[M10 and 11] - Pneumonia, COVID, and TB

pneumonia

acute infection of the lung parenchyma

pneumonia etiology

normal defense mechanisms become incompetent or overwhelmed

air filtration affected = aspiration risk

epiglottis closure affected = aspiration risk

cough reflex diminished = buildup of mucus leading to infection

3 ways microorganisms can reach the lungs:

- aspiration of normal flora from naso/oropharynx

- inhalation of microbes present in the air

- hematogenous spread from primary infection elsewhere in the body

community-acquired pneumonia (CAP)

acute infection in patients who have NOT been hospitalized or resided in a long-term care facility within 14 days of symptom onset

• can be treated at home or hospitalized depending on patient (age, vitals, mental status, co-morbs, and current condition)

hospital-acquired pneumonia (HAP)

“nosocomial pneumonia”; occurs 48 hours after hospitalization and not present at time of admission

• associated with longer hospital stays, increased associated costs, sicker patients, increased mortality

ventilator-associated pneumonia

occurs > 48 hours after endotrachial intubation

viral pneumonia

most common; involves immune system

• may be mild or life-threatening

bacterial pneumonia

can occur during viral infection due to weakened immune system (“superinfection”); may require hospitalization

“walking” pneumonia

mycoplasma (atypical) pneumonia; milder symptoms caused by Mycoplasma pneumoniae bacteria

patient can usually go about their ADLs

necrotizing pneumonia

rare complication of bacterial lung infection, causing lung tissue to turn into a thick, liquid mass; often resulting from CAP

signs/symptoms:

• immediate respiratory insufficiency/failure

• leukopenia

• bleeding into airways

necrotizing pneumonia treatment

long term antibiotics; possibly surgery

opportunistic pneumonia

caused by bacteria, virus, or microorganisms that don’t normally cause disease; most common in immunocompromised patients

aspiration pneumonia

abnormal entry of oral or gastric material into lower airway; trigger inflammatory response

bacterial infection is most common

aspiration pneumonia risk factors

- decreased LOC (depressed cough or gag reflex)

- difficulty swallowing

- insertion of nasogastric tubes

Pneumocystis jiroveci pneumonia

fungal infection, most common with HIV

slow onset and subtle symptoms (fever, tachycardia, tachypnea/dyspnea, non-productive cough, hypoxemia)

can be life threatening as it can spread to other organs

Pneumocystis jiroveci pneumonia treatment

trimethoprim/sulfamethoxazole (doesn’t response to antifungals)

cytomegalovirus (CMV) pneumonia

herpes virus

asymptomatic and mild to severe disease

most important life-threatening complications after hematopoietic stem cell transplantation

cytomegalovirus pneumonia treatment

antiviral meds and high-dose immunoglobulin

pneumonia pathophysiology

inflammatory response causes alveoli fill with fluid and debris (consolidation) and increased mucus production (airway obstruction)

results in decreased gas exchange

pneumonia most common manifestations

- cough (productive or non-productive)

• green, yellow, or rust-colored sputum

• fine or coarse crackles

- fever, chills

- dyspnea, tachypnea

- pleuritic chest pain

pneumonia generalized objective data (symptoms you measure)

- general: fever, restlessness, lethargy, splinting affected area

- respiratory: tachypnea, asymmetric chest movement, use of accessory muscles, nasal flaring, decreased excursion, crackles, friction rub, dullness on percussion, increased tactile fremitus, sputum amount and color

- tachycardia

- egophony: auscultatory sounds ‘E’ changes to ‘A’ due to consolidations

pneumonia complications

- atelectasis

- pleurisy

- pleural effusion

- bacteremia

- pneumothorax

- acute respiratory failure - leading cause of death in severe pneumonia

- sepsis/septic shock

- multidrug-resistant (MDR) pathogens (major problem in treatment)

pleurisy

inflammation of pleura

pleural effusion

liquid in pleural space

multidrug-resistant (MDR) pathogens risk factors

- advanced age

- immunosuppression

- history of antibiotic use

- prolonged mechanical ventilation

pneumonia diagnostic studies

- H&P

- chest x-ray

- thoracentesis and/or bronchoscopy

- pulse oximetry

- ABGs

- sputum gram stain, culture & sensitivity (ideally before antibiotics)

- blood cultures

- CBC w/diff

pneumonia interprofessional/nursing care

- prompt treatment with antibiotics, regardless of type

- adminster pneumococcal vaccine (used to prevent S. pneumoniae infection)

How can you tell if antibiotic treatment is working for pneumonia?

- decreased temperature

- improved breathing

- less chest discomfort

supportive treatment for viral pneumonia

antivirals: influenza, herpes, and COVID

generally resolves in 3 to 4 days

supportive treatment for pneumonia

- oxygen - hypoxemia

- analgesics - chest pain

- antipyretics - fever

- adjuvent drugs

- individualize rest and activity

- nutritional support

- adequate hydration - adjust for older patients, HF failure patients, and those with pre-existing respiratory conditions

nutritional support for pneumonia

- small, frequent, high-calorie, nutritious meals

- monitor weight

Why is adequate nutrition important for pneumonia?

- prevents dehydrations

- makes secretions thinner and looser

pneumonia nursing interventions: aspiration prevention

- elevate HOB 30 degrees

- sit up for all meals/assist with eating and drinking

- assess gag reflex

- monitor reflux and gastric residuals (NG tube)

- cough and deep breath, incentive spirometry

- early mobilization

- twice-daily oral hygiene

pneumonia nursing interventions: medical asepsis and infection control

- hand hygiene

- sterile technique w/ tracheal suction

- careful handling respiratory equipment

- avoid inappropriate antibiotic use (antibiotic resistance)

pneumonia nursing interventions: health promotion

- teach hygiene, nutrition, rest, regular exercise

- cough or sneeze into elbow

- avoid smoke and exposure to upper respiratory infections

- ID risk factors

- vaccines (flu, COVID, pneumococcal)

- oxygen, hydration, nutrition, breathing exercises, ambulation, and positioning

pneumonia nursing interventions: ambulatory care

- emphasize need to take full course of antibiotics

- drug-drug and drug-food interactions

- adequate rest and hydration

- avoid alcohol and smoking

- cool mist humidifier or warm bath

- chest x-ray, vaccinations

- takes several weeks (or more to recover)

When should you start empiric antibiotic therapy for pneumonia?

before knowing exact cause based on:

• risk factors

• early vs. late onset

• presentation

• underlying conditions

• hemodynamic stability

• when most likely a causitive organism

Which symptom is more unique to COVID?

loss of taste or smell

COVID complications

- immune system stimulation: virus may overreact with cytokines, causing inflammation, damages organs (especially lungs)

- immune system blunting: virus causes immune cells to multiply and become exhausted from turnover

- coagulopathy: more likely to develop DVT, PEs, stroke, microclots (more likely in critically ill patients)

Long COVID etiology

can affect anyone with COVID, even if asymptomatic

possibly caused by ongoing immune activation, or tissue/nerve damage

COVID nursing interventions

- wear N95 respirator, face shield, and goggles

- provide respiratory support: patients may need O₂, monitor SpO₂, consider prone position (esp. for critically ill), use incentive spirometer

- watch for signs of DVT and signs of stroke

COVID meds

- remdesivir: specific oral antiviral (start within 7 days of symptoms)

- corticosteroids: decreases inflammation or autoimmune response

- anticoagulants: heparin/enoxaparin to prevent clots

- bronchodilators: albuterol, esp. if patient has COPD or asthma

tuberculosis

infectious disease caused by Mycobacterium tuberculosis

affects 25% of the population

tuberculosis risk factors

poor, underserved minorities

• homelessness, poverty, poor access to healthcare, inner-city neighborhoods

• IV drug users

tuberculosis etiology/pathophysiology

- aerophilic (oxygen loving; has affinity for lungs)

- spread via airborne droplets

- transmission requires close, frequent, or prolonged exposure

• droplets lodge in bronchioles and alveoli and cause local inflammatory response

What factors influence tuberculosis transmission?

number, concentration, length of time for exposure, and immunity

• NOT spread by touching, shared utensils, kissing, or other physical contact

primary tuberculosis

bacteria are inhaled and inflammation response occurs

• if adequate immune response, infection doesn’t progress to disease

active tuberculosis

primary TB - active disease within 2 years of infection

reactivation TB (post-primary) - disease occurs > 2 years after infection; infectious TB

latent tuberculosis

- infected (positive skin test), but not active

- asymptomatic

- noninfectious (cannot transmit)

- may develop active TB later

- treat to prevent active TB

acute sudden presentation of active TB

- high fever

- chills, generalized flu-like symptoms

- pleuritic pain

- productive cough

- crackles and/or adventitious breath sounds

general symptoms of active TB

- dry cough that becomes productive (blood or sputum)

- fatigue

- malaise

- anorexia, weight loss

- low-grade fever

- night sweats

Which populations are less likely to have fever and other signs of infection with active TB? What symptoms do they have?

- HIV - investigate respiratory problems; rule out PJP or opportunistic diseases

- older adults - change in cognitive function may be only initial sign

tuberculosis complications

- miliary TB

- pleural TB

- empyema

tuberculosis complications of other organs

- spine: Pott’s disease (destruction of intervertebral discs and adjacent vertebrae)

- CNS: bacterial meningitis

- abdomen: peritonitis

- other: kidneys, adrenal glands, lymph nodes, urogenital tract

empyema

collection of pus in pleural space

infected fluid builds up and puts pressure on lungs, causing shortness of breath and pain

miliary TB

large numbers of organisms spread via bloodstream to distant organs

fatal if untreated, but slow progression

• fever, cough, and lymphadenopathy

• can include splenomegaly and hepatomegaly

tuberculosis diagnostic studies

- tuberculin skin test (TST)

- interferon-γ (IFN-gamma) release assays (IGRAs)

- chest x-ray

- TB culture

tuberculin skin test (TST)

TB screening; purified protein derivative (PPD) 0.1mL ID injection into ventral forearm

• inspect site for palpable, raised, hardened, swollen area (induration) in 48 to 72 hrs — indicates development of antibodies following TB exposure

false positive/negative can occur

What are the conditions for a positive TST test?

> 5mm — HIV+, recent contact with active TB patient, nodular or fibrotic changes on chest x-ray, organ transplant

> 10mm — recent arrival from high-prevalence countries, IV drug users, those from high-risk congregate settings, TB lab personnel, children < 4, infants, children, and adolescents exposed to high-risk categories

> 15mm — persons with no known TB risk factor(s)

interferon-γ (IFN-gamma) release assays (IGRAs)

blood test screening tool; detects IFN gamma release from T-cells in response to M. tuberculosis

rapid results, and several advantages over TST, but more expensive

chest x-ray findings in tuberculosis

- upper lobe infiltrates

- cavitary infiltrates

- lymph node involvement

- pleural and/or pericardial effusion

gold standard for tuberculosis diagnosis

TB culture

tuberculosis culture

gold TB diagnostic standard

• three consecutive sputum samples at 8 to 24 hours; at least specimen in early morning

• initial test: stained sputum examined for AFB

• definitive dx: mycobacterial growth (can take up to 6 weeks)

• can also collect samples from other suspected TB sites

active tuberculosis initial drug therapy

8 weeks to 3 months — 4 drugs

• isoniazid — contraindicated for hepatitis

• rifampin — contraindicated for hepatitis; can cause orange bodily fluids

• pyrazinamide — contraindicated for hepatitis

• ethambutol — adverse effect of ocular toxicity

active tuberculosis continuation drug therapy

following 8 weeks of initial therapy — 2 drugs

• isoniazid

• rifampin

active TB drug therapy nursing management

- educate patients about adverse/side effects and when to seek medical attention

- monitor LFTs due to non-viral hepatitis being a major side effect for 3 out of 4 first-line drugs

- alternatives available for patients who develop a toxic reaction

multidrug-resistant TB drug therapy

resistance to isoniazid and rifampin (most potent first-line)

MDR-TB causes

- incorrect prescribing of TB meds

- lack of public health case management

- nonadherence

- lack of funding for education and prevention

latent TB drug therapy

- isoniazid for 6 to 9 months

- isoniazid and rifapentine for 3 months

- rifapentine for 4 months

directly observed therapy for tuberculosis

for non-adherent patients

- provide drugs and watch patient swallow

- expensive, but ensures adherence

- may be given by public health nurses at clinic site

bacille-calmette-guerin (BCG) vaccine

live, attenuated strain of Mycobacterium bovis

• given to infants in parts of the world with high TB prevalence

• not recommended in US due to low risk of infection

• more effective in children than adults