What are the appropriate orders for a patient diagnosed with pneumonia, presenting with hypoxemia, cough, and weakness, including the potential use of steroids and scheduling of breathing treatments with Duoneb (ipratropium bromide and albuterol)?

From the Guidelines

For a patient with pneumonia who is hospitalized with oxygen saturation of 90%, cough, and weakness, I recommend starting with antibiotics appropriate for community-acquired or hospital-acquired pneumonia based on local resistance patterns (such as ceftriaxone 1-2g IV daily plus azithromycin 500mg IV/PO daily, or levofloxacin 750mg IV/PO daily) and providing supplemental oxygen to maintain O2 saturation ≥92% as per the BTS guideline for oxygen use in adults 1.

The patient's oxygen saturation is currently at 90%, which is below the recommended target saturation range of 94-98% for most patients, unless they have COPD or other risk factors for hypercapnic respiratory failure, in which case the target saturation range is 88-92% pending blood gas results 1.

For bronchodilator therapy, I recommend scheduled DuoNeb (ipratropium-albuterol) 3mL via nebulizer every 6 hours, with additional albuterol 2.5mg nebulizer treatments available every 4 hours PRN for breakthrough symptoms, as this combination provides both quick onset and prolonged bronchodilation through different mechanisms.

Regarding steroids, if the patient has COPD exacerbation or severe pneumonia with hypoxemia, methylprednisolone 40mg IV daily for 5-7 days would be appropriate, as suggested by the standards for the diagnosis and treatment of patients with COPD 2. Otherwise, steroids are not routinely recommended for uncomplicated pneumonia.

Adequate hydration, incentive spirometry every 1-2 hours while awake, and early mobilization are also important components of care to prevent complications and promote recovery, as emphasized in the guidelines for the management of adult lower respiratory tract infections 3 and the BTS guidelines for the management of community-acquired pneumonia in adults 4.

The choice of antibiotics should be guided by the patient's risk factors, severity of illness, and local resistance patterns, as outlined in the update of practice guidelines for the management of community-acquired pneumonia in immunocompetent adults 5 and the practice guidelines for the management of community-acquired pneumonia in adults by the Infectious Diseases Society of America 6.

Key considerations in the management of this patient include:

• Maintaining adequate oxygenation
• Providing appropriate antibiotic therapy
• Managing bronchospasm and airway clearance
• Considering the use of steroids in specific situations
• Promoting recovery through adequate hydration, incentive spirometry, and early mobilization.

From the FDA Drug Label

The usual dosage of ipratropium bromide inhalation solution is 500 mcg (1 Unit-Dose Vial) administered three to four times a day by oral nebulization, with doses 6 to 8 hours apart. Ipratropium bromide inhalation solution can be mixed in the nebulizer with albuterol or metaproterenol if used within one hour.

For a patient diagnosed with pneumonia, with an oxygen saturation of 90%, complaining of cough and weakness, ipratropium bromide and albuterol can be considered as part of the treatment plan.

• Steroids are not mentioned in the provided drug labels, so their use cannot be directly recommended based on this information.
• Breathing treatment schedule: Ipratropium bromide can be administered three to four times a day, with doses 6 to 8 hours apart.
• PRN and scheduled treatments like Duoneb: While the labels mention that ipratropium bromide can be mixed with albuterol, the specific schedule for PRN (as needed) and scheduled treatments is not directly addressed. However, based on the dosage information, scheduled treatments could be administered three to four times a day. 7 8 9

From the Research

Patient Care for Pneumonia

• The patient's oxygen saturation is 90%, which is considered low according to the study 10, where oxygen saturations less than 92% are associated with major adverse events in outpatients with pneumonia.
• The patient is complaining of cough and weakness, which are common symptoms of pneumonia.

Use of Steroids

• The use of systemic steroids is supported by the literature 11 for patients with asthma and COPD to improve symptoms and decrease hospital admissions.
• However, the patient's specific condition and medical history should be considered before administering steroids.

Breathing Treatment Schedule

• The study 12 suggests that the combination of oxygen and bronchodilators (such as salbutamol and ipratropium bromide) can improve exercise performance in patients with severe or very severe COPD.
• Duoneb, which is a combination of ipratropium bromide and albuterol, can be considered as a scheduled breathing treatment.
• The schedule for breathing treatment can be PRN (as needed) or scheduled, depending on the patient's response to treatment and medical history.
• Oxygen therapy should be titrated to maintain an oxygen saturation between 88-92% for patients with acute chronic obstructive pulmonary disease (COPD) exacerbation, as recommended by the study 11.

Monitoring and Adjustments

• The patient's oxygen saturation, symptoms, and response to treatment should be closely monitored and adjustments made as needed.
• The patient's medical history, current condition, and response to treatment should be considered when making decisions about their care.