NURS2003 Neuro Endocrine Health

Anatomy and physiology of the lungs to understand pneumonia:

The human respiratory system is seen to begin at nose and mouth where the air is inspired and expired. The air tube that extends from the nose is known as the nasopharynx. The tube which carries the breathed air from the mouth is called the oropharunx. The orophraynx also contain swallowed particles that pass into oesophagus and then to the stomach, the larynx is seen to contain trap door called the epiglottis (Troy et al., 2016). This section prevents different swallowed substances and regurgitated substances from entering into larynx and therefore towards the lungs. The picturing of the respiratory system look down like an inverted tree where the larynx continue into the trachea which looks like the tree trunk. This trachea divides into the tree limbs that are actually the right and left bronchi, each of the bronchus are seen to branch into the multiple smaller bronchi that course through the tissue of the lung. These bronchi further divide into the tubes of smaller and smaller diameter that end up in the terminal bronchioles. The air sacs of the lungs are responsible for the exchange of carbon-dioxide and these are clustered at the ends of the bronchioles like the leaves of tress called the alveoli.

Pneumonia can be transmitted when any airborne microbes from an already infected individual are inhaled by a healthy individual. Studies are of the opinion that most of the instances of pneumonia can be attributed to self-infection with one or more various types of microbes that might originate in the nose and the mouth (Kallet, 2015). It has been found that in case of healthy people, the typical upper airways bacterial germ residents like that of the Hemophilus influenza and Streptococcus pneumonia are the most common bacteria that have been responsible for causing community acquired pneumonia. On the other hand, hospital acquired pneumonia are found to be mainly caused by more resistant forms of bacteria like that of the Staphylococcus aureus, Klebsiella pneumoniae, Pseudomonas aeruginosa, and Escherichia coli. Researchers state that individuals who have severe impairment of the immune system are more prone to development of pneumonia caused by the mentioned types of opportunistic microbes like that of virus, bacteria, fungi that are related to tuberculosis which would normally do not cause any disorders in healthy individuals.

In order to help every individual to effectively cope with the exposure to various kinds of potentially infectious microbes, the lung executes a number of defense mechanisms. Such physical mechanisms mainly include prevention of the microns from reaching the alveoli that include structuring of the upper airway as well as the branching of the bronchial tree. The sticky mucus layer that line the airways as well as the hair like cilia help in propelling the mucus upward as well as the cough reflex (Gotts et al., 20160. Most of the micro-organisms that try to reach the alveoli are usually destroyed by a variety of immune cells. Therefore, pneumonias are seen to occur in people who suffer from one or more deficiencies in either their mechanical as well as defense mechanism.

Pneumonia is mainly seen to occur as an upper respiratory tract infection that in course of time, try to reach the lower respiratory tract. Studies have found that the normal flora of the lung tries to provide a tough competition to those opportunists for nutrients. It has been also found that immunoglobulin, reflex action of the glottis as well as the complement proteins help in providing protection to the individual (Ravimohan et al., 2018). However, microaspiration can take place of the contaminated secretions which can thereby infect the lower airways and can thereby cause the disorder of pneumonia. Three important aspects can help in determining the progress of pneumonia. These are the virulence of the pathogen, response of the body against infection as well as amount of organisms that can start the infection.

Such opportunists can spread via contaminated air droplets as well as also via blood. Once they reach lungs, they try to invade the spaces present between the cells and the alveoli. The immune system gets activates where the macrophages and the neutrophils try to inactivate the micro-organisms thereby releasing cytokines and activating the immune systems. This of often seen to result in fever (Mandell, 2015). Chills as well as fatigue in the affected individuals. The bacteria, neutrophils as well as the fluid from the surrounding vessels are seen to fill up the alveoli that result in development of the consolidation as seen on chest X-ray.

Asthma as a risk factor for pneumonia in the patient:

The patient in the case study named roger had developed bilateral pneumonia. One of the risk factor that might have contributed to increase in his vulnerability to develop pneumonia may be his childhood asthma. In order to understand how asthma in roger could have contributed to pneumonia, a short description of how asthma affects individuals need to be well known. Among asthma patients, inflamed airways are seen to react massively to environmental stimuli like that of smoke, dust, pollen and many others. The airways are seen to become narrow and thereby start producing excess of the mucus. This makes it difficult for the individuals to breathe. Asthma mainly results from the immune response in the bronchial airways. Studies opine that airways of the asthma are seen to be hypersensitive towards certain triggers like exercises, dander, pollens and many others which are also called stimuli (Crowley et al., 2016). In response to such triggers, the bronchi start contracting into spasms. This is then followed by inflammation and this leads to further narrowing of the airways as well as excessive secretion of the mucus production. This then results in coughing as well as breathing difficulties.  Muscle shortening also takes place due to acetylcholine released from the vagal efferent pathways and this initiates bronchoconstriction. In short, abnormal response of the immune system to the stimuli causes chronic inflammation in asthma patients causing hardening and thickening of the passageways and this causes breathing restriction.

Roger used to take inhaled steroids when he used to be affected by asthma to relieve himself after heavy exercises sessions. Studies are of the opinion that inhaled corticosteroids taken for asthma increases the risk for pneumonia. One 2017 study had stated that asthmatic people who are treated with inhaled steroids were 83% more likely to become vulnerable to develop pneumonia in comparison to those who do not take inhalers. It is clearly not understood how inhaled steroids can increase the risk of pneumonia but researchers opine that this might be due to the effect of steroids on the immune system (McCauley et al., 2015)). They are of the opinion that oral steroids have can contribute to the greatest risk of that of the infections as the steroids cause “calming effects” on the immune response. Roger had take salbutamol. This medication is a bronchodilator that usually remains in a combined form of with steroids that helps in reducing airway inflammation. This mainly helps in reducing the vigorous impact of the immune response by cooling the system down. This might make the scope of the opportunistic pathogen of pneumonia t o infect the lungs of the affected individuals. In case of roger as well, the use of inhalers could have made him more prone to develop the pneumonia symptoms.

Environmental risk factors like dust also cause pneumonia and roger might have been also exposed to dust whereas working in the Warehouse converting into gym. This might have acted as a risk factor for pneumonia (Cho et al., 2017).

One of the symptom as found in the patient named Roger is productive cough with green and malodorous sputum. Studies are of the opinion that pneumonia causes production of cough that in turn produces sputum. Sputum may of different colour and may include red-brown, yellow, green and similar others which are signs of bacterial infection. Whitish sputum indicates viral pneumonia. Researchers are of the opinion that green coloured sputum is mainly caused by bacterium like Pseudomonas, Haemophilus, and pneumococcal species (Festic & Scanlon, 2015). Hence, it can be well understood that Rogers is suffering from pneumonia caused by the mentioned bacterium. Phlegm or sputum is a type of mucus that is developed in the chest hen an individual is sick with cold or other underlying medical issues like bacterial infection. Coughing up phlegm is called sputum. This mucus is mainly formed as a part of immune system where mucus production helps in trapping of infectious micro-organism and helps to eliminate them.

Another important symptom of pneumonia is excessive chest pain. Roger had reported a chest pain of about 2 out of 10 as found of pain numerical scale. Pneumonia can be described as the inflammation of the lungs and is caused by infection. The pain is mainly caused wither by the strain of the muscles resulting from excessive coughing (Felten et al., 2015). It might be also caused by the inflammation of the linings of the lungs termed as pleurisy.

One of the other symptoms as found in the case study is breathlessness faced by the patient. Studies are of the opinion that damaged as well as restricted quantity of functioning of the lung tissues might create situations as breathlessness. Many researchers are of the opinion that lung oedema, pneumonia as well as lung tumours can have impact on the capability of the airways in filling and referring of oxygen into that of the blood stream (Cho et al., 2017).  It can be stated that breathless in Roger might be because of occurrence of pneumonia and this strengthens the diagnosis of the disorder.

ADME can be described as the abbreviation in pharmacokinetics as well as pharmacology. This is the short form for “absorption, distribution, metabolism, excretion.

IV benzylpenicillin:

This medication can be explained as a penicillin G which is actually a beta-lactam antibiotic. This is used for bacterial infections that are caused by susceptible, mainly gram positive bacteria. The patient named Roger is suffering from bacterial infection of pneumonia and hence he is advised to take this medication. The bactericidial activity of this disorder is seen to result from the inhibition of the synthesis of the cell wall of micro-organisms in the third and the last stage. Cell lysis then begins by the autolytic enzymes like that of autolysins (Lodha et al., 2016). It is mediated through the binding of the antibiotic to that of the penicillin binding proteins. It is stable against the mechanism of hydrolysis by a large number of beta-lactamases that might include penicillinases, and cephalosporinases and many others.

It is mainly absorbed rapidly following both intramuscular as well as subcutaneous injection. Since the medication is highly susceptible for acid-catalyzed hydrolysis, the absorption rate is found to be only 15 to 30 % and hence this absorption pathway is avoided. About 0.53–0.67 L/kg is the volume of distribution in individual adults with that of normal renal function. They are seen to bind mainly with protein serums accounting for about only 45 – 68% mainly albumin (Almatar et al., 2015). In case of metabolism, about 16 to 30% of the intramuscular dose is seen to be metabolized into that of an inactive metabolite called the penicilloic acid. Studies have found that smaller amounts of 6-aminopenicillanic acid have been recovered in urine. Also, a small amount of drug is seen to undergo hydroxylation into one or more of the active metabolites and these are also excreted via urine. The route of elimination is by the kidneys. Also non-renal clearance is seen to take place through non-renal clearance and this includes hepatic metabolism and to a very lesser extent through biliary excretion.

This can be described as the broad spectrum antibiotic which is prepared synthetically from oxytetracycline. Studies opine that this disorder is one of the second generation tetracycline and this is seen to exhibit lesser toxicity than that of the first generation tetracycline. Roger is affected by opportunistic bacterial organisms and hence this medication can help in controlling the bacterial community growth and their effective treatment (Ha et al., 2018). These forms of tetracyclines are seen to include doxycycline. These are seen to be bacteriostatic in nature and mainly cause suppression of the growth of bacteria or keep them restricted in their stationary phase of growth causing inhibition of protein synthesis. They have antimicrobial spectrum towards various kinds of gram-positive and gram-negative bacteria and helps in treatment of numerous infectious disorders.

This drug is readily absorbed and bond with the plasma proteins by different degrees. It is completely absorbed after oral absorption. This is lipid soluble and has low affinity for calcium binding and is not affected by ingestion of food and milk. The distribution includes diffusion into most tissues of the body as well as through different fluid cavities as well as the volume of distribution that has been measured as 0.7 L/kg. This drug is found to metabolize both in the gastrointestinal tract as well as in the liver and even concentrated in bile. Major pathways of metabolism are yet to be identified but enzyme inducers have been found to decrease the half life of the drug (Spivey et al., 2017). The route of elimination is found to be the urine as well as feces where the drug is eliminated as unchanged drug. It has been found that between 40 and 60% of the drug is released through urine by 92 hours and 305 of the drugs are released by feces.

Salbutamol has been found to be extremely useful in the symptomatic relief as well as prevention of bronchospasm that might take place due to bronchiole asthma, reversible obstructive airway disease, chronic bronchitis as well as other chronic bronchopulmonary disorders. This drug is also found to be effective for acute prophylaxis against that of the exercise induced bronchospasm as well as other stimuli that cause bronchospasm. It has been found that roger was exposed to two types of stimuli. One was exercise and other was dust and other toxic substances that might have risen during his turning of the warehouse into gym stations (Wang et al., 2018). This drug is the moderately selective beta (2)-receptor agonist that act as bronchodialator for managing of asthma. This drug has preferential effect on beta2-adrenergic receptors. This drug acts mainly as the functional antagonists for relaxing the airways irrespective of the involvement of spasmogen thus overcoming all bronchoconstrictor challenges. Increase in the cyclic AMP concentrations is also found to be associated with inhibition of release of mediators from mast cells in the airway.

To know about absorption, after inhalation, this drug acts on the bronchiole smooth muscles and absorbed there. It is not detectable in blood until 2 to 3 hours after which they are found in low levels in blood. This may be because of the portions of the drug that might have been swallowed in the gut. The volume of distribution can be recorded in case of that of the intravenously administered salbutamol and this is found to be around 156 +/- 38 L. this is found to bind with plasma proteins. It is not metabolized in lung but in the liver forming 4′-o-sulphate (salbutamol 4′-O-sulfate) ester. It might be also metabolised by conjugation or that of oxidative deamination (Demey et al., 2017). The route of elimination is that after oral administration,  58-78% of that of the dose is excreted through urine in the form of free drug and that as the metabolite.

References:

Almatar, M. A., Peterson, G. M., Thompson, A., McKenzie, D. S., & Anderson, T. L. (2015). Community?acquired pneumonia: why aren’t national antibiotic guidelines followed?. International journal of clinical practice, 69(2), 259-266.

Cho, K. H., Kim, Y. S., Linton, J. A., Nam, C. M., Choi, Y., & Park, E. C. (2017). Effects of inhaled corticosteroids/long-acting agonists in a single inhaler versus inhaled corticosteroids alone on all-cause mortality, pneumonia, and fracture in chronic obstructive pulmonary disease: a nationwide cohort study 2002–2013. Respiratory medicine, 130, 75-84.

Crowley, J. C., & Gropper, M. A. (2016). IV Immunoglobulin: A Useful Tool for the Severe Pneumonia Toolbox?. Critical care medicine, 44(1), 250-251.

Demey, L., Van Muylem, A., Michils, A., & Haccuria, A. (2017). Protective effect of salbutamol on peripheral airway constriction induced by sputum induction in asthma patients.

Felten, S., & Cydulka, R. K. (2015). Asthma, Chronic Obstructive Pulmonary Disease, And Pneumonia. Emergency Medicine Secrets, 177.

Festic, E., & Scanlon, P. D. (2015). Incident pneumonia and mortality in patients with chronic obstructive pulmonary disease. A double effect of inhaled corticosteroids?. American journal of respiratory and critical care medicine, 191(2), 141-148.

Gotts, J. E., & Matthay, M. A. (2016). Sepsis: pathophysiology and clinical management. Bmj, 353, i1585.

Ha, S. G., Oh, K. J., Ko, K. P., Sun, Y. H., Ryoo, E., Tchah, H., … & Cho, H. K. (2018). Therapeutic efficacy and safety of prolonged macrolide, corticosteroid, doxycycline, and levofloxacin against macrolide-unresponsive Mycoplasma pneumoniae pneumonia in children. Journal of Korean medical science, 33(43).

Kallet, R. H. (2015). The vexing problem of ventilator-associated pneumonia: observations on pathophysiology, public policy, and clinical science. Respiratory care, 60(10), 1495-1508.

Lodha, R., Randev, S., & Kabra, S. K. (2016). Oral antibiotics for community–acquired pneumonia with chest-indrawing in children aged below five years: A Systematic Review. Indian pediatrics, 53(6), 489-495.

Mandell, L. A. (2015). Community-acquired pneumonia: An overview. Postgraduate medicine, 127(6), 607-615.

McCauley, L., & Dean, N. (2015). Pneumonia and empyema: causal, casual or unknown. Journal of thoracic disease, 7(6), 992.

Ravimohan, S., Kornfeld, H., Weissman, D., & Bisson, G. P. (2018). Tuberculosis and lung damage: from epidemiology to pathophysiology. European Respiratory Review, 27(147), 170077.

Spivey, J., Sirek, H., Wood, R., Devani, K., Brooks, B., & Moorman, J. (2017, October). Retrospective Cohort Study of the Efficacy of Azithromycin Vs. Doxycycline as Part of Combination Therapy in Non-Intensive Care Unit Veterans Hospitalized with Community-Acquired Pneumonia. In Open Forum Infectious Diseases (Vol. 4, No. suppl_1, pp. S579-S580). US: Oxford University Press.

Troy, L. K., Young, I. H., Lau, E. M., & Corte, T. J. (2016). Exercise pathophysiology and the role of oxygen therapy in idiopathic interstitial pneumonia. Respirology, 21(6), 1005-1014.

Wang, H., Kjarsgaard, M., Ho, T., Brannan, J. D., & Nair, P. (2018). Loss of bronchoprotection to Salbutamol during sputum induction with hypertonic saline: implications for asthma therapy. Allergy, Asthma & Clinical Immunology, 14(1), 26.