Introduction

Definition of pneumonia

Pneumonia is irritation of the lungs caused by viral, bacterial or fungal infection. Most people recover from Pneumonia between 2-4 weeks, however, some individuals, such as the elderly, babies, or people with heart or lung conditions, are at greater risk of getting severely ill, which may lead to hospital admission.^1,2

Importance of effective treatment

It is important to effectively treat Pneumonia because it accounts for 14% of deaths of children aged under 5 years.² In 2019, over 740,180 children died from infection of pneumonia, and in 2021, close to 2 million pneumonia-related deaths were recorded in children under 5 years old.² If left untreated, pneumonia can lead to more serious complications, especially in babies with weakened immune systems because of the underlying health conditions.³

Role of respiratory therapy

Respiratory therapy helps people with pneumonia breathe better through a small machine called a nebuliser, which turns medicine into a mist to make it easier to inhale or breathe.⁴ Gentle tapping on the chest is also a technique used to help loosen mucus in the lungs.⁴ This therapy is administered by trained personnel or a respiratory therapist. Respiratory therapists keep a close eye on a patient's oxygen levels and provide extra oxygen if the body needs it. Additionally, respiratory therapists work with doctors and nurses to make sure patients diagnosed with pneumonia are getting the right medications, such as antibiotics, to treat the infection and speed up recovery.⁴

Causes of pneumonia

• Pneumonia is most commonly caused by bacterial (Streptococcus pneumoniae, Mycoplasma pneumoniae) or viral (Influenza, Rhinovirus, Parainfluenza) infection⁵
• It is contagious and can be acquired from an infected person
• It can also develop through other infections such as the flu, respiratory syncytial (RSV), and COVID-19
• Occasionally, Pneumonia can be caused by a fungal infection
• Pneumonia can also be caused if something finds its way into the lungs, such as food or water, leading to a condition known as aspiration pneumonia

 Symptoms of pneumonia

Signs of Pneumonia consist of a combination of respiratory symptoms, which include:

• Cough (with or without mucus) 
• Chest pain
• Difficulty in breathing
• Fever
• Low oxygen levels in the blood
• Fatigue and confusion (especially among the elderly)

Other symptoms include headache, sore muscles, serious fatigue, nausea, vomiting and diarrhoea.

Symptoms in older adults or those with underlying health conditions, or those who have weakened immune systems, may differ from the usual symptoms highlighted above. Rather than having a fever, they may have a lower-than-normal temperature (hypothermia).

Babies also do not usually exhibit usual signs, they may cough, vomit, have a fever or seem tired. Other symptoms common in babies are:

• Bluish lips and skin tone
• Grumpiness
• Breathing by pulling the muscles inside between the ribs
• Fast breathing
• Expansion of the nostrils with every breath⁶

Risk factors and population at risk

Older people, babies, individuals with weak immune systems, smokers and people with long-term illnesses are all at risk of pneumonia.

The following health conditions increase the chances of developing pneumonia: 

• Brain disorderssuch as dementia, stroke or Parkinson’s disease, can affect the ability to swallow. This can lead to food going into the lungs instead of the oesophagus, which can cause pneumonia
• Immune weakening conditions such as HIV/AIDS, pregnancy, bone marrow transplant, or chemotherapy
• Lung diseases such as asthma, damaged airways (bronchiectasis), and lung clogging disorder (cystic fibrosis) also increase pneumonia risk⁷

Introduction to respiratory therapy in pneumonia treatment

Respiratory therapy is a form of treatment or exercise that helps repair or improve the function of the lungs.⁸ It involves the use of specialised techniques to improve breathing and enhance lung function.

The aims of respiratory therapy for pneumonia are to

• Clear the airway
• Improve lung function
• Reduce airway resistance
• Prevent respiratory failure
• Remove fluid/pus that builds up due to swelling/infection⁹

When respiratory therapy is needed

• For moderate to severe pneumonia
• For moderate breathing difficulty (dyspnoea)
• Very low oxygen in the blood (severe hypoxemia)
• Hard-to-treat low oxygen (refractory hypoxemia)⁹

Types of respiratory therapy for pneumonia

Oxygen therapy

Oxygen therapy is provided when oxygen levels fall below 88% in pneumonia patients. ¹⁰ It helps improve blood oxygen levels. The oxygen therapy can be delivered through nasal cannula, face masks and high-flow oxygen therapy.

Inhalation therapy (Nebulisers and Inhalers)

These involve the use of devices (inhaler and nebuliser) to provide medication directly into the lungs to assist in opening airways and improve breathing. Nebulisers are used for patients who have difficulty using inhalers.

Airway clearance techniques

1. Chest Physiotherapy (CPT): To empty the lungs, chest physical therapy, also known as CPT or Chest PT, uses an airway clearance method (ACT) that may involve deep breathing, puffing or coughing, vibration, and percussion (clapping)¹¹
2. Positive Expiratory Pressure (PEP) Therapy: It involves the use of PEP, which is a little device that a patient wears a mask to exhale into. By applying pressure to the lungs, the PEP device prevents airways from narrowing. The PEP device's airflow facilitates the passage of mucus into the wider airway. The mucus in the airways can be cleared out with a hack cough¹²
3. Suctioning: When a patient breathes food or liquid (aspiration) into their lungs or has an obstruction in their airway, suctioning is an essential part of treating pneumonia. Aspiration pneumonia, which can be fatal if ignored, can be avoided with suctioning¹³
4. Mechanical Ventilation: It is a typical therapeutic procedure that can quickly increase oxygenation, correct low oxygen levels in the body, and raise oxygen level in other organs. Mechanical ventilation can take either the invasive or non-invasive method:
   • Non-invasive methods (CPAP, BIPAP): Sequential mechanical ventilation presents an alternative methodology to stabilise their state; individuals using this approach first undergo invasive ventilation. After patients get well, non-invasive ventilation is used, which helps them breathe without putting a tube in their windpipe by using a mask or other tools. By reducing the duration of invasive ventilation, this combination method aims to lower the risk of infections and other problems. The purpose of the trial was to determine whether this approach may speed up the recovery process for individuals suffering from respiratory failure and severe pneumonia¹⁴
   • Invasive ventilation: This involves inserting a tube into a person's windpipe through their mouth (a procedure known as intubation) or making a tracheotomy (or opening in their neck) to link them to a breathing apparatus. Long-term use of this technique is common, but there are hazards involved, including the possibility of infections like ventilator-associated pneumonia and difficulties removing the patient from the machine once they begin to recover¹⁴

E. humidification and aerosol therapy

For patients to breathe more easily, especially those who require long-term respiratory assistance, humidification is crucial. The two varieties are passive and active. During breathing support, vapour produced by warming sterile water with a heating device is administered to the patient's airways in an active humidification technique. With this configuration, patient secretions are kept out of the water, and the water is kept clean. A heat and moisture exchanger (HME) is a specialised device used in passive humidification. It maintains the patient's airways by absorbing heat and moisture from their breath and returning a portion of it with each inhale. Certain HMES have an HMEF filter, which prevents microorganisms from entering the respiratory system.¹⁵

Benefits of respiratory therapy in pneumonia management

1. Improves breathing
2. Shortens hospitalisation time
3. Improves exercise tolerance
4. It improves oxygenation and ventilation¹⁶

Challenges and considerations in respiratory therapy for pneumonia

1. Oxygen toxicity and over-oxygenation risk: Oxygen levels need to be closely monitored
2. Adherence to treatment by the patient, addressing difficulties in maintaining at-home inhalation or clearing treatments
3. Disparities in treatment across hospitals, outpatient clinics, and home care, and access to respiratory therapy in various healthcare settings. The function of emerging pathogens like COVID-19, and particular difficulties in treating pneumonia caused by pandemic respiratory diseases

Summary

The aim of respiratory therapy for pneumonia patients is to facilitate easier breathing and lung clearance. It involves procedures including chest tapping to release mucus, nebulisers to provide medication as a mist, and oxygen therapy to raise oxygen levels. In addition to monitoring breathing and supplying oxygen as needed, respiratory therapists collaborate with the medical staff to make sure the proper medications are administered. These treatments hasten healing, lessen symptoms, and enhance lung function. It is also important to consider the side effects of each type of respiratory therapy before deciding on the best fit for a patient.