Tuesday, April 2, 2013

Discussing Varieties of Pneumonia


This is pneumonia. Notice the opaque area, in the patient's right lung (as they face you)  Radiograph example from: www.studyblue.com  )

      Pneumonia is a serious infection which depending upon cause, can still cause death, particularly among those who are late to be diagnosed, or who have other medical issues. It remains a chief cause of death in the world, and takes the lives of four million people annually.   Certain people are more predisposed to pneumonia than others.  People with autoimmune illnesses, the elderly, the very young, those with any chronic illness, those with other respiratory illnesses such as COPD, asthma, and certainly cystic fibrosis, are predisposed. Those with neuromuscular disorders, and those who take proton pump inhibitors, like Omeprazole, for example, are all more prone to pneumonia than average.  Those who have GERD are also more prone to pneumonia than average.  ( Those who take proton pump inhibitors and those with GERD may reflux stomach contents during sleep and may develop an aspiration pneumonia.) Cancer patients, burn patients, and those confined to wheelchairs may also be at risk.  Anyone who is immobile for a period of time, may also develop a pneumonia.  All post operative patients have a heightened risk or potential predisposition for pneumonia.  Sometimes, an otherwise healthy person develops it.

This is an example of a normal, clear chest x-ray  ( Example by : radiopaedia.org )

                  Pneumonia is actually an inflammation, generally of a particular lobe, and on x-ray, an area of consolidation will likely be seen.  Consolidation on x-ray occurs when the normally clear portion of the lungs develops an area which is opaque. The opaque region is such because fluid, pus, blood,  exudate or inhaled water now occupies than region. More importantly, that region is also not available for air exchange. The area can be small or quite large.  Smaller areas of consolidation are likely to result in being treated and sent home, whereas larger areas are likely to result in a hospital admission with intravenous antibiotics and oxygen being provided.  Pneumonia may develop very quickly.
                The patient with pneumonia will not always present identically to others with the same illness.   In small children, especially those under five, a fever, with cough and difficulty breathing may be the only signs. In an infant, no cough may be present and so, any infant under one with a fever MUST be evaluated by a family practitioner or a pediatrician.
             In adults, most patients will present with a fever. Most patients will complain of chills.   Many will be reluctant to eat and may complain of having vomited while coughing.  Almost all of them will notice unusual tiredness or exhaustion.  Most will have a cough. Most will have sputum of some type. Most will have shortness of breath.  As many as half of them will complain of chest pain.  In elderly people or sometimes also in others, an altered level of awareness is often seen. When you see a newly confused elderly person, you should think potential infection, and often it will be a pneumonia.
             The causes of pneumonia are numerous.  Most cases of pneumonia are caused by viruses or by bacteria. Often, an infection will begin with a viral infection, and then a bacterial infection will become superimposed upon the viral infection.  This is why your physician may not treat a viral respiratory infection with antibiotics, and then later, be forced to add them, when the viral infection develops at least a bacterial component.  (Antibiotics are not effective against purely viral infections.)
             One type of pneumonia is aspiration pneumonia.  In this type, a patient who has GERD may inhale stomach contents while sleeping.  This leaves an area unable to exchange air, and this patient may wheeze. It can also become secondarily infected later with anaerobic microorganisms.   This is the reason that, before surgery, physicians ask that you have nothing to eat or drink from midnight on, to the morning of surgery. They don't want you to vomit and inhale your stomach contents perioperatively.    Partial drowning can also cause an aspiration pneumonia.  A child can inhale as little as a gulp of water, and this may not always be known to a parent. The child can get into trouble later, when that section of lung is no longer able to exchange air.  Larger amounts of this phenomenon are also known as a "dry drown".
            Another type of pneumonia can be caused by inhalation of a foreign substance. Inhaling gasoline while siphoning fuel has caused deaths.  Children playing with babypowder and inhaling sufficient amounts to cause pneumonia, has resulted in deaths.  Remember that a child's lungs are particularly small.
               Viral infections can also lead to pneumonia.  These may still be treated with antibiotics sometimes in order to prevent a secondary bacterial infection.  Viral causes of pneumonia can be RSV (respiratory syncytial virus, influenzas, parainfluenzas, adrenoviruses, coronaviruses, measles, and SARs like viruses. EBV can occasionally lead to pneumonia also.

                Bacterial pneumonia can be caused by a myriad of organisms.

       Organisms which cause bacterial pneumonia
  Jim Henson died of an unusual bacterial pneumonia caused by streptococcus pyogenes at only age 53.

    Bacterial pneumonias must be treated with the appropriate antibiotic, and selection of such can sometimes challenge physicians.  This is why sometimes a physician requests a consultation with either a pulmonologist or infection control specialist for a hospitalized pneumonia patient.   Hospitalized patients will also require nebulizer treatments, close monitoring, and possibly oxygen during the acute phase of their illness.

       An atypical pneumonia can caused by an organism called mycoplasma pneumoniae. There are other organisms which can also cause an atypical pneumonia.  This pneumonia can afflict those who are immune compromised.  Other forms of atypical pneumonias can be caused by protozoa, bacteria, viruses, or even fungi.  These can have very little, or no sputum at all.  Often, the patient looks better than the radiograph of the lungs suggests. This is why these forms of pneumonia are sometimes called "Walking pneumonia".  In reality though, all forms of pneumonia may be found in a person who is walking.
       From a standpoint of preparedness, there really isn't one antibiotic that our physician friends can provide to us in order to treat a pneumonia. Treating pneumonia can be challenging for physicians even under ideal conditions.  In fact, sometimes a physician will treat a pneumonia without having cultured sputum and will make an educated guess as to what the organism may be.  Sometimes the character and color of sputum will provide a clue as to the type of organism.  He will select an antibiotic, and tell the patient that if they do not see a marked improvement in condition within two days, to return for an antibiotic change.  From a survival standpoint or for local emergencies, we should cultivate a working relationship with a local physician so that in the event of an emergency, he will still treat you, albeit informally.

        Increasingly, pneumonias are being treated with antibiotics at home and not in hospitals.  If you have an occasion to do this, your nursing care should include.

1. A clean room where the patient can be kept by themselves.  It should have a window so that it can be periodically aired out.
2. A cool mist humidifier is desirable.
3. They need plenty of facial tissues and a nearby trash can. The trash should be emptied daily.
4. Family members who the room should wear a mask and wash hands after visits.
5. The patient should have cool water, with or without ice.  Liberal fluids should be encouraged, and an intake and output record should be maintained.
6. Your patient may eat a soft diet with nothing that may cause choking.
7. A nebulizer with physician ordered medication can be beneficial.
8. Your patients temperature should be taken every four hours and when he/she has chills.
    Record these times and temperatures.   Check a pulse and a blood pressure every four hours while awake.
9. As long as your patient is hydrated, you may give Acetaminophen every four hours for fever or discomfort.    High fevers can receive ibuprofen in the place of acetaminophen but only if the patient has eaten something, as ibuprofen is irritating to the gastrointestinal tract.
10. Stay in close touch with your doctor. Patients on antibiotics should begin to improve even after two days, and if this is not happening, or the patient is less active, coughing more, or has blue tinged lips or finger tips, you should speak with him.
 11. Ask your physician whether he is agreeable to your giving plain Mucinex to your patient. In many illnesses in which phlegm is produced, it can assist in liquifying secretions.  Mucinex does not work well unless you drink plenty of water.
12. The patient should be encouraged to take deep breaths and to cough and deep breathe and expectorate any mucus about every two hours while awake.  This should be done into a facial tissue and then thrown away.  If your patient can sit up in a chair a couple of times a day, particularly while the nebulizer is being used, this is very positive.
13. Encourage them to move their feet up and down, as periods of time on bedrest coupled with dehydration can lead to blood clots in the legs, for almost everyone except children.
14. Your patient should ambulate to the bathroom and not use a bedpan, if at all possible.

       Following pneumonia, you or your patient should see a physician again, in order to make sure that the pneumonia has resolved completely.
        In addition, in desperate circumstances, such as SHTF situations, tuberculosis, caused by the acid fast bacillus can also be a consideration.  Both pneumonia and tuberculosis can cause cavitation in the lungs, and this is the best reason of all to have a post recovery check up with your doctor.   



Dani said...

Hope you're feeling better?

JaneofVirginia said...

I am feeling better than I was. Still seeing the allergist immunologist for follow up this week. Hope you and your family are well.

FloraMarie said...

Read through this Jane. Very sobering and informative. Glad that you're feeling better!

JaneofVirginia said...

Thanks Marie, It certainly IS sobering.