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FURTHER RECOMMENDATIONS ON PNEUMONIA TREATMENT Fluid intake Oxygen-supplementation Antipyretics Antibiotic Treatment in Pneumonia Antitussiva Hydrotherapy On further Support regarding Care and Cure FURTHER RECOMMENDATIONS ON PNEUMONIA TREATMENT Fluid intake EMB ebm1,2015 For adults the daily fluid requirement is 30ml/kg + 500 ml per 1°C/1,8°F > 37 °C/98,6°F For Children in accordance with body weight per 24 hours: 100ml/kg for the first 1-10kg body weight 50ml/kg for the next 11-20kg body weight 20ml/kg for every further kg body weight above 20kg [Galic glt1: In addition to the basic amount of necessary liquid, supply the patient with extra fluid of 12 % more per 1 °C from 38 °C body temperature upward. Fluids can be water, tea, cold juice or milk - with sugar if appetite is low! In case of vomiting or diarrhea the patient needs even more than this! If there are signs of exsiccosis clinical monitoring and fluid-management is necessary, even if the choice of the homeopathic remedy is curative. [5 ml/kg KG/d additionally in case of feverpäd1,2016] [Ed.: We found two small randomized trials in which a positive effect was discovered of administering a modified enteral feed containing eicosapentaenoic acid (also contained in milk), gamma-linolenic acid, and various antioxidants to patients with ARDS - comparatively the control group's health did not improve . The authors found that the modified feed improved oxygenation, reduced the number of neutrophils in alveolar lavage fluid, decreased length of stay in the hospital, and reduced the requirement of mechanical ventilation.] Oxygen-supplementation EMB ebm1,2015 The goal is to adequately correct the oxygen deficit while avoiding over-correction, especially in patients with chronic hypoventilation. Oxygen should be delivered by venturi mask (28%-40%) or nasal cannula. With this treatment one attempts to achieve a partial pressure of oxygen of 60-75 mmHg and an oxygen saturation above 90%. For treatment of exacerbated COPD, the goal is 88-92% saturation. In children oxygen therapy should be used to maintain a constant SaO2 > 95%. Conduct treatment with CPAP (continuous positive airways pressure) for cardiogenic pulmonary edema, pneumonia, and other gas exchange disorders when supportive oxygen administration alone is insufficient, and yet hypoventilation is not present. When assisted ventilation is used, a noninvasive option should be used whenever possible, especially in patients with COPD or immunosuppression. [Oxygen insufflation therapy is indicated in patients with SpO2 saturation < 92%. However, especially in patients with COPD, control BGAs should be performed after the initiation of O2 therapy in order to detect possible hypercapnia induced by O2 administration in time.] kroe1,2014 [Carbon dioxide, oxygen and the pH value are the three control variables that influence the respiratory rate (tidal volume). Normally the arterial partial pressure of CO2 is the leading control variable. However, if there is a loss of central chemosensitivity (medulla oblongata) in pulmonary dysfunction with chronic hypercapnia (e.g.: COPD) or in sleep drug intoxication, spontaneous breathing is stimulated mainly by the hypoxia influence on the peripheral chemosensors (glomus caroticum and glomus aorticum). In these cases, the administration of pure oxygen can lead to life-threatening apnea, since the respiratory drive, which is most effective under these circumstances, is shut down by this therapy.] vau1,2015 Complications of mechanical ventilation include barotrauma such as pneumothorax, pneumomediastinum, as well as the necessity of sedation and paralysis, which should be avoided due to the risk of post-paralysis myopathy and ventilator-associated pneumonia (with a mortality rate of 20-50%). Because of these possible complications, great care must be taken when using ventilators. Ed. Antipyretics Galic: glt1,2023 From my perspective antipyretic treatment is indicated only for acute relief, if the requirements for higher metabolism and the ability to fulfill the needs for liquids - due to the higher body temperature - cannot be met by the body due to prior impairment. This is imperative especially within advanced cardio-pulmonary diseases. According to recommendations of some experienced homeopaths in the 19. century, (for example Fennimore fbx,1930, etc.), giving the patient alcoholic drinks in some cases of pneumonia has a similar effect as administering antipyretic medication. New clinical research-data validates the observation in (homeopathic) practice, that routine prescription of antipyretics is more likely to cause harm to the patient and often influences the disease course in a negative way. One of the world-wide first clinical studies in a hospital day-to-day-setting, which analyzed the phenomenon fever and antipyresis in its relation to clinical outcome for 400 patients diagnosed with pneumonia of Hull and East Yorkshire Hospital NHS Trust showed the following results: In those patients - whose body-temperature was kept at 36°C/96,8°F by means of antipyretics - 33% died within 30 days of disease-onset. In patients who were allowed to have elevated body-temperature only 18% died. But the real sensation came in the group who could develop body-temperature of 40°C/104°F and higher - In this group every patient survived! NOTE - Please put the sources below in a footnote on the same page as the above! Original source: Some clinical data; Gavin Barlow, consultant in infectious diseases and honorary senior lecturer, Patrick Lillie, clinical research fellow, Dilip Nathwani, honorary professor of infectious diseases, Peter Davey, professor and lead clinician for clinical quality improvement - BMJ 2010; 340:c905 doi: 10.1136/bmj.c905 (Published 16 February 2010) Avoid unnecessary prescribing of fever and cough medications. ebm1,2015 Ed.: There is also a considerable amount of research-data on fever as fruitful and important physiological defense-mechanism. This data can be very valuable in discussions with patients, parents or physicians on the topic of scientifically based therapy and case management. Antibiotic Treatment in Pneumonia Beneficial antibiotic treatment is a complex field and should - from our perspective - be selected according to various factors such as the type of pneumonia, drug resistance, age, etc. as well as a sound knowledge of the used drugs and their potential side effects. Here in this book we only want to address some thoughts from the homeopathic and integrative medical perspective regarding antibiotic treatment. We, the editors of this book, would appreciate extensive, high-quality scientific research on the results of homeopathic and/or antibiotic treatment of different cases of pneumonia and/or pleurisy, also taking into account at what stage which therapy leads to the best outcome for patients in short and long term. We see a large potential for the cost effective, economical homeopathic treatment. At the same time, we also recognize the risks, if the homeopathic physician fails to find the curative remedy. Nonetheless, the risks of side-effects resulting from antibiotic treatment, the related environmental risks, and the increasing problem of drug resistance and consequential problems are serious. As there are large regional and temporal differences in antibiotic resistance, the choice of antibiotic should be based on the local guidelines for antibiotic treatment of the pneumonia-patient in question. Ed. [Local or metastatic infectious complications also contribute to treatment failure. Empyema is one of the most frequent complications in pneumonia and is thus a cause of nonresponse that must be evaluated with thoracocentesis when a pleural effusion is present. Other causes of treatment failure are abscess formation and necrotizing pneumonia. Metastatic infections such as endocarditis, arthritis, pericarditis, meningitis, or peritonitis can contribute to treatment failure and are more common in bacteremic pneumonia. In approximately 30% of the cases, no specific cause for lack of response can be identified despite adequate antibiotic treatment. This may be due to the presence of comorbidities or to an exaggerated or diminished inflammatory response.] mur1,2016 Galic glt1,glt2,2023 Bacterial pneumonias more often lead to a severe disease course whereas viral pneumonia often tend to have a long-lasting, yet less severe course. Indicators for bacterial involvement are: High fever, frequently a rise in CRP and Procalcitonin in bloodsamples at the beginning of the disease, later on also a rise of the erythrocyte sedimentation rate. Leucocyt count goes up to 90.000/µl with toxic granulocytes, eosino- and lymphocytopenia. If the condition of the patient is not better within 24 hours after begin of antibiotic treatment it is clear that this antibiotic is not helpful. And even if the antibiotic treatment is helpful it takes 3 to 5 weeks until the disease is over with this treatment. This can be seen due to persisting general symptoms like weakness and sweating. Mind and remember: If the patient has already been treated with antibiotics, the morphological changes in the lung are not shortened in time. Therefore caution the patient to not exert himself too early during reconvalescence, otherwise relapse or other complications may arise! glt1,Herold,2017 Antitussiva The last Conchrane Review on the topic (2014) of over the counter medications (OCT) to reduce cough (mucolytics or cough suppressants) during antibiotics for acute pneumonia in children and adults gave the following result: "There is insufficient evidence to decide whether OTC medications for cough associated with acute pneumonia are beneficial. Mucolytics may be beneficial (Number needed to treat = 5) but there is insufficient evidence to recommend them as an adjunctive treatment for acute pneumonia. This leaves only theoretical recommendations that OCT medications containing codeine and antihistamines should not be used in young children." This conclusion is based on only four studies with a total of 224 participants which met the scientific criteria that the authors of the review put on. (Over the counter medications to reduce cough ... Chang CC, Cheng AC, Chang AB, The Cochrane Library, 2014) [The American Academy of Pediatrics has highlighted the fact that the efficacy of antitussive preparations in children is lacking and that these medications may be potentially harmful. Their recommendation is that cough due to acute viral airway infections is self-limiting and should be treated only with fluids and humidity.] mur1,2016 [Avoid unnecessary prescribing of fever and cough medications.] ebm1,2015 On Antitussives containing Codeine Based on scientific literature research we could not find any studies on the benefits or risks of antitussives such as codeine or paracodeine in treatment for pneumonia. Ed. The codeine package insert in Austria lists pneumonia and acute respiratory depression as contraindications. Galic glt1 considers cough suppressants such as codeine to be a possible threat during treatment of patients with pneumonia. [The respiratory center is inhibited by morphine. Even after therapeutic doses, an increase in the threshold for the physiological stimulus (via µ2 opiate receptors diminished response to pCO2 elevation. Ed.) can be observed. The inhibition of the respiratory center is dose-dependent. The respiratory center of neonates and infants is particularly sensitive to opiates.] luel1,2003 Hydrotherapy Fisher - Pneumonia in children fsr2,1895: Baths are permissible during pneumonia, as in other acute fevers, according to the judgment of the physician. If the temperature be exceedingly high, the skin hot, dry and parched, frequent sponge bathings are grateful and helpful. In the onset of pneumonia the wet pack is an adjuvant of value. If the engorgement be extensive, the temperature high and the patient threatened with convulsions it should be applied immediately and repeatedly every half hour or hour until the dangerous symptoms have subsided. In a recent contribution to the Medical Century, Dr. J.C. Daily, of Fort Smith, Arkansas, accords it extravagant praise, relying upon it in almost every case of pneumonia in the first stage. Poultices and hot fomentations on the affected side have long been used in domestic practice by the profession. It is doubtful if they are beneficial, but the loosely quilted cotton jacket, made by stitching cotton batting on oiled silk, should be applied in all cases of true croupous pneumonia and continued throughout the course of the case. This prevents chilling of the chest and promotes moderate respiration. Where the cotton jacket is not accessible the chest should be protected by a closely-fitting flannel undervest; and an outing-flannel nightdress, extra long and with long sleeves, should be worn throughout the course of the disease. Blackwood bwax,1902: It will be found (Ed. in broncho-pneumonia) that cold baths or what is often better, dashing cold water over the chest and spine provokes further inspirations, and assists in overcoming the danger of pulmonary collapse. Sponging with tepid water is often beneficial to the patient as it equalizes the circulation and allays the nervous symptoms. bwax,1902 Gatchell gccx,1902: Sponge the chest at intervals with hot water, and dry carefully. When there is high temperature, with dry, hot skin, use tepid sponging. Avoid the use of poultices. If there is local pain, the best application is a hot compress. If the fever is high and the skin of the chest is hot, do not bundle the chest in any way. Fenimore fbx,1930: Bathing is necessary for cleanliness but as a rule it is not needed as an aid in reducing temperature (like Sponge bathing). Saine snex,2023: Hydrotherapy can - built on the principal of promoting blood supply - accelerate recovery. In pneumonia it is recommended to use a tight T-shirt which is trenched in cold water. The patient should be covered warmly afterwards. Due to the thermal loss increase of blood-circulation happens, (- the higher the fever, the quicker the reaction -), until the T-shirt is dry. Hydro- and/or thermotherapy can be applied auxiliary to homeopathic treatment. It is remarkable that even Hahnemann recommends hydrotherapy as an accompanying measure in his Organon. On further Support regarding Care and Cure As with any acute illness, patient care is also of particular importance from a therapeutic point of view. This includes the condition of the immediate surroundings, nutrition, hygiene and physiotherapeutic measures. As with most other recommendations opinions about what is necessary and best for patients vary. Here is a short conclusion from our homeopathic literature research on patients with pneumonia: Physical and mental rest is most important, the earlier a patient gets to bed the better. The environment should be cool and moderate in terms of both temperature (about 68°F/20°C) and humidity (- esp. not too dry). Direct sunlight and radiant heat from a heater should be avoided. The room should be well ventilated but without draughts. Strong odors from disinfection, food or excretions should be avoided. The number of visitors and patients should also be reduced as far as possible. Easily digestible food such as soups, fruit juices, milk etc. should be preferred. Pay attention to the fluid intake as described in the "Liquid intake" chapter. In the case of people addicted to alcohol, a moderate intake of alcohol should also be allowed as not to provoke a withdrawal syndrome. Also monitor hygienic measures. This concerns excretion and gentle cleaning of the patient, including tooth brushing. Clothing should be not too cold nor too warm and made of natural materials. An upright position may help the patient cough. Frequent changes of position can be helpful to reduce soreness of muscles. Stay cautious when caring for patients with low blood pressure to avoid collapse or falls resulting in injury. Massaging the respiratory muscles counteracts tension and sore muscles. This is of special value in children and very weak patients. Respiratory gymnastics and hydrotherapy can be valuable physiotherapeutic supplements. |