Definition
A.Viral pneumonia is inflammation and consolidation of lung tissue due to a viral pathogen.
B.Hospitalization is recommended for patients who are significantly immunocompromised and the frail elderly.
Incidence
A.Viral pneumonia accounts for a small portion of pneumonia cases in adult pneumonia. It is not uncommon to have concurrent viral and bacterial infections.
B.Elderly persons have the highest rate of influenza-associated hospitalizations.
Pathogenesis
A.Pneumonia results from inflammation of the alveolar space and may compromise air exchange. Viral pneumonia is caused by influenza viruses, parainfluenza virus, adenovirus, and respiratory syncytial virus (RSV).
B.Influenza is the most common cause of viral pneumonia in adults.
C.Viruses and bacteria are spread from a cough or sneeze.
D.Pneumonia can also be spread via blood.
Predisposing Factors
A.Age extremes.
B.Frailty or immunocompromised conditions.
C.Exposure to viral illness.
D.Lack of immunization.
Common Complaints
A.Fever.
B.Cough.
C.Dyspnea.
D.Tachypnea.
E.Wheezing (more common in viral pneumonia).
Other Signs and Symptoms
A.Upper respiratory prodrome.
B.Poor appetite.
C.Malaise/lethargy.
D.Myalgia.
E.Muscle aches.
F.Headache.
G.Fatigue.
H.Chest pain/tightness.
Subjective Data
A.Determine onset, duration, and course of illness.
B.Has the patient had fever, cough, and upper respiratory infection?
C.Have there been any flulike symptoms?
D.Has there been any labored breathing?
E.Has there been a cough? Is it a productive cough? What color is the sputum?
F.Are the breathing problems affecting the ability to eat or drink?
G.Has the patient had nausea, vomiting, or diarrhea?
H.Review if the patient is up to date on immunizations.
I.Review all medications, including over-the-counter (OTC) and herbal products.
J.If diabetic, ask about home blood glucose readings/control.
K.Is there localized pain in chest?
L.Pneumonia history.
M.Pneumonia and influenza vaccine history.
Physical Examination
A.Temperature, blood pressure (BP), pulse, respirations, and pulse oximetry. Observe level of consciousness (LOC).
B.Inspect:
1.Observe overall appearance. Is the patient septic? Consider the clinical presentation, age of person, and history.
2.Observe respiratory pattern, grunting, nasal flaring, retractions, and use of accessory muscles.
3.Check pulse oximetry. An O2 saturation less than 92% is an indicator of severity and the need for oxygen therapy.
4.Check nail beds and lips for cyanosis.
5.Examine eyes, ears, nose, and throat.
C.Auscultate:
1.Auscultate heart.
2.Auscultate lungs for the following (auscultate bases first in geriatric patients):
a.Crackles, decreased breath sounds.
b.Whispered pectoriloquy (patient’s whispered sounds are louder than normal).
c.Egophony (patient’s e
sounds like a
).
d.Bronchophony (voice sounds louder than usual).
D.Percuss: Percuss chest for dull sound (consolidation).
E.Palpate:
1.Palpate lymph nodes for swelling.
2.Palpate chest for tactile fremitus (increased conduction when patient says 99
).
3.Palpate sinuses.
Diagnostic Tests
A.Chest radiograph (CXR) that reveals interstitial, perihilar, or diffuse infiltrates.
B.Complete blood count (CBC) with differential.
C.Rapid viral tests per nasal swab.
D.Sputum Gram stain if indicated.
Differential Diagnoses
A.Viral pneumonia.
B.Bacterial pneumonia.
C.Varicella pneumonia.
D.Herpes pneumonia.
E.Cytomegalovirus pneumonia.
F.Pertussis.
G.Asthma.
H.Bronchitis/bronchiolitis.
I.Sinusitis.
J.Foreign-body obstruction.
K.Aspiration.
L.Fungal pneumonias (especially in the immunocompromised).
M.Severe acute respiratory syndrome (SARS).
N.Middle East respiratory syndrome coronovirus (MERSCoV).
O.Avian flu.
P.Pulmonary tuberculosis (TB).
Plan
A.General interventions:
1.Tell the patient to rest during acute phase.
2.Avoid smoking or secondhand smoke.
3.Require respiratory isolation; may use facial masks.
4.Encourage good handwashing or use of hand sanitizer.
B.
See Section III: Patient Teaching Guide Pneumonia, Viral.
C.Dietary management: Encourage fluids and nutritious diet.
D.Chest physiotherapy is not prescribed for pneumonia.
E.Pharmaceutical therapy: Antiviral agents have limited support for efficacy. Treatment should be targeted based on viral etiology:
1.Zanamivir (Relenza) is the recommended initial choice when influenza A or B infection or exposure is suspected. Zanamivir is administered by a metered-dose inhaler (MDI). Zanamivir is effective only if it is started within 24 to 48 hours of onset of fever and symptoms.
2.The combination of oseltamivir (Tamiflu) and rimantadine, an adamantane, is considered a second-line alternative. Tamiflu resistance emerged in the United States during the 2008 to 2009 influenza season.
3.Amantadine or rimantadine started within 24 hours of the onset of viral symptoms decreases fever and other symptoms by 1 day in uncomplicated cases.
4.Acyclovir (Zovirax) for herpes viruses is administered as an intravenous (IV) infusion.
F.Patients with viral pneumonia who are superinfected with bacterial organisms require antibiotic therapy.
G.Avoid cough suppressants. The suppression of a cough may interfere with airway clearance.
H.Give acetaminophen (Tylenol) for fever.
I.Immunizations:
1.Recommend the pneumonia and influenza vaccines for prevention:
a.Administer pneumonia vaccine for patients 65 years and older, or beginning at age 19 if immunocompromised or chronic respiratory condition is present. Consider revaccination every 5 to 10 years for high-risk patients.
b.Sequential administration of the pneumococcal conjugate vaccine (PCV13) and pneumococcal polysaccharide vaccine (PPSV23) is recommended (download Centers for Disease Control and Prevention [CDC] guide here: www.cdc.gov/vaccines/vpd/pneumo/downloads/pneumo-vaccine-timing.pdf ). In the vaccine naïve patient, give PCV13 first, then the PPSV23 12 months later.
c.In older adults who received PPSV23 at age 65 or older, give PCV13 in 1 year or more.
d.In older adults who received PPSV23 BEFORE age 65, give PCV13, then 5 years after the initial PPSV23, give a second PPSV23.
e.Give a one-time second dose of PPSV23 for persons with chronic renal failure or nephrotic syndrome, functional or anatomic asplenia, or immunocompromising conditions.
Administer yearly flu vaccine. Trivalent or quadrivalent influenza vaccines are available. Give the patient the vaccine in late September, at least 6 weeks before the flu season. Yearly flu vaccination information is available on the CDC website.
Follow-Up
A.Signs and symptoms may vary greatly according to the viral pathogen, severity of disease, and patient’s age:
1.Tell the patient to return to the clinic if no improvement is seen after 48 hours on antiviral agents.
2.Follow up by phone in 24 hours.
3.Consider follow-up at 2 weeks if bronchoconstriction is noted on exam.
Emergent Issues/Instructions
A.Patients demonstrating the following should receive same-day ED evaluation:
1.Respiratory compromise.
2.Neurologic changes including obvious central nervous system (CNS) involvement.
3.Profound dehydration or alterations in vital signs.
Consultation/Referral
A.Consult a physician if viral pneumonia is strongly suspected.
B.Consult a physician if the patient is pregnant.
C.Consult a physician or transfer to the hospital if patient is in respiratory distress, dehydrated, or hypoxemic.
D.Consider consultation with a pulmonologist.
Individual Considerations
A.Pregnancy:
1.Ribavirin is contraindicated in pregnancy, class X drug.
2.Acyclovir is given in the third trimester at 10 mg/kg IV every 8 hours for 5 days.
3.The varicella-zoster immune globulin (VZIG) may be considered in pregnancy.
4.The measles virus is a live-attenuated virus and should not be given during pregnancy.
5.Pneumonia in pregnancy is associated with higher morbidity rates. Physician consultation is advised.
B.Geriatrics:
1.Mortality rates from pneumonia are highest in geriatric groups.
2.Geriatric patients may present initially with confusion only, not with typical signs and symptoms of younger patients, and unable to mount a fever.
3.Geriatric red flags: Geriatric patients with viral pneumonia may have worsening of any of the following geriatric syndromes:
a.Weight loss related to anorexia with viral illness.
b.Delirium/confusion due to illness.
c.Falls related to orthostasis with viral illness.