CASE STUDY ON COMMUNITY ACQUIRED PNEUMONIA (CAP)

IZYAN LIYANA BINTI ZAINAL ABIDIN 01-200904-00377

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INTRODUCTION

DEFINITION :Pneumonia

Pneumonia is defined as "inflammation of the lung caused by bacteria, in which the air sacs (alveoli) become filled with inflammatory cells and the lungs become solid" During a Pneumonia infection, the alveoli of one or both lungs fill up with pus or fluid. This increases the labor of breathing, and thus gaseous exchange cannot occur .

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A FEW TYPES OF PNEUMONIA

Bacterial Pneumonia Bronchial Pneumonia Community-acquired pneumonia Hospital-acquired Pneumonia

TYPES OF PNEUMONIA

Viral Pneumonia

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Community Acquired Pneumonia

Community-Acquired Pneumonia (CAP). People with this type of pneumonia contracted the infection outside a hospital setting. This means the infection was acquired at home. It is one of the most common infectious diseases. The disease often follows a viral respiratory infection such as the flu. One of the most common causes of bacterial CAP is Streptococcus pneumoniae. Other causes include Haemophilus influenzae, mycoplasma, and Chlamydia.

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EXAMPLES

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CAUSES OF PNEUMONIA
Infective pneumonia:
the infection and inflammatory response of the lungs and bronchial tubes when bacteria or a virus enters the lung and proliferates can occur through inhaling small droplets containing pneumonia causing organisms such as Streptococcus pneumoniae Aspiration pneumonia: caused by inhaling vomit, mucous, bodily fluids, or certain chemicals causing the lungs and bronchial tubes to become inflamed

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STAGES OF PNEUMONIA
Resolution
Grey hepatization Red hepatization Congestion

STAGES OF PNEUMONIA

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1. Congestion (1-2 days)

Gross: (i) Lungs are dark-red color & pits Text pressure (due to edema). on (ii) Cut surface: bloodstained frothy fluid comes out.
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Microscopic features: (i) Alveolar capillaries are This is a placeholder text. dilated. (ii) Alveoli contain edema fluid & pneumococci. (iii) Air is still present in the alveoli.

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2. Red hepatization (2nd-4th day)

Gross: (i) Affected part of the lung is consolidated, reddish-brown & sinks in water. (ii) Outer surface is covered with fibrinious exudates. (iii) Cut surface is rough, dry & granular.

Microscopic feature:

i) Alveoli are airless & filled up with inflammatory exudates consisting of RBCs, neutrophils & fibrin strands.
ii) Alveolar wall is thick (due to edema) with congested blood vessels

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3. Grey hepatization (4th-6th day)

Gross: (i) Consolidated part is gray colour & more friable. (ii) In outer surface pleural exudates is thicker.

(iii) Cut surface is moist & brownish-gray colour .

Microscopic features: (i) Alveolar exudates have lost their freshness (due to action of proteolytic enzymes). Nuclei of polymorphs are broken & indistinct and fibrin threads contract to form a clear zone adjacent to alveolar wall. (ii) Alveolar wall is thin (due to lack of edema) and congested blood vessels disappear.

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4. Resolution (8th-9th day)

Gross: (i) Lung is soft & translucent (jelly like).

Microscopic features:
(i) Macrophages invade exudates. (ii) Alveolar exudates is liquefied by proteolytic enzyme & removed. Thus the consolidated lung is restored to normal

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SIGN AND SYMPTOMS

Initially symptoms are similar to that of a cold followed by: o A high fever (pyrexia)

o
o

Shaking chills
A productive cough .Cough (with some pneumonias you may cough up greenish or yellow mucus, or even bloody mucus) .Sputum may be discoloured and may become blood-stained as the pneumonia progresses. Shortness of breath

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The following may also occur:
o o o o o o o o o o o o dyspnoea sharp chest pain worsening cough headaches malaise muscle pains cyanosis due to poorly oxygenated blood loss of appetite rapid breathing wheezing or grunting during breathing intercostal muscle recession during breathing vomiting
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CONT..

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RISK FACTORS
The elderly, infants and young children are more at risk of contracting community-acquired pneumonia than young and middle-aged adults. Underlying health problems such as: flu

cancer
AIDS heart disease

diabetes
asthma chronic bronchitis emphysema chronic obstructive pulmonary disease
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brochiectasis immunosuppressive disorders and therapy debility or stroke

coma
problems with swallowing alcoholism intravenous drug abuse Cause a person's immune system to be weakened - thus leaving them at risk of contracting Pneumonia. It has also been found that frequent exposure to cigarette smoke increases the risk of developing Pneumonia.

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DIAGNOSIS
Medical and Personal History
The patient's history is an important part of the diagnosis of pneumonia. The patient should be sure to report any of the following:

Recent or chronic respiratory infection Exposure to people with pneumonia or other respiratory illnesses (such as tuberculosis) History of smoking Alcohol or drug abuse Recent travel Occupational risks

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CONT
Physical Examination
Use of the Stethoscope. The most important diagnostic tool for pneumonia is the stethoscope. Sounds in the chest that may indicate pneumonia are the following: Rales (a bubbling or crackling sound). Rales on one side of the chest and rales heard while the patient is lying down are strongly suggestive of pneumonia. Rhonchi (abnormal rumblings indicating the presence of thick fluid). Percussion. The physician will also use a test called percussion, in which he or she taps the chest lightly. A dull thud, instead of a healthy hollow-drum-like sound, indicates certain conditions that suggest pneumonia. These conditions including consolidation (a condition in which the lung becomes firm and inelastic), and pleural effusion (fluid build-up in the space between the lungs and the lining around it).

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CONT.
Laboratory Tests for Diagnosing Infection and Identifying Bacterial Agents
Sputum Tests. Looking at the mucus (sputum) sample coughed up from the lungs tells the doctor how severe the disease is. Only a sputum sample will reveal the infecting organism. The patient coughs as deeply as possible. (A shallow cough produces a sample that usually only contains normal mouth bacteria.) Some patients may need to inhale a saline spray to help them produce an adequate sample. In some cases, a tube will be inserted through the nose down into the lower respiratory tract to induce a deeper cough. The physician will check the sputum for:

Blood, which means there is an infection

Color and consistency -- if it is yellow, green, or brown, infection is likely

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Blood Tests. The following blood tests may be performed:
White blood cell count (WBC). High levels indicate infection. Blood cultures. Cultures are done to detect the specific organism causing the pneumonia, but they usually can not distinguish between harmless and dangerous organisms. They are accurate in only 10% to 30% of cases. Their use should generally be limited to severe cases. Detection of antibodies to S. pneumoniae. Researchers are using specialized techniques to detect antibodies to S. pneumoniae. Antibodies are immune factors that target specific foreign invaders. It is unclear if these techniques are accurate. Polymerase Chain Reaction (PCR). In some difficult cases, PCR may be performed. A test makes multiple copies of the genetic material (the RNA) of a virus or bacteria so it becomes detectable

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Urine Tests
A urine test called NOW can detect S. pneumonia within 15 minutes. It may identify up to 77% of pneumonia cases and may rule out the infection in 98% of patients who do not have S. pneumonia. However, it may not be very useful in diagnosing S. pneumoniae as a cause of pneumonia in children.

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CONT

Chest X-Rays and Other Imaging Techniques

X-rays are a form of electromagnetic radiation (like light). They are of higher energy, however, and can penetrate the body to form an image on film. Structures that are dense (such as bone) will appear white, air will be black, and other structures will be shades of gray depending on density. X-rays can provide information about obstructions, tumors, and other diseases, especially when coupled with the use of barium and air contrast within the bowel.
A chest x-ray may reveal the following: White areas in the lung called infiltrates, which indicate infection Complications of pneumonia, including pleural effusions and abscesses

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Other Imaging Tests.
Computed tomography (CT) scans or magnetic resonance imaging (MRI) scans may be useful in some circumstances, especially when: X-ray results are unclear Patients do not respond to antibiotics Complications occur

Patients have other serious health problems

CT and MRI can help detect the presence of tissue damage, abscesses, and enlarged lymph nodes. They can also detect some tumors that block bronchial tubes. No imaging technique can determine the actual organism causing the infection.

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CONT

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COMPLICATIONS

No. Types 1. Pleural effusion

Explanations o When fluid accumulates between the pleura and the chest wall due to the large amount of fluid already present in the lungs. o As a result of the Pneumonia, a pleural effusion may develop which could lead to the collapse of the lungs if not treated appropriately

2.

Empyema

o Pus may be present in the lungs due to the infection. o Thus pockets of pus may develop in the cavity between the pleura and the chest wall, or in the lung itself which is otherwise known as empyema

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3. Lung abscess o A lung abscess develops when the infection has destroyed lung tissue and a cavity filled with pus is formed o This occurs when the infection is no longer contained within the lungs and moves into the bloodstream, thus the blood is infected o When bacteremia occurs septicemia can follow, as this is an infection that is spread throughout the body. o The infected blood is the best way for the infection to manifest in other parts of the body 6. Meningitis o The infection may spread to the meninges that cover the brain and spinal cord, leading to meningitis

4.

Bacteremia

5.

Septicemia

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7.

Septic arthritis

o When bacteremia has occurred septic arthritis is also a danger, as the bacteria manifests in the joints through which blood passes

8.

Endocarditis or pericarditis

o As blood is also circulated through the heart muscles and the pericardium, the risk of developing an infection there is very high if bacteremia is present

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TREATMENT

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PHYSIOTHERAPY MANAGEMENT
Modified postural drainage - this allows gravity to drain secretions from specific segments of the lungs

Coughing and huffing exercises - to expectorate secretions

Shaking and vibes - to mobilize secretions

Administer humidification to mobilize secretions

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Breathing exercises Localized and Diaphragmatic IPPB administration to increase lung volumes Regain exercise tolerance and fitness

Mobilization of the patient done to increase air entry, increase chest expansion, and to loosen secretions

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CASE STUDY

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CASE STUDY 7

A 48 year old in-patient was referred to physiotherapy after 2 days of admission. He was diagnosed a Community Acquired Pneumonia (CAP). Patient has no other known medical illness. He is able to ambulate to the toilet independently but with shortness of breath.
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CARDIORESPIRATORY ASSESSMENT
DEMOGRAPHIC DATA Name Age Gender Occupation Address :Mr. X :48 years old :Male :Construction worker :No.17, Jalan Dua Tiang, Taman Tiga Segi 50250 Kuala Lumpur. Date of Assessement Date of Admitted Date of Surgery :16th June 2011 :14th June 2011 : Nil

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Doctor's Diagnosis Doctor Management : Community acquired pneumonia (CAP) on lower right lobe : Conservative management and referred physiotherapy

SUBJECTIVE EXAMINATION Chief Complaint : Chest hurt when take a deep breath and develop a cough and dull-aching chest pain after returned from overseas. Knowing that these were just forms of little discomfort, he self medicated with paracetamol. However, he noticed no changes, so he sought medical consultant.

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Present History : 2 days prior to admission, patient had positive signs and symptoms of cough, yellowish phlegm and persistent fever. : Nil : Heavy smoker ( 2 packs per day) and alcoholic : There are no history of illness in the family. There are no hereditary disease. His spouse has hypertension and his children does not have any illness.

Past History Personal History Family History

Socioeconomic History : Live with wife and two children in a double storey house.

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General Condition Past Medical Hx(PMHx) Investigation Medication : The patient is awake, lying on bed and conscious : Nil : X-ray taken on 14th June 2011, show white patches in lower right lobe : Penicillin

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ON OBSERVATION GENERAL OBSERVATION General Health : Good

LOCAL OBSERVATION VITAL SIGNS

Blood Pressure
Heart Rate/Pulse Respiratory Rate Temperature

: 148/77mmHg
: 110bpm : 24bpm : 101.8 F/ 38.7 Degree Celsius

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He is present with the arterial blood gases (ABG) values as below:

pH
PaO2 PaCO2

: 7.29
: 82 mmHg : 55 mmHg

HCO3
Note

: 21 mmol/l

: Blood pH is acidic, PaCO2 is high which mean a respiratory

acidosis or hypercapnia. Patient is respiratory acidosis.

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Breathing Pattern
Chest Deformity Coughing Sputum

: Fast and shallow with apical breathing

: Nad (NO ABNORMALITY DETECTED) : Productive cough : Yes Colour Amount Consistency : Yellowish : Moderate : Thick

Skin Colour Clubbing Dyspnoea

: Bluish which indicate cyanosis : Yes : Yes

Edema

: Nil

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CONT
ON PALPATION

Chest Expansion Measurement

: Male

: 2 :1 :1

: Female : 1 :2 :1
Level
Axilla T4/ Nipple line Xiphoid

Inspiration
34 inch 32 inch 31 inch

Expiration
33 inch 32.5 inch 31.5 inch

Differences
1 inch 0.5 inch 0.5 inch

Chest Symmetry Measurement Palpation of Respiratory Muscle

: Chest rising and falling not equally on right side. : Contraction of the sternocleidomastoid muscles
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AUSCULTATION
Lung Sound Vocal Fremitus : Crackles in right lower lobe : Increase in right lower lobe

Chest Percussion note : Flat or dull at the level of 7th and 8th ribs Lung Function Test : Spirometry result show at moderate level
Predicted Value FVC FEV1 FEV1/FVC 6.00L 5.00L 83% Measured Value 4.00L 2.00L 50% % Predicted 67% 40% 60%

Exercise tolerance

: Only 4 meter in 3 mins walking

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PHYSIOTHERAPY IMPRESSION

Problem List

: - Pain over lower right lobe while taking a

deep breath due to inflammation

- Productive cough due to secretions retention in the lower right lobe - Shortness of breath due to lung hardening - Reduce in exercise tolerance due to shortness of breath

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CONT
Short Term Goal : - To reduce pain while breathing due to inflammation - To clear out lung fields of secretions due to sputum retention in lower right lobe - To gain full re-expansion of the lungs due to shortness of breath - To regain exercise tolerance and fitness

due to reduce in exercise tolerance

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Long Term Goal : - Developing and optimizing independence in daily living activities - Patients back to normal

Treatment Plan

: - Reduce chest pain on deep breathing technique with splinting - Clear out secretions with ACBT technique , postural drainage and percussion every

4 hours

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CONT
- Gain full re-expansion of the lung with deep breathing at least every 2 hours - Regain exercise tolerance and fitness with ambulation gradually

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THANK YOU

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