Treatment:

The approach to treating patients with pneumonia generally involves:

• Deciding who can be treated at home and who needs to be in the hospital
• Deciding whether a patient needs antibiotics, and which antibiotics are appropriate
• Providing appropriate supportive care
• Deciding what follow-up and preventive care are needed

Whether patients are treated at home or admitted to the hospital, receiving their first dose of antibiotics quickly improves the outcome of the illness and the speed at which they get better.

Determining the Need for Hospitalization

Studies indicate that many patients do not need to be hospitalized for pneumonia, and can be safely treated at home. Likewise, many patients who are admitted to the hospital could be released sooner. A number of strategies are being devised to determine which patients can be safely discharged and when they can be discharged. Studies have shown that low-risk patients with mild-to-moderate pneumonia do just as well when treated as outpatients. They return to work and normal activities faster than those treated in the hospital.

A variety of guidelines and tools have been developed to help determine who can safely be treated at home and who cannot. One commonly used tool is called the Pneumonia Severity Index. All of these assessment tools are looking for risk factors. The more of these risk factors that are present, the less likely that the patient can be safely treated at home. Several of these risk factors determine a specific score. All of them must be used along with the doctor's clinical judgment.

Some of the important factors used to make a decision include:

Demographics.

• Patients who have been living in a nursing home or other residential facility are of greater concern.
• Elderly patients and infants, particularly infants who are less than 1 month old, are more likely to be admitted.

Other Medical Illnesses. Patients may be considered at greater risk if they have:

• Cancer
• Heart failure
• History of stroke
• Kidney failure
• Liver disease

Findings on a Physical Exam. Concerning findings include:

• Altered mental status (confused, less responsive)
• Appearance of being dehydrated, especially if the person is unable to drink fluids
• Fast breathing (more than 30 breaths per minute)
• Heart rate greater than 120 beats per minute
• Systolic blood pressure less than 90 mm Hg
• Temperature greater than 104 °F

Laboratory and X-ray Findings. Laboratory findings that are of concern include:

• Elevated blood sugar
• Fluid in the sac around the lung (on chest x-ray)
• Low oxygen in the blood
• Low sodium levels
• Poor kidney function
• Significant anemia (hematocrit less than 30%)

Patients with very few of these risks often can be discharged with outpatient care only. This determination can often be made with a simple physical examination and history. Sometimes a patient only needs to be hospitalized for 24 hours for observation.

Patients with higher scores on these assessment tests often have many risk factors and usually are hospitalized.

When possible, treatment of community-acquired pneumonia should be started within 4 hours of admission to the emergency room or hospital to reduce the chances of mortality and decrease the amount of time a patient needs to spend in the hospital.

Home care may be possible, even in severe cases, when there is good support and available home nursing services. Often, caregivers can even be trained to administer intravenous antibiotics and chest therapy to patients at home.

Home Treatment

The following tips are suggested:

• Drink plenty of liquids.
• Do not suppress a cough. Coughing is an important reflex for clearing the lungs. Some doctors advise taking expectorants, such as guaifenesin (Breonesin, Glycotuss, Glytuss, Hytuss, Naldecon Senior EX, Robitussin) to loosen mucus. However, there is no proof that any of these products make much difference in a patient's outcome.
• Mild pain can be treated with aspirin (in adults only), acetaminophen (Tylenol), or ibuprofen (Advil, Motrin).
• For severe pain, codeine or another stronger pain reliever may be prescribed. It should be noted, however, that codeine and other narcotics suppress coughing, so they should be used with care in pneumonia. Such pain relievers often require monitoring.
• A laboratory study reported that aromatic oils containing oregano, thyme, and rosewood destroyed S. pneumoniae. It is not known whether they have any effect on pneumonia in people.
• Practice chest therapy.

Hospitalization Guidelines

Treatment. If the pneumonia is severe enough for hospitalization, the standard treatment is intravenous antibiotics for 5 - 8 days. In cases of uncomplicated pneumonia, many patients may need only 2 or 3 days of intravenous antibiotics followed by oral therapy. Antibiotics taken by mouth are prescribed when the patient has improved substantially or leaves the hospital.

ITSA/ATS guidelines recommend that patients admitted to the hospital (but not the ICU) be treated with fluoroquinolones or a beta-lactam plus a macrolide (preferably cefotaxime or ceftriaxone and ampicillin).

Duration of Stay. Patients should remain in the hospital until all their vital signs are stable. Most patients become stabilized in 3 days. Many experts use seven variables to measure stability and to determine whether the patient can go home:

• Temperature. Some experts believe that patients can go home when their temperature drops to 101 °F. Stricter criteria require that it be at or close to 98.6 °F.
• Respiration rate. Goal is a normal breathing rate, although expert opinion differs on the degree of normality required for discharge.
• Heart rate. Goal is 100 beats per minute or less.
• Blood pressure. Goal is systolic blood pressure of 90 mm Hg or greater.
• Oxygenation. Goal is determined by the physician.
• The ability to eat. Goal is regular appetite.
• Mental function. Goal is normal.

Patients or their families should discuss these criteria with their doctor.

Chest Therapy

Chest therapy using incentive spirometry, rhythmic inhalation and coughing, and chest tapping are all important techniques to loosen the mucus and move it out of the lungs. It should be used both in the hospital and during recovery at home.

Incentive Spirometry. The patient uses an incentive spirometer at regular intervals to improve breathing and loosen sputum. The spirometer is a hand-held clear plastic device that includes a breathing tube and a container with a movable gauge. The patient exhales and then inhales forcefully through the tube, using the pressure of the inhalation to raise the gauge to the highest level possible.

Rhythmic Breathing and Coughing. During recovery, the patient performs rhythmic breathing and coughing every 4 hours:

• Before starting the breathing exercise, the patient should tap lightly on the chest to loosen mucus in the lung. If available, a caregiver should also tap on the patient's back.
• The patient inhales rhythmically and deeply three or four times.
• The patient then coughs as deeply as possible with the goal of producing sputum.