Introduction
Approximately 2.5 million individuals in the United States contract pneumonia annually, and 55,000 of those individuals die as a result. In fact, pneumonia was the eighth prominent cause of morbidity and is the number one communicable disease in the United States. Pneumonia is the leading deadly hospital-contracted disease and contributes to a sizable amount of deaths in unindustrialized countries as well. It is a grave illness that can impact individuals in all age groups, but it is especially serious in adolescents, the elderly population, and in people with fundamental medical issues such as ischemia, low blood sugar, and systemic respiratory illnesses. It is usually rampant in colder weather and appears more often in tobacco users and males. This evidence-based paper will synthesize relevant information about pneumonia by performing a qualitative analysis of several published research studies that contribute novel findings or ideas regarding pneumonia by screening the National Center for Biotechnology Information database and the Cochrane Library database. Screening criteria included key words such as, pneumonia, pathophysiology, inflammation, diagnoses, treatment, antibiotics, pharmacology, children, elderly, microbial etiology, and streptococcus. All studies chosen were published within the last decade to exclude any outdated findings.
Pathogenesis
Pneumonia is an infection caused by acute-inflammation due to microbial invasion and aggregation in one or both of the lungs parenchyma, over stimulating the first line of defense, which is the innate immune system. The body has many lines of defense including the particular contour of the nose and pharynx, which aids in enclosing the pathogens thereby deterring these organisms from entering the parenchyma (Medina, 2006 p. 409). Other defense mechanisms are coughing and cilia that help move pathogens away from the bronchi. The innate immune system triggers an inflammatory response whereby exudates such as chemokines and ctyokines are released into the alveolar. When microorganisms accumulate, the immune system reacts by directing leukocytes or white blood cells to the alveoli (Moret, 2012). The alveoli then became irritated and inflamed which is why symptoms associated with pneumonia include but are not limited to fever, chest pain, shortness of breath, cough, nausea, and rapid exhalation and inhalation rate.
There are two terms used to categorize pneumonia, nosocomial or community. Nosocomial is the most common type of pneumonia and it is acquired in the hospital site while community pneumonia is when the disease emerges in non-hospitalized patients. In the respiratory system, the upper tract is colonized with commensal bacteria, whereas the lower tract is considered sterile. The airways and lungs are constantly exposed to pathogens in the external environment. Organisms from the upper respiratory tract typically infringe bacteria upon the lower respiratory tract via the bloodstream or by contiguous spread from the chest wall. The upper airway has defense mechanisms such as enzymes, growth inhibitors, and a slimy layer of protection (Boyd, 2011). Bacteria are the usual cause of pneumonia but viruses, parasites, etc. can also cause it. In fact, there are over 45 identified microorganisms that can lead to pneumonia. These bacteria can be stimulated by changes in the normal flora caused by systemic illness, under nutrition, hospitalization, or antibiotic exposure.
In terms of genomic issues underlying pneumonia, there are a lot of answered questions regarding the process of inflammation at a molecular level. Research shows important transcription factors and mechanism like Toll-like receptors, can determine the likelihood of a person to experience overstimulation of their immune system and acute inflammation (Moret, 2012). Previous studies on the innate immune system reveal critical roles of IL-8, CXC10, and TLR4 specifically in creating the feedback loop that results in sepsis (Campbell, 2004 p. 667). Thus, further research must be done to understand what controls these factors and how they can be targeted by therapeutics.
Normal defense mechanisms can be impaired by tobacco use or tracheal intubation because these allow pathogens to reach airspaces and multiply. Subsequently, neutrophils are directed to the lungs in an excessive manner causing accumulation that has been explored in various studies using mice models (Medina, 2006 p. 407). The pathogenesis of pneumonia originates when a pathogen can come into contact with the air pockets in the lungs and the host defense mechanisms are overwhelmed as a result by virulence or by the inoculum volume. In a case study of 800 participants, researchers found that the internal sources of microorganisms are nasal carriers, sinusitis, oropharynx, gastric, or tracheal colonization, and hematogenous spread (Berlan, 2015).
Diagnosis
A patient can have several symptoms of Pneumonia and still not actually have the disease because the symptoms are so common amongst other infectious agents like the flu. Pneumonia is typically diagnosed when the doctor performs a review of the patient’s medical history. Thereafter, the physician performs a physical examination. This is routine protocol however, if the physical examination reveals one or more of the following: a rapid heart rate, elevated temperature, quick, shallow inhalation and exhalation, chest pain, low oxygen levels, or muscle aches. The physician will use a stethoscope instrument to listen to the chest and watch out for any noises caused by fluid movement in the alveoli, or any resonances created by friction between inflamed lung tissue, and wheezing.
Depending on the results of the medical history and physical examination, a chest x-ray will be conducted. The chest x-ray of a pneumonia infected will exhibit dark spots caused by empty pockets of air, pulmonary consolidation, or effusion. Once the chest computed tomography confirms the results of the medical history and physical examination, more diagnostic tests may be necessary depending on the individual’s risks and the gravity of the illness. Sputum testing is a tool used to identify which pathogen caused the pneumonia, which would benefit the treatment program. Urine antigen testing and blood oxygen measurement tests may be performed to see if prescribed antibiotics are effective. Nurses may take blood sample form the patient’s vein to perform a complete blood cell count and potentially distinguish the pneumonia causing bacteria in order to better design a medication plan for treatment. If the antibiotics prescribed fail to improve the patient’s health, bronchoscopy technique can be used to get a clear picture of the lungs, gather a biopsy, and conclude the fundamental root of the infection, whether it be growth or an inhaled extraneous pathogen.
The laboratory analysis approach for the Pneumonia Etiology Research for Child Health (PERCH) study intentions are to integrate a comprehensive variety of diagnostic assessments that will be consistent in seven clinical trial sites. The results have not been published yet but, they will reveal a hoax of information because PERCH will gather ten varying samples in a projected 6000 pneumonia incidents so that as technology continues to advance and new tools emerge, these samples of specimens can be utilized and ensure standardized procedure in future treatment plans (Murdoch, 2011). This brands PERCH as one of the greatest pneumonia etiology reports commenced thus far.
Less than half of the particular pathogen causing pneumonia has been impossible to find even while using the broad list of diagnostic tools. This phenomenon is due to the constraints of the diagnostic exams. However, determining the microbial etiology of pneumonia remains a challenge, principally in adolescents. This is mainly because of the varying use of assays between analyses, strains in specimen assembly, and difficulties in decoding the manifestation of pathogens as being causally connected to the pneumonia incident.
Therefore, pneumonia disease can be categorized according to the environment or location whereby the illness was contracted since patients from analogous settings tend to have analogous results. The doctor is generally not around when the patient has the aspiration episode, pneumonia is diagnosed when radiographic images reveal intrusion in features of the respiratory system. Several case studies show that other common bacterial sources include Haemophilus influenzae, Legionella pneumophila, and Staphylococcus aureus (Gilani, 2010). In a pilot study using mouse models, mycoplasma was shown as a typical causative pathogen of non-severe pneumonia that sporadically cause a more severe pneumonia (Kamangar, 2015). But the study did not reveal the molecular reasons behind this observation and it still remains an unanswered question in the field.
Regardless of the individual carrying the disease, bare in mind that the primary causative agent of bacterial pneumonia is the pneumococcus strain. Thus, the best approach to diagnosis and treatment will be determined with pneumococcus strain in awareness. This form of therapy is empiric and according to the Center of Disease Control guidelines on management of pneumonia, it is the best therapeutic method available. Distinction between community acquired pneumonia, healthcare-associated pneumonia, hospital-acquired pneumonia, and added mechanisms of respiratory illness is crucial in providing the best treatment strategy on an individual basis because the different organisms that occupy each category determine the most beneficial route of empiric therapy. Even though pneumonia is a sort of normal illness in society, the wide array of research and published works regarding the disease is controversial when it comes to how the disease should be assessed and managed. More often than not, diagnostic examinations are seen as the foremost essential techniques but some argue that empiric therapy is the most significant method in alleviating pneumonia. All of the research literature concludes that there are three main features that must be considered in handling pneumonia: determining the presence of pneumonia, assessing disease severity at the time of presentation, and identifying the causative agent (Gilani, 2010). It is noteworthy to mention that diagnostic testing plays a central role in these three main features of managing the pneumonia disease.
Treatment
Like many other illnesses, the focus of treating people with pneumonia is to handle the infection and counteract chances of further disease complications. Often times, individuals began to improve after the antibiotics are administered based upon empiric practice. It is not extraordinary for individuals to be sent home with antibiotic prescription but those who are a part of the high-risk group or just gravely ill will remain in the hospital for constant monitoring of heart rate, blood oxygen levels, fever, and breathing rate. In those affected by the disease, cases of poor ventilation can be alleviated with steroids to counteract inflammation in the lung tissue. In a recent studying examining the success of corticosteroids in treating pneumonia, the researchers screened the Cochrane Central Register of Controlled Clinical Trials and found that these steroids are largely valuable when trying to quickly alleviate painful symptoms of pneumonia (Yew, 2011). Nevertheless, proof from the incorporated studies was not convincing enough to generate any recommendations.
The amount of time an individual remains hospitalized depends on the rate of recovery because the immune defense is weakened or maybe the infection has spread.
There are different courses of antibiotic therapy regimens proven to be successful in treating pneumonia but the doctor has to consider each individual on a unique basis because certain factors may make drug-resistant bacteria more likely. In all ways, it is vital that the patient complete the antibiotic regime as directed to avert further complications. In an analysis performed to determine the clinical value or short versus long treatment, evidence depicts antibiotic regime of three days is just as successful as five days in non-severe cases of pneumonia. The study population was children under the age of six totaling above 6,000 participants and results in differences between the two regimes were found insignificant with a 95% confidence interval (Haider, 2011). This could be particularly in hospitals lacking resources or access to high medication volume. However, it is necessary to conduct further randomized controlled trials with proper design features to ensure the efficacy of this study.
In another study, researchers screened the Cochrane Library and Medline Database to review randomized controlled trials that reveal differences and similarities in efficacy of parenteral versus antibiotic treatment of pneumonia. The study population was adolescent, between 1 and five years old. Results depict oral therapy as an efficient and secure option to parenteral antibiotics in patients with no severe symptoms (Rojas‐Reyes, 2009). Further studies must be performed to determine if the patients with severe symptoms find parenteral or oral treatment more effective.
An additional study on therapy in pneumonia explored vitamin C as a therapeutic route or preventative measure in managing pneumonia. Vitamin C has long been used for its medicinal power in fighting infections but there is a lack of evidence to support therapeutic benefits. The objective of the paper was to examine potential prophylactic and therapeutic benefits of vitamin C in pneumonia patients based upon six trials (Hemilä, 2013). The entirety of the study was high quality but the six trails were performed in extraordinary conditions and are considered rather heterogeneous which brings doubt to applying results to the entire population. Thus, more research is necessary especially in regards to prophylactic use considering only one prophylactic trial was examined here. Still, evidence from this study is significant enough to apply remedial vitamin C supplementation since none of the six trials ended in adverse effects.
A majority of pneumonia patients began to show improvement after three days in of antibiotic therapy in a randomized controlled clinical study (Haider, 2011). Improvement can be outlined as expressing less symptoms, for example, reduced contagion and temperature. 65% of study participants continued to feel fatigue after antibiotic therapy for five to seven days. Almost all non-hospitalized participants found themselves feeling back to normal after a week of antibiotic treatment but being treated for pneumonia in the hospital revealed a recovery period of at least 21 days.
According to Emergency Medical clinical guidelines, it is absolutely imperative for patients treated for pneumonia at home to have a follow-up appointment with the physician within less than seven days of the diagnoses because further complications can occur and it is imperative to ensure the patient has not abandoned their antibiotic regime (Campbell, 2004 p. 669). Hospitalized patients require a follow-up visit as well. Pneumonia can be a deadly disease if the proper steps and measures are not taken to ensure the infection is completely gone, even after proper treatment.
References
Berlan, D. (2015). Pneumonia’s second wind? A case study of the global health network
for childhood pneumonia. Health Policy Plan. Health Policy and Planning. Retrieved March 22, 2016, from http://heapol.oxfordjournals.org/content/early/2015/10/01
Boyd, A. R., & Orihuela, C. J. (2011, December 2). Dysregulated Inflammation as a Risk
Factor for Pneumonia in the Elderly. Retrieved March 22, 2016, from
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3265328/
Campbell, S., Patrick, W., Urquhart, D., Maxwell, D., Ackroyd-Stolarz, S., Murray, D.,
& Hawass, A. (2004). Patients with community acquired pneumonia discharged from the emergency department according to a clinical practice guideline. Emergency Medicine Journal : EMJ, 21(6), 667–669. http://doi.org/10.1136/emj.2003.011833
Gilani, Z. (2010, June 4). Clinical Infectious Diseases. Retrieved March 22, 2016,
Hemilä H, Louhiala P. (2013) Vitamin C for preventing and treating
pneumonia. Cochrane Database of Systematic Reviews 2013, Issue 8. Art. No.: CD005532. Retrieved March 22, 2016, from http://www.ncbi.nlm.nih.gov/pubmed/23925826
Haider BA, Lassi ZS, Bhutta ZA. (2011) Short‐course versus long‐course antibiotic
therapy for non‐severe community‐acquired pneumonia in children aged 2
months to 59 months. Cochrane Database of Systematic Reviews 2008, Issue 2.
Retrieved March 22, 2016, from http://www.ncbi.nlm.nih.gov/pubmed/18425930
Kamangar, N. (2015, October). Bacterial Pneumonia Treatment & Management.
Retrieved March 22, 2016, from http://emedicine.medscape.com/article/300157-
Medina, E. (2006). Murine Model of Pneumococcal Pneumonia. Methods in
Molecular Biology Mouse Models for Drug Discovery, 405-410.
Moret, L. (2012, March 9th). Increased lung neutrophil apoptosis and inflammation
resolution. Retrieved March 22, 2016, from http://erj.ersjournals.com/content/39/3/790
Rojas‐Reyes MX, Granados Rugeles C. (2009 ) Oral antibiotics versus parenteral
Antibiotics for severe pneumonia in children. Cochrane Database of Systematic Reviews 2006, Issue 2. Art. Retrieved March 22, 2016, from http://www.ncbi.nlm.nih.gov/pubmed/16625618
Yew, C. (2011, March 2). Corticosteroids for Treatment of Pneumonia. Retrieved March
22, 2016, from http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0014588/
