art & science clinical practice

Pneumonia: classification, diagnosis and nursing management

Dunn L (2005) Pneumonia: classification, diagnosis and nursing management. Nursing Standard. 19, 042, 50-54. Date of acceptance: March 29 2005.

Summary
This article provides an overview of pneumonia as a high-Incidence respiratory disease of varying severity in the 21st century. Many cases are mild to moderate and patients are successfully treated with antibiotics at home and v^'ith no lasting damage to the lungs. Vaccinations for influenza and, more recently, pneumococcal infections are becoming widely available for vulnerable groups of people, which will help to reduce the incidence of these diseases. However, pneumonia causes death in more severe cases with atypical forms such as Legionnaires' disease and severe acute respiratory syndrome (SARS) causing fatal outbreaks.

care. Minima! investigation is needed other than taking a clinical history from the patient and chest auscultation. The most common antibiotics used for a bacterial pneumonia are amoxicillin or erythromycin (usually prescribed if a person is sensitive to penicillin). More serious cases warrant further investigation, tests and treatment with intravenous antibiotics, oxygen therapy and chest physiotherapy, and therefore these patients require admission to hospital (BTS 2001 b, Woods and Hathaway 2004).

Author
Liz Dunn is clinical nurse manager, haemostasis and thrombosis, Guy's and St Thomas' Foundation Trust London. Email: elizabeth,dunn@gsttsthames.nhs.ul<

Respiratory tract
The respiratory tract (Figure 1) comprises the nose, paranasal sinuses, pharynx, larynx, trachea, bronchi, bronchioles and alveoli. The upper respiratory tract refers to the area above the larynx and the lower respiratory tract to the area below it. In the upper region, inspired air is moistened, warmed and airborne particles are filtered out. The mucous membrane from the nose to the terminal bronchioles consists of a layer of epithelial cells with a brush border of hair-like cilia interspersed with mucus-secreting goblet cells. The mucus traps particles of dust and airborne pollutants and the cilia move in synchronised 'waves' to carry the substances out ofthe lungs. Ty pe s 0 f pneumonia Pneumonia is inflammation and infection in the terminal bronchioles and alveoli, causing consolidation. Consolidation occurs when the alveolar spaces and small airways are filled with fluid (or possibly another substance) instead of air (Hansall and Padley 1999). This is seen as 'shadowing' on a chest X-ray and can be detected on auscultation. There are a number of ways to classify pneumonia (Anon 2003): According to the part of lung affected, for example, lobar or bronchial pneumonia. According to the organism causing the condition.
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Keywords
Infection; Pneumonia; Respiratory system and disorders These keywords are based on the subject headings from the British Nursing Index. This article has been subject to double-blind review. For related articles and author guidelines visit the online archive at www.nursing-standard.co.uk and search using the keywords.

THE INCREASING emphasis on reducing admissions to hospital and minimising length of patient stays makes it important to consider the impact of respiratory disease on the NHS. Respiratory illness is the single most common reason for emergency hospital admissions in the UK (BritishThoracic Society (BTS) 2001a). The number of people requiring admission peaks in early January each year and contributes to the well-acknowledged 'winter bed crisis' [Damiani and Dixon 2002). A significant number of these patients have pneumonia. An estimated five million people worldwide die of pneumonia each year - older people and the very young are among the most vulnerable (Farr 1997]. The average length of stay for patients admitted with a community-acquired pneumonia is 11 days, and one in ten patients is admitted to intensive care (McDonald etal 1997). The majority of cases can be treated in the community provided that patients are given good nursing
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 Most commonly, whether the pneumonia is acquired in the community or in hospital. Hospital-acquired pneumonia is so-called when the illness becomes apparent more than 48 hours after admission. Pneumonia can be caused by bacterial, viral or, more rarely, fungal organisms. Fungal infections are more likely to affect those who are immunosuppressed and have Pneiimocystis carm//(PCP).PCP is an atypical, opportunistic protozoa (Bastow2000). Bacterial pneumonia triggers alveolar inflammation and oedema leading to engorgement ofthe capillaries and subsequently stasisof blood. As the alveolar capillary membrane breaks down, the alveoli fill with blood and inflammatory exudate, resulting in atelectasis. In viral pneumonia the bronchiolar epithelial ceils are affected causing interstitial inflammation and desquamation, which spreads to the alveoli. The severe acute respiratory syndrome (SARS) virus was caused by a coronavirus similar to the common cold and spread to close contacts (Mazzuli etal2004). International travel of infected people accelerated the outbreak in 2003 (BUPA 2003). Atypical pneumonias include Legionnaires' disease and are often spread by infected air-conditioning plants. Legionnaires' disease became recognised following a large outbreak of a pneumonia-type illness with many fatalities among war veterans (Legionnaires) attending a convention in America in the summer ofl976 (Van Arsdalle^^/1983). Aspiration pneumonia includes the aspiration of gastric contents, oropharyngeal secretions, lipids, such as those contained in oral laxatives and nasal decongestants, and water inhalation in cases of near drowning. This results in an inflammatory response in the affected area and can significantly inactivate surfactant, leading to alveolar collapse. Surfactant is the fluid which forms a lining over the surface of the alveoli. In healthy lungs this reduces alveolar surface tension and the alveoli are able to expand effectively on inspiration and are prevented from collapsing during expiration. In the case of gastric aspiration, acid may damage the airways and particles may cause obstruction. Secondary bacterial pneumonia is caused by the already inflamed lung tissue. Ventilator-associated pneumonia may occur in patients who are ventilated - they are already increasinglyvulnerableto infections because of the general deterioration in their condition. The bypassing ofthe body's natural defence mechanisms against respiratory infection by the presence of an endotracbeal tube poses a specific risk by allowing oropharyngeal pathogens to enter tbe trachea and lower airways. The most common microorganisms in ventilator-associated
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pneumonias are the Gram-negative enteric bacilli, Staphylococcus aureus and Pseudomonas aeruginosa {Sirvent etal 2003). 'Community' organisms, for example, Sfrf-ptococcHS pneumoniae, may also be present in the early stages. Complications of pneumonia include pleurisy, multiple lungabscesses,empyema,bacteraemias, septicaemias, and death-particularly in patients who have recently had influenza. Diagnosis Diagnosis is often based on the presence of clinical symptoms, includmg malaise, fever, persistent cough and pleuritic pain (Hateley 2001). Despite these symptoms, a productive cough may or may not be present, making a definitive diagnosis difficult. If present, sputum may be yellow, green, rusty or blood-stained, which usually indicates a bacterial cause. The absence of purulent sputum usually indicates a viral or atypical cause. Theadmmistration of ultrasonically nebulised hypertonic saline may be necessary to obtain a sputum specimen. Over a period of 15-20 minutes, small particles are able to penetrate the smaller airways, enabling debris to move into larger airways from where they can be expectorated. The most common cause of pneumonia is bacterial infection, Streptococcus pneumoniae, often known as the pneumococcus. Most pneumonic illnesses are treated empirically, meaning that antibiotic regimens are commenced early rather than waiting for culture and sensitivity FIGURE 1 The respiratoty tract

Upper respiratory tract Nasal cavity Pharynx Larynx Trachea Lower respiratory tract Main bronchi Branch bronchi Bronchioles Alveolar sacs containing alveoli

- Pleura

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of sputum specimens to become availahle. However, if symptoms are not responding to the chosen treatment, for example, in the case of an atypical pneumonia, the results of initial sputum tests are important. Some patients are more susceptible to contracting pneumonia than others, including those (Johnson 1990): With underlying chest illness., such as lung cancer, bronchiectasis, chronic bronchitis, asthma, diabetes or renal or liver impairment. Who arc immuno-impaired by, for example, splenal removal, chemotherapy or HIV/AIDS. Overtheageof 65. With a history of alcohol and/or substance misuse. Who are very young with underdeveloped immune systems. Who are homeless or undernourished.

In close communities or institutions, such as nursing homes, hostels or prisons. On prolonged bed rest (cardiovascular accident, trauma, intensive care).
Britisii Tiioracic Society guidelines The BTS

(2001b|guidelinesand update (BTS 2004) identify certain prognostic criteria that determine the severity ofthe patient's condition and whether he or she needs to be treated in hospital. The updated version includes the person's age, that is, over 65 years. This assessment, known as CURB-65 if urea levels are included, or CRB-65 if excluded, gives an accurate assessment ofthe severity ofthe pneumonia (Box 1). Each positive measure scores one point, with a total of more than one point indicating the need for hospitalisation (BTS 2004). Tests Chest X-ray is indicated in severe cases to aid diagnosis, detect associated lung diseases and assess the patient's response to treatment (Figure 2). Chest X-ray findings in pneumonia may he near normal or show focal or diffuse interstitial tendencies (more usually viral type) or focal or diffuse consolidation of the lung parenchyma (more common in bacteria! types). Sputum forculture sensitivity and Gram stain, and Ziehl-Neelsen (ZN) stain for tuberculosis.

CURB seventy criteria C = New mental cotifiision U = Urea >7mmo 1/litre R = Raised respiratory rate of > 30 breaths/minute B = Low blood pressure <90mmHg systolic and/or <60rnrnHg diastolic (BTS 2004)

Urine antigen tests for Streptococcus pneumoniaeandlegioneWa (BTS2004). Blood cultures, urea and electrolytes. Blood cultures can indicate septicaemia or bacteraemia. Urea and electrolytes indicate renal function and can reveal specific features of legioneiia infection. White cell count-this will be raised in cases of bacterial pneumonia. Pulse oximetry may be used to determine oxygen saturation level and the need for supplemental oxygen. In more severe cases, arterial blood gas analysis may be required to determine respiratory compromise and the need for mechanical ventilation. Serology tests are required if viral pneumonia suspected. Lung scan can show abnormalities. Pleural fluid culture could reveal empyema. Bronchoscopy and culture of bronchial 'washings' to aid diagnosis.

FIGURE 2 Chest X-ray siiowing pneumonia in the ieft iung

Nursing care
Administration of antibiotic therapy Since it is not possible to reliably predict the organism 52 June 29 :: vol 19 no 42 :: 2005 NURSING STANDARD

responsible for community-acquired pneumonia or to have immediate results of sputum culture if sputum specimen is available-a broad-spectrum antibiotic such as amoxicillin is generally prescribed (British National Formulary (BNF) 2005). The most likely organisms are pneumococcus and Hae/Jiophilus itifluenzae. Hospital-acquired pneumonia is diagnosed when the patient has spent the whole ofthe incubation period in hospital and is the third most common nosocomial infection after urinary and wound infections. It affects between two and SIX patients per one thousand patients ultimately discharged (Hughes 1992). An antibiotic targeted to Ciram-negative bacilli alone or in combination with anti-pseudomonas therapy is the accepted first-line treatment. Hydration Aminimumof2.5 litres over 24 hours should be encouraged orally or., if necessary, administered intravenously. Natural fluid loss occurs via the kidneys, skin and through respiration and can be increased considerably via the latter two with fever and a raised respiratory rate. Adequate hydration will aid the expectoration of mucus by lessening its viscosity. Elimination of urine It is important to recognise a diminished urinary output because this can indicate a serious deterioration in a patient's condition. A urine output of less than .30ml per hour in 24 hours should be reported to medical staff immediately. Observations Monitoring the patient's temperature, pulse, blood pressure and respirations including rate, depth and distress, are important to assess and record the patient's condition. Oxygen saturation and oxygen therapy A peripheral oxygen saturation (SpO2) below 92 percent would indicate the need for supplemental oxygen (BTS 2001b) so the patient would usually be in hospital.However, if the person hasan underlyingchronic chest condition such as chronic obstructive pulmonary disease then he or she may already use oxygen at home. It may be possible to titrate the increased requirement for oxygen in the home setting with careful monitoring, though severe deterioration from hisor her "baseline" would be a contraindication for home care. Pulse oximetry is a simple and useful way to monitor the SpO2 of arterial blood and contributes to the patient's initial respiratory assessment and subsequent observations. Continuous evaluations of responses to clinical interventions and treatments are possible, particularly since oxygen saturation changes are often rapid. Coughing and deep hreathing Pneumonia caused by bacteria tends to cause a severe cough with purulent sputum (although the cough may be dry in the early phases), whereas this is not
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characteristic of viral and atypical disease. Coughing and deep breathing will aid the expectoration of mucus and therefore improve ventilation so should be encouraged. Sputum should be observed for colour, amount and viscosity as an indication of how the disease is progressing and specimens sent for culture and sensitivity as required. Expectorants may be used to aid clearance of secretions. Positioning In severe cases of pneumonia bed rest is necessary, with thepatient kept In an upright position with a backrest and pillows to ensure adequate ventilation. It is important to advise regular leg exercises to avoid the complication of deep vein thrombosis. Pressure area care This is particularly important for the debilitated patient and those with paralysis or neuromuscular disease. Pressurerelieving techniques and mattresses are important to ensure adequate oxygenation of body tissues. Mouth care The patient's mouth may be uncomfortable because of fever and dryness, and some patients develop herpes simplex around their lips. Regular mouth care and adequate hydration will help to ease this discomfort. Oxygen therapy also causes dryness of the muctjus membranes in the nose and mouth. Nutrition A nutritious, balanced diet will aid recovery and supplements such as Maxijul may be helpful if a patient is compromised through breathlessness and lack of appetite. In severe cases parenteral nutrition may be necessary. Analgesics The use of analgesic agents helps to reduce pleuritic pain which will make deep breathing easier tor the patient. Paracetamol or aspirin will help to reduce pyrexia where present. Hand washing It is important for patients with pneumonia to wash their hands with soap and water after blowing their nose. Healthcare workers should practise strict infection control measures such as hand washing, the use of alcohol hand wipes or gels and changing aprons and gloves between caring for/treating patients. Isolation procedures It is particularly important to isolate infections patients when possible in single rooms, or practise isolation procedures in a bay or ward area, as occurred during the SARS epidemic. When a diagnosis is uncertain and tuberculosis (TB) is suspected, patients in hospital should be cared for in single accommodation and, if multi-drug resistant TB is a possibility, negative pressure rooms are essential. The negative pressure airflt)ws ensure that air does not circulate into other areas ofthe hospital (Interdepartmental Working Group on Tuberculosis (IWGT) 1998, Wilson 2001). Reassurance and rehabilitation Reassuring patients IS an important aspect of nursing care since respiratory distress can cause great anxiety. Depending on the severity of the illness.
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rehabilitation may take some time and involve, for example, mobilisation and managing fatigue. Social circumstances, for example, poor housing conditions, inadequate heating and homelessness, are important considerations when discharging patients from hospital and both patients and carers may need support. Prevention Pneumonia remains a common illness affecting those who are very young or old,

At-Hsk conditions
Asplenia or severe dysfunction of the spleen (including homozygous sickle cell disease) Coeliac syndrome Chronic renal disease or nephritic syndrome Chronic respiratorydisease Chronic heart disease Liverdisease including cirrhosis Diabetes Immunodeficiency or immunosuppression caused by disease or treatment (including HIV Infection) Cochlear implants (Chief Medical Officer ef al 2003)

who have co-morbidities or are in a socially disadvantaged position. Improving social situations, educating people about how to keep healthy and warm, and early recognition of illness and the need for antibiotic treatment can prevent more serious illness. For those who smoke cigarettes, education and help with stopping will significantly improve their health. Vaccination Annual influenza vaccinations, and a single pneumococcal vaccination can help to reduce the chance of developing the most common cause of pneumonia. Practice nurses are ideally placed to deliver vaccination programmes and all those at risk should be targeted (Box 2|. Mortality among nursing home residents is up to nine times higher than among similar age groups in the community (Koivula ef a/1994). Conclusion Although many people who develop pneumonia can be nursed at home, the condition is potentially life-threatening. Vaccination for those at risk can help prevent them developing pneumonia. Following the SARS outbreak, international protocols have been put in place to improve communication and health care (BUPA 2003). Nursing interventions focusing on education and disease prevention could significantly reduce the numbers of older people presenting with pneumonia. Providing holistic care for patients with pneumonia, both in hospital and community settings, can aid recovery together with effective antibiotic therapy NS

References
Anon (2003) What you need to know about... pneLimonia. Nursing Times. 99, 42, 23. Bastow V (2000) Identifying and treating PCP. Nursing Times, 96,37 tml {Last accessed: June 15 2005.) Chief Medical Officer, Chief Nursing OfRcei-, Chief Pharmaceutical Officer (2003) Adult Immunisation Update. The Stationery Office, London. Damiani M, Dixon J (2002) Managing the Pressure: Emergency Hospital Admissions in London, 1997-2001. King's Fund, London. Farr B (1997) Prognosis and decisions in pneumonia. New England Journal of Medicine. 336,4, 288-289 Hansall D, Padley S (1999] Imaging. In Albert R,SpiroS,JettJ (Eds) Comprehensive Respiratory Medicine. Harcourt Brace and Company, London, Ch 1,1.16. Hateley P (2001) Respiratory infections. In Esmond G (Ed) Respiratory Nursing. Bailliere Tindall, London, 179-185. Hughes JM (1992) Epidemiology and pfeventioti of tiosocomial pneumonia. In Remington JS, Swartz MN (Eds) Current Clinical Topics in Infectious Disease. McGraw Hill, New York NY Interdepartmental Working Group on Tuberculosis (1998) The Prevention and Control of Tuberculosis in the United Kingdom. UK Guidance on the Prevention and Control of Transmission of I HIV-related Tuberculosis 2. Drug-resistant Including Multiple Drug-resistant Tuberculosis. Department of Health, Wetherby. Johnson N (1990) Respiratory Medicine. Blackwell Scientific Publications, Oxford. Koivula I, Sten M, Makela PH (1994) Risk factors for pneumonia in the elderly. American Journal of Medicine. 96,4,313-320. Mazzuli T, Farcas GA, Poutanen 5 M ef o/ (2004) Absolute association of coronavirus in lung tissue from fatal cases of severe acute respiratory syndrome. Canadian Journal of Respiratory Therapy. 4 0 , 1 22-28. McDonald R Friedman EH, Banks A, Anderson R, Carman V (1997) Pneumococcal vaccine campaign based in general practice, British MedicalJournal. 314,7087 1094-1098. Sirvent J M , Vidaur L, Gonzalez S ef o/(2003) Microscopic examination of intracellular organisms in protected bronchoalveolar mini-lavage fluid for tbe diagnosis of ventilator-associated pneumonia. Chest. 123, 2,518-523. Van Arsdall JA, WundeHich HF, Meio JC, Nagar D, Ferris FZ, Raff M J (1983) The protean manifestations of Legionnaires' disease. Journal of Infection. 7 L 51-62. Wilson J (2001) Infection Control in Clinical Practice. Second edition. Bailliere Tindall, London. Woods A, Hathaway L (2004) Treating community-acquired pneumonia. Nurse Practitioner. 29,6, 11-D.

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