PNEUMONIA

DEFINITION
Pneumonia is an acute inflammation
of the lung parenchyma caused by a
microbial organism.

INCIDENCE
Pneumonia is associated with
significant morbidity and mortality.
About 90% of ARTI deaths are due to
pneumonia.
In developed countries, incidence of
pneumonia is low as 3% to 4%
In developing countries, it is high as
20% to 30%.

ETIOLOGY
Bacteria,viruses,mycoplasma, fungal
agents,and protozoa.
Streptococcus pneumoniae (major
cause).
Staphylococcus aureus
Mycoplasma pneumoniae
Aspiration of food,fluid,vomitus or from
inhalation of toxic or caustic
chemicals,smoke,dusts, or gases.
Complication of immobility and chronic

Factors predisposing to
pneumonia

Advanced age
History of smoking
Air pollution
Altered consciousness: alcoholism, haed
injury,seizures, anaesthesia, drug overdose,stroke,
Altered oropharyngeal flora secondary to
antibiotics.
Bed rest and prolonged immobility.
Chronic diseases: chronic lunf disease,DM,heart
disease,cancer,ESRD.
Deblitating illness
HIV infection

Factors predisposing to
pneumonia..
Immunosuppressive drugs:
corticosteroids,cancer
chemotherapy,immunosuppressive
therapy after organ transplant.
Intestinal and gastric feedings via
nasogastric and nasointestinal tubes.
Malnutrition
Tracheal intubation
URTI

TYPES OF PNEUMONIA
On the basis of area involved,
segmental pneumonia
lobar pneumonia
bilateral pneumonia

 On the basis of location and

radiologic appearance,
bronchopneumonia
Interstitial pneumonia
Alveolar pneumonia
Necrotising pneumonia

 According to causative organisms,

community acquired pneumonia
Hospital acquired pneumonia
fungal pneumonia
aspiration pneumonia
opportunistic pneumonia

ANATOMY AND
PHYSIOLOGY

PATHOPHYSIOLOGY
Pneumococal pneumonia is the most
cause of bacterial pneumonia and is
caused by the Streptococus
pneumoniae organism.
The organism is generally found in
the nose and throat. When it invades
the lungs, pneumonia can occur.

 There are 4 characteristic stages of

disease process.
1. Congestion
2. Red hepatization
3. Grey hepatization
4. Resolution

1. Congestion:
After the pneumococcus organism
reach the alveoli, there is an outpouring
of fluid into the alveoli.
. The organism multiply in the serous
fluid ,and the infection is spread.
. The pneumococci damage the host by
their overwhelming growth and by
interfering with lung function.

2. Red Hepatization:
There is massive dilation of the
capillaries, and alveoli are filled with
organisms,neutrophils, RBCs and
fibrin.
The lungs appear red and granular,
similar to liver, which is why the
process is called hepatization.

3. Gray hepatization:
Bloodflow decreases and leukocytes and
fibrin consolidates in the affected part of the
lung.
4. Resolution:
Complete resolution and healing occurs if
there are no complications.
The exudate becomes lysed and is
processed by the macrophages.
The normal lung tissue is restored and the
persons gas-exchange ability returns to
normal.

Pathophysiology
Aspiration of S.pneumoniae

Release of bacterial endotoxin

Inflammatory response
Attraction of neutrophils,release of
inflammatory mediators, accumulation of
fibrinous exudates,RBCs and bacteria.

Red Hepatization and

consolidation of lung
parenchyma.

Leukocyte
infiltration

Gray hepatization &

deposition of fibrin and
pleural
surfaces.Phagocytosis in
alveoli

Resolution of Infection
Macrophages in alveoli ingests and remove
neutrophils,fibrin & bacteria.

CLINICAL FEATURES
Sudden onset of symptoms:
Fever
Shaking chills
Shortness of breath
Productive cough of purulent sputum
(rust coloured sputum in pneumococal
pneumonia)
Pleuritic chest pain
Confusion and stupor, in elderly patients.

Signs of pulmonary consolidation:

Dullness to percussion
Increased fremitus
Bronchial breath sounds
Crackles.
Pneumonia may manifest atypically with a
more gradual onset. Symptoms includes:
- Dry cough, extrapulmonary manifestations
such as headache, myalgia, fatigue, sore
throat, nausea, vomiting and diarrhoea.

COMPLICATIONS
1. PLEURISY: Inflammation of the Pleura.
2. PLEURAL EFFUSION: transudate fluid in the pleural
space.
3. ATELECTASIS: Collapsed, airless alveoli.
4. BACTEREMIA: Bacterial infection in the blood.
5. LUNG ABSCESS: seen in pneumonia caused by S.aureus
and gram negative pneumonia.
6. EMPYEMA: Accumlation of exudate in the pleural cavity.
7. PERICARDITIS: Results from spread of infecting
organisms from infected pleura or via hematogenous
route to the pericardium.
8. MENINGITIS: caused by S.pneumonia.
9. ENDOCARDITIS: can develop when the organisms
attack the endocardium and the valves of the heart.

DIAGNOSTIC STUDIES
History and physical examination
Chest X-ray: shows typical pattern
characteristics of the infecting organism
and is vulnerable in diagnosis.
- Lobar or segmental consolidation
suggests bacterial cause.
- Diffuse pulmonary infiltrates are caused
by infection with viruses or pathogenic
fungi.
- cavity shadows suggests the presence
of necrotising infection with destruction
of lung tissue.

 Gram stains and cultures of sputum:

LRT sputum specimen for culture is
recommended before initiating antibiotic therapy.
ABG analysis:
reveals hypoxemia, hypercapnia and acidosis.
CBC, differential and routine blood chemistries:
leukocytosis in majority of cases.
WBC > 15000/cmm

 Blood cold agglutinin test

Urine streptococcus pneumonia
antigen
Urine legionella neumophilia rapid
test.
USG Abdomen and bilateral venous
doppler.

MANAGEMENT
COLLABORATIVE MANAGEMENT
Prompt treatment with appropriate
antibiotic s almost cures bacterial and
mycoplasma pneumonia.
In uncomplicated cases, the patients
responds to drug therapy with in 48-72
hrs.
Supportive measures include:
Oxygen therapy
Analgesics

 For viral pneumonia, two antiviral drugs:

- amantidine
- rimantadine. Are approved for use within
48hrs of onset of symptoms in the treatment of
Influenza-A virus.
The neuraminase inhibitors,
Zanamivir and oseltamir
are active against both Influenza A and B.

 VACCINATION: mainstay of prevention

- Both inactivated influenza vaccine and
live attenuated vaccines can be used.
- LAIV (Flumist) is an intravenously
administered vaccine only for person
aged 5-49 yrs.
- Pneumococcal vaccines: 50% to 80%
effective in preventing bacteremic
pneumococcal disease.

Nutritional therapy
Fluid intake of atleast 3L/day for
supportive treatment.
If oral intake cannot be maintained,
IV administration of fluids and
electrolytes may be necessary for
acutly ill patients.
Small and frequent meals are better
tolerated by the dyspneic patient.

NURSING MANAGEMENT