Medical Pathologies of Respiratory system
The respiratory system supplies oxygen for cellular metabolic need and removes
carbon dioxide (CO2), a waste product of cellular metabolism. Respiratory disorders
and diseases are common, ranging from mild to life threatening. Disorders that
interfere with breathing or the ability to obtain sufficient oxygen greatly affect
respiratory and overall health status, the disorders that affect this system includes
inflammatory and infective disorders, the pneumonia is predominant infective
disorder among others.
Pneumonia is an acute infection of the pulmonary parenchyma. Despite being the
cause of significant morbidity and mortality, pneumonia is often misdiagnosed,
mistreated, and underestimated.
Causes of pneumonia
Pneumonia is classified according to its etiology; bacterial pneumonia is referred
to as typical pneumonia. Some of the most common causal microorganisms
include bacteria, virus, fungi. Some examples of bacterial microorganisms that may
cause pneumonia including pneumococcal pneumonia caused by streptococcus
pneumonia, staphylococcus pneumonia caused by staphylococcus aureus, gram
negative bacterial pneumonia caused by klebsiella pneumonia, anaerobic bacterial
pneumonia caused by normal oral flora. Some examples of virus that may cause
pneumonia are viral pneumonia: Influenza virus A&B adenoviruses, respiratory
syncytial virus, parainfluenza viruses. Mycoplasma: Mycoplasma pneumonia: by
mycoplasma microorganism. Fungal agents: Fungal pneumonia: by histoplasmosis,
candidiasis. Protozoa: Parasitic pneumonia, common organism is pneumocystis
carinii.
Nosocomial pneumonia is acquired within a hospital to the patient admitted to
the hospital for something else. Risk increased with an underlying illness, recent
surgery, recent intubation, and in persons already on antibiotics.
The following are some risk factors for pneumonia: advanced age,
immunocompromised, underlying lung disease, alcoholism, altered consciousness,
smoking, endotracheal intubation, malnutrition, immobilization, most cases of
pneumonia are preceded by an upper respiratory infection (often viral).
Pathophysiology overview of pneumonia
Pneumonia results from the proliferation of microbial pathogens at the alveolar
level and the host’s response to those pathogens. Many pathogens are inhaled as
contaminated droplets.
When microorganisms evade upper respiratory defense mechanisms, the alveolar
macrophage is capable of removing most infectious agents without triggering
a significant inflammatory or immune response. However, if the microbe is
virulent or present in sufficiently high numbers, it can overwhelm macrophages
and result in a full-scale activation of systemic defense mechanisms. These
mechanisms include the release of multiple chemical mediators of inflammation,
infiltration of white blood cells, and activation of the immune response.
Tight adherence of some bacteria (e.g., Pseudomonas) to the tracheal lining and biofilm
of an endotracheal tube makes clearance of these microbes from the airways
difficult and accounts, in part, for their highly virulent nature. In non-hospitalized
people, bacteria reach the lung by one of four routes:
• Inhalation of microorganisms that have been released into the air when an
infected individual coughs or sneezes
• Aspiration of bacteria from the upper airways
• Spread from contiguous infected site
• Hematogenous spread
Signs and symptoms of pneumonia
Symptoms vary for the different types of pneumonia. The onset of bacterial
pneumonia is sudden. The client experiences fever, headache, myalgia, arthralgia,
chills, chest pain, a productive cough (mucoid, purulent, bloodstained sputum),
dry cough, dyspnea, tachypnea, and hemoptysis and discomfort in the chest wall
muscles from coughing. 20% of patients may have gastrointestinal symptoms such
as nausea, vomiting, and/or diarrhea. Physical examination: Dullness to percussion,
crackles, egophony, individuals also may demonstrate signs and symptoms of
underlying systemic disease or sepsis and decreased level of consciousness.
Pneumonia can be categorized into 3 types:
• Community Acquired Pneumonia (CAP) caused by Streptococcus
pneumonia, Haemophilus influenza, Legionella pneumophila, Mycoplasma
pneumonia, Influenza virus types A, B, adenovirus, parainfluenza,
cytomegalovirus, coronavirus, Chlamydia pneumonia.
• Hospital Acquired Pneumonia (HAP) caused pseudomonas aeruginosa,
Staphylococcus aureus, Klebsiella pneumonia.
• Pneumonia in Immunocompromised Host caused by Pneumocystis carinii,
Aspergillus fumigatus, Mycobacterium tuberculosis.
Investigations
The sputum culture and sensitivity studies can help to identify the infectious
microorganism. A chest film (chest x-ray) shows areas of infiltrates and consolidation.
A complete blood count (CBC) discloses an elevated with Blood Cells (WBC) count.
Blood cultures also may be performed to rule out any microorganisms in the blood.
Adequate medical diagnosis
The auscultation of the chest reveals wheezing, crackles, and decreased breath
sounds. Cyanosis of nail beds, lips, and oral mucosa may be observed during
physical examination (inspection).
The most common investigations to be carried out during pneumonia suggests
the chest x-ray, the biological laboratory tests needed to be performed such as full
blood count (FBC) elevated (more than10000/mm3), although it may be low (below
6000/mm3) if the individual is debilitated. Sputum: Gam-stain and culture, blood
culture, Chest x-ray show infiltrates that may involve a single lobe of the lung (lobar
pneumonia) or may be more diffuse (bronchopneumonia).
Treatment plan for pneumonia
Medical management
The treatment plan of pneumonia depends on the causative agents.
The following are different treatment options:
• Antibiotics in case of bacterial pneumonia such as a macrolide (Clarithromycin/
Erythromycin) or Doxycycline.
– In case of comorbidities or antibiotics in past 3 months: High dose
Amoxicilline or Ceftriaxone plus Macrolide/ doxycycline
– In case of hospitalization: Cefotaxime or Ceftriaxone or Ampicillin plus a
macrolide/ doxycycline
• Adequate hydration to thin secretions
• Supplemental oxygen to alleviate hypoxemia
• Good pulmonary hygiene (deep breathing, coughing)
• Supportive therapy in case of viral pneumonia
Bronchodilators, analgesics, antipyretics, cough expectorants or suppressants,
chest physiotherapy and postural drainage may be used depending on the nature
of the client’s cough.
Nursing management
The nursing management of pneumonia depends on the status of the patient upon
admission.
The following are different nursing interventions:
• Auscultate lung sounds and monitor the client for signs of respiratory difficulty.
Check oxygenation status with pulse oximeter, and give appropriate oxygen
therapy if necessary.
• Monitor the client’s vital signs
• Assessments of cough and sputum production.
• Put the client in the semi-Fowler’s position to aid breathing and increase the
amount of air taken with each breath.
• Ensure increased fluid intake because it helps to loosen secretions and
replace fluids lost through fever and increased respiratory rate.
• Monitor fluid intake and output, skin turgor, vital signs, and serum electrolytes.
• Administer medications as indicated and ordered
• Help cough up secretions
• Suction mucus.
Take samples for lab investigation
• Observation of the level of consciousness,
Preventive measures for pneumonia
• Stop smoking and reduce alcohol intake
• Adequate nutrition
• Immunization
• Practice good hygiene and sanitation
• Physical exercise
For hospitalized individuals:
• Promote coughing and expectoration of secretions if client experiences
increased mucus production.
• Change position frequently if client is immobilized for any reason.
• Encourage deep-breathing and coughing exercises at least every 2 hours.
• Perform chest physiotherapy as indicated
• Suction secretions in case of inability to expectorate.
• Prevent aspiration in clients at risk.
• Apply infection control measures
• Cleanse respiratory equipment on a routine basis.
• Promote frequent oral hygiene.
Evolution and complications of pneumonia
When pneumonia is early and managed effectively, the outcome is observed in few
days. However, in case of late management the following complications may occur:
• Pleural effusion
• Lung abscess
• Respiratory failure