Learning Objectives
By the end of this section, you will be able to:
- Discuss the pathophysiology, risk factors, and clinical manifestations for pneumonia and aspiration
- Describe the diagnostics and laboratory values in the disease of pneumonia and aspiration
- Apply nursing concepts and plan associated nursing care for the patient with pneumonia and aspiration
- Evaluate the efficacy of nursing care for the patient with pneumonia and aspiration
- Describe the medical therapies that apply to the care of pneumonia and aspiration
Pneumonia is common and affects persons without medical problems as well as persons with a variety of comorbid conditions. Pneumonia causes infections, hospitalizations, and deaths. While there are various types of pneumonia, community-acquired pneumonia (CAP) is the eighth leading cause of death in the United States. Worldwide, CAP is the leading cause of sickness and death (Ferreira-Coimbra et al., 2020). Significant mortality exists for patients hospitalized with pneumonia in the United States, at a rate of 13 percent (Ferreira-Coimbra et al., 2020).
Pathophysiology
Pneumonia is an umbrella term for a variety of infections that affect the lungs and cause inflammation (Figure 11.27). Infection can be caused by a virus, bacteria, or fungi. In aspiration pneumonia, food, fluid, upper airway secretions, or emesis enter the trachea and respiratory tract, causing an inflammatory response (Figure 11.28). When a virus, bacteria, or fungi enters the lungs, macrophages try to eradicate the pathogen by surrounding it. This triggers inflammatory cells to travel to the infected area. Once lung tissues become inflamed, the capillaries become damaged. The affected alveoli can fill with fluid or pus, limiting the body’s ability to oxygenate and ventilate.
A variety of organisms can cause pneumonia. Common pathogens implicated in pneumonia are listed in Table 11.6.
| Type of Pathogen | Causes |
|---|---|
| Bacteria | Streptococcus pneumoniae Haemophilus influenzae Moraxella catarrhalis Staphylococcus aureus Group A streptococci Aerobic gram-negative bacteria (e.g., klebsiella, Escherichia coli) Legionella Mycoplasma pneumoniae Chlamydia pneumoniae Chlamydia psittaci Coxiella burnetiid |
| Viruses | Influenza A and B viruses Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) Other coronaviruses (e.g., CoV-229E, CoV-NL63, CoV-OC43, CoV-HKU1) Rhinoviruses Parainfluenza viruses Adenoviruses Respiratory syncytial virus Human metapneumovirus Human bocaviruses |
| Fungi | Blastomyces Histoplasma Coccidioides |
When pneumonia develops in a hospital setting, it is classified as hospital-acquired pneumonia (HAP). If it occurs after a ventilator is initiated, it is termed ventilator-associated pneumonia (VAP). The most common organisms seen in HAP and VAP are pseudomonas aeruginosa, Escherichia coli, staphylococcus aureus, enterobacter, and acinetobacter (Jain et al., 2022).
Risk Factors
A variety of risk factors can increase the risk of pneumonia. These can include demographic factors as well as comorbid conditions. Pneumonia disproportionately affects patients who are under-resourced and face high poverty rates. Environmental factors, like crowded living conditions (e.g., areas with high poverty rates, prisons, shelters) and exposure to toxins like gasoline and certain paints also increase the likelihood of CAP. Older adults, persons who smoke, and persons living with lung disease, cardiac problems, diabetes, and immunosuppression are all at increased risk for severe illness and death. A diagnosis of COPD is the most significant risk factor for hospitalization with pneumonia (Jain et al., 2022; Ramirez, 2022). More specifically:
- Adults older than age sixty-five, compared with the general population, are three times more likely to be hospitalized with CAP.
- Chronic lung disease, especially COPD, significantly increases the likelihood of pneumonia.
- Viral infections can cause viral pneumonia and increase the risk of secondary bacterial pneumonia.
- All immunocompromised patients are at higher risk of pneumonia when compared with the general population; this is especially true about fungal pneumonias.
- Patients with aspiration due to dysphagia, anesthesia, or drug and alcohol use are at high risk of developing pneumonia.
- Smoking, heavy alcohol use, and opioid use increase the risk of pneumonia.
- Comorbid conditions, including chronic heart disease, malnutrition, and diabetes, increase the likelihood of severe infection.
- Socioeconomic factors, including poverty, crowded living conditions, and exposure to toxins, all increase the risk of pneumonia (Jain et al., 2022; Ramirez, 2022).
When providing care to patients with pneumonia, clinicians need to be able to identify which patients are likely to require hospital admission. An evidence-based severity score called CURB-65 uses several different criteria to assess pneumonia patients and predict need for hospitalization (Table 11.7).
| Description | Points | |
|---|---|---|
| C | Confusion | 1 |
| U | Uremia: blood urea nitrogen > 7 mmol/L (20 mg/dL) | 1 |
| R | Respiratory rate: ≥ 30 breaths/minute | 1 |
| B | Blood pressure: systolic < 90 mmHg or diastolic < 60 mmHg | 1 |
| 65 | Age ≥ 65 years | 1 |
| Score of 0 or 1: Outpatient management is typically adequate. Score of 2 or 3: Hospital admission is generally recommended. Score of 4 to 5: ICU admission is recommended. |
||
Clinical Manifestations
Many patients with pneumonia will display signs of systemic infection, such as fatigue, fever, chills, muscle pain, and decreased appetite. A cough is common and may be productive of yellow, green, brown, or blood-tinged sputum. Many patients with pneumonia will experience dyspnea. Some patients will demonstrate altered mental status, chest pain, or abdominal pain.
Vital sign abnormalities can include increased respiratory rate, fever, tachycardia, and decreased oxygen level. Lung auscultation can reveal crackles or decreased breath sounds. In severe cases, patients will demonstrate signs of respiratory distress, such as accessory muscle usage, nasal flaring, and difficulty speaking (Jain et al., 2022).
Assessment and Diagnostics
Diagnostic testing for pneumonia can utilize a variety of modalities. Imaging and laboratory tests are utilized to diagnose pneumonia, track its severity, and identify treatable organisms. Subjective and objective data are equally assessed to determine the best plan of care for each patient.
For a conclusive diagnosis of pneumonia, imaging is required. While a chest x-ray is utilized most often, chest CT is also an option; both can demonstrate visual evidence of pneumonia. Areas of inflammation and consolidation caused by pneumonia are often identifiable as whitish areas of opacity. A complete blood count can show increased white blood cells. Viral swabs and sputum cultures are done to identify the responsible organism so appropriate medications are given to the patient. When certain types of pneumonia (e.g., legionella) are suspected, urinary antigen testing is used. C-reactive protein and procalcitonin are used to differentiate bacterial and viral pneumonia. Lactic acid level may be checked if septic pneumonia is suspected. In severe cases, arterial blood gas analysis may indicate low oxygen levels. To evaluate patients with potential VAP, bronchoscopy may be used. A thin tube called a bronchoscope is inserted into the mouth or nose and a camera allows visual examination of lung tissue. The bronchoscope can obtain biopsy samples and treat blockages. In VAP patients, using a bronchoscope to obtain a sample can identify the organism to treat (Figure 11.29) (Jain et al., 2022).
Nursing Care of the Patient with Pneumonia and Aspiration
While pneumonia is common and often easily treatable, there is the potential for life-threatening illness. Close monitoring and timely intervention can, in many cases, prevent complications.
Recognizing Cues and Analyzing Cues
The nurse caring for a patient with suspected or confirmed pneumonia considers patient-reported data as well as objective assessment findings. Self-reported symptoms may include cough, dyspnea, and general signs of systemic infection. Purulent or blood-tinged sputum can occur with bacterial pneumonia. Sputum associated with viral pneumonia is often watery, though occasionally contains both mucus and pus (Jain et al., 2022). Understanding the patient’s medical history is essential, especially any known lung diseases, neurological insult, such as stroke, cardiac problems, diabetes, and being immunocompromised. Objectively, vital signs are evaluated with a focus on respiratory rate and oxygen saturation. Fever and tachycardia may be present. Lung auscultation may reveal crackles or diminished breath sounds in some lung fields. The nurse identifies if breathing is labored or unlabored.
Clinical Safety and Procedures (QSEN)
QSEN Competency: Safety
Disclaimer: Always follow the agency’s policy for medication administration.
Definition: Minimizes risk of harm to patients and providers through both system effectiveness and individual performance. The nurse will…
Skill: Demonstrate effective strategies to reduce the risk of harm to self or others.
Attitude: Value the contributions of standardization/reliability to safety. Patients suspected of having pneumonia should be made NPO right away, until cleared by a provider, because one of the major complications is aspiration pneumonia leading to additional infections.
- The patient should remain NPO until a trained provider or speech pathologist can perform a swallow screen using an evidence-based tool.
- Swallow should be evaluated before any PO food, fluids, or medications are given to identify dysphagia and prevent aspiration.
Prioritizing Hypotheses, Generating Solutions, and Taking Action
In patients with pneumonia, signs of respiratory distress and decreased oxygenation are the highest priority. The nurse will monitor vital signs, administer oxygen, or prepare a patient for imaging and/or procedures. A decreased oxygen level, increased respiratory rate, signs of labored breathing, and alterations in mental status are all signs that supplemental oxygen (and possibly ventilation) is urgently required. Medication administration may include antibiotics, antiviral medications, or bronchodilators. Instruction on energy conservation and pacing can be helpful as patients recover. Due to the possibility of spread via droplet or airborne particles, PPE is often indicated when providing care to patients with pneumonia.
Clinical Safety and Procedures (QSEN)
Evidence-Based Practice: Strategies to Prevent Aspiration Pneumonia
Many cases of aspiration pneumonia can be prevented. Prevention strategies address oral hygiene and actual or potential swallowing problems.
- Improve oral hygiene and increase access to dental care to decrease the likelihood of harmful bacteria in the oral cavity.
- In hospitalized patients, assist with toothbrushing, denture care, and routine oral care. This may include suctioning out excess saliva, swabbing the mouth with moisturizer, and applying lip balm.
- When aspiration risk is related to swallowing problems, collaborate with speech-language pathologists for expert guidance on strategies for safe swallowing.
- An upright position (at least 30 degrees), appropriate head position, and maintaining an upright position after eating can decrease the risk.
- Many patients will benefit from a slow pace while eating and drinking.
- Some patients will require a specialized diet with textures that decrease the risk of aspiration. - When feeding tubes are utilized, it is important to ensure correct placement so that food, fluid, and medications do not inadvertently enter the respiratory tract.
- For planned procedures requiring anesthesia, preprocedure fasting is suggested (Texas Health and Human Services).
Evaluation of Nursing Care for the Patient with Pneumonia and Aspiration
With skilled interprofessional care, most patients with pneumonia will recover well. Close assessment during the recovery period provides information about illness trajectory and need for ongoing treatment. The most important outcomes related to pneumonia center on resolution of respiratory symptoms. The nurse monitors pulse oximetry, oxygen requirement, and lung sounds. Signs of infection are evaluated, including temperature, white blood count, and sputum production. Patient-reported symptoms to reevaluate include dyspnea, cough, fatigue, fever, and chills. Repeat imaging may be required to identify if pneumonia is improving or has resolved.
Life-Stage Context
Gerontological Considerations
When caring for older adults, the nurse must consider various gerontologic considerations to ensure optimal outcomes. Age-related changes, such weaker immune systems, make them more prone to developing pneumonia. The older adult populations have more comorbidities to consider, such as previous strokes, decline in cognition, and Parkinson’s disease and dementia. These contribute to a higher probability of aspiration, which can lead to aspiration pneumonia. Older adults with identified risks for aspiration should have nursing interventions implemented to reduce these risks. The primary methods used to prevent aspiration during oral intake include:
- Referral for a swallow study
- Texture modification of food/liquids
- Positional swallowing maneuvers, such as chin-tuck
- Thickened liquids
Older adults are also at an increased susceptibility to increased risk of infection, due to lower immunity thresholds, all of which necessitate a tailored approach to the older population.
Medical Therapies and Related Care
Medical therapy varies based on the severity of illness (Table 11.8). When community-acquired pneumonia occurs, oral antibiotic therapy is usually utilized. A stronger antibiotic may be needed if the patient smokes or has comorbid conditions like COPD, heart disease, or diabetes. When patients are admitted to the hospital with severe pneumonia, intravenous antibiotics are often needed. Inhaled bronchodilators can be used to improve the sensation of shortness of breath. Viral pneumonia may be treated with antiviral medications, such as oseltamivir. Antifungal medications are used to treat fungal pneumonias.
| Severity of Pneumonia | Appropriate Therapy |
|---|---|
| CAP, CURB-65 score 0 to 1 | If adverse comorbidities are present: fluoroquinolones or beta-lactams plus macrolides If no adverse comorbidities are present: macrolides or doxycycline |
| CAP, CURB-65 score 2 to 3 | Fluoroquinolones or macrolides plus beta-lactams |
| CAP, CURB-65 score 4 to 5 | Beta-lactams plus fluoroquinolones or beta-lactams plus macrolides |
| VAP & HAP | Broad-spectrum antibiotics:
|
In many cases, hospitalized patients will require supplemental oxygen. In severe cases, ventilatory support may be needed. This can be noninvasive (e.g., BiPAP) or invasive (e.g., ventilator) (Figure 11.30). Bilevel positive airway pressure, or BiPAP, can provide breathing support to patients in respiratory distress. A tight-fitting mask goes over the nose and/or mouth, and the attached machine blows air into the airway. Bilevel means there are two pressure settings: inhalation positive airway pressure (IPAP) and exhalation positive airway pressure (EPAP). BiPAP can increase oxygen levels and lower carbon dioxide levels. The care of a patient with pneumonia can be complex. It involves close collaboration between physicians, nurses, respiratory therapists, pharmacists, and radiologists (Ramirez, 2022).