PNEUMONIA

INTRODUCTION
Pneumonia is a lung infection that can range from mild to so severe that you have to go to the
hospital. It happens when an infection causes the air sacs in your lungs (your doctor will call
them alveoli) to fill with fluid or pus. That can make it hard for you to breathe in enough oxygen
to reach your bloodstream. Anyone can get this lung infection. But infants younger than age 2
and people over age 65 are at higher risk. That’s because their immune systems might not be
strong enough to fight it.
You can get pneumonia in one or both lungs. You can also have it and not know it. Doctors call
this walking pneumonia. Causes include bacteria, viruses, and fungi.  If your pneumonia results
from bacteria or a virus, you can spread it to someone else. Lifestyle habits,
like smoking cigarettes and drinking too much alcohol, can also raise your chances of getting
pneumonia.

CAUSES AND RISK FACTORS

Common Causes
Pneumonia isn't one single disease, and the cause determines what treatment is needed.
A. BACTERIA
Bacterial pneumonia is the most common type of pneumonia and often only affects one area of
your lung.2 It sometimes occurs after you've had some other type of infection that weakens your
immune system, like a cold or the flu, but the condition can also occur on its own without a
preceding infection.
Bacterial pneumonia is usually treated with antibiotics.
Examples of bacteria that can cause bacterial pneumonia include:
 Streptococcus pneumoniae: This is by far the most common type of bacteria responsible
for community-acquired bacterial pneumonia in the United States.3
 Haemophilus influenzae: These bacteria often cause pneumonia in older adults and
people with pulmonary diseases such as cystic fibrosis and chronic obstructive
pulmonary disease (COPD).
 Mycobacterium tuberculosis: This is a common cause of pneumonia in people in
developing countries, as well as in some parts of the United States.4
 Gram-negative bacilli: This group of bacteria doesn't typically cause pneumonia in the
general population, but it's the second most common type associated with pneumonia
 that's severe enough to require hospitalization in the intensive care unit (ICU),
after Streptococcus pneumoniae. Examples of gram-negative bacilli include Klebsiella
pneumoniae, Pseudomonas aeruginosa, Acinetobacter, Escherichia
coli, Enterobacter, Serratia, and Proteus.
 Anaerobes: These bacteria are associated with pneumonia caused by aspirating
(inhaling) food, drink, saliva, or vomit into your lungs.

B. ATYPICAL BACTERIA
Atypical bacteria are bacteria that are unable to be cultured with standard methods. Atypical
bacteria that cause pneumonia include:
 Mycoplasma pneumoniae: This bacterium causes a type of pneumonia referred to as
"walking pneumonia," which typically has mild symptoms, and responds to
antibiotics.5 Because it's contagious, living or working in crowded places like
dormitories, schools, or prisons increases your risk of picking up this type of pneumonia.
 Chlamydia pneumoniae: This bacterium also usually causes an infection with mild
symptoms and mostly affects adults ages 40 to 59.6
 Legionella pneumophila: Pneumonia related to this type of bacteria is also known as
Legionnaire's disease. It is typically transmitted by inhaling aerosols that contain it, and
outbreaks have been connected with exposure to whirlpool spas, showers, fountains, and
cooling towers.

C. VIRUSES
Viral pneumonia, by definition, is caused by a virus and is the most common cause of pneumonia
in children under age 5.8 It's usually not as serious as bacterial pneumonia, though it puts you at a
higher risk of developing it.
Most people with viral pneumonia recover within one to three weeks without treatment, though
some cases become severe and require hospitalization.
Examples of viruses that can cause viral pneumonia include:
 Influenza viruses: Influenza A, B, and avian flu viruses can cause pneumonia,
particularly in adults. 
 Respiratory syncytial virus (RSV): RSV is the most common cause of viral pneumonia
in infants under a year old,9 but it can also cause pneumonia in any age group and can be
especially severe in adults over 65 and in people whose immune systems are
compromised.
  Human parainfluenza viruses: These viruses cause respiratory infections, including
pneumonia, in people of all ages, especially in young children, the elderly, and people
with suppressed immune systems.
 Adenovirus: This type of virus can cause anything from a cold to a sore
throat, bronchitis to pneumonia.
 Rhinovirus: This is the virus that causes the common cold, which can lead to
pneumonia.
 Human metapneumovirus (HMPV): This is yet another respiratory virus that can cause
pneumonia, particularly in young children and older adults.

D. FUNGI
Fungal pneumonia is caused when spores enter your lungs and multiply. It commonly occurs in
people with compromised immune systems or chronic health problems.10 However, it can occur
in otherwise healthy adults too.
Fungal infections that are picked up from the soil in certain areas of the United States can lead to
fungal pneumonia, including:
 Pneumocystis pneumonia: This infection, caused by the Pneumocystis jirovecii fungus,
often causes serious pneumonia and usually occurs in people whose immune systems are
suppressed, such as those with human immunodeficiency virus (HIV) or acquired
immunodeficiency syndrome (AIDS), people who are undergoing cancer treatments, and
those who have had organ transplants.11
 Coccidioidomycosis: Also known as "valley fever," the fungus that causes this
infection, Coccidioides, is found in southern Arizona, central California, southwestern
New Mexico, and west Texas.
 Histoplasmosis: The Histoplasma capsulatum fungus is found in the Ohio and
Mississippi River valleys and is spread through soil that's contaminated by bird and bat
droppings. Extensive exposure to highly contaminated areas causes people to develop
pneumonia.12
 Cryptococcus: The Cryptococcus fungus is found in soil all over the world, but
pneumonia typically only occurs in people with compromised immune systems.

E. ASPIRATION
Aspiration happens when a foreign object, such as a piece of food, gum, liquid, or vomit, is
inhaled. The object then becomes lodged in one or both lungs where it's trapped, unless you're
able to cough it up. When you aspirate a foreign object or liquid, it increases the presence of
bacteria as the object begins to rot, leading to an infection. 
Aspiration pneumonia, or the collection of infectious material in the lungs due to the presence of
a foreign object, can make it difficult to breathe.
Some people may have an ongoing condition where they accidentally swallow food into their
lungs instead of into their esophagus, the tube that moves food to the stomach. Many people
never even realize that a piece of food has gone down the "wrong pipe." This problem is more
common in the elderly, who are more likely to have problems with swallowing. The risk of
pneumonia due to aspiration while under anesthesia is also why patients are asked not to eat or
drink prior to surgery.

Health Risk Factors

Pneumonia can affect anyone at any age, but the two age groups at the highest risk both for
contracting it and for having more severe cases are children under age 2 and adults over age 65.
Other risk factors include:
 Being in the hospital: Because your immune system is already weakened, your risk of
developing pneumonia is higher if you're hospitalized in the ICU.13 Your risk is even
higher if you're on a ventilator to help you breathe.
 Having a chronic disease: If you have COPD, asthma, heart disease, bronchiectasis,
cystic fibrosis, diabetes, celiac disease, or sickle cell disease, your risk of contracting
pneumonia is higher than that of the general population.14
 Having a suppressed immune system: If you have HIV or AIDS, have had an organ or
bone marrow transplant, are receiving chemotherapy or long-term steroids, or have an
autoimmune disorder, you're at higher risk for pneumonia.
 Difficulty swallowing: If you have a hard time swallowing due to a condition like
Parkinson's disease or because of a stroke, you're at a higher risk of aspirating food,
drink, saliva, or vomit and, thus, developing aspiration pneumonia.15
 Reduced consciousness: Whether you're sedated, prone to generalized seizures, or have
had anesthesia, these episodes of reduced consciousness can contribute to aspiration
pneumonia.
 Difficulty coughing: Not being able to cough properly or often enough can lead to
pneumonia.

Lifestyle Risk Factors

Risk factors that may have to do with your lifestyle choices increase your likelihood of
developing pneumonia and include:
 Smoking: If you smoke, your risk of contracting pneumonia is higher than that of the
general population because smoking compromises your immune system's ability to
defend itself from the organisms that make you sick.16
 Drug or excessive alcohol use: Drinking too much alcohol or using drugs is another risk
factor for pneumonia because you may aspirate food, drink, or vomit into your lungs
while you're under the influence.
 Malnutrition: Being undernourished contributes to a higher risk of developing
pneumonia and of it being more severe, especially in young children and older adults. It's
estimated that malnutrition is the underlying cause of death in 45 percent of
children under the age of 5 worldwide.17
 Poor dental health: Poor oral hygiene can contribute to pneumonia, especially if you
have dentures.
 Exposure to animals, chemicals, or environmental toxins: Being around animals can
expose you to infected droppings that get in the soil. Certain chemicals and pollutants
may also increase your risk of pneumonia.18
It's important to be aware that your risk of pneumonia increases with each additional health or
lifestyle risk factor you have.
2. PATHOPHYSIOLOGY

3. DIAGNOSIS
Your doctor will start by asking about your medical history and doing a physical exam, including
listening to your lungs with a stethoscope to check for abnormal bubbling or crackling sounds
that suggest pneumonia.
If pneumonia is suspected, your doctor may recommend the following tests:
 Blood tests. Blood tests are used to confirm an infection and to try to identify the type of
organism causing the infection. However, precise identification isn't always possible.
 Chest X-ray. This helps your doctor diagnose pneumonia and determine the extent and
location of the infection. However, it can't tell your doctor what kind of germ is causing
the pneumonia.
 Pulse oximetry. This measures the oxygen level in your blood. Pneumonia can prevent
your lungs from moving enough oxygen into your bloodstream.
 Sputum test. A sample of fluid from your lungs (sputum) is taken after a deep cough and
analyzed to help pinpoint the cause of the infection.
Your doctor might order additional tests if you're older than age 65, are in the hospital, or have
serious symptoms or health conditions. These may include:
 CT scan. If your pneumonia isn't clearing as quickly as expected, your doctor may
recommend a chest CT scan to obtain a more detailed image of your lungs.
 Pleural fluid culture. A fluid sample is taken by putting a needle between your ribs from
the pleural area and analyzed to help determine the type of infection

4. MEDICAL MANAGEMENT

Pharmacologic Therapy 
Pharmacologic therapy for pneumonia differs depending on the causative agent, the type of
infection as well as the age of the patient. Once appropriate pharmacologic treatment is
commenced patients will generally recover in around seven to 10 days.
The choice of oral pharmacologic therapy or the use of intravenous therapy is dependent on
several factors. More severe cases of pneumonia, where hospitalization occurs are likely to
require intravenous (IV) antibiotic therapy. Switching from one therapy to another will be
determined by the progress of the patient. For example, the hospitalized patient may commence
on IV antibiotic therapy, but when discharged from the healthcare setting may commence oral
antibiotics
Antibiotics also referred to as antibacterials, are the mainstay treatment for bacterial pneumonia.
Antibiotics fight against the bacteria by:
 destroying the bacteria or
 inhibiting the growth of the bacteria
Destroying or inhibiting bacteria growth helps the body’s natural immune system to fight the
bacterial infection. Different antibiotics work against different types of bacteria (NPS
MedicineWise 2019).

Bacterial pneumonia 
Bacterial pneumonia is the most common type of pneumonia. Oral antibiotics are most
commonly used to treat bacterial pneumonia.
In the absence of the causative bacteria being identified, empirical antibiotics or antibiotics are
chosen to treat the likely pathogen causing bacterial pneumonia are often used. Within three to
five days of commencing antibiotic treatment for bacterial pneumonia symptoms should start to
improve.
If symptoms do not improve it is possible that the antibiotic treatment selected is not the right
treatment for the pathogen causing bacterial pneumonia. Alternative antibiotic treatment that is
pathogen directed will, therefore, be required.
The following are examples of antibiotics that may be used to treat bacterial pneumonia:
 Narrow-spectrum antibiotics such as glycopeptides
Narrow-spectrum antibiotics are effective in targeting specific types of bacteria. Vancomycin
and flucloxacillin are both narrow-spectrum antibiotics used to treat bacterial pneumonia caused
by methicillin-resistant Staphylococcus aureus (MRSA).
 Broad-spectrum antibiotics such as macrolides and penicillins 
Broad-spectrum antibiotics are effective in treating bacterial pneumonia caused by common
causative bacteria. Azithromycin and Ceftriaxone are broad-spectrum antibiotics commonly
prescribed to treat bacterial pneumonia.
Viral pneumonia
Antibiotics do not treat viral pneumonia. Following diagnostic testing, if it is confirmed that the
cause of the pneumonia is a viral infection, then antiviral therapy will be prescribed to treat viral
pneumonia. Viral pneumonia is caused by viruses such as influenza A and B. The following
antivirals are examples of those used to treat viral pneumonia:
 Oseltamivir used to treat the Influenza A virus
 Rimantadine used to treat various influenza viruses

Fungal pneumonia 
Fungi is the least common cause of pneumonia, however, Mattila et al. (2014) indicate that there
is an increasing incidence of fungal pneumonia. Fungal pneumonia may be caused by a variety
of different fungi including Histoplasma capsulatum and mucormycosis.
Antifungals are used to treat fungal pneumonia. Antifungals work by stopping the growth of
fungi. The following are examples of antifungal treatments used to treat fungal pneumonia:
 Voriconazole
 Fluconazole
 Itraconazole

O2 Therapy
Supportive oxygen therapy will be required if the patient has oxygen saturations under 92%. The
target saturation range for patients with acute medical conditions, pneumonia, asthma, and acute
coronary syndrome is 92–96% (Pilcher & Beasley 2015). To assist the patient with
expectoration, humidified oxygen therapy may be beneficial.

5. NURSING INTERVENTION
In this section are the ineffective airway clearance nursing interventions and actions for
pneumonia and its rationales or scientific explanations.
1. Elevate the head of the bed, change position frequently.
Doing so would lower the diaphragm and promote chest expansion, aeration of lung
segments, mobilization, and expectoration of secretions.

2. Teach and assist the patient with proper deep-breathing exercises. Demonstrate
proper splinting of the chest and effective coughing while in an upright position.
Encourage patient to do so often.

 Deep breathing exercises facilitates maximum expansion of the lungs and

smaller airways, and improves the productivity of cough.
 Coughing is a reflex and a natural self-cleaning mechanism that assists the
cilia to maintain patent airways. It is the most helpful way to remove most
secretions.
 Splinting reduces chest discomfort and an upright position favors deeper
and more forceful cough effort making it more effective.
3. Suction as indicated: frequent coughing, adventitious breath sounds, desaturation
related to airway secretions.
Stimulates cough or mechanically clears airway in a patient who cannot do so because of
ineffective cough or decreased level of consciousness. Note: Suctioning can cause
increased hypoxemia; hyper oxygenate before, during, and after suctioning.

4. Maintain adequate hydration by forcing fluids to at least 3000 mL/day unless

contraindicated (e.g., heart failure). Offer warm, rather than cold, fluids.
Fluids, especially warm liquids, aid in the mobilization and expectoration of secretions.
Fluids help maintain hydration and increases ciliary action to remove secretions, and
reduces the viscosity of secretions. Thinner secretions are easier to cough out.

5. Assist and monitor effects of nebulizer treatment and another respiratory

physiotherapy: incentive spirometer, IPPB, percussion, postural drainage. Perform
treatments between meals and limit fluids when appropriate.
  Nebulizers humidify the airway to thin secretions and facilitates
liquefaction and expectoration of secretions.
 Postural drainage may not be as effective in interstitial pneumonias or
those causing alveolar exudate or destruction.
 Incentive spirometry serves to improve deep breathing and helps prevent
atelectasis.
 Chest percussion helps loosen and mobilize secretions in smaller airways
that cannot be removed by coughing or suctioning.
 Coordination of treatments and oral intake reduces likelihood of vomiting
with coughing, expectorations.
6. Encourage ambulation.
Helps mobilize secretions and reduces atelectasis.

7. Administer medications, as indicated:

 Mucolytics increase or liquefy respiratory secretions.

 Expectorants increase productive cough to clear the airways. They liquefy
lower respiratory tract secretions by reducing its viscosity.
 Bronchodilators are medications used to facilitate respiration by dilating
the airways.
 Analgesics are given to improve cough effort by reducing discomfort, but
should be used cautiously because they can decrease cough
effort and depress respirations.
8. Use humidified oxygen or humidifier at the bedside.
Increasing the humidity will decrease the viscosity of secretions. Clean the humidifier
before use to avoid bacterial growth.

9. Monitor serial chest x-rays, ABGs, pulse oximetry readings.

Follows progress and effects and extent of pneumonia. Therapeutic regimen and may
facilitate necessary alterations in therapy. Oxygen saturation should be maintained at
90% or greater. Imbalances in PaCO2 and PaO2 may indicate respiratory fatigue.

10. Assist with bronchoscopy and/or thoracentesis, if indicated.

 Bronchoscopy is occasionally needed to remove mucous plugs, drain

purulent secretions, obtain lavage samples for culture and sensitivity.
 Thoracentesis is done to drain associated pleural effusions and prevent
atelectasis.
11. Anticipate the need for supplemental oxygen or intubation if the patient’s
condition deteriorates.
These measures are needed to correct the hypoxemia. Intubation is needed for deep
suctioning efforts and provides a source for augmenting oxygenation.
12. Urge all bedridden and postoperative patients to perform deep breathing and coughing
exercises frequently.
To promote full aeration and drainage of secretions.

6. COMPLICATIONS
Complications
Pneumonia is usually treatable with antibiotics (if bacterial). If it is untreated it can lead to
serious complications, such as:
 Bacteremia: infection that spreads to the bloodstream
 Lung abscesses: Pus formation in the lung cavities
 Impaired breathing: trouble getting enough oxygen; ventilator may be required
 Acute respiratory distress syndrome: severe form of respiratory infection
 Pleural effusion: fluid build-up in tissue that lines the lungs