Pneumonia

DRG Category: 177

Mean LOS: 6.9 days

Description: Medical: Respiratory Infections and Inflammations With Major Complication or Comorbidity

DRG Category: 193

Mean LOS: 5.2 days

Description: Medical: Simple Pneumonia and Pleurisy With Major Complication or Comorbidity

DRG Category: 207

Mean LOS: 13.9 days

Description: Medical: Respiratory System Diagnosis With Ventilator Support > 96 Hours

DRG Category: 208

Mean LOS: 6.7 days

Description: Medical: Respiratory System Diagnosis With Ventilator Support ≤ 96 Hours

DRG Category: 3

Mean LOS: 30.3 days

Description: Surgical: ECMO or Tracheostomy With Mechanical Ventilation > 96 Hours or Principal Diagnosis Except Face, Mouth, and Neck With Major Operating Room Procedures

Introduction ⬆ ⬇

An increasing global awareness now exists because of the threat of epidemics of pneumonia, the severity of which can range from a mild illness to a life-threatening condition. Viral diseases such as severe acute respiratory syndrome (SARS), the novel coronavirus 2019 disease (COVID-19), avian influenza (A/H5N1), and H1N1 (swine flu) are examples of viral pneumonias associated with high mortality and morbidity. Bacterial pneumonia is also a significant problem. In the United States, acute lower respiratory infections cause more disease and death than any other bacterial infection. Bacterial pneumonia can occur in several settings: community-acquired pneumonia (CAP), nursing home–acquired pneumonia (NHAP), healthcare-associated pneumonia (HCAP), hospital-acquired pneumonia (HAP), and ventilator-associated pneumonia (VAP). Nosocomial pneumonia is an older term that incorporates HAP and VAP.

Pneumonia is an inflammatory condition of the interstitial lung tissue in which fluid and blood cells escape into the alveoli. Even when no epidemic such as COVID-19 exists, more than 3 million people in the United States are diagnosed each year with pneumonia. The disease process begins with an infection in the alveolar spaces. As the organism multiplies, the alveolar spaces fill with fluid, white blood cells, and cellular debris from phagocytosis of the infectious agent. The infection spreads from the alveolus and can involve the distal airways (bronchopneumonia), part of a lobe (lobular pneumonia), or an entire lung (lobar pneumonia).

The inflammatory process causes the lung tissue to stiffen, resulting in a decrease in lung compliance and an increase in the work of breathing. The fluid-filled alveoli cause a physiological shunt, meaning that venous blood passes unventilated portions of lung tissue and returns to the left atrium unoxygenated. As the arterial oxygen tension falls, the patient begins to exhibit the signs and symptoms of hypoxemia. In addition to hypoxemia, pneumonia can lead to complications such as respiratory failure, lung abscess, and septic shock. Infection may spread via the bloodstream and cause endocarditis, pericarditis, meningitis, or bacteremia.

Causes ⬆ ⬇

Primary pneumonia is caused by the patient's inhaling or aspirating a pathogen, such as bacteria or a virus. Bacterial pneumonia, often caused by staphylococcus, streptococcus, or Klebsiella, usually occurs when the lungs' defense mechanisms are impaired by such factors as suppressed cough reflex, decreased cilia action, decreased activity of phagocytic cells, and the accumulation of secretions. Viral pathogens account for up to a fourth of CAPs in adults and are most commonly caused by the influenza virus. Viral pneumonia occurs when a virus attacks bronchiolar epithelial cells and causes interstitial inflammation and desquamation, which eventually spread to the alveoli. In addition to the influenza viruses mentioned earlier, other common viruses include respiratory syncytial virus (RSV); influenza A; parainfluenza 1, 2, and 3; and adenovirus (see Emerging Infectious Diseases [COVID-19] for an explanation of COVID-19).

Secondary pneumonia ensues from lung damage that was caused by the spread of bacteria from an infection elsewhere in the body or by a noxious chemical. Aspiration pneumonia is caused by the patient inhaling foreign matter, such as food or vomitus, into the bronchi. Factors associated with aspiration pneumonia include old age, impaired gag reflex, surgical procedures, debilitating disease, and decreased level of consciousness.

The most common causes of CAP are Streptococcus pneumoniae (pneumococcus), Mycoplasma pneumoniae, Haemophilus influenzae, Chlamydia pneumoniae, and respiratory viruses. CAP in the intensive care unit is most commonly caused by S pneumoniae, Staphylococcus aureus, Legionella species, and gram-negative bacilli such as Escherichia coli and Klebsiella pneumoniae. Risk factors for the development of pneumonia include cigarette smoking, chronic obstructive pulmonary disease, asthma, immunosuppression, protein pump inhibitors, alcohol abuse, major surgery, drug dependence or abuse, altered mental status, seizure disorder, and recent pulmonary infections with the flu or cold.

Genetic Considerations ⬆ ⬇

Heritable immune responses could be protective or could increase susceptibility.

Sex and Life Span Considerations ⬆ ⬇

Children and young adults up to age 30 years are at risk for several forms of viral pneumonia, including mycoplasma pneumonia, adenovirus pneumonia, rubeola pneumonia, and RSV pneumonia. Neonates with multisystem disease are also at risk for viral pneumonia caused by cytomegalovirus. Pregnant patients with viral pneumonia have a higher risk for severe disease than other patients. Adults are at risk for varicella viral pneumonia. As people age past 65 years, rates of viral pneumonia again increase. More than 60% of hospitalizations and 85% of deaths from viral pneumonia occur in older adults. People over age 40 years are at greater risk to contract all forms of bacterial pneumonia, with older men more susceptible to streptococcal bacterial pneumonia and Klebsiella bacterial pneumonia. Staphylococcal pneumonia tends to strike those who are debilitated or who have a history of influenza or IV drug abuse.

Health Disparities and Sexual/Gender Minority Health ⬆ ⬇

Black men are more likely to die from bacterial pneumonia than White men, although little is known about the reasons for this disparity. Black and White women have similar mortality rates with respect to bacterial pneumonia. Sexual and gender minority status has no known effect on the risk for pneumonia except for Pneumocystis jirovecii pneumonia (see Pneumocystis jirovecii Pneumonia).

Global Health Considerations ⬆ ⬇

The World Health Organization (WHO, 2019) states that pneumonia is the single largest infectious cause of death in children in the world. It occurs around the world but is most prevalent in South Asia and sub-Saharan Africa. Serious pneumonia in children and overall deaths from pneumonia for all ages occur more often in developing than in developed countries. WHO reported that in 2017, approximately 800,000 children died from pneumonia and accounted for 15% of all deaths in children under 5 years of age. Environmental factors that contribute to pneumonia in children are indoor cooking with biomass fuels such as wood or dung, living in crowded homes, and parental smoking (WHO, 2019).

Assessment ⬆ ⬇

ASSESSMENT

History

Ask if the patient has experienced recent air travel, exposure to contaminated air-conditioning or water systems, exposure to crowds or overcrowded institutions (jails, homeless shelters), or exposure to animals such as cattle, rabbits, rodents, sheep, turkeys, or chickens. The patient may have a history of a recent upper respiratory infection, influenza, or a viral syndrome. The patient may report a productive cough, fever, chest pain, or difficulty breathing. Elicit a history of a chronic pulmonary disease, such as asthma, bronchitis, or tuberculosis; prolonged immobility; sickle cell anemia; neurological disorders that cause paralysis of the diaphragm; surgery of the thorax or abdomen; smoking; alcoholism; IV drug therapy or abuse; and malnutrition. Establish any history of exposure to noxious gases, aspiration, or immunosuppressive therapy. Determine if the patient recently underwent general anesthesia. Ask the patient to describe the type of cough and the nature of the sputum production. Determine the location of any pain, especially chest pain. Ask about sore throat or chills, vomiting, diarrhea, and anorexia. Ask if the patient has comorbid conditions such as diabetes mellitus, stroke, or autoimmune diseases.

Physical Examination

The major symptoms of pneumonia are cough, fever, sputum production, chest pain, and shortness of breath. Observe the patient's general appearance and respiratory pattern to determine level of fatigue, presence of cyanosis, and presence of dyspnea, tachypnea, or tachycardia. Examine the patient's extremities, torso, and face for rash. Assess vital signs for rapid, weak, thready pulse; fever; and blood pressure changes such as hypotension and orthostasis (postural hypotension). Palpate the chest to determine any areas of consolidation or tactile fremitus. Percuss the chest to detect dullness over the area of consolidation. When you auscultate the patient's breathing, listen for rales, crackles, rhonchi, and wheezes; “E” to “A” changes; and whispered pectoriloquy.

Psychosocial

The patient with pneumonia may be anxious, fatigued, and in pain from the constant coughing. Assess the patient's ability to cope with a sudden, debilitating illness. The patient and family will likely be very anxious because of difficulty breathing and distressed over purulent sputum. Pneumonia can be life threatening if not treated promptly, and the family and patient will likely recognize this serious situation.

Diagnostic Highlights

Test	Normal Result	Abnormality With Condition	Explanation
Rapid detection test: Reverse-transcriptase-polymerase chain reaction	Negative for influenza, RSV, rhinoviruses, parainfluenza, and other viruses	Positive for virus	Obtained through nasal swabs; sensitivity for influenza in adults ranges between 50% and 60%, and specificity is greater than 90%
Sputum cultures and sensitivities	Negative cultures and sensitivities (other than normal bacterial flora)	Presence of infecting organisms	Cultures identify organism; sensitivity testing identifies how resistant or sensitive the bacteria are to antibiotics
Chest x-ray	Clear lung fields	Areas of increased density; can be a lung segment, lobe, one lung, or both lungs	Findings reflect areas of infection and consolidation

Other Tests: Arterial and venous blood gases, complete blood count, coagulation profile, blood cultures, serum lactate level, serum free cortisol value, serum electrolytes, blood urea nitrogen, creatinine, glucose, bronchoscopy. Chest computed tomography and chest ultrasound may be completed.

Primary Nursing Diagnosis ⬆ ⬇

Diagnosis

DiagnosisIneffective airway clearance related to increased production of secretions and increased viscosity as evidenced by cough, wheezing, dyspnea, and/or shortness of breath

Outcomes

OutcomesRespiratory status: Airway patency; Respiratory status: Gas exchange; Respiratory status: Ventilation; Symptom severity; Medication response; Knowledge: Treatment regimen

Interventions

InterventionsAirway management; Oxygen therapy; Airway suctioning; Airway insertion and stabilization; Cough enhancement; Mechanical ventilation: Invasive; Mechanical ventilation: Noninvasive; Respiratory monitoring; Medication management

Planning and Implementation ⬆ ⬇

PLANNING AND IMPLEMENTATION

Collaborative

Patients have a range of symptoms, which may be mild to severe. Bacterial pneumonia is treated with antibiotics as the mainstay of therapy, but some patients need oxygen and noninvasive or invasive ventilatory support for hypoxemia and fluid resuscitation for volume depletion. Physicians may request regular measurements of peak and trough levels of antibiotics, especially for patients who are receiving aminoglycosides, which can produce severe side effects such as renal failure and hearing loss. High fever may be treated with antipyretics or IV hydration to replace fluid loss. The patient's condition may change rapidly; continuous monitoring of cardiovascular parameters and oxygenation is critical. Percussion and postural drainage may be prescribed to assist the patient in expectorating secretions. Appropriate nutrition and early mobilization speed recovery and reduce complications.

Pharmacologic Highlights

Medication or Drug Class	Dosage	Description	Rationale
Antibiotics	Varies with drug	Depends on bacteria. Initial antibiotic: Macrolides including erythromycin, azithromycin, roxithromycin, and clarithromycin. Other antibiotics: Penicillin G for streptococcal pneumonia; nafcillin or oxacillin for staphylococcal pneumonia; aminoglycoside or a cephalosporin for Klebsiella pneumonia; penicillin G or clindamycin for aspiration pneumonia. Cephalosporins: Cefepime, cefotaxime, cefuroxime. Alternatives: Amoxicillin and clavulanate (Augmentin); doxycycline; trimethoprim and sulfamethoxazole (Bactrim DS, Septra); levofloxacin (Levaquin); cefazolin, aztreonam, cefepime, ciprofloxacin	Macrolides provide coverage for likely organisms in community-acquired bacterial pneumonia
Antivirals	Varies with drug	Acyclovir may be used for varicella and herpes simplex pneumonia; ganciclovir and immunoglobulin are used in immunocompromised patients with cytomegalovirus pneumonia	Few specific antiviral agents are available to manage pneumonia

Independent

Make sure the patient coughs and uses deep-breathing exercises at least every 2 hours. Encourage drinking 3 L of fluid daily, unless contraindicated, to help expectorate secretions. If the patient cannot cough up secretions, you may have to perform nasotracheal or orotracheal suction to maintain an open airway. Turn and position patients on bedrest to help keep the airway open and free of secretions and to reduce the risk of pulmonary aspiration. Elevate the head of the bed to at least 45 degrees to help the patient maintain an open airway and find positions that ease breathing. Place the patient in an upright position with both arms well supported on pillows or position the patient to lean forward and rest the arms on the overbed table.

Involve the patient in as much decision making as possible and, when possible, include the family in teaching situations. Explain all procedures, particularly intubation and suctioning. Teach the importance of adequate rest and the deep-breathing and coughing exercises that are designed to clear lung secretions.

Teach proper ways to dispose of secretions and proper hand-washing techniques to minimize the risk of spreading infection. Advise annual influenza vaccinations or avoidance of using antibiotics indiscriminately because such use creates a risk for upper airway colonization by antibiotic-resistant bacteria.

Evidence-Based Practice and Health Policy

Yamagata, A., Ito, A., Nakanishi, Y., & Ishida, T. (2020). Prognostic factors in nursing and healthcare-associated pneumonia. Journal of Infection and Chemotherapy, 26, 563–569.

Nursing and healthcare-associated pneumonia (NHCAP) is a category of healthcare-associated pneumonia used in Japan. The authors implemented a prospective study to determine the prognostic factors related to 30-day mortality in patients with NHCAP by analyzing prospective data. They analyzed patients hospitalized for NHCAP (N = 817) and collected data on age, sex, comorbidities, vital signs, and laboratory findings, with primary outcome as the 30-day mortality.
The mean age was 78.0, 71% were men, and 30-day mortality was 13.1%. Male sex, malignancy, temperature, heart rate, respiratory rate, serum albumin, and blood urea nitrogen were predictive factors for mortality. The risk of drug-resistant pathogens was not necessarily related to poor prognosis.

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DRG Information ⬇