Pneumonia

Description

Alternative Names

Treatment

The general approach to the patient with pneumonia is the following:

• Respiratory support with oxygen, if needed.
• Antibiotics, with the decision based on test results for specific organisms or if organisms are unknown based on individual risk factors (e.g., age, health, and severity of the illness).

Categorizing Severity and Determining Hospitalization

Up to 10% of all adult hospitalizations in the US are due to pneumonia. Studies are indicating that many patients are hospitalized unnecessarily for pneumonia and those that are could be released sooner. A number of strategies are being devised to determine when and which patients can be safely discharged. One approach for determining whether a patient should be hospitalized categorizes patients into five classes depending on risk factors for severity, with class 1 being the least severe (having less than 0.5% risk for mortality) and class 5 being the most severe (having at least a 10% mortality risk).

Ruling out the Least Severe Cases. The procedure for deciding on hospitalization or not starts by ruling out patients in the lowest risk groups (referred to as class 1 and 2), who can be discharged with outpatient care only. This can often be done with a simple physical examination, which can often rule out a severe condition. Patients in low-risk categories have the following characteristics:

• Under age 50 and not a patient in a nursing home.
• No other major illnesses are present.
• No serious symptoms are present (e.g., altered mental state, rapid breathing rate with cough or difficulty in breathing, bluish skin indicating cyanosis, very low blood pressure, very high fever).

Even these criteria, however, should not be carved in stone. Physicians still must use their own judgment and take mitigating factors into consideration. As examples, the following young people with signs of pneumonia should be hospitalized, even if they otherwise fit low-risk (class 1) categories:

• Any infant under a month.
• Young adults with alcoholism or severe psychiatric conditions.
• Young adults or children with abnormal heart rhythms.
• Young adults or children who are vomiting heavily.
• Children who are dehydrated.

Determining The Next Levels of Severity. If a patient is not in a class 1 category or does not obviously need hospitalization, the next step is to determine which of the other four higher classes the patient fits. This step involves assigning points to other findings, including the following:

• Laboratory test results.
• X-ray findings.
• Demographics (i.e., male or female, nursing home patient).

The points are added and the patients are scored:

• Patients who score low points on these findings are assigned class II and III; they can usually be treated at home or need only to be hospitalized for 24 hours for observation.
• Patients with higher scores are placed in classes IV and V and are hospitalized.

Home care may be possible even in severe cases, when there is good support and available home nursing services. Often, caregivers can even be trained to administer intravenous antibiotics and chest therapy to patients at home.

Home Treatment

Most patients with mild pneumonia can be treated at home with oral antibiotics, typically amoxicillin. (A well-conducted 2002 study suggested that children with mild bacterial pneumonia may do as well with three days versus five days of amoxicillin. This is important because shorter duration ensures better compliance.)

The following are also suggested:

• Patients should be sure to drink plenty of liquids.
• Coughing should not be suppressed, since this is an important reflex for clearing the lungs. Some physicians advise taking expectorants, such as guaifenesin (Breonesin, Glycotuss, Glytuss, Hytuss, Naldecon Senior EX, Robitussin), to loosen sputum. There is no proof that any of these products make much difference in outcome.
• Mild pain can be treated with aspirin (adults only), acetaminophen (Tylenol and other brands), or ibuprofen (Advil, Motrin).
• For severe pain, codeine or other stronger pain relievers may be prescribed. It should be noted, however, that codeine and other narcotics suppress coughing, so they should be used with care in pneumonia and often require monitoring.
• Of some interest is a laboratory study reporting that aromatic oils containing oregano, thyme, and rosewood destroyed S. pneumoniae. It is not known whether they have any effect on pneumonia in people, but they are harmless and pleasant in any case.
• Patients should practice chest therapy.

Hospitalization Guidelines

Treatment. If the pneumonia is severe enough for hospitalization, the standard treatment is intravenous administration of antibiotics for five to eight days. (In cases of uncomplicated pneumonia, many patients may require only two or three days of intravenous antibiotics followed by oral therapy.) Oral antibiotics are prescribed when the patient has improved substantially or leaves the hospital.

Duration of Stay. In the past, patients remained in the hospital eight to 11 days, but hospital stays are shorter now in most cases. Of interest, was a 2002 study in which patients who were first treated in the emergency room were able to go home sooner than those admitted directly to a hospital room. The reason for this was that ER patients tended to be given the appropriate antibiotics and to be treated sooner than those in the hospital itself.

It is important to stress, in any case, that once patients have been hospitalized, they should remain there until all their vital signs are stable. Most patients become stabilized in three days. Many experts use seven variables to measure such stability and to determine if the patient can go home:

• Temperature. (Opinions differ on temperature goal. Some experts believe that a patient can go home if the temperature levels drop to 101 degrees F. Stricter criteria would require that it be at or close to normal.)
• Respiration rate. (Goal is a normal breathing rate, although expert opinion differs on the degree of normality required to be discharged.)
• Heart rate. (Goal is 100 beats per minute or less.)
• Blood pressure. (Goal is systolic blood pressure of 90 mmHg or greater.)
• Oxygenation. (Goal of oxygen levels in the blood determined by the physician.)
• The ability to eat. (Goal is regular appetite.)
• Mental function. (Goal is normal.)

Patients or their families should discuss these criteria with the physician. In a 2002 study, 42% of patients who had two or more signs of instability when they left the hospital were either readmitted or had died within 30 days. This compared to a 10.5% 30-day failure in completely stabilized patients.

Chest Therapy

Chest therapy using incentive spirometry, rhythmic inhalation and coughing, and chest tapping are all important techniques to loosen the mucus and move it up out of the lungs. It should be used both in the hospital and when the patient returns home during recovery.

Incentive Spirometry. The patient uses an incentive spirometer at regular intervals to improve breathing and loosen sputum. The spirometer is a hand-held clear plastic device that includes a breathing tube and a container with a movable gauge. The patient exhales and then inhales forcefully through the tube, using the pressure of the inhalation to raise the gauge to the highest level possible.

Rhythmic Breathing and Coughing. During recovery, the patient performs rhythmic breathing and coughing every four hours:

• Before starting the breathing exercise, the patient should tap lightly on the chest to loosen mucus within the lung. If available, a caregiver should also tap on the patient's back.
• The patient inhales rhythmically and deeply three or four times.
• The patient then coughs as deeply as possible with the goal of producing sputum.