04/11/20231

Pneumonia

SOAP

Saeid kashefi2nd year post.baccNovember 12, 2011, has been

proclaimed World Pneumonia Day.

Every 20 seconds a child dies from pneumonia

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Fluid and pus filled air space

contains bacteria

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Who Gets Pneumonia?

• Anyone can get pneumonia, but some people are at a higher risk than

others.

• Risk factors include:

Cigarette smoking

Recent viral respiratory infection—a cold, laryngitis, influenza, etc.

Difficulty swallowing (due to stroke, dementia, Parkinson's disease, or other

neurological conditions)

Chronic lung disease such as COPD, bronchiectasis, or cystic fibrosis

Heart disease, liver cirrhosis, or diabetes  

Living in a nursing facility

Impaired consciousness (loss of brain function due to dementia, stroke, or

other neurologic conditions)

Recent surgery or trauma

Having a weakened immune system due to illness, certain medications, and

autoimmune disorders

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Community-acquired Pneumonia (CAP) was the 4th leading cause of death in the

world in 2012 according to the WHO and 6th leading cause of death in the U.S.

It’s a Inflammation of one or both lungs.

What Causes Pneumonia?

The infection may be bacterial, viral, fungal.

Pneumonia is extremely contagious

Pneumonia can be a serious and life-threatening infection. This is true especially in

the elderly, children, and those who have other serious medical problems, such as

COPD, heart disease, diabetes, and certain cancers.

Pneumonia

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Pneumonia confirmed by chest X-ray testing. (dense white patch)

CT scan

With pneumonia, sputum is sometimes bloody

Sputum Gram Stain and culture

Pulse oximetry

Routine lab testing –

CBC

BMP (basic metabolic panel)

LFTs

ABG (arterial blood gas)

Diagnosis of Pneumonia

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How do we classify pneumonia?

• Community AcquiredCAP

• Health Care Associated HCAP

• Hospital AcquiredHAP

• ICU AcquiredICUAP

• Ventilator AcquiredVAP

Nosocomial Pneumonias

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Treatment of Community Acquired Pneumonia (CAP)

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Table 116-8 Evidence-Based Empiric Antimicrobial Therapy for Pneumonia in AdultsClinical Setting Usual Pathogens Empiric Therapy

Outpatient/community acquired

•Previously healthy S. pneumoniae, M. pneumoniae, H influenza, C. pneumoniae, M. catarrhalis

Macrolide/azalide, or tetracycline

•Comorbidities (diabetes, heart/lung/liver/renal disease, alcoholism

Fluoroqinoloned or -lactam + macrolideb

•Elderly S. pneumoniae, Gram-negative bacilli Piperacillin/tazobactam or cephalosporine or carbapenemf

Inpatient/community acquired •Non-ICU S. pneumoniae, H. influenza, M.

pneumoniae, C. pneumoniae, Legionellasp. Fluoroquinoloned or -lactam + macrolideb

•ICU S. pneumoniae, S.aureus, Legionella sp, gram-negative bacilli, H. influenza

β-lactam + macrolide or fluoroquinolone; piperacillin/tazobactam

meropenem or cefepime + fluoroquinolone , β-lactam + AMG + azithromycin β-lactam + AMG + respiratory

fluoroquinoloneIf MRSA suspected Above + vancomycin or linezolid

Hospital acquired, ventilator associated, or healthcare associated

•No risk factors for MDR pathogens

S. pneumoniae, H. influenzae, MSSA enteric Gram-negative bacilli

Ceftriaxone or fluoroquinoloned or ampicillin/sulbactam or ertapenem or doripenem

•Risk factors for MDR pathogen

P. aeruginosa, K. pneumoniae (ESBL), Acinetobacter sp.,

Antipseudomonal cephalosporine or antipseudomonal carbapenem or -lactam/-lactamase + antipseudomonal fluoroquinoloned or AMG

If MRSA or Legionella sp. suspected Above + vancomycin or linezolid•Aspiration Mouth anaerobes, S. aereus, enteric Gram-

negative bacilli Penicillin or clindamycin or piperacillin/tazobactum + AMG

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SOAP

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*Bilateral pneumonia and ARDS

*Right sided pneumonia

*Septic shock

Problem List

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*C/O sudden onset breathlessness since morning (3 AM)

*Associated with shivering, severe sweating

Subjective Evidence

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Physical Examination:

*RR-35/min

*SpO2-60% ( 95-100%)

*RS : Right B/L basal creps+

Objective Evidence

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*WBC: 22.0 x103 cells/mm3

*N: 90.9 (35-75)%

* L: 4.9 (20-45)%

Routine Biochemical Investigation

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*Bilateral pneumonia and ARDS

*Right sided pneumonia

*Septic shock

FINAL DIAGNOSIS

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ETIOLOGY

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Table 116-6 Pneumonia Classifications and Risk Factors

Type of Pneumonia Definition Risk FactorsCommunity

acquired (CAP)Pneumonia developing in patients with no contact to

a medical facility

•Age >65 years •Diabetes Mellitus •Asplenia •Chronic cardiovascular, pulmonary, renal and/or liver disease •Smoking and/or alcohol abuse

Healthcare associated (HCAP)

Pneumonia developing in patients not in medical facility but two or more risk factors for MDR pathogens

•Recent hospitalization 2 days within past 90 days •Nursing home or long-term care facility resident •Recent (past 30 days) antibiotic use, chemotherapy, wound care or infusion therapy either at a healthcare facility or home •Hemodialysis patients •Contact with a family member with infection caused by MDR pathogen

Hospital-acquired (HAP)

Pneumonia developing >48 hours after hospital admission

•Witnessed aspiration •COPD, ARDS, or coma •Administration of antacids or H2-antagonists •Supine position •Enteral nutrition, nasogastric tube •Reintubation, tracheostomy, or patient transport •Prior antibiotic exposure •Head trauma, ICP monitoring •Age >60 years •See healthcare associated for MDR risk factors •Same as hospital acquired

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*Yes, therapy is indicated to Reduce morbidity and mortality

Prevent complications and Improve quality of life.

Assessment if therapy is indicated?

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Drug with Dose & Route 12/10

 13/10

 14/10

15/10

16/10

Generic Name Dosage form

Brand Name   1ICU

2ICU

3ICU

4 5

Piperacillin/Tazobactam

Inj. Tazillin 4.5 g IV 

Stat in 50 ml of NS over 1 hrs

  Over 30min

Methylprednisolone Inj. Solumedrol 40 mg

in 40 ml NS Q8H

     

 Dopamine Inj. Dopamine 6 ml/hr      

Ipratropium (20mcg/1puff)Levosalbutamol (50mcg)

Neb. Duolin Q6H      

Pantoprazole Tab. Pan 40mg 1-0-0 (b/f)      

Paracetamol Tab. Dolo 650mg SOS      

Chlorpheniramine Inj Avil IV 1amp SOS      

Ondansetron Inj. Emeset 4mg IV SOS      

 NA Inf Na        

Montelukast Tab Montair Stat-1      

 Salbutamol (100ml) Neb Asthalin Stat      

Chlorpheniramine (4mg/5mL)/ Dextromethorphan (10mg)

Syp Aerodil 2tsp 1-0-1

     

   Cap Becelac forte 1-1-1      

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Assessment of

Current Therapy

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*Class: Piperacillin : extended-spectrum beta-lactam antibiotic of the ureidopenicillin class.

Tazobactam: β-lactamase inhibitor.

*MOA: Piperacillin inhibits bacterial cell wall synthesis.

Tazobactum inhibits the action of bacterial β-lactamases.

*Indication: is indicated for Community-acquired pneumonia (moderate severity only),

Nosocomial pneumonia (moderate to severe)

*Justification: It is correctly indicated according to the Infectious Diseases Society of American Guidelines on the Management of CAP in Adults.

*Dose, dosage and schedule were found to be correct.

*ADR: Prolongation of bleeding time, anaphylaxis, nausea,

vomiting, diarrhea.

Inj. Tazillin 4.5 g IV (Piperacillin/Tazobactam) Stat in 50 ml of NS over 1 hrs Days 1-5

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*Class: Corticosteroid drug

*MOA: It inhibit the potent mediators of inflammation such as prostaglandins and

leukotrienes.

*Indication: It is indicated for breathlessness

*Justification: It is correctly indicated as patient was having breathlessness as

symptoms of pneumonia

*Dose, dosage and schedule were found to be correct.

*ADR: Hypercalciuria, hypokalemic alkalosis, CHF, PUC, HTN, viral infections,

itching, allergic skin reactions.

Inj. Solu medrol 40 mg (Methylprednisolone) in 40 ml NS Q8H DAY 1

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*MOA: increases blood pressure by acting on both α and β-1 receptors.

*Indication: It is given for the treatment of severe hypotension and septic shock

*Justification: It is correctly indicated as the patient had hypotension on day 1 and septic shock

*Dose, dosage and schedule were found to be correct.

*ADR: nervousness, headache, dysrhythmias, palpitations, chest pain, dyspnea,

nausea, and vomiting.

INJ. Dopamine 6 ml/hr DAY 1

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*Class: anticholinergic agent/Stimulates β- receptors

*MOA: Ipratropium bromide: decreased contractility of smooth muscle/

Levosalbutamol: Stimulates β-receptors

*Indication: breathlessness.

*Justification: It is indicated correctly because patient had breathlessness from day 1

*Dose, dosage and schedule were found to be correct.

*ADR: tremor, tachycardia, leg cramps, dizziness, vomiting

Neb. Duolin (Ipratropium (20 mcg/1puff)Levo-salbutamol (50 mcg)) Q6H DAYS 1-3

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Class: proton pump inhibitor (PPI)

MOA: Pantoprazole inhibit H+/K+ - ATPase enzyme

Indication: for prevention of gastric irritation

Justification: It is indicated to prevent gastric irritation due to poly pharmacy

Dose, dosage and schedule were found to be correct.

ADR: Weakness, dizziness, nausea, vomiting, anxiety, dyspnea, pain, pharyngitis, cough,

arthralgia, rhinitis, chest pain, bronchitis, backache, urinary frequency, UTI, hyperlipidemia.

Tab. Pan 40 mg (Pantoprazole) 1-0-0 (b/f) Day 1-5

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*Class: NSAIDs (antipyretic and analgesic)

*Indication: for chills (as symptoms of pneumonia) as well as RA.

*Justification: It is indicated correctly because the patient had chills on day 1 and RA

according to medical history. (Patient has been taking paracetamol)

*Dose, dosage and schedule were found to be correct.

*ADR: Bronchospasm, blood dyscrasias, centribular necrosis, liver damage,

hypoglycemic coma, hepatic necrosis, liver failure, skin rashes, GI adverse effects.

Tab. Dolo 650mg (Paracetamol) SOS DAYS

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*Class: first-generation alkylamine antihistamine

*MOA: it is H1-receptor antagonist

*Indication: cough, running nose (since 4 days back)

*Justification: It is correctly indicated as the patient had cough

*Dose, dosage and schedule were found to be correct.

*ADR: Blurred vision, dry eyes, mydriasis, drowsiness, constipation, fatigue, headache, dizziness, psychomotor impairment, dry mouth, gastrointestinal disturbances.

Inj. Avil IV (Chlorpheniramine) 1amp SOS

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Inj. Emeset 4mg IV (Ondansetron) S.O.S. days 1-2

Class: prevent nausea and vomiting caused by cancer chemotherapy, radiation therapy, and surgery.

MOA: serotonin (5HT3) antagonist

Indication: given for vomiting

Justification: It is given due to patient suffering from vomiting.

Dose, dosage and schedule were found to be correct.

ADR: Headache, dizziness, drowsiness, tiredness, or constipation may occur.

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*Class: catecholamine (adrenergic agonists)

*MOA: norepinephrine stimulates cardiac contractility.

*Indication: hypotensive states, septicaemia

*Justification: It is correctly indicated as the patient had hypotension and septic

shock. (Norepinephrine is used to treat shock, because it increases vascular resistance and, therefore,

increases blood pressure. Other actions of norepinephrine are not considered to be clinically significant.)

*Dose, dosage and schedule were found to be correct.

*ADR: ausea, stomach upset, skin rash, acute toxicity.

Inf. NA (Noradrenaline) day-2

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*Class: leukotriene receptor antagonist

*MOA: Montelukast selectively antagonizes LTD4, preventing smooth muscle

contraction.

*Indication: breathlessness

*Justification: This reduces the bronchoconstriction caused by the leukotriene, and

results in less inflammation

*Dose, dosage and schedule were found to be correct.

*ADR: Angioedema, headache, restlessness, abdominal pain, agitation, oedema,

allergy anaphylaxis.

Tab. Montair (Montelukast) Stat-1 DAY- 1

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*Class: β2-agonist

*MOA: direct-acting sympathomimetic which producing bronchodilating effects.

*Indication: breathlessness

*Justification: It is given correctly as the patient complained of breathlessness

*Dose, dosage and schedule were found to be correct.

*ADR: Fine skeletal muscle tremor especially hands, tachycardia, palpitations, muscle

cramps, headache, angioedema, urticaria, hypotension and collapse.

Neb. Asthalin (Salbutamol (100ml)) Stat

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*Class: Lactobacillus acidophilus 2000lacs, Folic acid 1.5 mg, Vit.B12 15 mcg ,Niacinamide 100 mg, Calcium pantothenate 50 mg, Biotin 100mcg.

*MOA: It helps to prevent harmful bacterial growth.

*Indication: Used For vitamins and minerals deficiency due to diarreha.

*Justification: It is given correctly as in cases of mild Antibiotic induced diarrhea.

*Dose, dosage and schedule were found to be correct.

Cap Becelac forte 1-1-1 day 4-5

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*Class: Antitussive agent

*MOA: Chlorpheniramine is an H1-antagonist. Dextromethorphan acts as

antagonist to the NMDA glutamatergic receptor

*Indications: used for treatment and prevention of cough.

*Justification: correctly indicated as patient suffered from cough.

*Dose, dosage and schedule were found to be correct.

*ADR: Dependency, dizziness, drowsiness, vomiting, restlessness, mental confusion,

excitation

Syrp. Aerodil (Chlorpheniramine (4mg/5mL)/ Dextromethorphan (10mg)) 2 tsp 1-0-1 day 4

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PLANNING

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* Eradication of the offending organism through selection of the

appropriate antibiotic and complete clinical cure

*To decrease morbidity and mortality

*To prevent complications

*To relieve patient symptoms

*To improve quality of life

Goals of Therapy

Monitoring Parameters

Therapeutic Monitoring Toxicity Monitoring

vitals, RR, SpO2-

chest Xray

RS :B/L basal creps+,

WBC:

plateleate

Electrolytes

Heart rate

Fatiguability

Pedal edema

Jaundice

Input/output

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*Patient having high TSH which indicated for hypothyroidism.

*Blood urea nitrogen level

*Ondansetron is not for preventing nausea or vomiting that is caused by factors other than cancer treatment or surgery.

Points to Physician

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Points to the patient:

You have infection in your lung and it can be treated if you adhere to your therapy.

It is contagious which can be spread easily.

Hence care must be taken.

Points to Patient

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How to Strengthen Your Lungs After Having Pneumonia

Method 1: Performing Breathing Exercises

1-Practice deep breathing.

2-Do pursed-lip breathing.

3-Try breathing from your diaphragm

4-Practice huff-cough breathing.

Life Style Modification

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At Home

*Rest as much as possible to help speed your recovery.

*Drink plenty of fluids throughout the day.

*Take the entire course of any prescribed medications.

*Get enough vitamins and minerals.

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Tab pan 40 mg 1-0-0

Tab tazillin 4.5 gm Q8h

Syr aerodil 2tsp 1-0-1

Tab dolo 650mg sos

Points to Patient on Discharge Medication

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*It is antibiotic which is indicated for treatment of pneumonia.

*It should be taken one tablet each every 8 hours.

*You may have nausea, vomiting and diarrhea as side effects.

Tab tazillin 4.5 gm Q8h

Tab pan 40 mg 1-0-0

*It is indicated to prevent gastric irritation due to multi drugs.

*One tablet should be taken 30 min. before breakfast.

*You may have weakness, dizziness, nausea, vomiting or anxiety as side effects.

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*It is indicated to reduce your cough.

*It should be taken 2 tea spoon each 12hours.

*You may have dizziness, drowsiness, vomiting, restlessness as side effects.

Syr aerodil 2tsp 1-0-1

Tab dolo 650mg sos

It is indicated for your Rheumatoid Arthritis.

You should take it whenever there is pain in your joints.

You may have nausea, vomiting and diarrhea as side effects.

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*To review SOS

Follow up/Review

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