Friday, April 6, 2012

PNEUMOCYSTIS CARINII PNEUMONIA



·         A lung disease caused Pneumocystis jiroveci (fungus)
·         Most common opportunistic infction & major cause of mortality in HIV infected individuals especially in children.
·         People with HIV are potentially at risk from PCP if their CD4 cell count falls <200 cells/mm3.
·         It is usually the first sign of AIDS.

Signs & Symptoms:

ü  Fever & chills
ü  Non-productive cough
ü  Shortness of breath (especially with activity )
ü  Tachypnea
ü  Tachycardia
ü  Weight loss (wasting)
Additional findings in children:
ü  Cyanosis
ü  Nasal flaring
ü  Intercostal retractions

Diagnostic Exams:

§  Sputum induction: identifies presence of organism in the sputum
§  Bronchial-alveolar lavage: an invasive procedure which identifies presence of organism in lung tissue.
§  Transbronchial biopsy
§  Chest X-ray: widespread pulmonary infiltrates
§  CT Scan & Gallium 67 scan: helpful if CXR is vague.
§  ABG: to evaluate the need for possible adjunctive corticosteroid

Complications:

·         Pneumothorax
·         Respiratory Failure
   
Treatment:

Medications:
·         Prophylactic treatment for adults with HIV should start if CD4 count is <200/µL.
·         trimethoprim (TMP)/ sulfamethoxazole (SMX) (Bactrim®, Septra®): standard first-line treatment

Adverse Effects: rash, neutropenia, thrombocytopenia & Steven-Johnson syndrome, photophobia
·         pentamidine (Nebupent®, Pentacarinat®): antiprotozoal medication, used as 2nd-line therapy for patient who can’t take TMP/SMX.
·         atovaquone (Mepron®): broad-spectrum antiprotozoal compound
·         clindamycin (Dalacin®, Evoclin®): inhibits bacterial growth
·         trimetrexate (Neutrexin®): licensed treatment for people who do not respond to, or are allergic to co-trimoxazole. It has to be taken with folinic acid to protect human cells against the drug's toxicities and target its effects against the PCP organisms.
·         Dapsone (Dapsone®): given with trimethoprim;  inhibit bacterial growth
·         Corticosteroid: initial therapy for patients with severe PCP.
·         Mechanical ventilation/ endotracheal tube insertion
·         Prophylactic treatment with TMP-SMX for infant with HIV infected mother should start at 4-6 weeks of life.

Nursing Interventions:

·         Monitor CD4 cell count.
·         Administer prescribed medications; carefully assess for adverse effects.
·         Promote rest periods.
·         Assist patient in semi or High Fowler’s position.
·         Provide pulmonary care (cough, deep breathing, postural drainage and vibration).
·         Decrease viscosity of secretions by humidifying inspired air as prescribed.
·         Administer oxygen therapy as ordered. < 90% SO2
·         Assist with ET intubation and maintain settings of mechanical ventilation as ordered.
·         Perform tracheal suctioning as needed.

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