Pneumonia

Pathophysiology

Pneumonia occurs when pathogens find their way to the lower respiratory tract-- which is normally kept sterile by all the defenses of the upper respiratory tract. The signs and symptoms of pneumonia occur because both ventilation and diffusion (the movement of oxygen from the lung space into the bloodstream) are affected. 

When the bronchioles and alveoli become inflamed due to infection, the delicate membranes become swollen and there is an increased production of secretions and mucus. The secretions coat the surface of the alveolar membrane (so oxygen can’t be moved through to the capillary bed) and can actually obstruct small branches of the lung (preventing ventilation of all the lung distal to the plug). 

Unique Assessment Findings

• General signs of infection: chills, fever, fatigue
• Tachypnea
• Shortness of breath
• Decreased SpO2
• Productive cough
• Pleuritic chest pain 

Nurse pro tip: Pleuritic chest pain tends to be described as sharp, stabbing, or burning and is worsened by coughing and deep breathing. If your patient was admitted with pneumonia, had sharp lung pain rated 4/10 this morning, and now with a coughing fit that pain is a 9/10 (but same in location and quality), this is totally expected. Monitor for that pain to lighten up with a little time and slow calm breaths. However, if your patient is having new/different, sudden, severe chest pain, it’s not your job to figure out what the cause is right at that moment. Call an RRT, get a provider to the bedside, and/or follow your facility’s chest pain protocol if you have one.

Typical Patient Pathway

Patients with pneumonia usually present to the ED with a chief complaint of shortness of breath. They may have those general symptoms of infection (fever, chills, fatigue) and report having had an upper respiratory infection recently. Vital signs will be checked and if their oxygen saturation is low they will be placed on some supplemental O2 while the respiratory workup proceeds. If this patient has a history of chronic respiratory illness their respiratory distress may advance quickly because they have very little reserves with which to compensate.

Diagnostics

Chest X-ray 

• Pulmonary infiltrates: This is a non-specific term for junk in the airways-- it could be fluid, pus, blood, etc. This junk shows up white on the x-ray. The more white on a chest x-ray, the worse the situation. 
• Consolidation: if the infiltrates are limited to a specific area of the lungs they may be called consolidations.

See the below CXR and note the bright white on the patient's right lower lobe - that's pneumonia!

Now, compare that to a normal chest x-ray below. (Please note, this is not the same patient.)

Sputum culture: to identify the infectious pathogen and aid in the choice of antibiotics

CBC: to evaluate WBC as a sign of infection

Arterial blood gas (ABG): to evaluate oxygenation status and acid-base balance

Blood culture: to detect whether the infectious pathogen has passed into the bloodstream

Hospital Course

The primary treatment for pneumonia is antibiotic administration (so long as the causative pathogen is bacterial, not viral). Patients may spend the first few days on IV antibiotics and then transition to PO as they get closer to discharge. Viral pneumonia is treated only with supportive therapy. 

Other than antibiotics, the treatment for viral vs bacterial pneumonia is the same, with the goal to optimize respiratory status. Patients will likely have an order for continuous pulse oximetry or capnography (depending on what’s preferred at your facility). Treat hypoxemia with supplemental oxygen as ordered. Depending on the severity of respiratory distress, patients may require high-flow nasal cannula (ex: OptiFlow) or non-invasive positive pressure ventilation (CPAP or BiPAP) for a period of time. Additional supportive therapies include IV fluids, antipyretics, and antitussives.

Nurse pro tip: Remember to utilize your respiratory therapists! If your patient is struggling a little more than earlier, see if RT can come to assess the patient. Airway and breathing are their whole deal and they are so helpful in identifying what therapies the patient might benefit from. 

Patients admitted for pneumonia will typically require 4-6 days in the hospital. However, the length of stay will be greater depending on:

• the patient’s initial presentation (How advanced was their respiratory distress when they arrived at the hospital? Requiring any days in the ICU?)
• the patient’s history (Are they immune-compromised? History of COPD, asthma, or cystic fibrosis?)
• the nature of the causative organism (multi-drug resistant bacteria will require multiple antibiotics and may take longer to treat completely) 

Possible complications of pneumonia include pleural effusion and respiratory failure, which can progress to septic shock. 

When associated with infectious pneumonia, the contents of a pleural effusion can be thick and purulent, called an empyema. This may be treated with thoracentesis or placement of a chest tube, as well as a significantly longer course of antibiotics (4-6 weeks). 

If the pneumonia infection continues to advance and the patient is no longer able to compensate, they will experience respiratory failure. The type of respiratory support provided will progress to more invasive therapies and could result in intubation and mechanical ventilation. 

As a med-surg nurse, it is your job to notice when a patient’s condition is worsening and notify the provider so that the patient can be moved to a higher level of care as appropriate. In addition to monitoring respiratory symptoms (oxygen sats, respiratory rate, lung sounds, patient comfort of breathing), keep thinking about the other signs of clinical deterioration (increasing HR, decreasing BP, changing mental status, etc.). Some patients, especially otherwise relatively healthy patients, are able to compensate for a long time. Keep an eye on the whole picture to detect a patient’s decline before they are truly in trouble. 

Nurse pro tip: When I first started nursing I thought I needed to be able to keep my patient in the same or better condition than when I received them, and that by having to call an RRT or transfer to a higher level of care I had failed as this patient’s nurse. That is obviously untrue. Patients are sick-- that’s why they are in the hospital-- and sometimes they take a turn for the worse. You are succeeding as a nurse if you are attentive to your patient’s changing condition and by getting them the care they need, which may be a higher level of care. 

Important Nursing Considerations

Your patient’s respiratory status is going to be in a compromised state, and any sort of activity will feel harder for them and actually require more energy than usual. For that reason, activity is a delicate balance. We want our patients up and walking at least a few times each day (opens up their lungs, encourages deeper breathing), but understand that each walk may really take a lot out of them. Even things like eating a meal or having a conversation can make them feel winded. Plan activity for when they are most likely to feel rested and encourage nutrient-rich foods to support their additional energy needs. 

Because pneumonia can cause lots of secretions in the lungs, it is important to help the patient to stay as hydrated as possible. Having supportive IV fluids and encouraging PO fluid intake will help to thin secretions, making them easier to move up and out with coughing. Additionally, an increased respiratory rate means they are breathing off the water more quickly than normal and therefore are at an increased risk for dehydration. If your patient no longer has IV fluids ordered, but now needs to be NPO for a period of time, check with the provider to see if some maintenance IFVs would be appropriate. 

For bacterial pneumonia, antibiotics are the key to treatment. Emphasize the importance of completing the antibiotic regimen as ordered after discharge. If they had complicated pneumonia (multi-drug resistant, developed an empyema, etc.) their course of antibiotics may involve multiple medications and last several weeks. They should not stop taking their antibiotics just because they are feeling well!