CARE OF BABIES WITH CONGENITAL PNEUMONIA

PRESENTED BY RN III VIOLET ISRAVELSCBU, AHMADI HOSPITAL

INTRODUCTION Pneumonia is an inflammatory pulmonary

process that may originate in the lung or be a focal complication of a contiguous or systemic inflammatory process.

Abnormalities of airway patency as well as alveolar ventilation and perfusion occur frequently due to various mechanisms.

These derangements often significantly alter gas exchange and dependent cellular metabolism in the many tissues and organs that determine survival and contribute to quality of life.

DEFINITIONCongenital Pneumonia is an inflammatory condition of the lung—affecting primarily the microscopic air sacs known as alveoli at birth.

It is usually caused by infection with viruses or bacteria and less commonly other microorganisms, certain drugs and other conditions such as autoimmune diseases.

Such pathologic problems, superimposed on the underlying difficulties associated with the transition from intrauterine to extrauterine life, pose critical challenges to the immature human organism.

EPIDEMIOLOGY In 2008, pneumonia occurred in approximately

156 million children (151 million in the developing world and 5 million in the developed world)

Many of these deaths occur in the newborn period. The World Health Organization estimates that one

in three newborn infant deaths is due to pneumonia.

Neonatal pneumonia ranges from 20 to 32 percent of live-born and from 15 to 38 percent of stillborn infants.

congenital pneumonia accounted for 30 of these 56 infections, caused by maternal enteric organisms frequently accompanies chorioamnionitis and/or funisitis in these congenital infections.

TYPES Morphologyo Lobar pneumoniao Bronchopneumoniao Interstitial pneumonia

Onseto True congenital pneumoniao Intrapartum pneumoniao Postnatal pneumonia

Etiologyo viralo Bacterialo Mycoplasmalo Aspiration

RISK FACTORS Unexplained preterm labor Rupture of membranes before the onset of labor Membrane rupture more than 18 hours before

delivery Maternal fever (>38°C/100.4°F) Uterine tenderness Foul-smelling amniotic fluid Infection of the maternal genitourinary tract Previous infant with neonatal infection Nonreassuring fetal well-being test results Fetal tachycardia Meconium in the amniotic fluid Recurrent maternal urinary tract infection Gestational history of illness consistent with an

organism known to have transplacental pathogenic potential

ETIOLOGY Congenital pneumonia may be infectious or

noninfectious Group B Streptococcus (GBS) Nontypable Haemophilus influenzae Other gram-negative bacilli Listeria monocytogenes Enterococci Staphylococcus aureus noninfectious pneumonia are a class of diffuse

lung diseases. They include: diffuse alveolar damage, organizing pneumonia, nonspecific interstitial pneumonia, lymphocytic interstitial pneumonia, desquamative interstitial pneumonia, Aspiration

TRUE CONGENITAL PNEUMONIA

Transmission of congenital pneumonia usually occurs via 1 of 3 routes: Haematogenous

Mom with bacterial or viral(micro organisms) accumulation in blood.

Ascending Ascending infection from the birth canal

Aspiration Aspiration of infected or inflamed amniotic fluid

PATHOPHYSIOLOGYDue to the etiological factors

If the mother has a bloodstream infection

defenses are limited in fetuses

can readily cross the placental barrier

dissemination and illness may result

before birth or relatively shortly before birth

pneumonia is already established at birth

SIGNS AND SYMPTOMS Elevated respiratory rate Retractions Grunting when exhaling Nasal flaring Increase of mucous and other fluid substances in

the airways (White, yellow, green, or hemorrhagic colors and creamy or chunky textures)

Unstable body temperature Poor feeding, Abdominal distention Jaundice at birth Glucose intolerance Hypoperfusion Oliguria Cyanosis of central tissues, such as the trunk.

DIAGNOSIS Physical exam Observe for signs of respiratory distress Examination of the chest may be normal, but

may show decreased chest expansion on the affected side.

Harsh breath sounds from the larger airways that are transmitted through the inflamed lung are termed bronchial breathing, and are heard on auscultation with a stethoscope.

Crackles (rales) may be heard over the affected area during inspiration.

Percussion may be dulled over the affected lung, and increased, rather than decreased, vocal resonance distinguishes pneumonia from a pleural effusion.

RADIOLOGICAL INVESTIGATIONWhen considering pneumonia, devote particular attention to the following: Costophrenic angles

Pleural spaces and surfaces

Diaphragmatic margins

Cardiothymic silhouette

Pulmonary vasculature

Right major fissure

Air bronchograms overlying the cardiac shadow

Lung expansion

Patterns of aeration

RADIOLOGICAL INVESTIGATIONX-ray examination of the chest may reveal certain abnormal changes associated with pneumonia. Localized shadows obscuring areas of the lung may indicate a bacterial pneumonia, while streaky or patchy appearing changes in the x-ray picture may indicate viral or mycoplasma pneumonia.

LABORATORY INVESTIGATIONS Complete Blood Count White Blood Cell Count (5000-25000) Inflammation markersCRP, Procalcitonin, cytokines Culture The most useful laboratory tests for congenital pneumonia facilitate the identification of an infecting microorganism. Results can be used for therapeutic decisions as well as prognostic and infection control considerations. Arterial Blood Gas Indicated for S/S of Hypoxia

TREATMENT Therapy in infants with neonatal pneumonia is

multifaceted. The goals of therapy are to eradicate infection

and provide adequate support of gas exchange to ensure the survival and eventual well being of the infant.

This is not to imply that eradication of invasive microbes should not be a goal;

Drainage of a restrictive or infected effusion or empyema may enhance clearance of the infection and will improve lung mechanics

Even if the infection is eradicated, many hosts develop long-lasting or permanent pulmonary changes that adversely affect lung function, quality of life, and susceptibility to later infections

RESPIRATORY SUPPORTAdequate gas exchange depends not only on alveolar ventilation, but also on perfusion and gas transport capacity of the alveolar perfusate (ie, blood). Airway patency• Gentle vibration and percussion is used in some

centers to mobilize the secretions. • Deep suctioning should be avoided because it can

cause airway trauma and swelling, which, in turn, may cause large airway obstruction.

• Use of mucolytic agentsVentilatory support may be rendered unusually challenging by alveoli with variable degrees of inflation from the unpredictable distribution of surfactant inactivation, partial airway obstruction, and fluid exudation.

OTHER SUPPORTIVE MEASURES Red blood cells should be administered to

achieve a hemoglobin concentration of 13-16 g/dL in the acutely ill infant, to ensure optimal oxygen delivery to the tissues.

Delivery of adequate amounts of glucose and maintenance of thermoregulation, electrolyte balance, and other elements of neonatal supportive care are also essential.

Nutrition: Attempts at enteral feeding often are withheld in favor of parenteral nutritional support until respiratory and hemodynamic status is sufficiently stable. Transfer

(If no facilities)stabilize the neonate and transfer to a tertiary care neonatal intensive care unit.

MEDICATIONSANTIBIOTICS & ANTVIRALSPrimary Antibiotic Protocol Ampicillin 50 mg/kg/dose IV or IM q12 hours Cefotaxime 50mg/kg IV or IM q12h Erythromycin 30-50 mg/kg/d PO divided Q8H Gentamicin 2.5 mg/kg/dose IV/IM Q24H Antiviral agents acyclovir (Zovirax) Acyclovir treatment should be considered when a diagnosis of herpes simplex virus is suspected and when the infant is not responding to antibiotic therapy.

COMPLICATIONS Restrictive pleural effusion Infected pleural effusion Empyema Systemic infection with metastatic foci Persistent pulmonary hypertension of the

newborn Air leak syndrome, including pneumothorax,

pneumomediastinum, pneumopericardium, and pulmonary interstitial emphysema

Airway injury Obstructive airway secretions Hypoperfusion Chronic lung disease Hypoxic-ischemic and cytokine-mediated end-

organ injury

PREVENTION Consider intrapartum antibiotic chemoprophylaxis with penicillin or another

appropriate antimicrobial agent in mothers at risk for early-onset group B streptococcal disease.

Risk factors are as follows: Known colonization of birth canal by group B Streptococcus Premature delivery Membrane rupture more than 18 hours before delivery Intrapartum fever Group B streptococcal bacteriuria History of previous infant with early-onset neonatal group B streptococcal

infection Consult the Red Book for the most current recommendations for infants at risk

for group B streptococcal sepsis/pneumonia.[38] Prevention strategies may include antepartum and intrapartum broad-spectrum

antibiotic treatment in mothers with preterm rupture of membranes or in whom chorioamnionitis is suspected.

In the presence of particulate amniotic fluid meconium, suction the trachea immediately after birth if the infant is not vigorous.[39]

Currently, there is little evidence demonstrating the potential efficacy of the following interventions in neonates:

Elevating the head Use of antireflux medications Differential policies for oral care and changes of suction and ventilator tubing Other potential interventions

PROGNOSISContinued growth and development of pulmonary and other tissues offers good prospects for long-term survival and progressive improvement in most infants who survive congenital pneumonia. Nevertheless, although quantitation of risk is difficult and is strongly influenced by gestational age, congenital anomalies, and coexisting cardiovascular disease, there is a consensus that congenital pneumonia increases the following: Chronic lung disease

Prolonged need for respiratory support

Childhood otitis media

Reactive airway disease

Severity of subsequent early childhood respiratory infections

Complications attendant to these conditions

PARENT EDUCATION

Education of parents whose infant has had congenital pneumonia is principally directed toward subsequent care.

Counsel parents regarding the need to prevent exposure of infants to tobacco smoke.

Educate parents regarding the benefit infants may receive from pneumococcal immunization and annual influenza immunization.

Discuss potential benefits and costs of respiratory syncytial virus immune globulin.

Educate parents regarding later infectious exposures in daycare centers, schools, and similar settings and the importance of hand washing.

Emphasize careful longitudinal surveillance for long-term problems with growth, development, otitis, reactive airway disease, and other complications.

NURSING CARE PLAN

NURSING DIAGNOSES & INTERVENTIONS

1.Impaired Gas Exchange (cyanosis ,irritability, nasal flaring,tachycardia)

2.Ineffective Breathing Pattern (nasal flaring)

Monitor ventilator settings hourly.(if on ventilator)

Elevate head of bed. Provide chest physiotherapy and postural

draining Monitor blood gases and act accordingly Admin nebulizer and respiratory stimulant

3.Altered body Temperature [Fever, cold and clammy skin] Monitor neonate’s condition. Monitor Vital signs Provide neutral environment Ensure that all equipment used for infant is

sterile, scrupulously clean. Do not share equipment with other infants

Ensure optimal hydration status. Administer Anti-pyretics as ordered

4.Decreased Cardiac Output (tachycardia, cyanosis,pallor, mottling)

5.Ineffective Tissue Perfusion, peripheral (hypotension, skin color changes in limbs cyanosis, pallor, mottling)

Assess respiratory rate, depth, and quality Assess skin for changes in color, temperature Monitor neonate’s condition. Monitor Vital signs Q1H Note quality & strength of peripheral pulses Elevate Head of bed Elevate affected extremities with edema Provide a quiet, restful atmosphere Administer oxygen as ordered Maintain fluid & electrolyte balance

6.RISK FOR INFECTION Thorough hand washing by care givers Wear gloves Use disposable IV cannula Thorough skin preparation All IV ports should be wiped with alcohol Early identification of extravasation Avoid unnecessary IV infusion Keep cord dry Hygiene of Baby No unnecessary intervention Better management of IV Lines Disinfection of Equipments

7.Altered Nutrition: less than body requirements (decreased oral intake)

8.Fluid Volume deficit (hypotension, fever)

Assess for S/S of dehydration Avoid enteral feed, if sick Check weight twice a day Maintain strict intake and output Start IV Fluid, Infuse 10% D 2ml/Kg stat to

Maintain normoglycaemia Maintain fluid & electrolyte balance and

tissue perfusion If CRT > 3 sec infuse 10 ml / Kg NS

9.Altered parenting

Interview parents, noting their perception of situation and individual concerns

Educate regarding child growth & deve lopment, addressing parental perceptions

Involve parents in activities with the baby that they can accomplish successfully

Recognize & provide positive feedback for protective parenting behaviors

Provide NICU Tel.No & encourage visiting Provide baby’s picture

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