Pneumonia, lung abscess and atelectasis

1Pneumonia

Definition and types

Infection of the lung tissue in which the alveoli fill with inflammatory fluid and cells (consolidation).

• By setting: community-acquired; hospital-acquired (starting 48 hours or more after admission); ventilator-associated; aspiration pneumonia.
• By pattern: lobar (one lobe), bronchopneumonia (patchy, both lungs), interstitial (viral, atypical).
• By organism: bacterial (pneumococcus commonest), viral, atypical, fungal, TB.

Key features

• Fever, cough, sputum (rusty in pneumococcal), pleuritic chest pain, breathlessness, fast breathing; confusion in the elderly.
• Signs over the consolidation: dull percussion, bronchial breathing, crackles, increased vocal resonance.
• X-ray: white consolidation with air bronchograms (dark airways inside white lung) and no loss of volume.

Medical point that matters for physio

Antibiotics, oxygen (target SpO₂ 94–98%, or 88–92% if at risk of CO₂ retention), fluids. Early consolidation is solid exudate, not loose sputum, so percussion and drainage do not clear it.

ICF summary

Impairments: fever, breathlessness, low oxygen, pleuritic pain, sputum (later), weakness. Activity: walking, self-care. Participation: work and family roles during illness. Environment: hospital or home care.

PT management by problem

• Low oxygen: positioning; in one-sided pneumonia, lie with the good lung down to improve oxygenation.
• Deconditioning: sit out within 24 hours (20 minutes or more), then progressive walking.
• Sputum retention (resolving stage): ACBT with huffing, 1–2 times a day; affected lung uppermost for drainage when tolerated; humidification.
• Pleuritic pain: supported breathing and coughing; pain relief before treatment.
• On a ventilator (S20, W24): see the worked plan below.

Ventilated pneumonia (W24: 35-year-old, both lungs, CMV, FiO₂ 0.6, PEEP 10 for 3 days)

Read the settings first. FiO₂ 0.6 and PEEP 10 cmH₂O are high: his lungs are stiff and poorly oxygenated, close to ARDS. Losing PEEP even briefly (disconnecting the circuit) can collapse alveoli and drop his SpO₂.

• Safety check every session: SpO₂, FiO₂ and PEEP trend, HR, BP, sedation level, and the doctor's plan. At FiO₂ 0.6 and PEEP 10 he is at the upper limit for active mobilisation, so start with in-bed treatment.
• Positioning: head of bed up 30–45° (prevents aspiration and ventilator pneumonia); regular side-lying turns to change ventilation and drain secretions; prone positioning for severe hypoxaemia is decided by the doctors, and physiotherapists help to turn the patient safely.
• Secretions: atypical pneumonia often produces little sputum, so suction only when needed, using a closed (in-line) suction system to keep PEEP. Avoid bagging off the ventilator at this PEEP; if hyperinflation is needed, the ventilator can deliver it (ventilator hyperinflation).
• Limbs: passive then active-assisted movement of all joints, ankle splints or positioning against foot drop, pressure care with regular turns.
• Progress as oxygen needs fall and sedation lightens: active exercise, sitting over the edge of the bed, in-bed cycling, then standing and walking with the ventilator.
• After extubation: deep breathing, ACBT, incentive spirometry as an add-on, early walking, strengthening and inspiratory muscle training if weak.

Ventilator modes and weaning, suction and positioning are covered in more detail on the mechanical ventilation, suctioning and positioning cards.

Precautions

• Watch for sepsis (low BP, confusion), worsening hypoxia and fatigue.
• Infection control: hand hygiene, masks for viral pneumonia.

Exam points

• Consolidation vs collapse: consolidation keeps lung volume; collapse loses it.
• Physio is not routine in uncomplicated pneumonia.

2Lung abscess

Definition and types

A localised area of lung necrosis forming a cavity filled with pus.

Causes and key features

• Aspiration of mouth contents (alcohol, seizures, reduced consciousness, poor teeth, swallowing problems). Commonest sites: posterior segment of the right upper lobe and superior segment of the right lower lobe (the lowest parts when lying on the back).
• Other causes: severe pneumonia (Staphylococcus, Klebsiella), blocked bronchus (tumour, foreign body).
• Swinging fever, large amounts of foul-smelling sputum, haemoptysis, weight loss, clubbing.
• X-ray: a thick-walled cavity with an air–fluid level.

Medical point that matters for physio

Several weeks of antibiotics; drainage or surgery if it does not resolve. Once the abscess drains into a bronchus, sputum is copious.

ICF summary

Impairments: copious foul sputum, fever, fatigue, weight loss. Activity and participation: reduced work and social life (embarrassment from sputum smell).

PT management by problem

• Copious sputum: gravity-assisted drainage of the affected segment with ACBT, 2–3 times a day, once the abscess communicates with a bronchus (the patient is coughing it up).
• Encourage strong huffs and coughs during drainage so pus is cleared, not spilled into other lobes.
• Breathing exercises, mobilisation, nutrition and mouth hygiene advice.

Precautions

• Haemoptysis: stop drainage and percussion.
• Weak or drowsy patients may not clear a sudden large release of pus: have suction ready.

Exam points

• Cavity with an air–fluid level; foul sputum; aspiration risk factors; drain the affected segment.

3Atelectasis (collapse)

Definition and types

Incomplete expansion or collapse of part or all of a lung.

• Obstructive (resorption): mucus plug, tumour or foreign body; air beyond is absorbed.
• Compressive: effusion, pneumothorax, tumour pressing on the lung.
• Passive (micro-atelectasis): shallow breathing after surgery or with pain.
• Adhesive: surfactant loss (neonatal RDS, ARDS). Cicatrisation: scarring (TB, fibrosis).

Key features

• May be silent when small; larger collapse: breathlessness, low SpO₂, reduced breath sounds.
• X-ray: increased opacity with loss of volume: trachea and mediastinum pulled towards the collapse, raised hemidiaphragm, displaced fissures, crowded ribs.

Medical point that matters for physio

Post-operative and mucus-plug collapse respond well to physiotherapy; bronchoscopy for a plug that will not clear.

ICF summary

Impairments: reduced lung volume, low oxygen, retained secretions. Activity: mobility limited by breathlessness and the underlying cause.

PT management by problem

• Reduced lung volume: deep breathing with a 3-second inspiratory hold (sustained maximal inspiration), thoracic expansion to the affected area, 5–10 breaths every hour while awake.
• Positioning: affected area uppermost to ventilate and drain it.
• Mucus plug: humidification, ACBT with huffs, suction if needed.
• Early mobilisation: the best "deep breathing" exercise.
• In ventilated or very weak patients: positive pressure (CPAP, manual hyperinflation, IPPB) as prescribed; incentive spirometry only as an add-on.

Precautions

• Positive pressure is contraindicated with an undrained pneumothorax.
• Compressive collapse needs the fluid or air drained first.

Exam points

• Collapse pulls structures towards; effusion and pneumothorax push away; consolidation keeps volume.

4Exam corner

• W24 Q4(a), 15 marks35-year-old man with infective atypical pneumonia of both lungs, on CMV with FiO₂ 0.6 and PEEP 10 for 3 days, referred for physiotherapy. Functional diagnosis and physiotherapy management. Worked plan in section 1.
• S20 Q3(b), 5 + 3 + 7 marks60-year-old farmer with a COPD exacerbation and respiratory failure, in ICU on SIMV, with right lower lobe pneumonia (see the COPD page).

Technique cards for this topic: ICU physiotherapy, mechanical ventilation, suctioning, positioning.