbation)

Quick Review: Why is Mr. C at increased risk for developing CAP? History of Smoking Corticosteroids Yes, smoking reduces the ability to remove bacteria Yes, immune system is compromised with steroid use History of Alcoholism Yes, decreases ability to remove bacteria from alveoli

(Wikipedia 2012)

Common Signs & Symptoms Indicative of CAP Caused by Streptococcus Pneumoniae Sudden onset High fever Shaking chills Productive cough – watery at first and then becomes blood tinged • Pleuritic pain • • (Porth 2009)

Mr C’s Physical Assessment Mr. C has an oral temperature of 100 degrees. His blood pressure is 138/70, heart rate is 90 and respiratory rate is 34. You notice that he is using accessory muscles to breath. He reports pain on inspiration when you auscultate his lungs. You are able to hear crackles in the left lower lobe. Mr C begins to cough and grabs a tissue to spit out blood tinged sputum. You obtain his pulse ox and find that it is 90%. Low grade fever Productive cough Pain with Breathing Yes! Trick question: Fever is less likely to be elevated in elderly Yes! WBCs, RBCs and exudate are coughed up Yes! Inflammation in lung tissue can lead to pain with inspiration

Clinical Assessment Findings Indicative of CAP • • • High Fever Rapid, shallow breathing Tachycardia Decreased breath sounds Adventitious breath sounds Leukocytosis

Diagnostic Testing • • • Chest Radiograph Pulse Oximetry (Pulse Ox) White Blood Cell Count (WBC) Blood Urea Nitrogen (BUN) Sputum culture

Chest Radiograph May show hyper-expansion, atelectasis or infiltrates Normal Pneumonia (Wikipedia 2012)

Pulse Ox Evaluate for Hypoxemia Inflammation, edema and infection decreases perfusion (Wikipedia 2012)

Laboratory Tests • WBC-(leukocyte count) increases with the presence of infection • BUN-measures the level of nitrogen in the blood derived from urea. An elevated BUN can indicate dehydration or impaired kidney function • Sputum Culture-identifies causative bacteria to determine antibiotic therapy required to treat CAP (Microsoft Images)

CURB-65 Prediction Rule to Assist in Determining Site of Care • Confusion (disorientation to person, place or time) • • Urea (BUN > 7 mmol/L) Respiratory Rate (RR > 30 breaths/minute) Blood Pressure (systolic< 90 mm. Hg-diastolic< 60 mm Hg) 65 (years of age or greater) One point for each prognostic variable 0 -1 treat as outpatient, 2 general inpatient admission, 3 -5 intensive care admission (Uptodate 2012)

Use the CURB-65 Scale to determine where Mr. C’s pneumonia will be managed Outpatient Hospitalize on General Inpatient Floor Sorry! Mr. C has 3 out of 5 predictive indicators which means that he should be admitted to the intensive care unit Almost Correct! Yes, Mr. C should be admitted. 3/5 predictive indicators shows that intensive care observation is needed Hospitalize in the Intensive Care Unit Yes! Mr. C has 3 out of 5 predictive indicators which would guide us to admit him for care in the intensive care unit

Medical Management • You decide to admit Mr. C to the hospital for IV antibiotics, oxygen therapy and monitoring • You repeat his lab work upon admission because the sample drawn in the clinic has hemolyzed • Empiric treatment is based on presumptive diagnosis of pneumococcal pneumonia – Combination therapy of Beta-lactam and macrolide • Oxygen is administered via nasal cannula to maintain pulse ox > 93% (Mandell et al 2007)

In less than 72 hours Mr. C is off his oxygen, on a general care inpatient unit and is changed to oral antibiotics. His discharge planning will include: • Smoking cessation • Yearly influenza vaccination • Pneumococcal vaccination with booster in 5 years • Importance of fluid intake

Let’s Review • Community Acquired Pneumonia CAP is the leading cause of infectious death in the U. S. • Streptococcus Pneumoniae is the most common cause of CAP • Compromised defense mechanisms put individuals at risk for developing CAP • Empiric therapy is based on presumptive cause of CAP • Age and co-morbid disease increase risk and morbidity of infection from pneumonia • Prevention education should be included in anticipatory guidance during clinic visits

References • Alcon, A. , Fabregas, N. , & Torres, A. (2005). Pathophysiology of pneumonia. Clinics in Chest Medicine, 26, 39 -46. doi: 10. 1016/j. ccm. 2004. 10. 013 • Boldt, M. D. , & Kiresuk, T. (2001). Community-acquired pneumonia in adults. The Nurse Practitioner, 26(11), 11 -23. Retrieved from www. tnpj. com • File, T. (2011, October 4). Treatment of community-acquired pneumonia in adults in the outpatient setting. Retrieved February 23, 2012 from Up. To. Date online textbook: http: //www. uptodate. com • File, T. (2011, October 15). Treatment of community-acquired pneumonia in adults who require hospitalization. Retrieved February 23, 2012 from Up. To. Date online textbook: http//www. uptodate. com • Fung, H. B. , & Monteagudo-Chu, M. O. (2010). Community-acquired pneumonia in the elderly. The American Journal of Geriatric Pharmacoltherapy, 8(1), 47 -62. doi: 10. 1016/j. amjopharm. 2010. 01. 003

References • Haessler, S. , & Schimmel, J. J. (2012). Managing community-acquired pneumonia during flu season. Cleveland Clinic Journal of Medicine, 79, 6778. doi: 10. 3949/ccjm. 79 a. 11108 • LM, B. , TJM, V. , & MM, K. (2009). Antibiotics for community acquired pneumonia in adult outpatients. The Cochrane Library, i-31. Retrieved from www. thecochranelibrary. com • Mandell, L. A. , Wunderink, R. G. , Anzueto, A. , Bartlett, J. G. , Campbell, G. D. , Dean, N. C. , . . . Whitney, C. G. (2007). Infectious diesease society of american/american thoracic society consensus guidelines on the management of community-acquired pneumonia in adults. Clinical Infectious Diseases, 44, S 27 -S 72. doi: 10. 1086/511159 • Niederman, M. S. (2004). Review of treatment guidelines for communityacquired pneumonia. The American Journal of Medicine, 117, 51 S-57 S. doi: 10. 1016/j. amjmed. 2004. 07. 008

References • Porth, C. M. , & Matfin, G. (2009). Pathophysiology: Concepts of altered health states (8 th ed. ). Philadelphia, PA: Lippincott Williams & Wilkins. • Waterer, G. W. , Rello, J. , & Wunderlink, R. G. (2010). Management of community-acquired pneumonia in adults. American Journal of Respiratory Critical Care Medicine, 183(), 157 -164. Doi: 10. 1164/rccm. 201002 -0272 CI • http: //faculty. alverno. edu/bowneps/inflammation/inflammprint. htm retrieved February 23, 2012 with permission • http: //en. wikipedia. org/wiki/Pneumonia retrieved February 23, 2012 with permission