Foundations of Respiratory Medicine by Simon Hart & Mike Greenstone

Author:Simon Hart & Mike Greenstone
Language: eng
Format: epub
ISBN: 9783319941271
Publisher: Springer International Publishing

Principles of Treatment

The mainstays of treatment in pneumonia can be divided into general measures and antibiotic therapy.

General Measures

Patients are often hypoxaemic, but the optimal level of PaO2 to improve outcomes in pneumonia is undefined; supplemental oxygen is generally used to maintain a PaO2 ≥8 kPa, or for oxygen saturations to be maintained at 94–98%. Insensible fluid loss is often underestimated and requires correction. As with all systemic inflammatory processes, pneumonia generally promotes venous thrombus formation, which is compounded by immobility. Patients should have thromboprophylaxis unless specifically contra-indicated, and mobilised from bed as quickly as is feasible.

Pneumonia induces a significant catabolic effect that is multifactorial and is probably responsible for systemic upset and muscle wasting. Physiotherapy and dietetic input is important to maintain muscle tone and independent mobility, and to increase calorific intake. Anti-emetics can obviously help in allowing better calorific intake. The profound fatigue of pneumonia can persist for weeks or months after an otherwise full recovery. The pleurisy that accompanies about 15% of cases of pneumonia should be treated with analgesics, and opioids may be required to relieve pain and allow more effective aeration of the affected side, but there is no evidence for their use as antitussives.

If a patient with pneumonia fails to respond to apparently good treatment, the most likely explanation is that the diagnosis of pneumonia is incorrect, or that the underlying medical condition that predisposed to pneumonia is dictating the tempo of the illness. Failure to respond should lead to consideration of complications such as empyema . Other possibilities (particularly in HAP/VAP, aspiration, and severe CAP) include inadequate or inappropriate antibiotic coverage for the responsible pathogen(s), or the involvement of an antibiotic-resistant organism(s).

On discharge, patients must be followed up, as pneumonia can occasionally be the first declaration of a tumour occluding a bronchus, and so a repeat CXR at 6–8 weeks is generally advised, particularly in smokers and in patients aged over 50. Complete radiographic resolution is age-dependent and lags well behind clinical improvement, but all CXRs should be improving by 6–8 weeks, and failure of resolution should prompt further investigation, usually with CT in the first instance.

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