Condition

Pneumonia

Pneumonia is an acute infection of the respiratory system that can occur in one or both lungs causing inflammation of the lung tissue. The inflammation interferes with the body’s ability to deliver oxygen and remove carbon dioxide from the blood.

Article by Heather Henry

First published: 05 Jul 2021 Last updated: 04 Jan 2024

Expand all

Collapse all

Overview

Pneumonia can affect adults of any age, but it's more common, and can require hospital treatment, in certain groups of people, such as:

older people
those who smoke or consume harmful levels of alcohol
those who are immunosuppressed, such as those receiving chemotherapy
people with long term conditions such as heart, kidney, liver or lung disease

To view the rest of this content login below or request a demo

Symptoms

Common symptoms of pneumonia include:

a dry or productive cough with thick yellow, green, brown or blood-stained sputum
difficulty breathing, even at rest, which may be rapid and shallow
tachycardia
pyrexia, sweating and shivering
general malaise
loss of appetite
chest pain that gets worse when breathing or coughing

Less common symptoms include:

haemoptysis
headache
fatigue
nausea and vomiting
wheeze
joint and muscle pain
confusion and disorientation, particularly in older people (NHS England, 2019)

COVID-19 can precipitate pneumonia. Please consult the latest guidelines (see resources section) for the specific diagnosis and management guidance.

Be alert for signs of sepsis (see resources section): blotchy skin or a rash that does not fade when you roll a glass over it.

To view the rest of this content login below or request a demo

Aetiology

Pneumonia can be caused by bacteria or by a virus. Less commonly, pneumonia can also be caused by fungal infection and aspiration.

Pneumonia is normally classified according to whether it is community acquired or hospital acquired. Hospital acquired pneumonia is an acute lower respiratory tract infection (usually bacterial) that is acquired after at least 48 hours of admission to hospital and is not incubating at the time of admission (Kalil et al, 2016). It is the most frequent hospital-acquired infection in patients who are critically ill (Mansour and Bendry, 2012).

To view the rest of this content login below or request a demo

Diagnosis

Diagnosis of pneumonia in adults can be difficult because the signs and symptoms are similar to common respiratory conditions such as asthma, bronchitis, an exacerbation of chronic obstructive pulmonary disorder, COVID-19, colds and influenza. Clinicians therefore rely on a full clinical examination to assess the likelihood and severity of infection.

Diagnosis in the community

perform auscultation of the chest for breath sounds
assess hydration status by measuring capillary refill time, examining skin turgor and dryness of mucous membranes, and assessing urine output
assess presence of pyrexia, tachycardia and tachypnoea
a chest X-ray is not routinely done with community acquired infections
perform pulse oximetry to look for low oxygen saturation levels of 93% or less on room air
obtain sputum sample if possible, prior to commencing antibiotic therapy
perform a CRB65 score to assess severity

CRB65 score for mortality risk assessment in primary care

A CRB65

To view the rest of this content login below or request a demo

Management

Management in the community

Advise rest, plenty of fluids to drink and not to smoke
Pleuritic pain should be relieved using simple analgesia such as paracetamol
Review patients after 48 hours or earlier as necessary including pulse oximetry
Consider hospital admission or chest X-ray for those who fail to improve after 48 hours of treatment

Safety-netting: advise people with community‑acquired pneumonia to consult their healthcare professional if they feel that their condition is deteriorating or not improving as expected (NICE, 2023).

Management in hospital

All patients assessed using the CURB65 Score considered to be at high risk of death on admission to hospital should be reviewed medically at least 12-hourly until shown to be improving
Observations including temperature, respiratory rate, pulse, blood pressure, mental status, oxygen saturation and inspired oxygen concentration should be made at least twice daily
Observations should be made for dehydration; some may need intravenous fluids
Heparin

To view the rest of this content login below or request a demo

Treatment

Treatment in the community

Oral antibiotics according to latest guidance (NICE, 2019)
For patients referred to hospital with suspected community acquired pneumonia and where the illness is considered to be life-threatening, prescribers should start administering antibiotics in the community as per latest guidance (NICE, 2019) as soon as possible

Treatment in hospital

A chest X-ray should be performed to confirm the diagnosis, preferably before antibiotic therapy commences, depending on the severity
Blood cultures are recommended for all patients with moderate and high severity community acquired pneumonia. Ideally, sensitivity of the causative organism should be ascertained before antibiotic therapy is commenced but this is not always practical and may delay treatment
Oxygen therapy: aim to maintain oxygen saturation at 94–98%.
Those at risk of hypercapnic (excess carbon dioxide) respiratory failure complicated by ventilatory failure should be guided by repeated arterial blood gas measurements
Oral antibiotics according to latest prescribing guidelines (NICE,

To view the rest of this content login below or request a demo

NMC proficiencies

Nursing and Midwifery Council: standards of proficiency for registered nurses

Part 1: Procedures for assessing people’s needs for person-centred care

1. Use evidence-based, best practice approaches to take a
history, observe, recognise and accurately assess people
of all ages

Part 2: Procedures for the planning, provision and management of person-centred nursing care

8.2 manage the administration of oxygen using a range of routes and best practice approaches

11.8 administer medications using a range of routes

To view the rest of this content login below or request a demo

Resources

National Institute for Health and Care Excellence (NICE). Rapid guideline for managing acute Covid-19. 2023. https://www.nice.org.uk/guidance/ng191 (accessed 4 January 2023)

National Institute for Health and Care Excellence. NICE guideline on delirium. 2023. https://www.nice.org.uk/guidance/cg103 (accessed 4 January 2024)

NHS England. Sepsis. 2022. https://www.nhs.uk/conditions/sepsis/ (accessed 4 January 2024)

References

Belli S, Prince I, Savio G et al. Airway clearance techniques: the right choice for the right patient. Frontiers in Medicine (Lausanne). 2021; 8:544826. https://doi.org/10.3389/fmed.2021.544826

Hodkinson HM. Evaluation of a mental test score for assessment of mental impairment in the elderly. Age Ageing. 1972;1(4):233-238. https://doi.org/10.1093/ageing/1.4.233

Lim WS, van der Eerden MM, Laing R et al. Defining community acquired pneumonia severity on presentation to hospital: an international derivation and validation study. Thorax. 2003;58(5):377-382. https://doi.org/10.1136/thorax.58.5.377

Lim WS, Baudouin SV, George RC. British Thoracic Society guidelines for the management of community acquired pneumonia in adults: update 2009. Thorax. 2009;64(Suppl III):iii1–iii55. http://dx.doi.org/10.1136/thx.2009.121434

National Institute for Health and Care Excellence (NICE). Pneumonia (community-acquired): antimicrobial prescribing. 2019.

To view the rest of this content login below or request a demo