CASE ANALYSIS

BRONCHOPNEUMONIA

Submitted to:

Ma’am Grifit
9th Floor

Submitted by:

Fitrilyn C. Dalhani
NCM121
3D-D3
Room No.: 918 Birthday: October
20, 2007
Patient Name: A.E. Age: 1 yr. old
Gender: Female
Attending Physician: Dr. Hembrador Medical Diagnosis:
Bronchopneumonia

I. Introduction:
• This case is about a 1 yr. old female girl named A.E. a resident of
Valenzuela City who was taken to World Citi Colleges with the chief
complaint of Difficulty of breathing.
• Clinical impression was bronchopneumonia, which is An inflammation of
the terminal bronchi, air-vesicles, and interstitial tissue of a few or many
of the lobules and a peculiarly a disease of early childhood and old
people, though enfeebled vitality and prolonged sickness of any kind
predisposes to broncho-pneumonia. In children it is especially apt to
follow the infectious diseases that affect the bronchi and are attended
by a cough, such as measles, whooping-cough, influenza, diphtheria,
and scarlet fever.

Tubercular patients, especially where the lungs are involved, are.

frequent subjects of this form of pneumonia. Typhoid fever, small-pox,
and diseases of like character, are not infrequently complicated with this
disease.

The inhalation of particles of food or broken-down material from the

throat, as from diphtheria or tonsillitis, may give rise to inflammation,
and is known as inhalation or deglutition pneumonia.

The disease is seen most frequently in the winter and early spring-
months, when the weather is marked by sudden changes.

Pathophysiology:

Inoculation of the respiratory tract by infectious organisms leads to an acute

inflammatory response in the host that typically lasts 1-2 weeks. This
inflammatory response differs according to the type of infectious agent.

 Viral infections
o These infections are characterized by the accumulation of
mononuclear cells in the submucosa and perivascular space,
resulting in partial obstruction of the airway. Patients with
these infections present with wheezing and crackles.
 o Disease progresses when the alveolar type II cells lose their
structural integrity and surfactant production is diminished, a
hyaline membrane forms, and pulmonary edema develops.

 Bacterial infections

o The alveoli fill with proteinaceous fluid, which triggers a brisk

influx of RBCs and polymorphonuclear cells (red hepatization)
followed by the deposition of fibrin and the degradation of
inflammatory cells (gray hepatization).

o During resolution, intra-alveolar debris is ingested and

removed by the alveolar macrophages. This consolidation
leads to decreased air entry and dullness to percussion.
Inflammation in the small airways leads to crackles. Wheezing
is less common than in viral infections.
o The inflammation and pulmonary edema that result from these
infections cause the lungs to become stiff and less distensible,
thereby decreasing tidal volume. The patient must increase his
or her respiratory rate to maintain adequate ventilation.
o Poorly ventilated areas of the lung may remain well perfused,
resulting in ventilation/perfusion (V/Q) mismatch and
hypoxemia. Tachypnea and hypoxia are common.
 Fungal infections

o Fungal infections are unusual and are typically found in
patients with inadequate immune function (eg, patients with
acquired immunodeficiency syndrome [AIDS], patients who
have undergone chemotherapy, newborn infants).
o The pathology may be a diffuse infiltrate of organisms or focal
areas of fungal growth.
o Patients often appear ill and may have more subtle physical
findings than their overall clinical appearance may suggest.

 The pathological changes are essentially those of bronchitis and of
pneumonia in about eighty per cent of the cases, both lungs being
involved.
 The pleural cavities usually contain their normal amount of fluid,
though their surfaces, pulmonary and parietal, may exhibit
inflammatory patches—fibrinous pleurisy.
 In most cases, the lung crepitates on handling, and will float when
placed in water, though the small, mahogany-colored nodules found
distributed throughout the lung, when excised, sink in water. The
 nodules are found in greater numbers in the posterior part of the
lower lobes. These nodules vary in size from a pinhead to a pea, and,
when pressed, a small amount of blood exudes. These nodules may
be so numerous as to resemble a hepatized lung; where these
indurated patches are few in number, the intervening lung tissue
may be normal, though usually it is congested or edematous.
 Surrounding the nodules, emphysematous lung-tissue is not
infrequently seen, with occasional collapsed areas—atelectasis.
 The bronchi, small and medium-sized, are the seat of catarrhal
inflammation, the walls of which are swollen and infiltrated with
round cells. The exudate within the bronchi consists of leukocytes
and micro-organisms.
 Northrup speaks of a mechanical dilatation of the smaller bronchi,
which occurs most frequently in the lower lobes.

II. Medical management

• If the cause is bacterial, the doctor will try to cure the infection with
antibiotics. If the cause is viral, typical antibiotics will NOT be
effective. Sometimes, however, your doctor may use antiviral
medication. It may be difficult to distinguish between viral and
bacterial pneumonia, so you may receive antibiotics.
• Patients with mild pneumonia who are otherwise healthy are usually
treated with oral macrolide antibiotics (azithromycin, clarithromycin,
or erythromycin).
• Patients with other serious illnesses, such as heart disease, chronic
obstructive pulmonary disease, or emphysema, kidney disease, or
diabetes are often given one of the following:

• Fluoroquinolone (levofloxacin (Levaquin), sparfloxacin (Zagam), or

gemifloxacin (Factive), moxifloxacin (Avelox)
• High-dose amoxicillin or amoxicillin-clavulanate, plus a macrolide
antibiotic (azithromycin, clarithromycin, or erythromycin)

• Many people can be treated at home with antibiotics. If you have an

underlying chronic disease, severe symptoms, or low oxygen levels,
you will likely require hospitalization for intravenous antibiotics and
oxygen therapy. Infants and the elderly are more commonly admitted
for treatment of pneumonia.
• You can take these steps at home:

• Drink plenty of fluids to help loosen secretions and bring up phlegm.

• Get lots of rest. Have someone else do household chores.
• Control your fever with aspirin or acetaminophen. DO NOT give aspirin to
children.
 • When in the hospital, respiratory treatments to remove secretions may
be necessary. Occasionally, steroid medications may be used to reduce
wheezing if there is an underlying lung disease
• Medical Treatment.—The treatment is similar to that of bronchitis or
lobar pneumonia. The specific remedies being given for specific
conditions.

• Aconite.—Where there is fever, with small, frequent pulse, there

is no better remedy than aconite. This may be combined with
any one of a half-dozen remedies that are frequently called for.
• Rhus Tox.—Where there is restlessness and the child is unable to
sleep, the pulse quick and sharp, rhus goes nicely with the
sedative aconite. Where the smaller tubes are choked up, and
oppression is a marked feature, lobelia is the remedy par
excellence.
• Ipecac.—We sometimes meet a case where there is marked
irritation. The cough is hacking and persistent; the tongue is red
and pointed; the pulse is quick and hard; the child is cross and
peevish. Here ipecac alone, or combined with the sedative, is
sure to give good results.

Tartar Emetic.—Where the cough is loose, and the bronchioles are choked
with mucus, there are few, if any, remedies that can take the place of tartar
emetic. It was a most effective remedy with my father, who used it for over
forty years with the best results. Take about one-tenth of a grain of the crude
drug to a half a glass of water; teaspoonful every hour. If nausea or vomiting
follow, add more water.

Medical Care

• Chest percussion is usually unnecessary in children with pneumonia.

Studies in adults have not shown benefit; however, no definitive
studies have been performed in children. Although most children do
not expectorate sputum, they are able to clear it from their lungs and
to swallow it. In young infants with bronchiolitis, chest percussion can
be helpful in moving mucus and improving air entry (postpercussion
auscultation often results in increased wheezes and crackles because
of the better air entry) and oxygenation. However, the few studies that
have involved children have not shown shortened hospital stays.
• Bronchodilators should not be routinely used. Bacterial lower
respiratory tract infections rarely trigger asthma attacks, and the
wheezing that is sometimes heard in patients with pneumonia is
usually caused by airway inflammation, mucus plugging, or both and is
not bronchodilator responsive. However, infants or children with
reactive airway disease or asthma may react to a viral infection with
 bronchospasm, which responds to bronchodilators. The role of steroids
in this situation is controversial, and steroids should probably not be
initiated as routine because of the lack of evidence that they are
beneficial and because of the risk of immunosuppression.
• A few small studies in adults suggest that glucocorticoid use might be
beneficial in the treatment of serious (hospitalized) community-
acquired pneumonia, although the study designs and sizes limit the
ability to properly interpret this data.5 Until definitive studies are
performed, steroids should not be routinely used for uncomplicated
pneumonia. Extra humidification of inspired air (eg, room humidifiers)
is also not useful, although supplemental oxygen is frequently
humidified for patient comfort.

• School-aged children
•
o Many of these children do not require hospitalization and respond well
to oral antibiotics. Macrolide antibiotics are useful in this age group
because they cover the most common bacteriologic and atypical
agents. However, increasing levels of resistance to macrolides among
streptococcal isolates should be considered (depending on local
resistance rates).
o Usually, these patients are not toxic or hypoxic enough to require
supplemental oxygen. Unless they are vomiting, they do not require
intravenous fluids or antibiotics. A parapneumonic effusion that
requires drainage usually dictates a hospital admission.
• Children younger than 5 years: These children are hospitalized more often,
but their clinical status, degree of hydration, degree of hypoxia, and need for
intravenous therapy dictate this decision.
III. Surgical Intervention:
• Drainage of parapneumonic effusions with or without intrapleural
instillation of a fibrinolytic agent (eg, tissue plasminogen
activator [TPA]) may be indicated.
• Chest tube placement for drainage of an effusion or empyema
may be performed.
• VATS procedure may be performed for decortication of organized
empyema or loculated effusions.

Identifying the causative infectious agent is the most valuable step in

managing a complicated case of pneumonia. Unfortunately, an etiologic
agent can be difficult to identify. Therefore, in most patients with
community-acquired pneumonia who are treated on an outpatient basis,
treatment is empiric and based primarily on patient age and clinical
presentation.

In patients with complicated pneumonia who have not responded to

treatment or who require admission to the hospital, several diagnostic
studies aimed at identifying the infectious culprit are warranted, including
cultures, serology, and a CBC count with the differential and acute-phase
reactants (erythrocyte sedimentation rate [ESR], C-reactive protein [CRP]).

• Direct antigen detection

•
o Although antiviral therapies are not often used, performing a nasal
wash for respiratory syncytial virus (RSV) and influenza enzyme-linked
immunoassay (ELISA) and viral culture can help to establish a rapid
diagnosis, which may be helpful in excluding other diagnoses. In
addition, correct diagnosis allows for appropriate placement of patients
in the hospital. For example, if necessary, 2 infants with RSV infection
may share a room, whereas such patients would normally need
isolation and may unnecessarily tie up a bed.
o Viral cultures can be obtained in 1-2 days using newer cell culture
techniques and may permit discontinuation of unnecessary antibiotics.
• Sputum culture
•
 o Sputum is rarely produced in children younger than 10 years, and
samples are always contaminated by oral flora. An adequate sputum
culture should contain more than 25 polymorphonuclear (PMN) cells
per field and fewer than 10 squamous cells per field.
o The common agents that cause pneumonia may be normal oral flora.
For these reasons, sputum cultures are not useful in most children with
pneumonia, although a Gram stain may help.
• Bronchoscopy
•
o Flexible fiberoptic bronchoscopy is occasionally useful to obtain lower
airway secretions for culture or cytology.
o This procedure is most useful in immunocompromised patients who are
believed to be infected with unusual organisms (Pneumocystis, other
fungi) or in patients who are severely ill.
o Careful consideration of the diagnostic possibilities is necessary to
send the samples for the appropriate tests.
o Contamination of the bronchoscopic aspirate with upper airway
secretions is common; quantitative cultures can help distinguish
contamination from infection.
• Blood culture
•
o Although blood cultures are technically easy to obtain and relatively
noninvasive and nontraumatic, the results are rarely positive in the
presence of pneumonia and even less so in cases of pretreated
pneumonia.
o In a study of 168 patients with known pneumonia, Wubbel et al found
only sterile blood cultures. In general, blood culture results are positive
in 10-15% of patients with streptococcal pneumonia The numbers are
even less in patients with Staphylococcus infection. A blood culture is
still recommended in complicated cases of pneumonia.
• Lung aspirate
•
o This test is underused and is a significantly more efficient method of
obtaining a culture.
o A study that compared the incidence of (1) positive culture results
obtained with blood culture with (2) positive culture results obtained
with lung aspiration in 100 children aged 3-58 months with pneumonia
merits mention.3 Blood culture implicated an organism in 18% of the
patients compared with 52% with lung aspirate. The organisms
obtained in the blood and lung aspirate differed in 4 of the 8 children in
whom both culture results were positive, suggesting that a blood
culture may not always accurately reveal the lung pathogen.
o Other studies have demonstrated lung aspirate results to be positive in
50-60% of patients with known pneumonia. In these studies, 1.5-9% of
patients had a pneumothorax and 0.7-3% had transient small
hemoptysis complicating their lung aspirations. Because of the
possible risks associated with lung aspiration, it should be reserved for
patients who are ill enough to require hospitalization, have not
improved with previous empiric treatment, or are
immunocompromised and an exact etiology is needed.
 o A lung aspirate should not be performed in patients who are on
ventilators, patients with a bleeding diathesis, or in patients suspected
of having an infection with Pneumocystis.
• Thoracentesis
•
o This test is performed for diagnostic and therapeutic purposes in
children with pleural effusions.
o If the Gram stain or the culture result from the pleural fluid is positive
or the WBC is higher than 1000 cells/mL, by definition, the patient has
an empyema, which may require drainage for complete resolution.
o Other therapeutic decisions can be made based on the properties of
the effusion
• Serology
•
o Because of the relatively low yield of cultures, more efforts are
underway to develop quick and accurate serologic tests for common
lung pathogens, such as M pneumoniae.
o In a Finnish study, 278 patients diagnosed with community-acquired
pneumonia underwent extensive testing for Mycoplasma infection.4
o
• Acute and convalescent serum samples were collected and
tested using enzyme immunoassay for M pneumoniae
immunoglobulin M (IgM) and IgG antibodies. Nasopharyngeal
aspirates were tested using PCR and cultured with a Pneumofast
kit.
• Positive results were confirmed with Southern hybridization of
PCR products and an IgM test with solid-phase antigen. A total of
24 (9%) confirmed diagnoses of Mycoplasma infection were
made. All 24 cases had positive results with IgM-capture test
with convalescent-phase serum. Using an IgM-capture test in
acute-phase serum, 79% of results were positive, 79% were
positive using IgG serology, 50% positive using PCR, and 47%
positive using culture.
• The authors of this study concluded that IgM serologic studies
for Mycoplasma infection were not only quick but also sensitive
and were the most valuable tools for diagnosis of M pneumoniae
infection in any age group. IgM serology is much more sensitive
than cold agglutinin assessments, which are more commonly
used to aid in the diagnosis of Mycoplasma infection and
demonstrate positive results in only 50% of cases.

Procedures

• Bronchoscopy with BAL

• Lung biopsy (guided with CT scanning or ultrasonography, as part of a
video-assisted thorascopic surgery [VATS] procedure, or during
bronchoscopy) to assist in the diagnosis of infection with rare or
unusual organisms
IV. Nursing Management
• Teach patient how to Take deep breaths may help prevent
pneumonia if you are in the hospital -- for example, while
recovering from surgery. Often, a breathing device will be given
to you to assist in deep breathing.
• If Crackles are heard when listening to patients chest with a
stethoscope. Other abnormal breathing sounds may also be
heard through the stethoscope or via percussion (tapping on
your chest wall).The health care provider will likely order a chest
x-ray if pneumonia is suspected.
• If therapy fails to elicit a response, the whole treatment approach
must be reconsidered. After initiating therapy, the most
important tasks are resolving the symptoms and clearing the
infiltrate. With successful therapy, symptoms resolve much
sooner that the infiltrate. In a study of adults with pneumococcal
pneumonia, the infiltrate did not completely resolve in all
patients until 8 weeks after therapy (although it was sooner in
most patients).
• In a patient who is clinically doing well, follow-up radiography
should be performed after 8 weeks. Although some pneumonias
are destructive (eg, adenovirus) and can cause permanent
changes, most childhood pneumonias have complete radiologic
clearing. If a significant abnormality persists, consideration of an
anatomic abnormality is appropriate.

Always remind patient to:

 Wash your hands frequently, especially after blowing your

nose, going to the bathroom, diapering, and before eating or
preparing foods.
 Don't smoke. Tobacco damages your lung's ability to ward off
infection.
 Wear a mask when cleaning dusty or moldy areas.