ch 27 lower respiratory Flashcards
is a self-limiting inflammation of the bronchi in the lower respiratory tract.
Acute bronchitis
by viruses
Most acute bronchial infections are caused
Air pollution, dust, inhalation of chemicals, smoking, chronic sinusitis, and asthma are other triggers.
other causes of acute bronchial infections
may last for up to 3 weeks
Cough, which is the most common symptom(Acute bronchitis)
Clear sputum is often present, although some patients have purulent sputum. The presence of colored (e.g., green) sputum is not a reliable indicator of bacterial infection. Other symptoms may include headache, fever, malaise, hoarseness, myalgias, dyspnea, and chest pain.
other symp of Acute bronchitis
normal breath sounds or crackles or wheezes, usually on expiration and with exertion. Consolidation (which occurs when fluid accumulates in the lungs), suggestive of pneumonia, is absent with bronchitis
Assessment may reveal of Acute bronchitis
cough suppressants (e.g., dextromethorphan), encouraging oral fluid intake, and using a humidifier. Throat lozenges, hot tea, and honey may help relieve cough. β2-Agonist (bronchodilator) inhalers are useful for patients with wheezes or underlying pulmonary conditions. Antibiotics are not prescribed for viral infections because they have side effects and promote antibiotic resistance.
treatment for Acute bronchitis
is a highly contagious infection of the respiratory tract caused by the gram-negative bacillus Bordetella pertussis.
Pertussis
bacteria attach to the cilia of the respiratory tract and release toxins that damage the cilia, causing inflammation and swelling.
Pertussis pathophysiology
tetanus, diphtheria, and pertussis vaccine (Tdap) vaccination may decrease over time, allowing a milder (but still contagious) infection.
immunity from childhood for Pertussis
lasting 1 to 2 weeks, manifests as a mild upper respiratory tract infection (URI) with a low-grade or no fever, runny nose, watery eyes, generalized malaise, and mild, nonproductive cough.
Manifestations of pertussis occur in stages- first stage,
, from the second to tenth week of infection, is characterized by paroxysms of cough.
second stage pertussis
lasts 2 to 3 weeks. It is characterized by a less severe cough and weakness.
The last stage pertussis
is uncontrollable, violent coughing. Inspiration after each cough produces the typical “whooping” sound as the patient tries to breathe in air against an obstructed glottis.
hallmark characteristic of pertussis
Like acute bronchitis, the coughing is more frequent at night. Vomiting may occur with coughing. Unlike acute bronchitis, the cough with pertussis may last from 6 to 10 weeks.
acute bronchitis vs pertusis
nasopharyngeal cultures, polymerase chain reaction (PCR) of nasopharyngeal secretions, or serology testing
diagnosis of pertussis
is macrolide (erythromycin, azithromycin [Zithromax]) antibiotics to minimize symptoms and prevent spread of the disease. For the patient who cannot take macrolides, trimethoprim/sulfamethoxazole is used
treatment for pertussis
from the beginning of the first stage through the third week after onset of symptoms or until 5 days after antibiotic therapy has been started. Routine and droplet precautions are required for hospitalized patients.
patient is infectious (duration) for pertussis
Patients should not use cough suppressants and antihistamines as they are ineffective and may induce coughing episodes. Corticosteroids and bronchodilators are also not helpful. The CDC recommends postexposure antibiotics to those who have had close contact with the patient.
Medications NOT used for pertussis
from inhaled dust or chemicals
Environmental or occupational lung diseases result
the toxicity of the inhaled substance, amount and duration of exposure, and individual susceptibility
extent of lung damage is influenced by
pneumoconiosis, chemical pneumonitis, and hypersensitivity pneumonitis.
Environmentally induced lung disease includes
s a general term for a group of lung diseases caused by inhalation and retention of mineral or metal dust particles.
Pneumoconiosis
(e.g., silicosis, asbestosis, berylliosis)
Pneumoconiosis classified diseases according to the origin of the dust
inhaling silica from sand and rock.
silicosis occurs from
inhaling large amounts of coal dust
Coal worker’s pneumoconiosis (CWP), also known as black lung, is caused by
occurs from tissue repair after inflammation. Breathing problems become evident after many years of repeated exposure, resulting in diffuse pulmonary fibrosis (excess connective tissue).
Fibrosis
Breathing problems become evident after many years of repeated exposure=
pulmonary fibrosis (excess connective tissue).
is a group of minerals composed of microscopic fibers
Asbestos
Lung cancer, either squamous cell carcinoma or adenocarcinoma, is the .
most frequent cancer associated with asbestos exposure
both pleural and peritoneal, is associated with asbestos exposure.
Mesothelioma,
= from exposures to toxic chemical fumes
Chemical pneumonitis results
acute and chronic.
2 types of chemical pneumonitis:
, there is diffuse lung injury characterized by pulmonary edema.
Acutely chemical pneumonitis:
the clinical picture is that of bronchiolitis obliterans (obstruction of the bronchioles due to inflammation and fibrosis). It is usually associated with a normal chest x-ray or one that shows hyperinflation.
Chronically chemical pneumonitis:
is a form of parenchymal lung disease seen when a person inhales antigens to which they are allergic.
Hypersensitivity pneumonitis, or extrinsic allergic alveolitis,
There are acute, subacute, and chronic forms
Hypersensitivity pneumonitis, or extrinsic allergic alveolitis,
(exposure to particles in feathers and droppings of birds), and
Hypersensitivity pneumonitis, or extrinsic allergic alveolitis, ex: include bird fancier’s lung
(inhalation of hay dust particles).
Hypersensitivity pneumonitis, or extrinsic allergic alveolitis, ex:
farmer’s lung
may not occur until at least 10 to 15 years after the initial exposure to the inhaled irritant
Symptoms of many environmental lung diseases (occurrence)
dyspnea, cough, wheezing, and weight loss.
Manifestations common to all pneumoconioses include
often show reduced vital capacity. A chest x-ray often reveals lung involvement specific to the primary problem. CT scans have been useful in detecting early lung involvement.
Pulmonary function studies pneumoconioses include
, a condition in which the right side of the heart fails, is a late complication, especially in conditions characterized by diffuse pulmonary fibrosis.
Cor pulmonale
Other associated disorders include acute pulmonary edema, lung cancer, mesothelioma, and TB.
COPD is the most common complication of environmental lung disease.
is responsible for workplace safety and health regulations in the United States.
NIOSH
Strategies may include O2 therapy, IV fluid, inhaled bronchodilators, corticosteroids, nonsteroidal antiinflammatory drugs (NSAIDs), intubation and mechanical ventilation, percussion therapy, and pulmonary rehabilitation. Patients should be immunized against pneumococcal pneumonia and influenza
treatment for environmental lung disease.
is the leading cause of cancer-related deaths in the United States
Lung cancer
changes in the bronchial epithelium, which usually returns to normal with smoking cessation
Exposure to tobacco smoke causes
high levels of pollution, radiation (especially radon exposure), and asbestos
Other common causes of lung cancer include
Heavy or prolonged exposure to industrial agents, such as ionizing radiation, coal dust, nickel, uranium, chromium, formaldehyde, and arsenic, can
increase the risk for lung cancer, especially in smokers
are believed to arise from mutated epithelial cells.
Most primary lung tumors caused(pathophysiology)
carcinogens, is influenced by various genetic factors.
growth of mutations, which are caused by
cells grow slowly, taking 8 to 10 years for a tumor to reach 1 cm in size, the smallest lesion detectable on x-ray.
cells growth in cancer duration
in the segmental bronchi or beyond and usually occur in the upper lobes of the lungs
Lung cancers occur primarily (location in lung)
- non–small cell lung cancer (NSCLC) (85%)
- small cell lung cancer (SCLC) (15%)
Primary lung cancers are categorized into 2 broad subtypes
direct extension and through the blood and lymph system.
Lung cancers metastasize primarily by
lymph nodes, liver, brain, bones, and adrenal glands.
The common sites for metastasis are
paraneoplastic syndrome
Lung cancers can cause
may be caused by hormones, cytokines, enzymes (secreted by tumor cells) or antibodies (made by the body in response to the tumor) that destroy healthy cells.
Paraneoplastic syndrome
hypercalcemia, syndrome of inappropriate antidiuretic hormone secretion (SIADH), adrenal hypersecretion, polycythemia, and Cushing syndrome.
Examples of paraneoplastic syndrome include
may lead to pericardial effusion, cardiac tamponade, and dysrhythmias.
Mediastinal involvement
done for patients with suspected lung cancer.
chest x-ray is the first diagnostic test (cancer)
x-ray may be normal or identify a lung mass or infiltrate (Fig. 27.4). Evidence of metastasis to the ribs or vertebrae and a pleural effusion may be seen on chest x-ray
chest x ray in cancer pt shows
is used to further evaluate the lung mass. CT scans can identify the location and extent of masses in the chest, any mediastinal involvement, and lymph node enlargement.
CT scanning in cancer pt shows
cancer cells, but sputum samples are rarely used in diagnosing lung cancer because cancer cells are not always present in the sputum
Sputum cytologic studies can identify
Bone scans and CT scans of the brain, pelvis, and abdomen are
used to determine if metastatic disease is present
with A or B subtypes
TNM system, cancer is grouped into 4 stages
by TNM has not been useful because this cancer is aggressive and is always considered systemic. The stages of SCLC are limited and extensive.
Staging of SCLC
that the tumor is only on 1 side of the chest and regional lymph nodes.
Limited means
that the cancer extends beyond the limited stage.
Extensive SCLC means
extensive disease at time of diagnosis.
Most patients with SCLC have
Adults ages 55 to 77 with a history of smoking (30 pack-year smoking history or currently smoke) or who quit smoking but less than 15 years ago should have annual screening for lung cancer.
screening for high-risk patients lung cancer
NSCLC stages I to IIIA without mediastinal involvement.
Surgical resection is the treatment of choice in
(removal of 1 or more lobes of the lung), or
lobectomy
(removal of 1 entire lung).
pneumonectomy
may be used to treat lung cancers near the outside of the lung.
VATS
because of its rapid growth and dissemination at the time of diagnosis.
Surgery is generally not done for SCLC
Pulmonary function studies, ABGs, and anesthesia and critical care consults are often
done before surgery to assess the patient’s cardiopulmonary status.
may be used as treatment for both NSCLC and SCLC
Radiation therapy
curative therapy, palliative therapy (to relieve symptoms), or adjuvant therapy in combination with surgery, chemotherapy, or targeted therapy.
Radiation therapy may be given as
is unable to tolerate surgical resection because of co-morbidities
Radiation therapy may be used as primary therapy in the person who
dyspnea and hemoptysis from bronchial obstructive tumors and treats superior vena cava syndrome. It can treat pain from metastatic bone lesions or brain metastasis. Radiation before surgery can reduce the tumor mass before surgical resection.
Radiation therapy relieves symptoms of
include esophagitis, skin irritation, nausea and vomiting, anorexia, and radiation pneumonitis
Complications of radiation therapy
, is a newer lung cancer treatment
Stereotactic body radiotherapy (SBRT), also called stereotactic radiosurgery (SRS)
type of radiation therapy that uses high doses of radiation delivered to tumors outside the CNS.
Stereotactic body radiotherapy (SBRT)
uses special positioning procedures and radiology techniques to deliver a higher dose of radiation to the tumor and expose only a small part of healthy lung.
Stereotactic body radiotherapy (SBRT) (process)
It does not destroy the tumor, but damages tumor DNA. Therapy is given over 1 to 3 days. SBRT provides an option for patients with early-stage lung cancers who are not surgical candidates for other medical reasons
Stereotactic body radiotherapy (SBRT) (how it works)
or SCLC
Chemotherapy is the main treatment
nonresectable tumors or as adjuvant therapy to surgery.
NSCLC, chemotherapy may be used in the treatment of
etoposide (VP-16), carboplatin, cisplatin, paclitaxel (Taxol), vinorelbine (Navelbine), docetaxel (Taxotere), gemcitabine (Gemzar), and pemetrexed (Alimta)
Chemotherapy for lung cancer typically consists of combinations of 2 of the following drugs:
uses drugs that block the growth of molecules involved in specific aspects of tumor growth
Targeted therapy
Because this type of therapy inhibits growth rather than directly killing cancer cells,
targeted therapy may be less toxic than chemotherapy. bc
inhibits tyrosine kinase, an enzyme associated with speeding up molecular reactions
One type of targeted therapy for patients with NSCLC
which block signals for growth in the cancer cells, include cetuximab (Erbitux), erlotinib (Tarceva), afatinib (Gilotrif), gefitinib (Iressa), osimertinib (Tagrisso), and necitumumab (Portrazza).
Tyrosine kinase inhibitors,
Drugs in this class include crizotinib (Xalkori), brigatinib (Alunbrig), and ceritinib (Zykadia). These drugs directly inhibit the kinase protein made by the ALK gene that is responsible for cancer development and growth.
Another type of kinase inhibitor is used to treat patients with NSCLC who have an abnormal anaplastic lymphoma kinase (ALK) gene.
by targeting vascular endothelial growth factor. Bevacizumab (Avastin) is an angiogenesis inhibitor.
Another type of targeted therapy used to treat lung cancer inhibits the growth of new blood vessels (angiogenesis)
a protein on T cells that normally helps keep these cells from attacking other cells in the body.
Nivolumab (Opdivo), atezolizumab (Tecentriq), and pembrolizumab (Keytruda) are drugs that target PD-1,
=boost the immune response against cancer cells. This can shrink some tumors or slow their growth.
By blocking PD-1, these drugs
whose cancer has progressed after other treatments and with tumors that express PD-1.
Nivolumab and pembrolizumab can be used in people with metastatic NSCLC
, especially to the CNS.
Patients with SCLC have early metastases
can decrease the incidence of brain metastases and may improve survival rates in patients with limited SCLC
Prophylactic radiation
makes it possible to remove obstructing bronchial lesions.
Bronchoscopic laser therapy
makes it possible to remove obstructing bronchial lesions.
Bronchoscopic laser therapy
laser’s thermal energy is transmitted to the target tissue. It is a safe and effective treatment of endobronchial obstructions from tumors. Symptoms of airway obstruction are relieved due to thermal necrosis and shrinkage of the tumor.
Bronchoscopic laser therapy laser’s thermal energy (how it works in body)
is a form of treatment for early-stage lung cancers that uses a combination of a drug and a specific type of light.
Photodynamic therapy (PDT)
the drug, known as a photosynthesizer, is exposed to a specific wavelength of light.
Photodynamic therapy (PDT): Cancer cells are killed when
is the most used photosynthesize
Porfimer (Photofrin)
are used alone or in combination with other techniques for relief of dyspnea, cough, or respiratory insufficiency
Stents
is inserted during a bronchoscopy. The advantage of an airway stent is that it supports the airway wall against collapse or external compression and can delay extension of tumor into the airway lumen
stent process
is an acute infection of the lung parenchyma
Pneumonia
air filtration, epiglottis closure over the trachea, cough reflex, mucociliary escalator mechanism, and reflex bronchoconstriction
Mechanisms that create a mechanical barrier to microorganisms entering the tracheobronchial tree include
when defense mechanisms become incompetent or are overwhelmed by the virulence or quantity of infectious agents.
Pneumonia is more likely to occur
Tracheal intubation bypasses normal filtration processes and interferes with the cough reflex and mucociliary escalator mechanism.
Tracheal intubation defense mechanism corrupts by
Air pollution, cigarette smoking, viral URIs, and normal changes that occur with
aging can impair the mucociliary mechanism.
can suppress the immune system’s ability to inhibit bacterial growth
Chronic diseases affect defense mechanism
Aspiration of normal flora from the nasopharynx or oropharynx. Many organisms that cause pneumonia are normal inhabitants of the pharynx in healthy adults.
Pathogens that cause pneumonia reach the lung in 3 ways: (aspiration)
Inhalation of microbes present in the air. Examples include Mycoplasma pneumoniae and fungal pneumonias.
Pathogens that cause pneumonia reach the lung in 3 ways: (Inhalation )
hematogenous spread from a primary infection elsewhere in the body. Examples are streptococci and Staphylococcus aureus from infective endocarditis.
Pathogens that cause pneumonia reach the lung in 3 ways: (hematogenous )
the causative pathogens (e.g., bacterial, viral, fungal, etc.),
classifying pneumonia according to
is as either community-acquired or hospital-acquired pneumonia.
most widely recognized and effective way to classify pneumonia
most likely cause and the choice of antimicrobial therapy.
classification helps the HCP identify (pneumonia)
is an acute infection of the lung occurring in patients who have not been hospitalized or lived in a long-term care facility within 14 days of the onset of symptoms
Community-acquired pneumonia (CAP)
decision to treat the patient at home or admit to hospital is based on several factors. These include the patient’s age, vital signs, mental status, presence of co-morbid conditions, and current physiologic condition
CURB-65 MNEUMONIC (pneumonia acquired long-term care/community)
is pneumonia in a nonintubated patient that begins 48 hours or longer after admission to hospital and was not present at the time of admission.
Hospital-acquired pneumonia (HAP), also known as nosocomial pneumonia,
refers to pneumonia that occurs more than 48 hours after endotracheal intubation
Ventilator-associated pneumonia (VAP), a type of HAP,
longer hospital stays, increased associated costs, sicker patients, and increased risk for morbidity and mortality
HAP and VAP are associated with
treatment is started based on known risk factors, early versus late onset, presentation, underlying medical conditions, hemodynamic stability, and the likely causative pathogen
Once the diagnosis of CAP, HAP, or VAP is made,
the initiation of treatment before a definitive diagnosis or causative agent is confirmed, should be started as soon as pneumonia is suspected.
Empiric antibiotic therapy,(indication)
is based on the knowledge of drugs known to be effective for the likely cause.
Empiric antibiotic therapy (definition)
once the results of sputum cultures identify the exact pathoge
Antibiotic therapy can be adjusted
is the most common type of pneumonia
-mild and self-limiting or cause potentially life-threatening problems, such as acute respiratory failure in influenza.
Viral pneumonia
may be extremely unwell and need hospital admission.
bacterial pneumonia
, which has traits of both bacteria and viruses, is often referred to as “atypical” pneumonia. It is mild and occurs in persons younger than 40 years of age.
Mycoplasma pneumonia
results from the abnormal entry of material from the mouth or stomach into the trachea and lungs
Aspiration pneumonia
decreased level of consciousness (e.g., seizure, anesthesia, head injury, stroke, alcohol intake), difficulty swallowing, and insertion of nasogastric (NG) tubes with or without enteral feeding.
Conditions that increase the risk for aspiration include
the gag and cough reflexes are depressed and aspiration is more likely to occur.
With loss of consciousness, at risk bc
an inflammatory response.
aspirated material (food, water, vomitus, oropharyngeal secretions) triggers
is a primary bacterial infection.
The most common form of aspiration pneumonia
aerobes and anaerobes, since they both make up the flora of the oropharynx.
Typically, the sputum culture shows more than 1 organism, (in aspiration pneumonia = bacterial infection)
an assessment of probable cause, severity of illness, and patient factors (e.g., malnutrition, current use of antibiotic therapy).
initial antibiotic therapy is based on (aspiration pneumonia)
both gram-negative organisms and methicillin-resistant Staphylococcus aureus (MRSA).
patients who aspirate in hospitals, antibiotic coverage should include
chemical (noninfectious) pneumonitis, which may not need antibiotic therapy. However, secondary bacterial infection can occur 48 to 72 hours later.
Aspiration of acidic gastric contents causes
is a rare complication of bacterial lung infection
Necrotizing pneumonia
causes the lung tissue to turn into a thick, liquid mass. In some situations, cavitation occurs. This often happens with CAP.
Necrotizing pneumonia effect on lung
Staphylococcus, Klebsiella, and Streptococcus. Lung abscesses often occur.
Necrotizing pneumonia causative organisms include
immediate respiratory insufficiency and/or failure, leukopenia, and bleeding into the airways.
Necrotizing pneumonia Signs and symptoms include
includes long-term antibiotic therapy and possible surgery.
Necrotizing pneumonia Treatment
is inflammation and infection of the lower respiratory tract in immunocompromised patients. Persons at risk include those with altered immune responses.
Opportunistic pneumonia (define)
include people with severe protein-calorie malnutrition or immunodeficiencies (e.g., human immunodeficiency virus [HIV] infection) and those receiving radiation therapy, chemotherapy, and any immunosuppressive therapy, including long-term corticosteroid therapy. In addition to the risk for bacterial and viral pneumonia, the immunocompromised person may develop an infection from organisms that do not normally cause disease, such as Pneumocystis jiroveci (formerly carinii) or cytomegalovirus (CMV).
Opportunistic pneumonia at risk
rarely occurs in the healthy person. It is the most common form of pneumonia in people with HIV disease.
P. jiroveci pneumonia (PJP) (Opportunistic pneumonia)
onset is slow and subtle with symptoms of fever, tachypnea, tachycardia, dyspnea, nonproductive cough, and hypoxemia. The chest x-ray usually shows diffuse bilateral infiltrates. In widespread disease, the lungs have massive consolidation. PJP can be life-threatening, causing acute respiratory failure and death. Infection can spread to other organs, including the liver, bone marrow, lymph nodes, spleen, and thyroid.
P. jiroveci pneumonia (PJP) signs /symp (Opportunistic pneumonia)
Bacterial and viral pneumonias first must be ruled out because of the vague presentation of PJP. Although the causative agent is fungal, PJP does not respond to antifungal agents.
causative agent is fungal for PJP (Opportunistic pneumonia)
of a course of trimethoprim/sulfamethoxazole (Bactrim, Septra) either IV or orally depending on the severity of disease and the patient’s response.
***does not respond to antifungal agents.
fungal for PJP (Opportunistic pneumonia)Treatment consists
, a herpesvirus, can cause viral pneumonia. Most CMV infections are asymptomatic or mild.
CMV (cytomegalovirus)/(Opportunistic pneumonia)
complications after hematopoietic stem cell transplantation.
CMV is one of the most important life-threatening infectious
Antiviral medications (e.g., ganciclovir [Cytovene], foscarnet [Foscavir], cidofovir) and high-dose immunoglobulin are used for treatment.
treatment. for CMV (cytomegalovirus)/(Opportunistic pneumonia)
Inflammation, characterized by an increase in blood flow and vascular permeability, activates neutrophils to engulf and kill the offending pathogens. As a result, the inflammatory process attracts more neutrophils, edema of the airways occurs, and fluid leaks from the capillaries and tissues into alveoli. Normal O2 transport is affected, leading to manifestations of hypoxia (e.g., tachypnea, dyspnea, tachycardia).
pathophysiology of pneumonia
, the absence of gas or air in 1 or more areas of the lung, may occur with pneumonia.
Atelectasis (occur w/ pneumonia)
, a feature typical of bacterial pneumonia, occurs when the normally air-filled alveoli become filled with water, fluid, and/or debris
consolidation (occur w/ pneumonia)
are cough, fever, chills, dyspnea, tachypnea, and pleuritic chest pain
-cough may or may not be productive.
-Sputum may be green, yellow, or even rust colored (bloody)
most common presenting symptoms of pneumonia
may initially be seen as influenza, with respiratory symptoms appearing and/or worsening 12 to 36 hours after onset.
Viral pneumonia sign/symp
Confusion or stupor (possibly related to hypoxia) may be the only finding. Hypothermia, rather than fever, also may be seen in the older adult. Nonspecific manifestations include diaphoresis, anorexia, fatigue, myalgias, and headache.
elderly does NOT have classic symp of pneumonia instead
fine or coarse crackles may be auscultated over the affected region. If consolidation is present, bronchial breath sounds, egophony (an increase in the sound of the patient’s voice), and increased fremitus (vibration of the chest wall made by vocalization) may be present. Patients with pleural effusion may have dullness to percussion over the affected area
elderly does NOT have classic symp of pneumonia instead (on assessment)
. Common culprits include MRSA and gram-negative bacilli
major problem today is pneumonia caused by multidrug-resistant (MDR) pathogens
advanced age, immunosuppression, history of antibiotic use, and prolonged mechanical ventilation.
Risk factors for MDR (multidrug-resistant) pneumonia include
can identify MDR pathogens.
Antibiotic susceptibility tests
Atelectasis, pleurisy, pleural effusion, bacteremia, pneumothorax, acute respiratory failure, sepsis shock, multiple organ dysfunction syndrome
Other complications from pneumonia develop more often in older adults and those with underlying chronic diseases. These include:
Lung abscess is
not a common complication of pneumonia
it may occur with pneumonia caused by S. aureus and gram-negative organisms.
Lung abscess (puss built up in tissue)
, the accumulation of purulent exudate in the pleural cavity, occurs in less than 5% of cases.
Empyema
requires antibiotic therapy and drainage of the exudate by a chest tube or open surgical drainage.
Empyema treatment
History, physical examination, and chest x-ray often give enough information to make immediate decisions about early treatment. Chest x-ray often shows patterns characteristic of the infecting pathogen
-X-ray may also show pleural effusions. A thoracentesis and/or bronchoscopy with washings may be used to obtain fluid samples from patients not responding to initial therapy.
-Arterial blood gases (ABGs) may be obtained to assess for hypoxemia (partial pressure of O2 in arterial blood [PaO2] less than 80 mm Hg), hypercapnia (partial pressure of carbon dioxide in arterial blood [PaCO2] greater than 45 mm Hg), and acidosis (pH less than 7.35).
-Leukocytosis occurs in most patients with bacterial pneumonia. The white blood cell (WBC) count is usually greater than 15,000/μL (15 × 109/L) with the presence of bands (immature neutrophils).
common diagnostic procedures for pneumonia
beginning antibiotic therapy. However, antibiotic administration should not be delayed if a specimen cannot be obtained. Delays in antibiotic therapy can increase the risk for morbidity and mortality. Blood cultures are done for patients who are seriously ill.
sputum specimen for culture and Gram stain to identify the organism is obtained before (pneumonia)
• Increased fluid intake (at least 3 L/day), IV fluids
• Balance between activity and rest
• O2 therapy
• Physiotherapy
• VTE prophylaxis
• Critical care management, with mechanical ventilation as needed
management for pneumonia
Appropriate antibiotic therapy (Table 27.6)
• Antipyretics
• Analgesics
• Nonsteroidal antiinflammatory drugs (if no contraindications)
Drug treatment for pneumonia
both bacterial and mycoplasma pneumonia
Antibiotics are highly effective for
is used to prevent S. pneumoniae infection
- Prompt treatment with the appropriate antibiotic is essential.
- Antibiotics are highly effective for both bacterial and mycoplasma pneumonia. In uncomplicated cases, the patient responds to drug therapy within 48 to 72 hours
Pneumococcal vaccine
decreased temperature, improved breathing, and reduced chest discomfort.
Signs of improvement include(pneumonia)
than 7 days. A repeat chest x-ray may be done in 6 to 8 weeks to assess for resolution.
Abnormal physical findings can last more
include O2 therapy to treat hypoxemia, analgesics to relieve chest pain, and antipyretics (e.g., aspirin, acetaminophen) for fever. Although cough suppressants, mucolytics, bronchodilators, and corticosteroids are often prescribed as adjunctive therapy, the use of these drugs is debatable. However, they may be prescribed for patients with underlying chronic conditions.
management pneumonic part 2
no definitive treatment exists
-self-limiting and will often resolve in 3 to 4 days. Antiviral therapy may be used to treat pneumonia caused by influenza (e.g., oseltamivir, zanamivir) or a few other viruses (e.g., acyclovir [Zovirax] for herpes simplex virus).11
viral pneumonias treatment
empiric therapy based on the likely pathogen
Once the pneumonia is classified, the HCP selects
whether the patient has risk factors for MDR pathogens.
empiric antibiotic therapy is based on
must be adapted to local patterns of antibiotic resistance. Multiple regimens exist, but all should initially include antibiotics that are effective against both resistant gram-negative and resistant gram-positive organisms.
antibiotic regimen
• All children <2yrs
• All adults ≥65 yrs
• Anyone 2–64 yrs old with certain medical conditions (e.g., sickle cell disease, asplenia, immunodeficiencies, HIV infection, chronic renal failure, leukemia, cancer, long-term immunosuppressive therapy, CSF leaks, cochlear implant[s])
Pneumococcal conjugate vaccine (PCV13, Prevnar 13)
All adults ≥65yrs
• Anyone 2–64 yrs old with certain long-term health problems (e.g., heart disease, lung disease, diabetes, alcoholism, cirrhosis, sickle cell disease, CSF leaks, cochlear implant)
• Anyone 2–64 yrs with a disease or condition that weakens the immune system or taking drugs that lower the body’s resistance to infection (e.g., HIV infection; lymphoma or leukemia; kidney failure; damaged or no spleen; multiple myeloma; receiving immunosuppressive chemotherapy, radiation therapy, or long-term corticosteroids; after organ or bone marrow transplantation)
• Adults 19–64 yrs who smoke cigarettes or have asthma
Pneumococcal polysaccharide vaccine (PPSV23, Pneumovax 23)†
should be a minimum of 5 days. The patient should be afebrile for 48 to 72 hours before stopping treatment.
Total treatment time for patients with CAP
(e.g., side-lying, upright) that will prevent or minimize the risk for aspiration
altered consciousness in positions (aspiration pneumonia)
but not in the exact same location. The vaccines cannot be mixed into 1 injection.
Patients can receive the pneumococcal vaccine and influenza vaccine at the same time
is an infectious disease caused by Mycobacterium tuberculosis
Tuberculosis (TB)
It usually involves the lungs, but can infect any organ, including the brain, kidneys, and bones.
Tuberculosis (TB) infect
attributed to HIV disease and the emergence of drug-resistant strains of M. tuberculosis.
Tuberculosis (TB) infect mainly
the homeless, residents of inner-city neighborhoods, foreign-born people, those living or working in institutions (long-term care facilities, prisons, shelters, hospitals), IV injecting drug users, overcrowded living conditions, less than optimal sanitation, and those with poor access to health care. Immunosuppression from any cause (e.g., HIV infection, cancer, long-term corticosteroid use) increases the risk for active TB infection.
People most at risk TB include
Once a strain of M. tuberculosis develops resistance to the most potent first-line antitubercular drugs (isoniazid [INH] and rifampin [Rifadin]), it is defined as
multidrug-resistant tuberculosis (MDR-TB)
occurs when the organism is also resistant to any of the fluoroquinolones plus any injectable antibiotic agent
Extensively drug-resistant TB (XDR-TB)
several problems, including incorrect prescribing, lack of public health case management, patient nonadherence to the prescribed regimen, and lack of funding for education and prevention.
Resistance results from
is a gram-positive, aerobic, acid-fast bacillus (AFB). It is usually spread from person to person by airborne droplets expectorated when breathing, talking, singing, sneezing, and coughing
M. tuberculosis
. TB is not highly infectious, as transmission usually requires close contact and frequent or prolonged exposure.
Humans are the only known reservoir for TB
touching, sharing food utensils, kissing, or any other type of physical contact.
TB disease cannot be spread by
usually spread from person to person by airborne droplets expectorated when breathing, talking, singing, sneezing, and coughing. A process of evaporation leaves small droplet nuclei, 1 to 5 μm in size, suspended in the air for minutes to hours. Another person then inhales the bacteria.
-Once inhaled, these small droplets lodge in bronchioles and alveoli.
process of how TB spreads
(1) number of organisms expelled into the air, (2) concentration of organisms (small spaces with limited ventilation would mean higher concentration), (3) length of time of exposure, and (4) immune system of the exposed person.
Factors that influence TB transmission include the
local inflammatory reaction occurs, and the focus of infection is established. This is called the
Ghon lesion or focus.
represents a calcified TB granuloma, the.
hallmark of a primary TB infection
defense mechanism aimed at walling off the infection and preventing further spread. Replication of the bacillus is inhibited, and the infection is stopped.
The formation of a granuloma is a
