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What’s New in Managing Pneumonias

Anne Dabrow Woods, DNP, RN, CRNP, ANP-BC, AGACNP-BC Chief Nurse

Wolters Kluwer Philadelphia, PA

Acute Care Nurse Practitioner

Critical Care Service, Penn Medicine, Chester County Hospital West Chester, PA

Adjunct Faculty

Drexel University, College of Nursing & Health Sciences Philadelphia, PA

Copyright Anne Dabrow Woods; all rights reserved

Disclosure:

• I have nothing to disclose.

Objectives:

• At the conclusion of this session you will be able to:

• Identify the definitions and causes of community-acquired pneumonia (CAP), healthcare-associated pneumonia (HCAP), hospital-acquired pneumonia (HAP), and ventilator-associated pneumonia (VAP).

• Identify the presentation and the diagnostic studies for each type of pneumonia.

• Identify the treatment and prevention plans for each type of pneumonia and respiratory failure.

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Definition of pneumonia

• Acute, febrile inflammatory disorder of the lungs associated with cough and exertional dyspnea

• Infiltrate on chest x-ray

• Appearance on CXR may lag 24 to 48 hours behind clinical presentation

• Leukocytosis – elevated WBCs

Types of pneumonia

• Community-acquired pneumonia

• Hospital-acquired pneumonia

• Healthcare-associated pneumonia

• Ventilator-associated pneumonia

• Other ways to look at pneumonias

• Organism

• Bacterial

• Viral

• Fungal

• Mode of entry

• Aspiration

Let’s look at Bacteria…

• Classification

• Morphology: (cocci, bacilli, spirochetes)

• Gram Stain: cell wall presence and properties (gram-positive vs. gram-negative),

• Colony clustering: clusters, pairs or chains

• Growth requirements (aerobic vs. anaerobic)

• Presence of a capsule (e.g., encapsulated bacteria) or spores (e.g., spore-forming bacteria).

• Biochemistry and appearance on agar

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Gram + vs. Gram - Organisms

• Selective staining of the cell walls with crystal violet

• Gram positives absorb the stainpurple

• Gram negative organisms the stain easily washes awaypink

Gram positive cocci in clusters, Gram negative bacilli

Comparing organisms • Gram –

• Cocci – neisseria, moraxella

• Bacilli • Aerobic – vibrio,

enterobacter, acinetobacter, ecoli, klebsiella, haemophilus, proteus, salmonella, shigella, pseudomonas, acinobacter

• Anerobic – bacteroides, prevotella, fusobacterium

• Gram + • Cocci

• Aerobic • clusters (staph)

• chains/pairs (strep), enterococcus

• Anerobic – peptococcus

• Bacilli • Aerobic – lactobacillus,

gardenella, cornybacter, listeria

• Anerobic – actinomyces, clostridium

Atypical bacteria

• Colorless – do not color with gram staining

• Responsible for 20 to 30% of CAP

• The big 3 atypicals

• Mycoplasma pneumoniae

• Chlamydia pneumoniae

• Legionella pneumonphilia

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Let’s look at the alphabet soup of pneumonia…

Community-acquired pneumonia (CAP) • Acquired in the community; most common type of pneumonia

• 4 to 5 million cases per year • 25% of cases require hospitalization • In hospital mortality 10-12% (mild cases not admitted - < 1%)

• If patient gets admitted to the hospital and develops pneumonia within 48 hours – CAP • Cause: defense mechanism failure

• Cough reflex • Mucociliary clearance system • Immune response

• Organisms • Bacteria

• Strep pneumoniae (most common in adults) – gm + • Haemophilus influenza – gm - • Klebsiella pneumoniae – gm -

• Atypical • Chlamydia pneumoniae • Mycoplasma pneumoniae • Mycobacterium tuberculosis

• Viruses • Respiratory syncytial virus • Adenovirus • Rhinovirus

Hospital-acquired pneumonia (HAP)

• Definition:

• Occurs 48 hours after admission to the hospital and it wasn’t incubating at time of admission

• We gave it to the patient!

• Most common organisms

• Staphylococcus aureus – gram +

• Streptococcus pneumoniae – gram +

• Haemophilus influenzae – gram -

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Ventilator-associated pneumonia (VAP)

• Definition

• Pneumonia that occurs 48 to 72 hours post intubation

• Risk increases with poor oral care

• Most common organism

• Pseudomonas aeruginosa – gram -

Healthcare-associated pneumonia (HCAP)

• Definition

• Patient was in hospital or a healthcare setting for 2 or more days within 90 days of infection and develop pneumonia

• Long-term care facilities

• Assisted living

• Rehabilitation

• Nursing home

• IV therapy including antibiotics

• Chemotherapy – within 30 days of current infection

• Wound care – within 30 days of current infection

• Hemodialysis clinic

HCAP organisms

• More similar to HAP than CAP

• Staphylococcus aureus (gram +)

• Pseudomonas aeruginosa (gram -)

• Less likely but possible

• Streptococcus pneumoniae (gram +)

• Haemophilus influenzae (gram -)

• MRSA (gram +)

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Pneumonia categorized by risk factors

• Aspiration pneumonia or pneumonitis

• R upper and R middle lobe most commonly affected

• Obstruction of the airway

• Tumor

• Secretions

• Inhalation injury

• Hypersensitivity pneumonia

• Near drowning

Comorbidities that increase mortality…

• COPD

• Heart Failure

• Diabetes

• Chronic liver disease

• Chronic kidney disease

• Very old

• Very young

Patient presentation

• “Typical pneumonia”

• Fever

• Chills or Rigors

• Leukocytosis (increased WBCs)

• Cough

• Sputum production

• Increased fremitus

• CXR

• Usually involves one lung and one lobe

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Patient Presentation

• “Atypical pneumonia”

• Fever or low temperature

• Leukocytosis – may be absent or have left shift on CBC (presence of bands)

• Dry cough

• Sore throat

• Headache

• Excessive sweating

• Soreness in chest or with cough

• CXR

• More diffuse pattern on CXR

• May involve more than one lung and multiple lobes

Diagnostics

• Chest Xray

• Sputum culture

• Blood cultures

• CBC with diff

• Chem 20

• PT/INR – for those on warfarin

• ABG – if worried about acute respiratory failure

A word about CXR

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Normal CXR

RML pneumonia

LLL pneumonia

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Multilobar pneumonia – RUL,RML, RLL

To admit or not to admit…

• CURB-65 (predicts mortality)

• Confusion - 1 point

• Uremia (BUN > 19) – 1 point

• Respiratory Rate (> 30/min) – 1 point

• Blood pressure (SBP< 90 or DBP < 60) – 1 point

• Age (> 65 years) – 1 point

• Action

• 0 to 1: treat as outpatient

• 2: consider short stay in hospital or watch closely as outpatient

• 3-5: requires hospitalization

Pneumonia severity scale (PSI)

Step 1: Stratify to Risk Class I vs. Risk Classes II-V

Presence of:

Over 50 years of age Yes/No

Altered mental status Yes/No

Pulse ≥125/minute Yes/No

Respiratory rate >30/minute Yes/No

Systolic blood pressure

<90 mm Hg Yes/No

Temperature <35°C or ≥40°C Yes/No

History of:

Neoplastic disease Yes/No

Congestive heart failure Yes/No

Cerebrovascular disease Yes/No

Renal disease Yes/No

Liver disease Yes/No

If any "Yes", then proceed to

Step 2

If all "No" then assign to Risk

Class I

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Step 2: Stratify to Risk Class II vs III vs IV vs V

Demographics Points Assigned

If Male +Age (yr)

If Female +Age (yr) - 10

Nursing home

resident +10

Comorbidity

Neoplastic

disease +30

Liver disease +20

Congestive

heart failure +10

Cerebrovascula

r disease +10

Renal disease +10

Physical Exam Findings

Altered mental

status +20

Pulse

≥125/minute +10

Respiratory rate

>30/minute +20

Systolic blood

pressure <90 mm

Hg +20

Temperature

<35°C or ≥40°C +15

Lab and Radiographic Findings

Arterial pH <7.35 +30

Blood urea nitrogen

≥30 mg/dl (9 mmol/liter) +20

Sodium <130 mmol/liter +20

Glucose ≥250 mg/dl

(14 mmol/liter) +10

Hematocrit <30% +10

Partial pressure of arterial O2

<60mmHg +10

Pleural effusion +10

∑ <70 = Risk Class II

∑ 71-90 = Risk Class III

∑ 91-130 = Risk Class IV

∑ >130 = Risk Class V

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Treatment for pneumonia

• Right drug for the right bug – antibiotics, antivirals, antifungals

• Hydration

• NSS and LR for volume replacement

• Supplemental oxygen – keep SpO2 > 93%

• Nasal cannula

• HFNC

• Bipap

• Ventilator

• Fever management – fever helpful; don’t treat unless over 101.5 or symptomatic

• Acetaminophen – antipyretic and analgesic

• NSAIDS – antipyretic, analgesic, anti-inflammatory

• Bronchoscopy

• Supportive care

A word about …

• Antihistamines • Works for allergies not pneumonia

• Decongestants • Works for rhinitis and nasal congestion

• Cough suppressants • Only use at night to sleep

• If cough is productive – do not use

• Expectorants • Liquefies secretions

• Use if has nasal congestion or need to loosen secretions

Right bug…

• Gram –

• Cocci – neisseria, moraxella

• Bacilli

• Aerobic – vibrio, enterobacter, acinetobacter, ecoli, klebsiella, haemophilus, proteus, salmonella, shigella, pseudomonas, acinobacter

• Anerobic – bacteroides, prevotella, fusobacterium

• Gram + • Cocci

• Aerobic • clusters (staph)

• chains/pairs (strep), enterococcus

• Anerobic – peptococcus

• Bacilli • Aerobic – lactobacillus,

gardenella, cornybacter, listeria

• Anerobic – actinomyces, clostridium

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Atypical bacteria

• Colorless – do not color with gram staining

• Responsible for 20 to 30% of CAP

• The big 3 atypicals

• Mycoplasma pneumoniae

• Chlamydia pneumoniae

• Legionella pneumonphilia

Kill fast or kill slow…

• Bacteriostatic agent prevents growth (slower kill) of bacteria, keeping them in the stationary phase of growth.

• Bactericidal agents kill more than 99.9% of bacteria found in an inoculum.

• Always use bactericidal in these cases:

• Endocarditis secondary to cardiac vegetation

• Meningitis due to the poor immune competence of CNS

• Neutropenia due to the immunocompromised status of the host

Death or slow kill

• Cidals

• PCN

• Cephalosporin

• Carbapenems

• Vancomycin

• Quinalones

• Metrondiazole

• Static

• Macrolides

• Tetracyclines

• linezolid

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Right drug…

• Gram –

• Piperacillin/tazobactam – (Zosyn) – pseudomonas

• Cephalosporins – 3,4,5

• Aztreonam

• Quinalones (Levaquin)

• Metrondiazole

• Macrolides for CAP and travelers diarrhea

• Gram +

• Penicillins and Penicillin with Clavulanate (Augmentin)

• good for strep but not staph

• Zosyn

• Cephalosporins 1,2,3?

• Vancomycin – MRSA

• linezolid

Suspect Infection

Culture Suspected Sites

Begin empiric Therapy

Gram Stain

Identification of Organisms

Susceptibilities

Adjust to definitive therapy

Steps to antibiotic prescribing and use…

Antibiotic stewardship • Right drug for the right bug

• Only use antibiotics for bacterial infections

• Empiric coverage and then specific coverage

• Give antibiotics as ordered

• If on warfarin, watch INR

• INR prolonged with many antibiotics

• Instruct patient to take as instructed and for the full course of therapy

• Work with team to make sure sensitivities are monitored

• Re-culture if spikes temp over 101.5 after being on antibiotics for 48 hours

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Right drug: CAP treatment • CAP (no comorbid conditions) – macrolide (Azithromycin)

• CAP with risk factors – respiratory fluoroquinolone – (Levaquin)

• CAP inpatient (not ICU) –

• respiratory fluoroquinolone (Levaquin) OR

• Macrolide (Azithromycin) + beta-lactam antibiotic (amoxicillin/clavulanate; Augmentin)

• CAP requiring ICU

• respiratory fluoroquinolone (Levaquin) OR

• Macrolide (Azithromycin) + antipseudomonal coverage (piperacillin/tazobactam; Zosyn)

Right drug: HAP treatment

• Low risk of multiple drug-resistant pathogens; use one of the following

• Ceftriaxone (Rocephin)

• Moxifloxacin (Avelox)

• Levofloxacin (Levaquin)

• Ampicillin/sulbactam (Unasyn)

• Pipercillin/tazobactam (Zosyn)

Right drug: HAP/VAP: high risk of multi-drug resistance

• Chose one agent from each category

• Antipseudomonal coverage

• Cefipime

• Piperacillin/tazobactam (Zosyn)

• PCN allergic patients: aztreonam

• A second antipseudomonal coverage

• Levoflaxacin

• Coverage for MRSA

• Vancomycin IV (dosed based on renal function to achieve trough of 15-20 mcg/ml)

• Linezolid

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COPD exacerbation secondary to Pneumonia

Definition of COPD

• A preventable, progressive disease of the lungs caused by airflow limitation that is not fully reversible

• Cause – smoking!

• Chronic bronchitis

• Emphysema

Inflammation

Small airway remodeling and

alveolar destruction

Airflow limitation

The pathophysiology behind COPD

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Chronic bronchitis versus emphysema

The picture of COPD

Stages of COPD and treatment • I. Mild – Reduce risk factors, influenza vaccine, SABA if needed

• II. Moderate – SABA + anticholinergic + LABA + Rehab

• III. Severe – SABA + LABA + ICS (for repeated exacerbations

• IV. Very Severe – SABA + LABA + ICS + O2 + consider surgical treatment

• Understanding the acronyms

• SABA – short acting beta-agonist (albuterol)

• LABA – long acting beta-agonist [(salmeterol (Serevent)]

• Anticholinergic – ipratropium (atrovent) or tiotropium (Spiriva)

• ICS – inhaled corticosteroid (beclomethasone, budesonide, fluticasone, triamcinolone)

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What defines a COPD exacerbation?

• Increased sputum production

• Increased sputum purulence

• Increased dyspnea

Treatment • Oxygen – keep SpO2 88-92% • Hydration • Noninvasive ventilation

• HFNC • Bipap

• Albuterol – episodic symptoms • Duonebs – albuterol + atrovent every 4 to 6 hours (then switch to long

acting once exacerbation under control)- conflicting evidence • Antibiotics or antivirals if has underlying bacterial/viral infection • Flutter valve • Chest percussion • Steroids

• Oral 40-60 mg prednisolone x 5 days (taper if used over 7 days) • For impending respiratory failure

• IV: methylprednisolone 60 mg 1 to 4 times per day up to 240 mg/day; 5-14 days (taper if used over 7 days)

• Ventilatory support

Acute respiratory failure

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Etiology of Acute Respiratory Failure

• Failure of oxygenation or carbon dioxide elimination

• Reduced lung capacity and increased ventilation/perfusion mismatch

• Reduced chest wall compliance and diaphragmatic and intercostal muscle strength

• Reduced clearance of airway secretions

• Altered responsiveness to hypoxemia and hypercarbia

• Acute versus chronic

• Acute – occurs over minutes to hours

• Chronic – occurs over days – usually see renal compensation

Understanding the causes… • Type 1 – hypoxemia (PaO2 < 60 mm Hg)

• Cardiogenic cause

• Pulmonary edema

• Noncardiogenic cause

• Pneumonia

• Pulmonary hemorrhage

• Pulmonary embolism

• Type 2 – Hypercarbia (PaCO2 > 50 mm Hg)

• Hypoventilation secondary to

• Drug overdose

• Neuromuscular disease

• Hypercarbia secondary to

• Asthma

• COPD

• Pulmonary embolism

Acute respiratory failure…

• Type 1 – hypoxemic respiratory failure

• Problem is oxygen!

• PaO2 < 60 mm Hg with normal PaCO2

• Type 2 – hypercarbic respiratory failure

• Problem is carbon dioxide!

• PaCO2 > 50 mm Hg

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Identify the causes…

It’s all about the pump…

It’s all about the circulation…

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It’s all about gas exchange…

Arterial blood gases • pH

• Normal 7.35-7.45

• Below 7.35 – acidosis

• Above 7.45 - alkalosis

• PaCO2

• Normal 35-45 mm Hg

• Above 45 means – hypoventilation causing CO2 retention

• Below 35 means – hyperventilation, blowing off CO2

• PaO2

• Normal 80-100 mm Hg

• HCO3

• Normal 22-26 mEq/L ( metabolic compensation by the kidneys)

• High level – kidneys are increasing HCO3 in blood for alkalosis

• Low level – kidneys are decreasing HCO3 in blood for acidosis

• SaO2 – Normal is > 95% (doesn’t always correlate to the SpO2)

ABG interpretation • Step 1: Analyze the pH

• pH < 7.35 = acidosis • pH > 7.45 = alkalosis

• Step 2: Analyze the PaCO2 • PaCO2 > 45 = acidosis • PaCO2 < 35 = alkalosis

• Step 3: Analyze the HCO3 • HCO3 < 22 = acidosis • HCO3 > 26 = alkalosis

• Step 4: Match the PaCO2 or HCO3 with pH • pH < 7.35, PaCO2 > 45 and HCO3 normal = respiratory acidosis (pulmonary issue)

• Hypoventilation, respiratory infection, COPD, Asthma, pulmonary edema, central nervous system or spinal cord injury • Treat by increasing ventilation rate, tidal volume

• pH < 7.35, HCO3 < 22 and PaCO2 normal = metabolic acidosis (kidneys trying to buffer) • Renal failure, DKA, lactic acidosis, sepsis, drugs – ethylene glycol

• pH > 7.45, PaCO2 < 35 and HCO3 normal = respiratory alkalosis (pulmonary issue) • Hyperventilation, pain, anxiety, early stages of pneumonia or PE, excessive mechanical

ventilation • Treat by decreasing ventilation rate

• pH > 7.45, HCO3 > 26 and PaCO2 normal = metabolic alkalosis (kidneys trying to buffer) • Diuretics, steroids, excessive vomiting, dehydration, Cushings, liver failure, hypokalemia

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Acute Lung Injury versus Acute Respiratory Distress Syndrome

Acute Lung Injury (ALI) versus Acute Respiratory Distress Syndrome (ARDS)

• Definition

• Mild (ALI) – PaO2/FiO2 ratio 200-300

• Moderate ARDS – PaO2/FiO2 ratio 100-200

• Severe ARDS – PaO2/FiO2 ratio < or equal to 100

• Mortality rate - 40-45%

• Complications

• 2/3 of survivors have impairment of pulmonary function

• Barotrauma – secondary to pressure

• Volutrauma – secondary to volume of air used to inflate lungs

• Bacterial infections

• Delirium

• Goal: Prevent cellular ischemia and death while correcting the cause

Causes of ALI/ARDS • SIRS – systemic inflammatory response syndrome • Bacteremia • Pancreatitis • Massive trauma • Shock • Pneumonia – including aspiration • Transfusion related lung injury (TRALI)

• Cytokine mediated response • Inflammation • May occur after single blood product but more common with multiple

blood products

• Transfusion related circulatory overload (TACO) • No inflammation • Signs of volume overload • Elevated BNP

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Three phases of ARDS • Exudative phase

• 2 to 4 days post acute lung injury, up to 7 days

• Capillary leaking causes alveolar flooding • Atelectasis

• Inflammation

• No high dose steroids – does not improve outcomes

• Fibroproliferative/proliferative phase

• Connective tissue proliferation in response to initial injury

• Steroids maybe helpful in the first 7-14 days of ARDS – improves survivability; steroids may breakdown collagen and inhibit fibrosis

• Resolution and Recovery

• 6 to 12 months of recovery

Clinical presentation

• Tachypnea

• Dyspnea - Breathlessness

• Crackles

• Cyanosis

• Tachycardia

• Anxiety

• Confusion

• Somnolence

• CXR shows alveolar flooding!

Diagnostic studies • ABG

• CXR

• Sometimes helpful to get ECG

• Diagnostic tests to determine cause and to monitor clinical improvement

• CBC with diff

• PTT, PT/INR

• Fibrinogen, FDP

• Chem 20 – includes LFTs

• UA

• Blood, sputum, urine cultures

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Treatment • Treat the cause!

• Hypoxemia is major threat to organ dysfunction!

• Oxygen – keep SaO2 > 90%

• Permissive hypercapnia (PaCO2 60-70) with pH of 7.2-7.25

• Bipap

• Vent support • Goal is to increase PaO2 and decrease PaCO2

• Prevent barotrauma – keep TV around 6 ml/kg

• Maintain minimum of 5 cm peep

• Avoid dopamine – constricts the pulmonary capillary beds

• Transfuse as needed

Prevention of pneumonia • Pneumonia vaccine

• Influenza vaccine

• Hand hygiene

• Good oral care

• Stay away from sick people especially if high risk

• HOB elevated 30-45%

• Swallowing evaluation

• Increase activity • OOB

• increase mobility

• Incentive spirometry

• See healthcare provider if has URI

Questions?

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Thoracic Society Consensus guidelines on the management of community-acquired pneumonia in adults. Clinical Infectious Disease. Suppl. 2:s27.

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