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
Expand all
Collapse all
Overview
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.
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 read sample articles.
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 read sample articles.
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 read sample articles.
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 read sample articles.
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 read sample articles.
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 read sample articles.
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 read sample articles.
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 read sample articles.