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Home , Pectoriloquy, Pneumonia severity index, Whispered pectoriloquy

Community-acquired With accurate diagnosis, patients can be appropriately treated in and out of the hospital.

By Shari J. Lynn, MSN, RN

tive , anorexia, or confusion. within 14 days before symptom COMMUNITY -ACQUIRED PNEU - MONIA (CAP) is exactly what it onset sounds like—a infection ac - Risk factors • patient’s symptoms begin within quired while out and about in the Many factors contribute to an in - 4 days of hospital admission world. The cause may be a virus, creased chance of developing CAP. • patient doesn’t live in a long- bacteria, or fungus. (See CAP stats .) (See CAP risk factors .) Antibiotic term care facility. The estimated cost of treating treatment, chronic steroid use, and Bacterial pathogens and respira - CAP in the United States is about malnutrition increase the risk for tory viruses are common causes of $12.2 billion a year. Inpatient treat - CAP, as do comorbidities such as CAP. Bacterial organisms that are ment ranges from $7,500 to $10,227 chronic renal failure. In the elderly treatable in the outpatient setting per admission, whereas outpatient population, comorbidities as well as include Chlamydophila pneumoni - treatment ranges from $150 to $350 the effects of aging (such as re - ae, Haemophilus influenzae, Mo - per patient. This difference demon - duced mucociliary movement and rax ella catarrhalis, Mycoplasma strates the need for accurate diag - clearance, decreased cough reflex, pneumoniae , and Streptococcus nosis and appropriate treatment. increased potential for colonization pneumoniae . Respiratory viruses as - of gram-negative organisms, and sociated with outpatient treatment Immune response decreased immune response) in - of CAP include adenovirus, influen - A patient’s immune response to crease the risk for CAP. Additional za A and B, parainfluenza virus, CAP depends on the type of organ - risk factors include spleen removal, and respiratory syncytial virus. How - ism involved. Less noxious organ - HIV, hypogammaglobulinemia, and ever, any patient infected with isms typically are destroyed by sickle cell disease. these pathogens who shows severe macro phage engulfment, which re - symptoms may be admitted for in - sults in a moderate immune re - Classification and causes patient care as well as those infect - sponse. If the organism is highly CAP is just one classification of ed with anaerobes that are related virulent or is present in great num - pneumonia. (See CAP vs. HAP .) to aspiration and Legionella pneu - bers, a series of immune responses The criteria for CAP include: mophila . occur, including inflammation, cel - • patient hasn’t been hospitalized lular infiltration, and activation of Patient assessment the immune cascade. When the pa - Begin the patient assessment by tient can’t clear pulmonary secre - CNE identifying symptoms and their on - tions, a secondary infection may 1.51 contact set. Note symptom severity, includ - develop. (See Immune response .) hours ing characteristics of cough and In response to physiologic , descriptions of pain level, changes, the patient’s respiratory LEARNING OBJECTIVES factors that relieve or aggravate rate may increase in an attempt to 1. Identify the causes of and risk fac - symptoms, treatments the patient improve oxygen levels, but eventu - tors for community-acquired has already tried, and how the pa - pneumonia (CAP). ally he or she becomes exhausted tient describes illness severity. 2. Describe the assessment of the from the work of , and patient with CAP. Negative test results and negative the respiratory rate decreases, lead - 3. Discuss the management of the symptoms can help rule out other ing to and . patient with CAP. diagnoses. Ask about abdominal In addition, the patient may experi - pain, , hematuria, dys uria, The author and planners of this CNE activity have ence fever, pleuritic chest pain, disclosed no relevant financial relationships with edema, weight gain, and neurologi - coughing, dyspnea, and a general any commercial companies pertaining to this cal symptoms. In addition, gather activity. See the last page of the article to learn feeling of being unwell. In older how to earn CNE credit. information about the patient’s cur - adults, symptoms may not be as ob - rent medications (including pre - vious; they may have a less produc - scription and over-the-counter med -

American Nurse Today Volume 12, Number 12 AmericanNurseToday.com 6 ications and herbal remedies); to - CAP stats bacco, alcohol, and illicit drug use; These statistics reveal the prevalence of community-acquired pneumonia (CAP) environmental exposure to possible and why outpatient treatment is preferred when possible. lung irritants; and immunizations. • All age groups are susceptible to CAP, but the greatest morbidity and mortality Note allergies and past medical can be found in young patients under 6 years old and older patients over 75 history as well as social and family years old. histories. Ask about any comorbidi - • The incidence of CAP increases exponentially in patients over age 50 in indus - ties, such as cancer, autoimmune trialized countries. disease, and chronic respiratory is - • Even with the discovery of antibiotics, pneumonia is still prevalent on a global sues. Also note the patient’s resi - level and remains an economic burden on the healthcare system. dence (for example, home or long- • According to the World Health Organization, 1.4 million people die every year term care facility). from pneumonia, and it’s a predominant cause of in children. Examine all body systems to • In the United States, CAP is the eighth leading cause of death and the most determine infection severity, the common cause of death from an infectious agent. probability of CAP, and other ill - • The death rate for patients being treated in the outpatient setting is less than 5%. nesses that may have contributed • The death rate may increase to 10% and go as high as 30% for patients admit - to CAP. A head, ears, eyes, nose, ted to the intensive care unit. and throat exam may reveal an up - • The most prevalent reasons for death related to CAP are complications, such per-respiratory infection related to as refractory hypoxemia, multi-organ failure, sepsis, and shock. nasal congestion, ocular discharge, mouth , nasal flaring, or otitis media. Dullness and dryness of the lips, eyes, and mucosa may be signs of dehydration. Immune response Pulmonary and physical examination may reveal A patient’s immune response to the organism causing community-acquired pneumonia includes vasodilation of the pulmonary capillaries, resulting in permeability and leaking dull , chest tenderness, of protein-rich exudate into the interstitial space and eventually reaching the alveoli. As increased tactile , broncho - the alveoli fill with exudate, they stick together and inhibit gas exchange. ph ony, , and whispered The formation of neutrophils, as part of the inflammatory response, may damage the . You also may hear lung tissue and lead to fibrosis or . The tissue of the alveoli is delicate , rhonchi, or , and and can be damaged easily by the normal inflammatory response, which can be exac - the patient may have pleuritic chest erbated if the patient has underlying protective mechanism issues such as overproduc - pain that’s more severe on deep in - tion of mucous, immune deficiencies, and diminished ciliary action. spiration. Cardiovascular effects of CAP in - clude poor perfusion, prolonged capillary refill, and tachycardia. Be - cause of dehydration and caused by hypoxia, the patient’s skin may tent, and he or she may experience men tal status changes. Changes in mental status, loss of appetite, and falls (related to confu - sion and dizziness as a result of hy - poxia) also can be factors that are part of a CAP diagnosis.

Diagnostic tools Many tools (including the pneu - Pneumonia severity index Diagnosis of CAP includes a chest monia severity index, CURB-65 and The pneumonia severity index x-ray. Viral pneumonia commonly CRB-65, SMART-COP, and the Amer - (PSI) was developed to classify presents with interstitial infiltrates i can Thoracic Society criteria) are patients suspected of having CAP on x-ray; bacterial infection pres - available to help determine if the (goo.gl/Yk5JLH ). This tool, which ents with alve olar infiltrates. Viral patient with CAP can be treated has been used in emergency de - and bacterial infections can occur successfully as an outpatient or if partments, nursing homes, and simultaneously. hospital admission is required. community hospitals, looks at pa -

AmericanNurseToday.com December 2017 American Nurse Today 7 CAP risk factors CAP vs HAP Several factors place patients at risk This chart from the Wexner Medical Center of the Ohio State University College of for community-acquired pneumonia differentiates community-acquired pneumonia (CAP) and hospital- (CAP), including comorbidities, acquired pneumonia (HAP). lifestyle, and patient characteristics. CAP HAP Comorbidities Presentation • Altered mental state • Necessary features for diagnosis: Variable clinical features: • Cough • Fever • Bronchiectasis • Fever • Leukocytosis • Chronic obstructive pulmonary • Chest x-ray infiltrates • Increased respiratory secretions disease • Chest x-ray infiltrates • Cystic fibrosis Risk factors • Diabetes • Age extremes • Aspiration risks: • Heart disease • Alcohol misuse • supine positioning • Chronic corticosteroid use • swallowing dysfunction Lifestyle • Cormorbidities: • • cardiac disease • tracheostomy • Alcohol or substance misuse • liver disease • Elevated gastric pH • Homelessness • pulmonary disease • Intensive care unit admission • renal disease • Immunosuppression • Overcrowded living conditions • HIV/AIDS • Hyperglycemia/poor glycemic control • Smoking • Immunosuppression • • Preceding influenza • Oropharyngeal microbial colonization Patient characteristics • Tobacco use

• Extremes of age Most common pathogens • Immunocompromised status • Chlamydophila pneumoniae • Enteric gram-negative bacilli • Haemophilus influenza • Pseudomonas aeruginosa • Legionella pneumophila • Staphylococcus aureus tient characteristics such as: • Moraxella catarrhalis • demographics (gender and resi - • Mycoplasma pneumoniae dence) • Respiratory viruses • Streptococcus pneumoniae • physical assessment findings (mental status, pulse, respiratory rate, temperature, and systolic blood pressure) • laboratory results (pH, blood urea nitrogen [BUN], sodium glucose, hematocrit, and partial five (confusion, BUN > 19 mg/dL, outpatient treatment; and 3, 4, and pressure of arterial oxygen) respiratory rate > 30 breaths/ 5 as hospitalization and possible • comorbidities (liver disease, neo - minute, systolic blood pressure < ICU admission. CRB-65 rates patients plasm, stroke, heart disease, and 90 mmHg or diastolic blood pres - as 0 (no need for hospitalization), 1 renal failure) sure < 60 mmHg, and age > 65 to 2 (consider hospitalization), and • radiology results (presence of years) and CRB-65 has only four 3 to 4 (urgent recommendation for pleural effusion). (the same items as CURB-65, but hospitalization). PSI scoring places patients into BUN isn’t necessary if lab results one of five categories. The first aren’t available). (Visit goo.gl/ SMART-COP three recommend outpatient treat - qXJ76f to view the CURB-65 and SMART-COP (goo.gl/bkuDFo ) is used ment; the fourth and fifth recom - CRB-65 tools.) to de termine the severity of CAP in mend hospitalization. Both tools result in a rating that adults. The acronym represents the corresponds to patient care recom - information needed to make the CURB-65 and CRB-65 mendations. CURB-65 rates patients proper determination for care, and CURB-65 and CRB-65 are easier to with 0 or 1 as being acceptable for the data collected translates to a use than the PSI. Although the PSI outpatient treatment; 2 as short in - point system. Scoring for a patient has 20 items, CURB-65 has only patient stay or closely supervised who is under 50 years old is:

American Nurse Today Volume 12, Number 12 AmericanNurseToday.com 8 created criteria for patients with severe CAP who require ICU ad - mission. Minor criteria include: CAP HAP • respiratory rate > 30 breaths/ minute and Pa O /Fi O 250 2 2 ≤ Less common pathogens mmHg (A need for noninvasive ven tilation can substitute for a res - • Enteric gram-negative bacilli • Acinetobacter baumannii piratory rate > 30 breaths/minute • Pseudomonas aeruginosa • Candida sp. • Staphylococcus aureus • Hemophilus influenza or Pa O2/Fi O2 mmHg < 250.) • Influenza • multilobar infiltrates • Legionella pneumophilia • confusion/disorientation • Stenotrophomonas • uremia (BUN level 20 mg/dL) ≥ • Streptococcus pneumoniae and other Strep sp. • leukopenia as a result of the in - Diagnosis fection alone (white blood cell count < 4,000 cells/mm 3) • Chest x-ray infiltrate • or protected • Cough specimen brush with quantitative cultures • thrombocytopenia (platelet count • Fever • Clinical features are unreliable (fever, < 100,000 cells/mm 3) • Precise role for microbiologic leukocytosis, new chest x-ray infiltrate) • hypothermia (core temperature cultures is unclear. • Serial chest x-rays or CT scanning < 96.8° F [36° C]) • Suctioned/expectorated sputum • hypotension requiring aggressive Empiric treatments fluid resuscitation. Major criteria include: • Beta-lactams • Aminoglycosides • invasive mechanical ventilation • Macrolides • Antipseudomonal beta-lactams • Respiratory fluoroquinolone • Antipseudomonal fluoroquinolones • septic shock with the need for • Vancomycin or linezolid vasopressors. Other criteria to consider include Prevention hypoglycemia (in patients without diabetes), acute alcoholism or alco - • Comorbidity treatment • Gastric acidity maintenance hol withdrawal, hyponatremia, un - • Influenza vaccination • Head of bed elevation explained metabolic acidosis or ele - • Pneumococcal vaccination • Infection prevention measures • Smoking cessation • Invasive mechanical ventilation avoidance vated lactate level, cirrhosis, and • Oral and pharyngeal decontamination asplenia. • Subglottic suctioning

Source: The Ohio State University College of Medicine. scribd.com/document/114849137/Community- Nursing interventions and Acquired-Pneumonia-CAP-Vs treatment In the outpatient setting, patients with CAP are treated with antibi - Systolic blood pressure < 90 mmHg tors are the same except respiratory otics as outlined in guidelines from (2 points) rate (> 30 breaths/minute) and oxy - the American Thoracic Society and

Multilobar chest x-ray involvement gen level (Pa O2 < 60 mmHg or oxy - the Infectious Diseases Society of (1 point) gen saturation 90% or Pa O /Fi O America. (See Treatment options .) ≤ 2 2 Albumin < 35 g/L (1 point) < 250 mmHg). With the increase in antibiotic re - espiratory rate 25 breaths/ The total score determines the sistance, evidence-based prescribing R ≥ minute (1 point) patient’s risk for needing inten sive is crucial. To decrease the chance achycardia 125 beats/minute (1 respiratory vasopressor support. of antibiotic-resistant micro organ - T ≥ point) 0-2 = low risk isms developing and to reduce the Confusion—acute (1 point) 3-4 = moderate risk chances of adverse effects from Oxygen—low arterial oxygen pres - 5-6 = high risk antibiotic treatment, a short (5-day) sure (Pa O ) 70 mmHg or oxy - 7 = very high risk course of antibiotic treatment is 2 ≤ gen saturation 93% or Pa O / Patients with a score of 5 are con - recommended. Research shows ≤ 2 ≥ fraction of inspired oxygen sidered to have an increase risk for CAP. no difference between long- and

(Fi O2) < 333 mmHg (2 points) short-course antibiotic treatment pH < 7.35 (2 points). American Thoracic Society criteria of CAP, and the short course has For patients over 50, all the fac - The American Thoracic Society has been shown to reduce the risk of

AmericanNurseToday.com December 2017 American Nurse Today 9 Treatment options steroids (if reactive airway The Infectious Diseases Society of America/American Thoracic Society collaborated involvement secondary to CAP ex - to create these outpatient treatment options for those with community-acquired ists), bronchodilators, and cough pneumonia. suppressants may also be ordered. Teach patients the expected Patient considerations Treatment options guidelines for recovery, which in - clude: Patient is healthy, with no use of Macrolide (azithromycin, clarithromycin, • fever resolved in 1 week antimicrobials in the past 3 months erythromycin) OR • notably decreased chest pain Doxycycline (Note: macrolide preferred.) and sputum in 4 weeks • notably decreased cough and Patient with compromised immune Respiratory fluoroquinolone (moxifloxacin, breathlessness in 6 weeks system or other comorbidities gemifloxacin, levofloxacin [750 mg]) • resolution of symptoms (al - (chronic heart, lung, liver, or renal OR though fatigue may still be pres - disease; diabetes; asplenia; alcoholism; Beta-lactam (high-dose amoxicillin 1 g ent) in 3 months malignancy) or use of antimicrobials three times a day or amoxicillin-clavulanate • feeling back to normal in 6 within the previous 3 months 2 g twice a day by mouth* plus macrolide) months. Patients with underlying comor - Patient in region with high rate (> 25%) Respiratory fluoroquinolone (moxifloxacin, bidities may follow a different or of high-level (MIC ≥ 16 mcg/ml) gemifloxacin, levofloxacin [750 mg]) macrolide-resistant Streptococcus OR extended course of recovery. pneumoniae Beta-lactam (high-dose amoxicillin 1 g Follow-up for outpatient treat - three times a day or amoxicillin-clavulanate ment is usually 48 to 72 hours after 2 g twice a day** plus macrolide) the initial diagnosis, with another follow-up appointment with the The use of antivirals, when the course of treatment is started early with patients di - healthcare provider in 2 to 3 weeks. agnosed with viral pneumonia or a combination of viral and bacterial pneumonia, Instruct patients to contact their has resulted in a decrease in mortality rates. provider if any unexpected compli - cations develop. Patients who *Alternative for patients unable to take the medication because of a previous allergic reaction or contraindi - cated medical condition: ceftriaxone, cefpodoxime, and cefuroxime (500 mg two times daily); doxycycline is smoke should have additional fol - an alternative to the macrolide. low-up at the 6- to 12-week mark **High dose to cover patients with drug-resistant Staphylococcus pneumoniae (DRSP), patients < 2 or > 65 years old who have received beta-lactam therapy within the last 3 months, patients diagnosed with alco - for a repeat assessment and chest holism, patients with a compromised immune system or other comorbidities, and children exposed in day x-ray to rule out underlying pathol - care. Source: Mandell LA, Wunderink RG, Anzueto A, et al. Infectious Diseases Society of America/American Tho - ogy that may have been a factor in racic Society consensus guidelines on the management of community-acquired pneumonia in adults. Clin In - the original CAP diagnosis. fect Dis. 2007;44(suppl 2):s27-72. What’s in your toolkit? Clo stri dium difficile . pneumonia patients, specifically Using tools to assess whether CAP To qualify for short-course anti - related to CAP drug-resistant patho - patients can be treated in the com - biotic treatment, patients must be gens (CAP-DRP), including Pseudo - munity reduces care costs and deemed clinically stable by the monas aeruginosa, Acinetobacter protects patients with decreased im - health care provider. The definition baumannii , methicillin-resistant munity from being admitted to hos - of clinically stable includes 48 to 72 Staphylococcus aureus (MRSA), and pitals, where they may acquire oth - hours without a fever in the last 5 extremely resistant Enterobacteri - er infections. The assessment tools days of therapy, systolic blood pres - aceae . The goal of this research is to lead to treatment designed to limit sure > 90 mmHg, heart rate < 100 decrease the overuse of narrow- the creation of additional drug-re - beats/minute, respiratory rate < 24 spectrum antibiotics, which can re - sistant patho gens. Research regard - breaths/minute, oxygen saturation > sult in using inappropriate medica - ing CAP is fluid, so stay up-to-date 90%, and normal mental status. If tions and broad-spectrum antibiotics. with the most recent evidence- no improvement occurs after 5 days (Access an algorithm for treating based practices. of antibiotic use, treatment should CAP-DRPs at americannursetoday continue for another 2 days. .) .com/?p=36506 Visit americannursetoday.com/?p=36506 for a Recent research provides a better Other treatments include aceta - list of selected references. understanding of CAP patients re - minophen for pain and fever, early ceiving current treatments as com - ambulation, appropriate hydration, Shari J. Lynn is an instructor at the Johns Hopkins pared to health care-associated and nutritional meals. Systemic University School of Nursing in Baltimore, Maryland.

American Nurse Today Volume 12, Number 12 AmericanNurseToday.com 10 CNE Community Acquired Pneumonia POST-TEST • CNE: 1.51 contact hours Earn contact hour credit online at americannursetoday.com/article-type/continuing-education/

Provider accreditation The American Nurses Association’s Center for Continuing Edu - Post-test passing score is 80%. Expiration: 12/1/20 cation and Professional Development is accredited as a ANA Center for Continuing Education and Professional Devel - provider of continuing nursing education by the American opment’s accredited provider status refers only to CNE activities Nurses Credentialing Center’s Commission on Accreditation. and does not imply that there is real or implied endorsement of ANCC Provider Number 0023. any product, service, or company referred to in this activity nor Contact hours: 1.51 of any company subsidizing costs related to the activity. The ANA’s Center for Continuing Education and Professional Devel - author and planners of this CNE activity have disclosed no rele - opment is approved by the California Board of Registered Nurs - vant financial relationships with any commercial companies ing, Provider Number CEP6178 for 1.81 contact hours. pertaining to this CNE. See the banner at the top of this page to learn how to earn CNE credit.

Please mark the correct answer online. 6. of CAP include 11. The recommended course of antibiotic a. . treatment for CAP in a patient who is clinically 1. The body’s physiologic response to an b. increased appetite. stable is organism causing community-acquired c. decreased tactile fremitus. a. 3 days. pneumonia (CAP) includes d. lack of skin tenting. b. 5 days. a. vasoconstriction of pulmonary capillaries. c. 7 days. b. vasodilation of pulmonary capillaries. 7. Which statement about the use of chest x- d. 14 days. c. leaking of low-protein exudate. rays for diagnosing CAP is correct? d. leaking of low-carbohydrate exudate. a. Viral infection presents with alveolar 12. A 55-year-old man with CAP is otherwise infiltrates. healthy and has not used antimicrobials in the 2. A risk factor for CAP is b. Use of computed tomography scans is past 3 months. An appropriate treatment choice a. increased cough reflex. preferable over serial chest x-rays. is b. chronic renal failure. c. Bacterial infection presents with alveolar a. azithromycin. c. intermittent steroid use. infiltrates. b. amoxicillin. d. hypergammaglobulinemia. d. Viral and bacterial infections do not occur c. levofloxacin. simultaneously. d. gemifloxacin. 3. Which statement about mortality from CAP is correct? 8. Which tool used to assess whether a patient 13. Which of the following indicates a patient a. Older patients over age 75 are at higher risk with CAP can be treated as an outpatient with CAP is clinically stable and can be treated of mortality. requires only four parameters? with short-course antibiotic therapy? b. Patients between 20 and 40 years old are at a. SMART-COP a. Oxygen saturation of 85% higher risk of mortality. b. Pneumonia severity index b. Respiratory rate of 26 breaths/minute c. The mortality rate for patients treated in the c. American Thoracic Society criteria c. Systolic blood pressure of 95 mmHg outpatient setting is 15%. d. CRB-65 d. Heart rate of 90 beats/minute d. The mortality rate for patients treated in the intensive care unit is 5%. 9. Which tool uses minor and major criteria to 14. A 70-year-old woman with CAP lives in a assess whether patients with severe CAP need region that has a 30% rate of high-level (MIC ≥ 4. One of the most common pathogens that to be admitted to the intensive care unit? 16 mcg/ml) macrolide-resistant Streptococcus causes CAP is a. SMART-COP pneumoniae . An appropriate single-treatment a. Haemophilus influenzae . b. Pneumonia severity index choice is b. Pseudomonas aeruginosa . c. CURB-65 a. erythromycin. c. Staphylococcus aureus . d. American Thoracic Society criteria b. doxycycline. d. enteric gram-negative bacilli c. moxifloxacin. 10. What is the level of risk for needing d. clarithromycin. 5. Which patient most likely has CAP rather intensive respiratory vasopressor support for a than hospital-acquired pneumonia? patient who scores 3 on the SMART-COP tool? 15. Patients receiving treatment for CAP should a. Symptoms began 7 days after admission to a. Low be told which of the following is an expected the hospital. b. Moderate guideline for recovery? b. The patient was hospitalized 20 days before c. High a. Fever resolves in 2 weeks. symptoms started. d. Very high b. Chest pain and sputum notably decrease in c. The patient lives in a long-term care facility. 6 weeks. d. Symptoms began 3 days after admission to c. Cough and breathlessness notably decrease the hospital. in 6 weeks. d. Symptoms resolve in 2 months.

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Drug-resistant pathogen algorithm This diagnostic and treatment algorithm aids in treating patients at risk for community- acquired pneumonia drug-resistant pathogens.

Assess risk factors

0-1 risk 2 risk Aggressive 3 or more diagnostic factor factors testing risk factors

Assess Usual CAP MRSA risk Broad-spectrum drugs factors therapy

Culture Culture No Yes positive negative

Usual CAP Usual CAP + Specific Usual CAP drugs MRSA coverage therapy drugs

Culture Culture negative positive

Usual CAP Specific drugs therapy

CAP = community-acquired pneumonia, MRSA = methicillin-resistant Staphylococcus aureus Source: Wunderink RG. Community-acquired pneumonia versus healthcare-associated pneumonia. The returning pendulum. Am J Respir Crit Care Med . 2013;188(8):896-8. Reprinted with permission of the American Thoracic Soci - ety. Copyright 2017 American Thoracic Society.

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