1. Every 20 seconds a child dies from pneumonia
SOAP
Pneumonia
Every 20 seconds a child dies from pneumonia
Saeid kashefi
2nd year post.bacc
November 12, 2011, has been proclaimed World Pneumonia Day.
4/6/2017

2. Fluid and pus filled air space contains bacteria

3. Who Gets Pneumonia?
Anyone can get pneumonia, but some people are at a higher risk than others.
Risk factors include:
Cigarette smoking
Recent viral respiratory infection—a cold, laryngitis, influenza, etc.
Difficulty swallowing (due to stroke, dementia, Parkinson's disease, or other neurological conditions)
Chronic lung disease such as COPD, bronchiectasis, or cystic fibrosis
Heart disease, liver cirrhosis, or diabetes  
Living in a nursing facility
Impaired consciousness (loss of brain function due to dementia, stroke, or other neurologic conditions)
Recent surgery or trauma
Having a weakened immune system due to illness, certain medications, and autoimmune disorders

4. Pneumonia
Community-acquired Pneumonia (CAP) was the 4th leading cause of death in the world in 2012 according to the WHO and 6th leading cause of death in the U.S.
It’s a Inflammation of one or both lungs.
What Causes Pneumonia?
The infection may be bacterial, viral, fungal.
Pneumonia is extremely contagious
Pneumonia can be a serious and life-threatening infection. This is true especially in the elderly, children, and those who have other serious medical problems, such as COPD, heart disease, diabetes, and certain cancers.

7. Diagnosis of Pneumonia
Pneumonia confirmed by chest X-ray testing. (dense white patch)
CT scan
With pneumonia, sputum is sometimes bloody
Sputum Gram Stain and culture
Pulse oximetry
Routine lab testing –
CBC
BMP (basic metabolic panel)
LFTs
ABG (arterial blood gas)

8. How do we classify pneumonia? Nosocomial Pneumonias
Community Acquired
CAP
Health Care Associated
HCAP
Hospital Acquired
HAP
ICU Acquired
ICUAP
Ventilator Acquired
VAP
Nosocomial Pneumonias

9. Treatment of Community Acquired Pneumonia
(CAP)

10. ICU Inpatient/community acquired
Table Evidence-Based Empiric Antimicrobial Therapy for Pneumonia in Adults
Clinical Setting
Usual Pathogens
Empiric Therapy
Outpatient/community acquired
Previously healthy
S. pneumoniae, M. pneumoniae, H influenza, C. pneumoniae, M. catarrhalis
Macrolide/azalide, or tetracycline
Comorbidities (diabetes, heart/lung/liver/renal disease, alcoholism
Fluoroqinoloned or -lactam + macrolideb
Elderly
S. pneumoniae, Gram-negative bacilli
Piperacillin/tazobactam or cephalosporine or carbapenemf
Inpatient/community acquired
Non-ICU
S. pneumoniae, H. influenza, M. pneumoniae, C. pneumoniae, Legionellasp.
Fluoroquinoloned or -lactam + macrolideb
ICU
S. pneumoniae, S.aureus, Legionella sp, gram-negative bacilli, H. influenza
β-lactam + macrolide or fluoroquinolone;
piperacillin/tazobactam
meropenem or cefepime + fluoroquinolone,
β-lactam + AMG + azithromycin
β-lactam + AMG + respiratory fluoroquinolone
If MRSA suspected
Above + vancomycin or linezolid
Hospital acquired, ventilator associated, or healthcare associated
No risk factors for MDR pathogens
S. pneumoniae, H. influenzae, MSSA enteric Gram-negative bacilli
Ceftriaxone or fluoroquinoloned or ampicillin/sulbactam or ertapenem or doripenem
Risk factors for MDR pathogen
P. aeruginosa, K. pneumoniae (ESBL), Acinetobacter sp.,
Antipseudomonal cephalosporine or antipseudomonal carbapenem or -lactam/-lactamase + antipseudomonal fluoroquinoloned or AMG
If MRSA or Legionella sp. suspected
Aspiration
Mouth anaerobes, S. aereus, enteric Gram-negative bacilli
Penicillin or clindamycin or piperacillin/tazobactum + AMG

11. SOAP

12. Problem List Bilateral pneumonia and ARDS Right sided pneumonia
Septic shock

13. Subjective Evidence
C/O sudden onset breathlessness since morning (3 AM)
Associated with shivering, severe sweating

14. Objective Evidence Physical Examination: RR-35/min SpO2-60% ( 95-100%)
RS : Right B/L basal creps+

15. Routine Biochemical Investigation
WBC: 22.0 x103 cells/mm3
N: 90.9 (35-75)%
L: 4.9 (20-45)%

16. FINAL DIAGNOSIS Bilateral pneumonia and ARDS Right sided pneumonia
Septic shock

17. ETIOLOGY

18. Table 116-6 Pneumonia Classifications and Risk Factors
Type of Pneumonia
Definition
Risk Factors
Community acquired (CAP)
Pneumonia developing in patients with no contact to a medical facility
Age >65 years
Diabetes Mellitus
Asplenia
Chronic cardiovascular, pulmonary, renal and/or liver disease
Smoking and/or alcohol abuse
Healthcare associated (HCAP)
Pneumonia developing in patients not in medical facility but two or more risk factors for MDR pathogens
Recent hospitalization 2 days within past 90 days
Nursing home or long-term care facility resident
Recent (past 30 days) antibiotic use, chemotherapy, wound care or infusion therapy either at a healthcare facility or home
Hemodialysis patients
Contact with a family member with infection caused by MDR pathogen
Hospital-acquired (HAP)
Pneumonia developing >48 hours after hospital admission
Witnessed aspiration
COPD, ARDS, or coma
Administration of antacids or H2-antagonists
Supine position
Enteral nutrition, nasogastric tube
Reintubation, tracheostomy, or patient transport
Prior antibiotic exposure
Head trauma, ICP monitoring
Age >60 years
See healthcare associated for MDR risk factors
Same as hospital acquired

19. Assessment if therapy is indicated?
Yes, therapy is indicated to Reduce morbidity and mortality Prevent complications and Improve quality of life.

20. Ipratropium (20mcg/1puff) Levosalbutamol (50mcg) Neb. Duolin Q6H
Drug with Dose & Route
12/10
 13/10
 14/10
15/10
16/10
Generic Name
Dosage form
Brand Name 1
ICU 2 3 4 5
Piperacillin/
Tazobactam
Inj.
Tazillin 4.5 g IV
Stat in 50 ml of NS over 1 hrs
Over 30
min
Methylprednisolone
Solumedrol
40 mg
in 40 ml NS Q8H
 Dopamine
Dopamine
6 ml/hr
Ipratropium (20mcg/1puff)
Levosalbutamol (50mcg)
Neb.
Duolin
Q6H
Pantoprazole
Tab.
Pan 40mg
1-0-0 (b/f)
Paracetamol
Dolo 650mg
SOS
Chlorpheniramine
Inj
Avil IV
1amp SOS
Ondansetron
Emeset 4mg IV
 NA
Inf Na
Montelukast
Tab
Montair
Stat-1
 Salbutamol (100ml)
Neb
Asthalin
Stat
Chlorpheniramine (4mg/5mL)/ Dextromethorphan (10mg)
Syp
Aerodil
2tsp
1-0-1
 Cap
Becelac forte
1-1-1

22. Assessment of Current Therapy

23. Inj. Tazillin 4.5 g IV (Piperacillin/Tazobactam)
Stat in 50 ml of NS over 1 hrs Days 1-5
Class: Piperacillin : extended-spectrum beta-lactam antibiotic of the ureidopenicillin class. Tazobactam: β-lactamase inhibitor.
MOA: Piperacillin inhibits bacterial cell wall synthesis.
Tazobactum inhibits the action of bacterial β-lactamases.
Indication: is indicated for Community-acquired pneumonia (moderate severity only), Nosocomial pneumonia (moderate to severe)
Justification: It is correctly indicated according to the Infectious Diseases Society of American Guidelines on the Management of CAP in Adults.
Dose, dosage and schedule were found to be correct.
ADR: Prolongation of bleeding time, anaphylaxis, nausea,
vomiting, diarrhea.

24. Inj. Solu medrol 40 mg (Methylprednisolone) in 40 ml NS Q8H DAY 1
Class: Corticosteroid drug
MOA: It inhibit the potent mediators of inflammation such as prostaglandins and leukotrienes.
Indication: It is indicated for breathlessness
Justification: It is correctly indicated as patient was having breathlessness as symptoms of pneumonia
Dose, dosage and schedule were found to be correct.
ADR: Hypercalciuria, hypokalemic alkalosis, CHF, PUC, HTN, viral infections, itching, allergic skin reactions.

25. INJ. Dopamine 6 ml/hr
DAY 1
MOA: increases blood pressure by acting on both α and β-1 receptors.
Indication: It is given for the treatment of severe hypotension and septic shock
Justification: It is correctly indicated as the patient had hypotension on day 1 and septic shock
Dose, dosage and schedule were found to be correct.
ADR: nervousness, headache, dysrhythmias, palpitations, chest pain, dyspnea, nausea, and vomiting.

26. Neb. Duolin (Ipratropium (20 mcg/1puff) Levo-salbutamol (50 mcg)) Q6H DAYS 1-3
Class: anticholinergic agent/Stimulates β- receptors
MOA: Ipratropium bromide: decreased contractility of smooth muscle/ Levosalbutamol: Stimulates β-receptors
Indication: breathlessness.
Justification: It is indicated correctly because patient had breathlessness from day 1
Dose, dosage and schedule were found to be correct.
ADR: tremor, tachycardia, leg cramps, dizziness, vomiting

27. Tab. Pan 40 mg (Pantoprazole)
1-0-0 (b/f) Day 1-5
Class: proton pump inhibitor (PPI)
MOA: Pantoprazole inhibit H+/K+ - ATPase enzyme
Indication: for prevention of gastric irritation
Justification: It is indicated to prevent gastric irritation due to poly pharmacy
Dose, dosage and schedule were found to be correct.
ADR: Weakness, dizziness, nausea, vomiting, anxiety, dyspnea, pain, pharyngitis, cough, arthralgia, rhinitis, chest pain, bronchitis, backache, urinary frequency, UTI, hyperlipidemia.

28. Tab. Dolo 650mg (Paracetamol)
SOS DAYS
Class: NSAIDs (antipyretic and analgesic)
Indication: for chills (as symptoms of pneumonia) as well as RA.
Justification: It is indicated correctly because the patient had chills on day 1 and RA according to medical history. (Patient has been taking paracetamol)
Dose, dosage and schedule were found to be correct.
ADR: Bronchospasm, blood dyscrasias, centribular necrosis, liver damage, hypoglycemic coma, hepatic necrosis, liver failure, skin rashes, GI adverse effects.

29. Inj. Avil IV (Chlorpheniramine)
1amp SOS
Class: first-generation alkylamine antihistamine
MOA: it is H1-receptor antagonist
Indication: cough, running nose (since 4 days back)
Justification: It is correctly indicated as the patient had cough
Dose, dosage and schedule were found to be correct.
ADR: Blurred vision, dry eyes, mydriasis, drowsiness, constipation, fatigue, headache, dizziness, psychomotor impairment, dry mouth, gastrointestinal disturbances.

30. Inj. Emeset 4mg IV (Ondansetron) S.O.S.
days 1-2
Class: prevent nausea and vomiting caused by cancer chemotherapy, radiation therapy, and surgery.
MOA: serotonin (5HT3) antagonist
Indication: given for vomiting
Justification: It is given due to patient suffering from vomiting.
Dose, dosage and schedule were found to be correct.
ADR: Headache, dizziness, drowsiness, tiredness, or constipation may occur.

31. Inf. NA (Noradrenaline)
day-2
Class: catecholamine (adrenergic agonists)
MOA: norepinephrine stimulates cardiac contractility.
Indication: hypotensive states, septicaemia
Justification: It is correctly indicated as the patient had hypotension and septic shock. (Norepinephrine is used to treat shock, because it increases vascular resistance and, therefore, increases blood pressure. Other actions of norepinephrine are not considered to be clinically significant.)
Dose, dosage and schedule were found to be correct.
ADR: ausea, stomach upset, skin rash, acute toxicity.

32. Tab. Montair (Montelukast)
Stat-1 DAY- 1
Class: leukotriene receptor antagonist
MOA: Montelukast selectively antagonizes LTD4, preventing smooth muscle contraction.
Indication: breathlessness
Justification: This reduces the bronchoconstriction caused by the leukotriene, and results in less inflammation
Dose, dosage and schedule were found to be correct.
ADR: Angioedema, headache, restlessness, abdominal pain, agitation, oedema, allergy anaphylaxis.

33. Neb. Asthalin (Salbutamol (100ml))
Stat
Class: β2-agonist
MOA: direct-acting sympathomimetic which producing bronchodilating effects.
Indication: breathlessness
Justification: It is given correctly as the patient complained of breathlessness
Dose, dosage and schedule were found to be correct.
ADR: Fine skeletal muscle tremor especially hands, tachycardia, palpitations, muscle cramps, headache, angioedema, urticaria, hypotension and collapse.

34. Cap Becelac forte 1-1-1 day 4-5
Class: Lactobacillus acidophilus 2000lacs, Folic acid 1.5 mg, Vit.B12 15 mcg ,Niacinamide 100 mg, Calcium pantothenate 50 mg, Biotin 100mcg.
MOA: It helps to prevent harmful bacterial growth.
Indication: Used For vitamins and minerals deficiency due to diarreha.
Justification: It is given correctly as in cases of mild Antibiotic induced diarrhea.
Dose, dosage and schedule were found to be correct.

35. Syrp. Aerodil (Chlorpheniramine (4mg/5mL)/ Dextromethorphan (10mg)) 2 tsp 1-0-1 day 4
Class: Antitussive agent
MOA: Chlorpheniramine is an H1-antagonist. Dextromethorphan acts as antagonist to the NMDA glutamatergic receptor
Indications: used for treatment and prevention of cough.
Justification: correctly indicated as patient suffered from cough.
Dose, dosage and schedule were found to be correct.
ADR: Dependency, dizziness, drowsiness, vomiting, restlessness, mental confusion, excitation

36. PLANNING

37. Goals of Therapy
Eradication of the offending organism through selection of the appropriate antibiotic and complete clinical cure
To decrease morbidity and mortality
To prevent complications
To relieve patient symptoms
To improve quality of life

38. Monitoring Parameters Therapeutic Monitoring
Toxicity Monitoring
vitals, RR, SpO2-
chest Xray
RS :B/L basal creps+,
WBC:
plateleate
Electrolytes
Heart rate
Fatiguability
Pedal edema
Jaundice
Input/output

39. Points to Physician
Patient having high TSH which indicated for hypothyroidism.
Blood urea nitrogen level
Ondansetron is not for preventing nausea or vomiting that is caused by factors other than cancer treatment or surgery.

40. Points to Patient Points to the patient:
You have infection in your lung and it can be treated if you adhere to your therapy.
It is contagious which can be spread easily.
Hence care must be taken.

41. Life Style Modification
How to Strengthen Your Lungs After Having Pneumonia
Method 1: Performing Breathing Exercises
1-Practice deep breathing.
2-Do pursed-lip breathing.
3-Try breathing from your diaphragm
4-Practice huff-cough breathing.

42. At Home
Rest as much as possible to help speed your recovery.
Drink plenty of fluids throughout the day.
Take the entire course of any prescribed medications.
Get enough vitamins and minerals.

43. Points to Patient on Discharge Medication
Tab tazillin 4.5 gm Q8h
Tab pan 40 mg 1-0-0
Syr aerodil 2tsp 1-0-1
Tab dolo 650mg sos

44. Tab pan 40 mg 1-0-0 Tab tazillin 4.5 gm Q8h
It is indicated to prevent gastric irritation due to multi drugs.
One tablet should be taken 30 min. before breakfast.
You may have weakness, dizziness, nausea, vomiting or anxiety as side effects.
Tab tazillin 4.5 gm Q8h
It is antibiotic which is indicated for treatment of pneumonia.
It should be taken one tablet each every 8 hours.
You may have nausea, vomiting and diarrhea as side effects.

45. Syr aerodil 2tsp 1-0-1 Tab dolo 650mg sos
It is indicated to reduce your cough.
It should be taken 2 tea spoon each 12hours.
You may have dizziness, drowsiness, vomiting, restlessness as side effects.
Tab dolo 650mg sos
It is indicated for your Rheumatoid Arthritis.
You should take it whenever there is pain in your joints.
You may have nausea, vomiting and diarrhea as side effects.

46. Follow up/Review
To review SOS