What is the primary treatment approach for a patient with viral pneumonia?

Treatment of Viral Pneumonia

The primary treatment for viral pneumonia is supportive care with oxygen therapy, nutritional support, and monitoring for complications, as no specific antiviral therapy has proven efficacy for most viral pneumonias in randomized controlled trials. 1, 2

Supportive Care: The Foundation of Treatment

Monitoring and Basic Support

• Patients require bed rest with continuous monitoring of vital signs including heart rate, pulse oxygen saturation, respiratory rate, and blood pressure 1, 2
• Perform regular laboratory monitoring including complete blood count, CRP, PCT, organ function tests (liver enzymes, bilirubin, myocardial enzymes, creatinine, urea nitrogen), coagulation function, arterial blood gas analysis, and serial chest imaging 1, 2
• Ensure adequate hydration and maintain water-electrolyte balance, acid-base balance, and internal environment homeostasis 1

Nutritional Support

• For patients with nutrition risk scores <3 points: provide protein-rich foods (eggs, fish, lean meat, dairy) with energy intake of 25-30 kcal/(kg·d) and protein intake of 1.5 g/(kg·d) 1, 2
• For patients with nutrition risk scores ≥3 points: initiate early nutritional support with increased protein intake through oral supplements 2-3 times daily (≥18g protein/time), adding protein powder if needed to reach target 1, 2
• Place enteral nutrition tube when oral intake is insufficient; provide parenteral nutrition if enteral nutrition is not tolerated 1, 2

Fever Management

• When temperature exceeds 38.5°C, administer ibuprofen 0.2g orally every 4-6 hours as needed (maximum 4 times in 24 hours) 1, 2
• Temperatures below 38°C are acceptable and may support antiviral immune responses 1

Oxygen Therapy and Respiratory Support

Escalation Strategy

• Begin with oxygen therapy at 5 L/min, titrating to target oxygen saturation 1
• Escalate respiratory support based on severity following this sequence: nasal catheter → mask oxygen → high-flow nasal oxygen therapy (HFNO) → non-invasive ventilation (NIV) → invasive mechanical ventilation 1, 2
• For patients with moderate-to-severe ARDS (PaO₂/FiO₂ < 150), implement protective lung ventilation strategies with higher PEEP, prone positioning for >12 hours daily, and consider deep sedation with muscle relaxation within the first 48 hours of mechanical ventilation 2
• Consider Extracorporeal Membrane Oxygenation (ECMO) for patients with refractory hypoxemia that cannot be corrected by protective lung ventilation 1, 2

Antiviral Therapy: Limited Evidence

General Principles

• Currently, there is no evidence from randomized controlled trials supporting specific antiviral drug treatment for most viral pneumonias 1, 2
• If antiviral therapy is attempted, it should be initiated as early as possible in the disease course 2

Influenza-Specific Treatment

• For confirmed influenza pneumonia, neuraminidase inhibitors (oseltamivir or zanamivir) have been proven to reduce the need for ventilatory support and mortality rate when started within 36-48 hours of symptom onset 1, 3
• Oseltamivir 75 mg orally twice daily for 5 days is the standard regimen for adults 4
• Zanamivir 10 mg inhaled twice daily for 5 days is an alternative, though caution is needed in patients with underlying respiratory disease due to bronchospasm risk 5
• The anti-influenza neuraminidase inhibitors demonstrate slow emergence of resistance, low frequency of resistance, and reduced virulence in mutant viruses compared to older agents like amantadine 1

Other Viral Pneumonias

• For adenovirus pneumonia, intravenous ribavirin may be considered in severe cases or immunocompromised patients despite limited evidence 6
• For human metapneumovirus in immunocompromised patients with lower respiratory tract disease, consider ribavirin and/or intravenous immunoglobulin, though no randomized controlled trial data support this approach 7
• Alpha-interferon atomization inhalation (5 million U per time for adults in sterile injection water, twice daily) can be considered for coronavirus infections, though evidence is weak 1

Management of Secondary Bacterial Infections

Key Principles

• Avoid blind or inappropriate use of antibacterial drugs, especially broad-spectrum combinations 1, 2
• Enhance bacteriological surveillance and administer appropriate antibiotics only when secondary bacterial infection is suspected or documented 1, 2
• Secondary bacterial infections occur in approximately 10.9% of viral pneumonia cases overall, with a 15.2% mortality rate in COVID-19 patients who develop secondary infections 8

Antibiotic Selection Strategy

• For mild cases with suspected bacterial co-infection: use antibiotics effective against community-acquired pneumonia (amoxicillin, azithromycin, or fluoroquinolones) 1, 2
• For severe cases: initiate empirical broad-spectrum antibacterial treatment covering all possible pathogens, then de-escalate therapy once causative bacteria are identified 1, 2
• Most commonly implicated pathogens include antibiotic-resistant strains of Staphylococcus aureus and Klebsiella pneumoniae 8
• Prophylactic antibiotics are used in 63.7-73.5% of viral pneumonia cases, though this practice lacks strong evidence 8

Corticosteroid Use: Approach with Caution

When to Consider Steroids

• Corticosteroid use in viral pneumonia should be approached with extreme caution and reserved only for patients with rapid disease progression or severe illness 1, 2
• Routinely avoid corticosteroids in the treatment of viral pneumonia unless in a clinical trial or if steroids are indicated for another condition, as studies on influenza have found them to exacerbate infection and increase mortality rates 1

Dosing When Used

• If used, administer methylprednisolone 40-80 mg daily (not exceeding 2 mg/kg daily) for short periods (3-5 days) 1, 2
• Corticosteroids may improve clinical symptoms, reduce disease progression, and accelerate absorption of lung lesions in severe cases, but do not shorten hospital stay 1, 2
• Be aware of potential adverse reactions including bone marrow suppression and increased risk of secondary infections 1

Prevention of Additional Complications

Gastrointestinal Protection

• Use H2 receptor antagonists or proton pump inhibitors in patients with gastrointestinal bleeding risk factors including mechanical ventilation ≥48 hours, coagulation dysfunction, renal replacement therapy, liver disease, multiple complications, or higher organ failure scores 1, 2

Venous Thromboembolism Prophylaxis

• Evaluate venous thromboembolism risk in all patients and use prophylactic low-molecular-weight heparin or heparin in high-risk patients without contraindications 1, 2

Respiratory Secretion Management

• For patients with dyspnea, cough, wheeze, and increased respiratory secretions, consider selective (M1, M3) receptor anticholinergic drugs to reduce secretions, relax airway smooth muscle, relieve airway spasm, and improve pulmonary ventilation 1, 2

Infection Control

• Strictly follow aseptic operation and isolation protocols to prevent ventilator-associated pneumonia, catheter-related sepsis, urinary catheter-related infections, and other secondary infections 1
• Implement standard and droplet precautions, particularly for viruses demonstrating asymptomatic and prolonged shedding 7

Special Considerations

Immunocompromised Patients

• Higher corticosteroid exposure is associated with increased risk of severe disease 7
• Consider more aggressive antiviral therapy with ribavirin and/or intravenous immunoglobulin for lower respiratory tract involvement, particularly in hematopoietic stem cell transplant recipients 7
• Monitor for prolonged viral shedding and implement appropriate infection control measures 7

Psychological Support

• Provide psychological and humanistic care, especially for awake patients 1
• Use techniques like mindfulness-based stress reduction to relieve anxiety and panic by building optimistic confidence 1
• Respond to patient questions promptly and provide positive encouragement 1