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Jen Denno RN, BSN, CEN Slide 2 Pneumonia Vaccination Percent of adults 65 years and over who had ever received a pneumococcal vaccination: 59% Health Care Use Hospital inpatient care Number of discharges: 1.1 million Average length of stay: 5.2 days Nursing home care Number of residents with pneumonia: 33,700 Percent of residents with pneumonia: 2.3% Mortality Number of deaths: 50,774 Deaths per 100,000 population: 16.5 Slide 3 Slide 4 CURB-65 CURB-65 is a scoring system developed from a multivariate analysis of 1068 patients that identified various factors that appeared to play a role in patient mortality.[32] One point is given for the presence of each of the following: C onfusion Altered mental status U remia Blood urea nitrogen (BUN) level greater than 20 mg/dL R espiratory rate 30 breaths or more per minute B lood pressure Systolic pressure less than 90 mm Hg or diastolic pressure less than 60 mm Hg Age older than 65 years Current guidelines suggest that patients may be treated in an outpatient setting or may require hospitalization according to their CURB-65 score, as follows: Score of 0-1 Outpatient treatment Score of 2 Admission to medical ward Score of 3 or higher Admission to intensive care unit (ICU) Slide 5 AHRQ: Pneumonia Severity Index Age, men Starting point value is age in years Age, women Starting point value is age in years minus 10 points Nursing home resident Add 10 points Coexisting illnesses are scored as follows: Neoplasia Add 30 points Liver disease Add 20 points Congestive heart failure, cerebrovascular disease, renal disease Add 10 points for each Physical examination findings are scored as follows: Altered mental status Add 20 points Respiratory rate of 30 breaths or more per minute Add 20 points Systolic blood pressure less than 90 mmHg Add 20 points Temperature less than 35C or that is 40C or higher Add 15 points Pulse greater than 125 bpm Add 10 points Laboratory and radiographic findings are scored as follows: Slide 6 PSI Arterial pH less than 7.35 Add 30 points BUN value of 30 mg/dL or greater Add 20 points Sodium level less than 130 mmol/L Add 20 points Glucose level of 250 mg/dL or greater Add 10 points Hematocrit value less than 30% Add 10 points Partial arterial pressure (PaO2) less than 60 mm Hg or peripheral oxygen saturation (SpO2) less than 90% Add 10 points Pleural effusion Add 10 points The combined total points make up the risk score, which stratifies patients into 5 PSI mortality risk classes, as follows: 0-50 points = Class I (0.1% mortality) 51-70 points = Class II (0.6% mortality) 71-90 points = Class III (0.9% mortality) 91-130 points = Class IV (9.3% mortality) More than 130 points = Class V (27% mortality) Slide 7 Sputum production S pneumoniae is classically associated with a cough productive of rust-colored sputum. Pseudomonas, Haemophilus, and pneumococcal species may produce green sputum. Klebsiella species pneumonia is classically associated with a cough productive of red currant-jelly sputum. Anaerobic infections often produce foul-smelling or bad-tasting sputum. Slide 8 Black Lungs v. White Lungs On an x-ray, lungs can show up as either black or white. If the lung appears black, it is perfectly healthy, as black indicates that the x-ray passed through air. If the lung appears white on the x- ray image, the same color as bones and solid objects, it indicates that the lung is full of fluid. This is the case with an infected pneumonia lung. Slide 9 In the case of bacterial pneumonia, bacteria invade alveoli air sacs and elicit an immune response. White blood cells called neutrophils arrive and engulf bacteria In the case of viral pneumonia, viruses attack alveolar cells, which die or self destruct. This too triggers an immune response, this time by lymphocyte white blood cells. The lymphocytes release cytokines that cause fluid to leak into the alveoli Slide 10 Slide 11 Viral vs Bacterial Interstitial infiltrates on chest radiographs are generally believed to suggest a viral cause of pneumonia and alveolar infiltrates to indicate a bacterial cause Slide 12 Slide 13 Slide 14 VIRAL Viral infections are characterized by the accumulation of mono- nuclear cells in the submucosa and perivascular space, resulting in partial obstruction of the airway. Patients with these infections present with wheezing and crackles. Slide 15 VIRAL Disease progresses when the alveolar type II cells lose their structural integrity and surfactant production is diminished, a hyaline membrane forms, and pulmonary edema develops. Slide 16 Do we treat viral pneumonia with antibiotics? The influenza pandemic of 1918 was responsible for the deaths of approximately 40-50 million people worldwide (>600,000 deaths in the United States), many of which were likely ultimately due to secondary bacterial infection. With the 2009 H1N1 influenza A pandemic, the US Centers for Disease Control and Prevention (CDC) mortality estimates range from 8,800 to 18,000 between April 2009 and April 2010. The vast majority of deaths occurred in individuals younger than 65 years. Evaluation of 77 postmortem lung specimens by the CDC revealed that 29% of those that died also had evidence of bacterial coinfection. Slide 17 Bacterial In bacterial infections, the alveoli fill with proteinaceous fluid, which triggers a brisk influx of red blood cells (RBCs) and polymorphonuclear (PMN) cells (red hepatization) followed by the deposition of fibrin and the degradation of inflammatory cells (gray hepatization). During resolution, intra-alveolar debris is ingested and removed by the alveolar macrophages. This consolidation leads to decreased air entry and dullness to percussion; inflammation in the small airways leads to crackles. Slide 18 Four stages of lobar pneumonia have been described. Stage 1 In the first stage, which occurs within 24 hours of infection, the lung is characterized microscopically by vascular congestion and alveolar edema. Many bacteria and few neutrophils are present. What are the signs and symptoms of a new pneumonia? Slide 19 Stage 2 The stage of red hepatization (2-3 d), so called because of its similarity to the consistency of liver, is characterized by the presence of many erythrocytes, neutrophils, desquamated epithelial cells, and fibrin within the alveoli. What do you think the patient looks like during this stage? Slide 20 Stage 3 In the stage of gray hepatization (2-3 d), the lung is gray-brown to yellow because of fibrinopurulent exudate, disintegration of RBCs, and hemosiderin. What complications would you anticipate in a patient during this stage? Slide 21 Stage 4 The final stage of resolution is characterized by resorption and restoration of the pulmonary architecture. Fibrinous inflammation may lead to resolution or to organization and pleural adhesions. What co-morbidities could cause this stage to last a long time? Slide 22 What stage is coughing most present? 1 2 3 4 Slide 23 What nursing interventions are important during the stages with coughing? Slide 24 Klebsiella How do you get it? eating unwashed vegetables and drinking contaminated water. Slide 25 Most of the time, a Klebsiella pneumoniae infection is very common in patients with underlying diseases like diabetes, chronic lung diseases, chronic alcoholics, etc. It is mostly a nosocomial infection that occurs in hospitalized patients with weakened immune system. Slide 26 Once Klebsiella pneumoniae enters the lungs, it causes many destructive changes in the lungs. It leads to necrosis, inflammation, hemorrhage, etc. of the lung tissues. This leads to production of a very thick, jelly like mucus that is called 'currant jelly sputum'. The rapid destruction of the lung tissues is the distinguishing factor for Klebsiella pneumoniae infection. Initially, Klebsiella pneumoniae will cause a sudden high fever. This fever is generally more than 103F. The fever is accompanied by other symptoms like chills and dizziness. The patient will also cough up the thick currant jelly sputum. This sputum may show streaks of blood. Slide 27 As the condition spreads, it leads to formation of abscess. These abscesses are dead tissue pockets that contain millions of Klebsiella pneumoniae bacteria. Formation of abscesses cause the lungs to stick with the connective tissues surrounding them. This may lead to collapsed lungs in some patients. Soon, the infection spreads to the upper respiratory tract. When the infection spreads, it causes severe airway congestion. This leads to a foul-smelling nasal discharge. Slide 28 Other common pneumonias Strep Pseudomonas CORE MEASURES Order sets Slide 29 Current research The 3-steps of the critical pathway involved, first, the early mobilization of patients, followed by the use of objective criteria for switching to oral antibiotic therapy, and then the use of predefined criteria for deciding on hospital discharge. The median LOS was significantly shorter in the 3-step group than in the usual care group (3.9 days vs 6.0 days, respectively; P