What is pneumonia? Pneumonia is an infection of one or both lungs which is usually caused by bacteria, viruses, or fungi.

Prior to the discovery of antibiotics, one-third of all people who developed pneumonia subsequently died from the infection. Pneumonia facts Pneumonia is a lung infection that can be caused by different types of microorganisms, including bacteria, viruses, and fungi. Symptoms of pneumonia include cough with sputum production, fever, and sharp chest pain on inspiration (breathing in). Pneumonia is suspected when a doctor hears abnormal sounds in the chest, and the diagnosis is confirmed by a chest X-ray. Bacteria causing pneumonia can be identified by sputum culture. A pleural effusion is a fluid collection around the inflamed lung. Bacterial and fungal (but not viral) pneumonia can be treated with antibiotics.

Disease Process Leading to Pneumonia Pneumonia-causing agents reach the lungs through different routes: In most cases, a person breathes in the infectious organism, which then travels through the airways to the lungs. Sometimes, the normally harmless bacteria in the mouth, or on items placed in the mouth, can enter the lungs. This usually happens if the body's "gag reflex," an extreme throat contraction that keeps substances out of the lungs, is not working properly. Infections can spread through the bloodstream from other organs to the lungs.

However, in normal situations, the airways protect the lungs from substances that can cause infection. The nose filters out large particles. If smaller particles pass through, sensors along the airway prompt a cough or sneeze. This forces many particles back out of the body. Tiny particles that reach the small tubes in the lungs (bronchioles) are trapped in a thick, sticky substance called mucus. The mucus and particles are pushed up and out of the lungs by tiny hair-like cells called cilia, which beat like a drum. This action is called the "mucociliary escalator." If bacteria or other infectious organisms manage to avoid the airway's defenses, the body's immune system attacks them. Large white blood cells called macrophages destroy the foreign particles.

Background Pneumonia is an inflammation of the lung that is most often caused by infection with bacteria, viruses, or other organisms. Occasionally, inhaled chemicals that irritate the lungs can cause pneumonia. Healthy people can usually fight off pneumonia infections. However, people who are sick, including those who are recovering from the flu (influenza) or an upper

respiratory illness, have weakened immune systems that make it easier for bacteria to grow in their lungs. Defining Pneumonia by Location in the Lung Pneumonia may be defined according to its location in the lung: Lobar pneumonia occurs in one part, or lobe, of the lung. Bronchopneumonia tends to be scattered throughout the lung.

Defining Pneumonia by Origin of Infection Doctors often classify pneumonia based on where the disease is contracted. This helps predict which organisms are most likely responsible for the illness and, therefore, which treatment is most likely to be effective. Community-Acquired Pneumonia (CAP). People with this type of pneumonia contracted the infection outside a hospital setting. It is one of the most common infectious diseases. It 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. Pneumonia Arising in an Institutional Setting Hospital-Acquired Pneumonia. Hospital-acquired pneumonia is an infection of the lungs contracted during a hospital stay. This type of pneumonia tends to be more serious, because hospital patients already have weakened defense mechanisms, and the infecting organisms are usually more dangerous than those encountered in the community. Hospital patients are particularly vulnerable to Gram-negative bacteria and staphylococci. Hospital-acquired pneumonia is also called nosocomial pneumonia. Ventilator-associated pneumonia (VAPP). A subgroup of hospital-acquired pneumonia is ventilator-associated pneumonia (VAP), a highly lethal form contracted by patients on ventilators in hospitals and long-term nursing facilities. Pneumonia acquired in a nursing home or other long-term care facility.

Risk Factors Risk factors for pneumonia often depend on the specific type of disease. Risk Factors for Institutional- and Hospital-Acquired (Nosocomial) Pneumonia Pneumonia that is contracted in the hospital is called hospital-acquired or nosocomial pneumonia. It affects an estimated 5 - 10 of every 1,000 hospitalized patients every year. More than half of these cases may be due to strains of bacteria that have developed resistance to antibiotics. In fact, methicillin-resistant Staphylococcus aureus and multidrugresistant Pseudomonas aeruginosa are leading causes of death from hospital-acquired pneumonia. Those at highest risk: The elderly and very young.

People with chronic or severe medical conditions, such as lung problems, heart disease, neurologic disorders, and cancer. People who have had surgery, particularly people over age 80. Among the surgical procedures that pose a particular risk are removal of the spleen (splenectomy), abdominal aortic aneurysm repair, or operations that impair coughing. People who have been in the intensive care unit (ICU). This is particularly true for newborns or patients on breathing machines (mechanical ventilators). In one study, 10% of ICU patients on a breathing machine developed pneumonia. Such patients who lie flat on their backs are at particular risk for aspiration pneumonia. Raising the patient up may reduce this risk. People who have received sedation. Hospital patients who receive sedatives also have a higher risk of developing nosocomial pneumonia.

Hospitalized patients are particularly vulnerable to Gram-negative bacteria and staphylococci, which can be especially dangerous in people who are already ill. Risk Factors for Community-Acquired Pneumonia (CAP) CAP is the most common type of pneumonia. It develops outside of the hospital. Each year 2 - 4 million people in the US develop CAP, and 600,000 are hospitalized. The elderly, infants, and young children are at greatest risk for the disease. Chronic Lung Disease. Chronic obstructive lung disease (COPD), which includes chronic bronchitis and emphysema, affects 15 million people in the U.S. This condition is a major risk factor for pneumonia. In patients with COPD, vaccination with the pneumococcal vaccine can substantially reduce the risk of developing pneumonia or decrease its severity. People With Compromised Immune Systems. People with impaired immune systems are extremely susceptible to pneumonia. It is a common problem in people with HIV and AIDS. A wide variety of organisms, including Myobacterium species, Histoplasma capsulatum, Coccidioides immitis, Aspergillus species, cytomegalovirus, and Toxoplasma gondii, can cause pneumonia. In addition to AIDS, other conditions that compromise the immune system include: Adult and pediatric cancers, especially leukemia and Hodgkin's lymphoma Chemotherapy Organ transplantation

Patients who are on corticosteroids or other medications that suppress the immune system are also prone to infection. Also, drugs that treat gastroesophageal reflux (GERD) may slightly increase one's risk for community-acquired pneumonia. Patients at high risk for pneumonia should take gastric acid-suppressing drugs only when necessary and at the lowest possible dose. This association is strongest with protein pump inhibitors (PPIs) such as Prilosec and Nexium. Reducing levels of germ-killing stomach acid may allow germs to spread in the upper gastrointestinal tract and move into the respiratory tract. The risk posed by these medications is highest in: Children

o Patients with asthma, COPD, and compromised immune systems The elderly

Researchers have found that the risk is strongest when people have recently begun treatment with PPIs, and lessens over time. Swallowing disorders, including dysphagia. Difficulty swallowing has a variety of causes, including: Abnormalities of the muscles of the esophagus Illnesses such as Parkinson's disease Neurologic disorders involving the esophagus Stroke Surgical or radiation treatment for cancers of the mouth, throat, or esophagus Traumatic brain injuries

All of these may increase the risk of aspiration pneumonia. Dementia. The impaired vigilance while swallowing contributes to an increased risk of aspiration pneumonia. Gastroesophageal Reflux Disease. Gastroesophageal reflux disease (GERD) is a condition in which acids from the stomach move up into the esophagus. This is called reflux. Current studies indicate an association between GERD and various problems that occur in the sinuses, ears, nasal passages, and airways of the lung. People with GERD appear to have an above-average risk for: Chronic bronchitis Chronic sinusitis Emphysema Lung scarring (pulmonary fibrosis) Recurrent pneumonia

If a person inhales fluid (aspirates) from the esophagus into the lungs, it may trigger inflammation in these upper passages. Factors Associated with a Higher Risk in Healthy Adults Dormitory or Barrack Conditions. Recruits on military bases and college students living in dormitories are at higher-than-average risk for Mycoplasma pneumonia. These groups are at lower risk, however, for more serious types of pneumonia. Smoke and Environmental Pollutants. The risk for pneumonia in people who smoke more than a pack a day is three times that of nonsmokers. Those who are chronically exposed to secondhand cigarette smoke, which can injure airways and damage the cilia, are also at risk. Quitting smoking reduces the risk of dying from pneumonia to normal, but the full benefit takes 10 years to be realized. Toxic fumes, industrial smoke, and other air pollutants may also damage cilia function, which is a defense against bacteria in the lungs. Drug and Alcohol Abuse. Alcohol or drug abuse is strongly associated with pneumonia. These substances act as sedatives and can diminish the reflexes that trigger coughing and

sneezing. Alcohol also interferes with the actions of macrophages, the white blood cells that destroy bacteria and other microbes. Intravenous drug abusers are at risk for pneumonia from infections that start at the injection site and spread through the bloodstream to the lungs. Specific Risk Factors for Recurrent Pneumonia in Children Certain children have a higher-than-normal risk for pneumonia and recurrence. Conditions that predispose infants and small children to pneumonia include: Abnormalities in muscle coordination of the mouth and throat Asthma Certain genetic disorders such as sickle-cell disease, cystic fibrosis, and Kartagener's syndrome, which result in poorly functioning cilia, the hair-like cells lining the airways Gastroesophageal reflux disorder (GERD) Impaired immune system Inborn lung or heart defects Infection with the respiratory syncytial virus (RSV) Leukemia

Clinical Manifestations of Pneumonia Elevated temperature Diaphoresis Chest pain (often referred diaphragmatically) Productive cough Tachypnea Tachycardia Cyanosis Apprehension Crackles and Rhonchi upon auscultation

Assessment for Pneumonia 1. Health History : o o o o o A history of previous respiratory tract infection / cough, runny nose, takhipnea, fever. Anorexia, difficulty swallowing, vomiting. History of disease associated with immunity, such as; morbili, pertussis, malnutrition, immunosuppression. Other family members who suffered respiratory illness. Productive cough, breathing nostrils, rapid and shallow breathing, restlessness, cyanosis.

2. Physical Examination : o o o o Fever, takhipnea, cyanosis, nostrils. Auscultation of lung: wet ronchi, stridor. Laboratory: leukocytosis, AGD abnormal, the LED increases. Chest X-rays: abnormal (scattered patches of consolidation in both lungs).

3. Psychosocial Factors : o o o o o Age, growth. Tolerance / ability to understand the action. Coping. The experience of parting with the family / parents. The experience of previous respiratory tract infections.

4. Family Knowledge, Psychosocial : o o o o o The level family knowledge about the disease bronchopneumonia. Experience in dealing with the family of respiratory disease. Readiness / willingness of families to learn to care for her child. Family Coping The level of anxiety. Diagnosis Diagnostic Difficulties in Community-Acquired Pneumonia (CAP). It is important to determine whether the cause of CAP is a bacterium, atypical bacterium, or virus, because they require different treatments. In children, for example, S. pneumonia is the most common cause of pneumonia, but respiratory syncytial virus may also cause the disease. Although symptoms may differ, they often overlap, which can make it difficult to identify the organism by symptoms alone. The cause of CAP is found in only about half of cases. Nevertheless, in many cases of mild-to-moderate CAP, the physician is able to diagnose and treat pneumonia based solely on a history and physical examination. Diagnostic Difficulties with Hospital-Acquired (Nosocomial) Pneumonia. Diagnosing pneumonia is particularly difficult in hospitalized patients for a number of reasons: Many hospitalized patients have similar symptoms, including fever or signs of lung infiltration on x-rays. In hospitalized patients, sputum or blood tests often indicate the presence of bacteria or other organisms, but such agents do not necessarily indicate pneumonia.

Doctors making a diagnosis of pneumonia should rule out other conditions using: Chest x-ray Lung fluid sample Two sets of blood cultures Urine analysis for legionella

Invasive Diagnostic Procedures Invasive diagnostic procedures may be required when: AIDS or other immune problems are present Patients have life-threatening complications

Standard treatments have failed for no known reason

Invasive procedures include: Thoracentesis. If a doctor detects pleural effusion during the physical exam or on an imaging study, and suspects that pus (empyema) is present, a thoracentesis is performed. Fluid in the pleura is withdrawn using a long thin needle inserted between the ribs. The fluid is then sent to the lab for multiple tests.

Complications of this procedure are rare, but can include collapsed lung, bleeding, and introduction of infection. Bronchoscopy. Bronchoscopy is an invasive test to examine respiratory secretions. It is not usually needed in patients with community-acquired pneumonia, but it may be appropriate for patients with severely compromised immune systems who need immediate diagnosis, or in patients whose condition has worsened during treatment. A bronchoscopy is done in the following way: The patient is given a local anesthetic, supplementary oxygen, and sedatives. The physician inserts a fiber optic tube into the lower respiratory tract through the nose or mouth. The tube acts like a telescope into the body, allowing the physician to view the windpipe and major airways and look for pus, abnormal mucus, or other problems. The doctor removes specimens for analysis and can also treat the patient by removing any foreign bodies or infected tissue encountered during the process. Medical Management Antibiotics are prescribed based on Gram stain results and antibiotic guidelines (resistance patterns, risk factors, etiology must be considered). Combination therapy may also be used. Classifications: Antibiotics (Aminoglycosides: gentamycin, tobramycin, amoxicillin, erythromycin, penicillin, tetracycline) Indications: Prevent or treat infections caused by pathogenic microorganisms Selected Interventions: Before administering the first dose, assess the client for allergies and determine whether culture has been obtained. After multiple doses, assess the client for superinfection (thrush, yeast infection, diarrhea); notify the health care provider if superinfection occurs. Assess the insertion site for phlebitis if antibiotics are being administered I.V. To assess the effectiveness of antibiotic therapy, monitor the white blood cell count. Monitor peaks and troughs for aminoglycosides.

Prevention The best way to prevent serious respiratory infections such as pneumonia is to avoid sick people (if possible), and to practice good hygiene.

Pneumococcal Vaccines The pneumococcal vaccine protects against S. pneumoniae bacteria, the most common cause of respiratory infections. There are two effective vaccines available: 23-valent polysaccharide vaccine (Pneumovax, Pnu-Immune) for adults 7-valent conjugate vaccine (Prevnar or PCV7) for infants and young children.

Experts are now recommending that more people, including healthy elderly people, be given the pneumococcal vaccine, particularly in light of the increase in antibiotic-resistant bacteria. Prevention of community-acquired pneumonia Administration of influenza vaccine decreases fall and/or winter risk of viral influenza, which decreases the risk of bacterial superinfection. This vaccine is especially important in patients who are elderly and in those with comorbidity. In fact, influenza vaccination for elderly individuals results in a 48-57% reduction of the rate of hospitalization for pneumonia and influenza. Unfortunately, although pneumococcal vaccines are effective, they are underused. Streptococcus pneumoniae is the most common cause of fatal pneumonia and pneumonia overall. The incidence of pneumococcal disease is the highest in children younger than 2 years and in adults older than 65 years. Other important risk factors are chronic heart disease, chronic lung disease, cigarette smoking, and asplenia. A 23-valent capsular polysaccharide vaccine (Pneumovax 23) and a 13-valent proteinpolysaccharide conjugate vaccine (Prevnar 13) are currently available in the United States. Both vaccines are efficacious in the prevention of invasive pneumococcal disease. The role of the pneumococcal vaccine has not been defined as clearly as that of the influenza vaccine in adults. Pneumococcal 13-valent conjugate vaccine is approved for children aged 6 weeks to 5 years and adults aged 50 years or older. The pneumococcal 23-valent vaccine is approved for adults aged 50 years or older and persons aged 2 years or older who are at increased risk for pneumococcal disease. On October 12, 2012, the Advisory Committee on Immunization Practices (ACIP) published updated recommendations for pneumococcal vaccination of high-risk adults. The committee now recommends routine use of Prevnar 13 in addition to the previously recommended Pneumovax 23 for adults aged 19 years and older with immunocompromising conditions (eg, HIV, cancer, renal disease), functional or anatomic asplenia, cerebrospinal fluid leaks, or cochlear implants. Patients who have not previously received either vaccine should be given 1 dose of Prevnar 13 followed by 1 dose of Pneumovax 23 after at least 8 weeks. In patients who have previously received Pneumovax 23vaccine, administer 1 dose of Prevnar 13 at least 1 year after the last Pneumovax 23 dose.[65] It is also important to emphasize smoking cessation to patients who are at risk of pneumonia and influenza.

Prevention of nosocomial pneumonia A number of preventative strategies have been applied in the prevention of nosocomial pneumonia. Some of these probably are effective or promising, and some are currently being evaluated. The efficacious regimens are hand washing and isolation of patients with multiple resistant respiratory tract pathogens. Hand washing between patient contacts is a basic and often neglected behavior by medical personnel. Interventions that should be considered or undertaken include nutritional support, attention to the size and nature of the gastrointestinal reservoir of microorganisms, careful handling of ventilator tubing and associated equipment, subglottic secretion drainage, and lateralrotation bed therapy.

Complications
Potential complications of bacterial pneumonia include the following:

Destruction and fibrosis/organization of lung parenchyma, with scarring potential Bronchiectasis Necrotizing pneumonia Frank cavitation Empyema Pulmonary abscess Respiratory failure Acute respiratory distress syndrome Ventilator dependence Superinfection Death