Community Acquired
Pneumonia
Lisa Bennett RN, BSN
MSN 621, Friday
March 1, 2012
(Background image for all slides:Microsoft Images)
Community Acquired Pneumonia
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 who 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, used with permission)
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
Mechanisms
Nose and throat defenses
Function
•
•
Cough reflexes
IgA protects again the multiplying
of bacteria
Sneezing removes bacteria from
respiratory tract
Protect against aspiration
Factors That Impair
•
•
•
•
Decreased IgA
Nasal inflammation caused by
allergies
Common cold
Trauma to the nose
•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
IgG and IgM
Help to remove bacteria from the
blood
•
•
IgG deficiency
IgM 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%.
Which symptoms indicate CAP?
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 decrease 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 mmHg-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
Current Guidelines for Medical
Management
• You decide to admit Mr. C to the hospital for IV
antibiotics, oxygen therapy and monitoring
• You add a blood culture X 2 to the orders per
guidelines for patient with CAP admitted to ICU
• Empiric treatment is based on presumptive
diagnosis of pneumococcal pneumonia
• Combination therapy of Beta-lactam and macrolide
(eg. ceftriaxone and ampicillin)
• Oxygen is administered 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
UpToDate 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
UpToDate 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.79a.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, S27-S72. doi:10.1086/511159
• Niederman, M. S. (2004). Review of treatment guidelines for communityacquired pneumonia. The American Journal of Medicine, 117, 51S-57S.
doi:10.1016/j.amjmed.2004.07.008
References
• Porth, C. M., & Matfin, G. (2009). Pathophysiology: Concepts of altered
health states (8th 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.201002-0272CI
• 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