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Harold Haze S.

Cortez,
RN, MAN
IUDMC

D R O E R

Introducti
on

Pneumonia is defined as the


inflammation of lung tissue caused by
an infectious agent that results in
acute respiratory signs and symptoms.

Causative agents include:


bacteria (S. pneumoniae),
virus (H. influenzae),
fungi (P. jirovecii)

R
E
L
L
I
K
P
O
T

Pneumonia is the most common


presentation of IPD in children.
Most commonly affects the very young
Pneumonia is the top killer of Filipino
children <5 years old, accounts for 34%
of deaths

Pneumonia remains to be a major cause of morbidity and


mortality among Filipino children.

Pneumonia Morbidity Rate by Region


Rate per 100,000 population
CAR: 1750

Region II:
600

Region I: 400
Region III: 250

Region V: 3200
NCR: 450
Region IV-A: 700

Region VIII: 1400

Region IV-B: 350


Region VI: 900

CARAGA: 450

Region VII: 800

Region X: 600
Region XII: 1200

2008

Region IX:
650

ARMM:

Region XI: 1300

Types

Community-acquired pneumonia (CAP)


Onset in community or during 1st 2 days of

hospitalization (Strep. pneumoniae most


common) 75%

Hospital-acquired Pneumonia(HAP)
Occurring 48 hrs or longer after

hospitalization

Aspiration pneumonia
Pneumonia caused by opportunistic
organisms
Pneumocystis Carinii

DIAGNO

ASSESSMENT

TAKE IT OFF???!!

ASSESSMENT

Fevers, chills,
anorexia
Pleuritic chest pain
SOB
Crackles/wheezes
Cough, sputum
production
Tachypnea

Chest
Retractions

Seen in severe
pneumonia

Bacterial vs.
Viral
Features

Bacterial

Viral

Fever

T>38.5C

T<38.5C

Wheeze

Absent

Present

Alveolar infiltrates in Chest Xray or an


elevated white cell count favors
bacterial pathogen

DIAGNOSTICS

Pulse Oximetry
Chest X-Ray
Computed Tomography (CT scan)
Bronchoscopy
Thoracentesis
Pulmonary Function Tests
Sputum Specimen and Cultures

PULSE
Measures arterial oxygen
saturation
OXYMETRY
Pulse oximetry probe on

forehead, ears, nose, finger,


toes,
False readings
Intermittent or continuous
monitoring
Ideal values: 95-100%
When to Notify MD
< 91%
86% (Medical Emergency)

CHEST X-RAY
Screen, diagnose,

evaluate treatment

Instructions: No

metals/jewelry

NORMAL CHEST

Lateral View

Bronchial
Pneumonia

Lobar
Pneumonia

SPUTUM
To diagnose; evaluate
SPECIMEN
treatment

Specimen: ID organisms or
abnormal cells
Culture & Sensitivity (C&S)
Cytology
Gram stains
(e.g. Acid Fast Bacilli)

Computed
Images in cross-section
Tomography
(CT)
view

Uses contrast agents

Instructions:

Bronchoscopy

Diagnose problems and


assess changes in
bronchi/bronchioles

Performed to remove foreign


body, secretions, or to obtain
specimens of tissue or
mucus for further study
Procedure Care/Instructions:
NPO 6 -8 hrs prior
Sedation during procedure
Post Procedure:
HOB elevated
Observe for hemorrhage
NPO until gag reflex returns

Pulmonary
Evaluate lung function
Function
Observe for increased
Test(PFTs)
dyspnea or

bronchospasm

Instructions:
No bronchodilators 6
hours prior

Thoracentesis
Specimen from pleural

fluid
Treat pleural effusion
Assess for
complications
Post-Procedure care:
CXR after procedure

Positions
Sitting on side of bed over
bedside table chest
elevated
Lying on affected side
Straddling a chair

HEMATOLOGY

WHITE BLOOD CELL COUNT


ESR / CRP

MICROBIOLOGY
Blood C/S
Plueral fluid C/S
Tracheal aspiration C/S
Sputum C/S

considered as
having
communityacquired
For ages
3 months to 5 years are
tachypnea and/or chest indrawing
Pneumonia?
For ages 5 to 12 years are fever,
tachypnea, and crackles

considered as
having
communityBeyond
12 years of ages are the
acquired
presence of the following features:
Fever,
tachypnea, and tachycardia
Pneumonia?

At least one abnormal chest findings of


diminished breathing sounds, ronchi,
crackles or wheezes

Tachypnea is still the best predictor of


pneumonia

Who will
require
A patient who is at moderate to high
admission?
risk to develop pneumonia-related

mortality should be admitted

A patient who is minimal to low risk


can be managed on an outpatient
basis

Risk
Classification of
Pneumonia
Variables

PCAP A
Minimal risk

PCAP B
Low risk

PCAP C
Moderate risk

PCAP D
High risk

None

Present

Present

Present

Yes

Yes

No

No

Possible

Possible

Not possible

Not possible

Presence of dehydration

None

Mild

Moderate

Severe

Ability to feed

Able

Able

Unable

Unable

Age

>11 mos

>11 mos

<11 mos

<11 mos

Respiratory rate
2-12mos
1-5years
>5 years

50/min
40/min
30/min

>50/min
>40/min
>30/min

>60/min
>50/min
>35/min

>70/min
>50/min
>35/min

Co-morbid illness

Compliant caregiver
Ability to follow up

RESPIRATORY
RATE CRITIA

Variables

Respiratory rate
2-12mos
1-5years
>5 years

PCAP A PCAP B PCAP C


Minimal Low risk Moderat
risk
e risk

PCAP D
High
risk

50/min
40/min
30/min

>70/min
>50/min
>35/min

>50/min
>40/min
>30/min

>60/min
>50/min
>35/min

Risk
Classification of
Pneumonia

Variables

Signs of respiratory
failure
a. Retraction
b. Head bobbing
c. Cyanosis
d. Grunting
e. Apnea
f. Sensorium

Complication
(effusion,
pneumothorax)
Action Plan

PCAP A
Minimal risk

PCAP B
Low risk

PCAP C
Moderate risk

PCAP D
High risk

None
None
None
None
None
Awake

None
None
None
None
None
Awake

Intercostal/Subcostal
Present
Present
None
None
Irritable

Supraclavicular/Interco
stal/Subcostal
Present
Present
Present
Present
Lethargic/Stuporous/
Comatose

None

None

Present

Present

OPD follow up
at end of
treatment

OPD follow up
after 3 days

Admit to regular ward

Admit to ICU
Refer to specialist

RHONCHI
These are low

pitched, snore-like
sounds.
They are caused
by airway
secretions and
airway narrowing.
They usually clear
after coughing.

HEAD BOBBING

The presence of retraction on


admission was the best single
predictor of death

Inability to cry, head nodding and a


respiratory rate of >60/min were the
best predictors of hypoxemia

What diagnostic
aids are requested
for a patient
classified as PCAP
No
aids are initially
Adiagnostic
or PCAP
B?
requested for a patient classified
as either PCAP A or PCAP B who
is being managed in an
ambulatory setting

aids are initially


requested for a
patient classified as
either
PCAP
C requested:
or
The following should
be routinely
Chest x-ray PA-lateral
PCAP
White blood
cell count D?
Culture and sensitivity of
Blood for PCAP D
Pleural fluid
Tracheal aspirate upon initial intubation
Blood gas and/or pulse oximetry

When is
antibiotic
For a patient classified as either PCAP A or
recommended?
B and is:

Beyond 2 years of age


Having high grade fever without wheeze

For a patient classified as PCAP C and is:


Beyond 2 years of age
Having high grade fever without wheeze
Having alveolar consolidation in the CXR
Having WBC > 15,000

For a patient classified as PCAP D

Etiology

First 2 years: viruses

As age increases bacterial


pathogens become more prevalent

INTERVENTION/T
Treatment
REATMENT
Antibiotics choose based on age,

suspected cause & immune status

Supportive care IV fluids,

supplemental oxygen therapy,


respiratory monitoring, cough
enhancement

*may take 6-8 weeks for CXR to


normalize

MEDICATION
(BACTERIAL)

For a patient classified as PCAP A


or B without previous antibiotic,
oral Amoxicillin (40-50mg/kg/day
in 3 divided doses) is the DOC

For a patient classified as PCAP C


without previous antibiotic who has
completed primary immunization
against H.Influenza type b,
Penicillin G (100,000units/kg/day
in 4 divided doses) is the DOC

MEDICATION
(BACTERIAL)
If a primary immunization againts Hib
has not been completed, intravenous
Ampicillin (100mg/kg/day in 4
divided doses) should be given

For a patient classified as PCAP D,


a specialist should be consulted

DURATION OF
TREATMENT
5 -7 days - outpatients

7-10 days inpatients, S.


pneumoniae
10-14 days Mycoplasma,
Chlamydia, Legionella
14+ days - chronic steroid users

MANAGEMENT
(VIRAL ETIOLOGY)

Ancillary treatment should be given

Oseltamivir (2mg/kg/dose BID for 5


days) or Amantadine (4.48.8mg/kg/day for 3-5days) may be
given for influenza that is either
confirmed by laboratory or occurring
as an outbreak

patient be
considered as
RESPONDING TO
THE
Decrease CURRENT
in respiratory signs
(particularly tachypnea) and
defervescence
within 72hours after
ANTIBIOTIC?
initiation of antibiotic

Persistence of symptoms beyond 72


hours after initiation of antibiotics
requires reevaluation
End of treatment CXR, WBC, ESR or
CRP should not be done to assess
therapeutic response to antibiotic

should be
done if a
patient is
NOT
RESPONDI
NG to
current
antibiotic

PCAP A or B

If an outpatient classified as either


PCAP A or B is not responding
within 72hours, consider any one
of the following:
Change the initial antibiotic
Start an oral macrolide
Reevaluate diagnosis

PCAP C

If an inpatient classified as PCAP C is


not responding within 72hours,
consider consultation with a specialist
because of the following possibilities:
Penicillin resistant Streptococcus

pneumoniae
Presence of complication (pulmonary or
extrapulmonary)
Other diagnosis

PCAP D

If an inpatient classified as
PCAP D is not responding
within 72hours, consider
IMMEDIATE re-consultation
with a specialist

IV to Oral
Antibiotics

Switch from intravenous antibiotic


administration to oral from 2-3 days after
initiation is recommended in a patient who:
Is responding to the initial antibiotic
therapy
Is able to feed with intact gastrointestinal
absorption
Does not have any pulmonary or extra
pulmonary complication

NURSING ACTIONS:
Ancillary
Treament
Among inpatient,
oxygen and

herbal
medicines
are not
routinely
given in

communityacquired
pneumonia

hydration should be given if needed


Cough preparations, chest
physiotherapy, bronchial hygiene,
nebulization using normal saline
solution, steam inhalation, topical
solution, bronchodilators and
In the presence of wheezing, a
bronchodilator may be administered

COMPLICATIONS
Hypoxemia
Pleural effusion
Atelectasis
Pleurisy

Atelectasis
Pleurisy

Pleural Effusion

PREVENTION

Influenza vaccine
Pneumococcal Vaccine

PREVENTION
Isolation
(ICU
Patients)
of patients with resistant
respiratory tract infections
Enteral nutrition
Choice of GI prophylaxis
Subglottic secretion removal

HIGLY
CONTAGIOUS

STAY HEALTHY

Any
Questions?

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