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Pneumonia is also the most common fatal infection acquired by already hospitalized patients.

In developing countries, like the Philippines, pneumonia ties with diarrhea as the most common cause of death. Pneumonia remains in the list of the leading causes of morbidity and mortality in the Philippines. The incidence of pneumonia in developing countries in children less than 5 years old is almost 30% with a high mortality rate. Approximately 10-20% of all children <5 years old in developing countries develop pneumonia each year. Each year, acute respiratory infections cause approximately 2 million deaths among children <5 years old and are the leading cause of death in this age group. About 1% of pneumonia cases result in sequelae (e.g., bronchiectasis) which increase the risk of recurrent infections. Person-to-person transmission may occur by direct contact with infectious secretions. Most cases of pneumonia among children occur sporadically, not in outbreaks. Infants (especially premature or low birth weight) are at great risk. Nearly 75% of pneumonia deaths occur among infants under 1 year old. Risk also increases with malnutrition, malaria, and suppressed immunity. The 2003 NDHS revealed that only 46 percent of children below five years of age who had the symptoms of acute respiratory infection were taken to a health facility or health care provider for treatment. This is a 12 percentage point reduction from the 58 percent reported in the 1998 NDHS. This may imply that the reduction in deaths from pneumonia among young children may have been due to improved knowledge and skills in managing the fewer pneumonia cases that have been brought to the health facility.

Classification: A. Bronchopneumonia -implies that the pneumonic process is distributed in the patchy fashion having originated in one or more localized areas within the bronchi and extended to the adjacent surrounding lung parenchyma.


Lobar Pneumonia -involvement of a substantial portion of one or more lobes


Bacterial Pneumonia -more commonly caused by Streptococcal Pneumoniae

There are many causes of pneumonia, including bacteria, viruses, mycoplasmas, fungal agents and protozoa. Pneumonia may also result from aspiration of food, fluids, vomitus or from inhalation of toxic or caustic chemicals, smoke, dusts or gases. Pneumonia may complicate immobility and chronic illnesses. It often follows influenza.

Major risk factors for pneumonia include: advanced age, very young age, history of smoking, upper respiratory infection, tracheal intubation, prolonged immobility, nonfunctional immune system, malnutrition, dehydration and chronic disease states, such as diabetes, heart disease, chronic lung disease, renal disease and cancer. Additional risk factors are exposure to air pollution, altered consciousness from alcoholism, drug overdose, general anesthesia or a seizure disorder; inhalation of noxious substances; aspiration of food, liquid or foreign or gastric material; or residence in institutional setting where transmission of disease is more likely.

Predisposing / Precipitating factors Predisposing factors: >age especially infants due to their immature or underdeveloped immune system >immunocompromised individuals easily susceptible to such disease upon exposure to microorganisms >common colds these conditions when unresolved could lead to Pneumonia

Precipitating factors: >aspiration of foods or fluids provides a medium for growth of microorganisms.

>exposure to air pollution and inhalation of noxious substances allergens in the environment can further aggravate the condition >exposure to pathologic microorganisms due to the environment where the patient lives and due to immature immune system

Signs and symptoms with rationale Signs and Symptoms: Sudden onset of shaking chills- due to invasion of microorganism causing inflammatory process Rapidly rising fever (38-39.5), flushed skin- cause by release of endogenous pyrogens that reset the hypothalamic thermostat Stabbing chest pain aggravated by respiration and coughing- indicates pleural inflammation arising from parietal pleura, which is richly supplied by sensory nerve endings Marked tachypnea, rapid and bounding pulse- compensatory mechanism for hypoxemia Nasal flaring, dyspnea, cyanosis and use of accessory muscles of inspirationdue to interference in oxygen and carbon dioxide exchange, that causes hypoxemia Bacteremia- due to invasion of microorganisms Crackles- due to lung congestion or consolidation Wheezes- due to narrowed air passages cause by accumulation of secretions

Anatomy & Physiology of the Respiratory System

The respiratory system is situated in the thorax, and is responsible for gaseous exchange between the circulatory system and the outside world. Air is taken in via the upper airways (the nasal cavity, pharynx and larynx) through the lower airways (trachea, primary bronchi and bronchial tree) and into the small bronchioles and alveoli within the lung tissue. Move the pointer over the coloured regions of the diagram; the names will appear at the bottom of the screen) The lungs are divided into lobes; The left lung is composed of the upper lobe, the lower lobe and the lingula (a small remnant next to the apex of the heart), the right lung is composed of the upper, the middle and the lower lobes.

Appearance on X ray

AP CXR showing left lower lobe AP CXR showing right Normal AP CXR Normal lateral CXR pneumonia associated with a small left sided pleural effusion lower lobe pneumonia

Right upper lobe pneumonia as A lateral CXR showing right lower lobe pneumonia AP CXR showing pneumonia of the lingula of the left lung marked by the circle.

There are several ways to prevent infectious pneumonia. Appropriately treating underlying illnesses (such as AIDS) can decrease a person's risk of pneumonia. Smoking cessation is important not only because it helps to limit lung damage, but also because cigarette smoke interferes with many of the body's natural defenses against pneumonia.

Research shows that there are several ways to prevent pneumonia in newborn infants. Testing pregnant women for Group B Streptococcus and Chlamydia trachomatis, and then givingantibiotic treatment if needed, reduces pneumonia in infants. Suctioning the mouth and throat of infants with meconium-stained amniotic fluid decreases the rate of aspiration pneumonia. Vaccination is important for preventing pneumonia in both children and adults. Vaccinations against Haemophilus influenzae and Streptococcus pneumoniae in the first year of life have greatly reduced the role these bacteria play in causing pneumonia in children. Vaccinating children against Streptococcus pneumoniae has also led to a decreased incidence of these infections in adults because many adults acquire infections from children. Hib vaccine is now widely used around the globe. The childhood pneumococcal vaccine is still as of 2009 predominantly used in highincome countries, though this is changing. In 2009, Rwanda became the first low-income country to introduce pneumococcal conjugate vaccine into their national immunization program.[18] A vaccine against Streptococcus pneumoniae is also available for adults. In the U.S., it is currently recommended for all healthy individuals older than 65 and any adults withemphysema, congestive heart failure, diabetes mellitus, cirrhosis of the liver, alcoholism, cerebrospinal fluid leaks, or those who do not have a spleen. A repeat vaccination may also be required after five or ten years.[19] Influenza vaccines should be given yearly to the same individuals who receive vaccination against Streptococcus pneumoniae. In addition, health care workers, nursing home residents, and pregnant women should receive the vaccine.[20] When an influenza outbreak is occurring, medications such as amantadine, rimantadine, zanamivir, and oseltamivir can help prevent influenza.[21][22]

Treating Pneumonia

Typically, oral antibiotics, rest and fluids are sufficient for treatment of pneumonia. However, there is concern that expanded and sustained use of antibiotics to treat children with pneumonia could lead to increased antibiotic resistance, which would make the management of cases more difficult in the future.

High levels of antibiotic resistance to first-line treatments, notably cotrimoxazole, have been reported in many parts of the world. A study in Pakistan investigated the relationship between high levels of S. pneumoniae and Hib resistance to cotrimoxazole and the clinical efficacy of using this drug to treat children with pneumonia.1 However, this study found that despite high

levels of cotrimoxazole resistance, treatment failure rates were low among children with pneumonia.

It is important that scaling up treatment for pneumonia go hand-in-hand with rigorous training and oversight of health facility personnel and community health workers to ensure proper diagnosis and treatment of pneumonia in communities.

Nursing interventions and responsibilities in caring for the patient with pneumonia include administering oxygen and medications as prescribed and monitoring for thier effects. Monitoring vital signs including oxygen level, monitoring lung sounds, watching for edema and patients feeling of shortness of breath. It may also include doing chest physiotherapy, educating on the use of incentive spirometry and flutter valve. If the patient is immobile it is imperative that the patient be turned every two hours and encouraged to cough and deep breathe. If the patient has a tracheostomy proper trach care and suctioning after hyperoxygenating is also a responsibility.

Asthma is a common chronic inflammatory disease of the airways characterized by variable and recurring symptoms, airflow obstruction, and bronchospasm.[1] Symptoms include wheezing, cough, chest tightness, and shortness of breath.[2] Medicines such as inhaled short-acting beta-2 agonists may be used to treat acute attacks.[3] Attacks can also be prevented by avoiding triggering factors such as allergens[4] or rapid temperature changes[5] and through drug treatment such as inhaled corticosteroids.[6]Leukotriene antagonists are

less effective than corticosteroids, but have fewer side effects.[7] The monoclonal antibody omalizumab is sometimes effective.[8] It affects 7% of the population of the United States,[9] 6.5% of British people and a total of 300 million worldwide.[10] [citation needed] Asthma causes 4,000 deaths per year in the United States[11] and 250,000 deaths per year worldwide.[12] Prognosis is good with treatment. Although asthma is a chronic obstructive condition, it is not considered as a part of chronic obstructive pulmonary disease as this term refers specifically to combinations of bronchiectasis, chronic bronchitis, and emphysema. Unlike these diseases, the airway obstruction in asthma is usually reversible; however, if left untreated, asthma can result in chronic inflammation of the lungs and irreversible obstruction.[citation needed] In contrast to emphysema, asthma affects the bronchi, not the alveoli.[13] Public attention in the developed worldhas increased recently because of its rapidly increasing prevalence, affecting up to one quarter of urban children.


Clinical classification of severity[15]


Symptom frequency

Nighttime symptoms

%FEV1 FEV1 of predicted Variability


<1 per week 2 per month



Mild persistent

>1 per week >2 per month but <1 per day



Moderate persistent


>1 per week



Severe persistent





Asthma is clinically classified according to the frequency of symptoms, forced expiratory volume in 1 second (FEV1), and peak expiratory flow rate.[15] Asthma may also be classified as atopic (extrinsic) or non-atopic (intrinsic), based on whether symptoms are precipitated by allergens (atopic) or not (non-atopic).[16] [edit]Brittle asthma Main article: Brittle asthma

Brittle asthma is a term used to describe two types of asthma, distinguishable by recurrent, severe attacks.[17] Type 1 brittle asthma refers to disease with wide peak flow variability, despite intense medication. Type 2 brittle asthma describes background well-controlled asthma, with sudden severe exacerbations.[17] [edit]Signs

and symptoms

Because of the spectrum of severity among asthma patients, some people with asthma only rarely experience symptoms, usually in response to triggers, where as other more severe cases may have marked airflow obstruction at all times.[18] Common symptoms of asthma include wheezing, shortness of breath, chest tightness and coughing. Symptoms are often worse at night or in the early morning, or in response to exercise or cold air.[19] [edit]Asthma attack Severity of acute asthma exacerbations[17] Near-fatal asthma High PaCO2 and/or requiring mechanical ventilation Any one of the following in a person with severe asthma:Clinical signs Altered conscious level Exhaustion Life threatening asthma Arrhythmia Low blood pressure Cyanosis Silent chest Poor respiratory effort Acute severe asthma Any one of:Measurements Peak flow < 33% Oxygen saturation < 92% PaO2 < 8 kPa "Normal" PaCO2

Peak flow 33-50% Respiratory rate 25 breaths per minute Heart rate 110 beats per minute Unable to complete sentences in one breath Worsening symptoms Moderate asthma exacerbation Peak flow > 50% best or predicted No features of acute severe asthma

An acute exacerbation of asthma is commonly referred to as an asthma attack. The cardinal symptoms of an attack are shortness of breath (dyspnea), wheezing, and chest tightness.[20] Although the former is often regarded as the primary symptom of asthma,[21] some people present primarily with coughing, and in the late stages of an attack, air motion may be so impaired that no wheezing is heard.[17] When present the cough may sometimes produce clear sputum. The onset may be sudden, with a sense of constriction in the chest, as breathing becomes difficult and wheezing occurs (primarily upon expiration, but sometimes in both respiratory phases). It is important to note inspiratory stridor without expiratory wheeze however, as an upper airway obstruction may manifest with symptoms similar to an acute exacerbation of asthma, with stridor instead of wheezing, and will remain unresponsive to bronchodilators.[21] Signs of an asthmatic episode include wheezing, prolonged expiration, a rapid heart rate (tachycardia), and rhonchous lung sounds (audible through a stethoscope). During a serious asthma attack, the accessory muscles of respiration (sternocleidomastoid and scalene muscles of the neck) may be used, shown as in-drawing of tissuesbetween the ribs and above the sternum and clavicles, and there may be the presence of a paradoxical pulse (a pulse that is weaker during inhalation and stronger during exhalation), and over-inflation of the chest.[citation needed] During very severe attacks, an asthma sufferer can turn blue from lack of oxygen and can experience chest pain or even loss of consciousness. Just before loss of consciousness, there is a chance that the patient will feel numbness in the limbs and palms may start to sweat. The person's feet may become cold. Severe asthma attacks which are not responsive to standard treatments,

called status asthmaticus, are life-threatening and may lead to respiratory arrest and death.[citation

Though symptoms may be very severe during an acute exacerbation, between attacks a patient may show few or even no signs of the disease.[22]


Fluticasone propionate metered dose inhaler commonly used to prevent asthma attacks.

Prevention of the development of asthma is different from prevention of asthma episodes. Aggressive treatment of mild allergy withimmunotherapy has been shown to reduce the likelihood of asthma development. In controlling symptoms, the first step is establishing a plan of action to prevent episodes of asthma by avoiding triggers and allergens, regularly testing for lung function, and using preventive medications.

Current treatment protocols recommend controller medications such as an inhaled corticosteroid, which helps to suppress inflammation and reduces the swelling of the lining of the airways, in anyone who has frequent (greater than twice a week) need of relievers or who has severe symptoms. If symptoms persist, additional controller drugs are added until almost all asthma symptoms are prevented. With the proper use of control drugs, patients with asthma can avoid the complications that result from overuse of rescue medications. Patients with asthma sometimes stop taking their controller medication when they feel fine and have no problems breathing. This often results in further attacks after a time, and no long-term improvement. The only preventive agent known is allergen immunotherapy. Controller medications include the following:

Inhaled glucocorticoids such as beclomethasone are the most widely used prevention medications and normally come as inhalers. Side effects, while they may occur are generally not seen with the inhaled steroids when used in conventional doses for control of asthma due to the smaller dose which is targeted to the lungs, unlike the higher doses of oral or injected preparations. Deposition of steroids in the mouth may result in oral thrush. Deposition near the vocal cords can cause hoarse voice. These may be minimised by rinsing the mouth with water after inhaler use, as well as by using a spacer. Spacers also generally increase the amount of drug that reaches the lungs.

Leukotriene modifiers such as montelukast provide both anti-spasm and anti-inflammatory effects. They are less effective than inhaled corticosteroids, but do not have any steroid related side-effects and the benefit is additive with inhaled steroid.

Mast cell stabilizers such as (cromoglicate (cromolyn), and nedocromil). These medications are believed to prevent the initiation of the allergy reaction, by stabilizing the mast cell. They are not effective once the reaction has already begun, and typically must be used 4 times a day for maximal effect. But they do truly prevent asthma symptoms and are nearly free of side-effects.

Antimuscarinics/anticholinergics (ipratropium, oxitropium, and tiotropium). These agents both relieve spasm and reduce formation of mucous. They are more effective in patients with empysema or 'smokers lung.' They are rarely effective in asthma and are not true asthma controller medications.

Methylxanthines (theophylline and aminophylline). These agents are bronchodilators with minimal anti-inflammatory effect. At one time they were the only effective asthma medications available. They are sometimes considered if sufficient control cannot be achieved with inhaled glucocorticoid, leukotriene modifier, and long-acting -agonist combinations.

Antihistamines are often used to treat the nasal allergies which can accompany asthma. Older agents are too drying and can result in thick mucous so should be avoided. Newer antihistamines which do not have this effect can safely be used by patients with asthma.[verification

Allergy Desensitization, also known as allergy immunotherapy, may be recommended in some cases where allergy is the suspected cause or trigger of asthma. Allergy shots are dangerous in severe asthma and in uncontrolled asthma. However if allergy immunotherapy is started early in the disease there is a good chance that a remission of asthma can be induced (aka "asthma cure"). Typically the need for medication is reduced by about half with injection allergy immunotherapy, when done correctly. If a patient is only allergic to one or two items, oral allergy immunotherapy can be used. This is safe, much easier in young children, and is about half as effective. Unfortunately if a patient is allergic to more than 2 or 3 items then oral therapy cannot be given in a dose which is proven safe and effective.

Asthma is a chronic inflammation of the bronchial tubes (airways) that causes swelling and narrowing (constriction) of the airways. The result is difficulty breathing. The bronchial narrowing is usually either totally or at least partially reversible with treatments. Bronchial tubes that are chronically inflamed may become overly sensitive to allergens (specific triggers) or irritants (nonspecific triggers). The airways may become "twitchy" and remain in a state of heightened sensitivity. This is called "bronchial hyperreactivity" (BHR). It is likely that there is a spectrum of bronchial hyperreactivity in all individuals. However, it is clear that asthmatics and allergic individuals (without apparent asthma) have a greater degree of bronchial hyperreactivity than nonasthmatic and nonallergic people. In sensitive individuals, the bronchial tubes are more likely to swell and constrict when exposed to triggers such as allergens, tobacco smoke, or exercise. Amongst asthmatics, some may have mild BHR and no symptoms while others may have severe BHR and chronic symptoms. Asthma affects people differently. Each individual is unique in their degree of reactivity to environmental triggers. This naturally influences the type and dose of medication prescribed, which may vary from one individual to another.

According tohealth and nutrition, the oriental and Chinese herbs have the capability to strengthen the immune system directly to make itfunctionproperly for the prevention of asthma like problems. The only drawback of herbs is that they taste awful; therefore, to make your children gulp these herbal drinks easily is to mix them with theirfavorite juices to make them taste better. A certified health and nutrition expert having the experience of childrens treatments can judge your childs requirements and recommend an herbal medicine to cure congestion and develop the immune system. Massaging certain herbs on specific areas of your childs body during asthmatic periods can aid to give relief from cough, irritation and wheezing. Lung 1 releases blocked energy in the lungs: positioned on each side of the chest in the malleable area just below the lateral head of the collarbone. Ding chuan is a particular spot to ease asthma; positioned on the backside, just underneath and lateral to the most prominent vertebra in the base of neck.