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INTRODUCTION
Pneumonia is an infection of the lungs. It is a serious illness that
can affect people of any age, but it is most common and most
dangerous in very young children, people older than 65, and
people with underlying medical problems such as heart disease,
diabetes, or chronic lung disease. Pneumonia is more common
during the winter months. There are many cases of community
acquired pneumonia occurring in our area.
LUNG FUNCTION
During normal breathing, air is inhaled through the nose and
mouth and travels through the trachea (windpipe) and bronchi
(airways) to smaller tubes called the bronchioles. At the end of the
bronchioles, there are small air sacs, called alveoli. Alveoli have
thin, porous walls that contain tiny blood vessels called capillaries.
Your mouth and respiratory tract are constantly exposed to micro-
organisms (germs like viruses and bacteria) through the air you
breathe. However, your body's immune system, the shape of your
nose and throat (which helps trap microorganisms and tiny
particles in the air, preventing them from entering the lungs), your
ability to cough, and fine hair-like structures on the bronchi called
"cilia" all help to prevent micro-organisms from causing
pneumonia. The cilia help remove particles or bacteria that enter
the bronchi by moving the material up to your trachea, where it
can be coughed out. You can develop pneumonia if your body's
defenses are not adequate, you are exposed to a particularly
strong micro-organism, or you are exposed to a very large number
of micro-organisms. As the micro-organisms multiply, your
immune system responds by sending white blood cells to the
alveoli to help fight the infection. The infected alveoli become
inflamed (filled with white blood cells, proteins, fluid, and red
blood cells). These changes lead to the symptoms of pneumonia.
HIGH-RISK GROUPS
Some groups of adults are at a higher risk of developing
pneumonia. You are considered at higher risk if you:
-Are older than 65 years
-Smoke cigarettes
-Are malnourished due to health conditions or lack of access to
food
-Have underlying lung disease, including cystic fibrosis, asthma, or
chronic obstructive pulmonary disease (emphysema)
-Have other underlying medical problems, including diabetes or
heart disease
-Have a weakened immune system due to HIV, organ transplant,
chemotherapy, or long-term use of steroid medications
-Have difficulty coughing due to stroke, sedating drugs or alcohol,
or limited mobility
-Have had a recent viral upper respiratory tract infection including
influenza
PNEUMONIA CAUSES
Pneumonia can be caused by a variety of micro-organisms,
including viruses, bacteria, and, less commonly, fungi. The most
common bacterial cause of pneumonia in the United States is a
type of bacteria called Streptococcus pneumoniae (also called
pneumococcus). Other bacteria can cause pneumonia as well.
Viruses are estimated to be the cause of community-acquired
pneumonia in adults in at least 20 percent of cases. Influenza ("the
flu") is a common viral cause of pneumonia. Some of the same
viruses that cause the common cold can also cause pneumonia.
Fungi rarely cause pneumonia in people who are generally
healthy; however, people with a weakened immune system (eg,
have HIV infection, have received an organ transplant, or are on
chemotherapy) are at higher risk of fungal infection. Let your
doctor know if you have traveled recently or if you been to or lived
in an area where a certain type of pneumonia is more common
(eg, Valley fever or coccidioidomycosis in the southwestern United
States; Middle East respiratory syndrome in the Arabian Peninsula;
H7N9 strain of avian influenza in Asia). The risk of pneumonia
caused by new micro-organisms (so-called "emerging pathogens")
changes over time, but your doctor will know if any of the places
that you have been to or lived in put you at increased risk for
pneumonia.
PNEUMONIA SYMPTOMS
Common symptoms of pneumonia include fever, chills, shortness
of breath, chest pain with breathing, a rapid heart and breathing
rate, nausea, vomiting, diarrhea, and a cough that often produces
green or yellow sputum (mucus from the lungs); occasionally, the
sputum is rust colored. Most people have a fever (temperature
greater than 100.5ºF or 38ºC), although this is less common in
older adults. Shaking chills (called rigors) and a change in mental
status (confusion, unclear thinking) can also occur. The
characteristic symptoms of pneumonia are different from those of
a more common infection, acute viral bronchitis, which does not
usually cause fever and does not require treatment with an
antibiotic.
PNEUMONIA DIAGNOSIS
Pneumonia is usually diagnosed with a medical history and
physical examination as well as a chest X-ray. The need for further
testing depends upon the severity of the illness and the person's
risk of complications.
Chest X-ray — If your doctor thinks you might have pneumonia
based on your symptoms and examination, he or she will probably
order a chest X-ray to look at your lungs. In certain cases,he or she
might also order another imaging study, such as a computed
tomography (CT) scan.
Sputum testing — Sometimes, the doctor might test your sputum
too. Sputum testing requires a sample of sputum (mucus that you
cough up). Culture of sputum is used to identify the micro-
organism that caused the pneumonia and can help determine
which antibiotic is best.
Urine testing — Urine tests can be helpful for diagnosing
pneumonia caused by two bacteria, Streptococcus pneumoniae
and Legionella pneumophila. These tests can be done easily by a
lab technician and provide immediate results.
Blood testing — People who are hospitalized require blood
testing, including a complete blood cell count (CBC) and often a
blood culture. A CBC measures the number of many types of blood
cells, including white blood cells (WBC); these cells increase in
number when there is a bacterial infection. An increased number
of WBCs is one indicator that a bacterial infection, including
pneumonia, may be present. A blood culture is used to determine
whether the infection has spread from the lungs into the blood
stream. It involves taking a sample of blood from a vein and
testing it for bacteria. Normally, there should be no bacteria in the
bloodstream. Blood cultures are used to identify the bacteria that
caused the pneumonia and to guide the choice of antibiotic. Your
doctor may switch you to a different antibiotic when results of the
blood or sputum cultures are completed
(usually after 48 to 72 hours).
Blood oxygen measurement — Pneumonia can decrease the
amount of oxygen circulating in the blood. As a result, a blood
oxygen level is often measured with a small clip that attaches to
your finger or ear. In people who are sicker, the oxygen level may
be measured by taking a sample of blood from an artery for
testing.
Bronchoscopy — People who present initially with severe
pneumonia or who fail to improve (or get worse) during their
hospitalization despite treatment with antibiotics may require
further testing with bronchoscopy. For this procedure, a doctor
inserts a thin, flexible tube through your nose or mouth and into
your trachea. The tube has a camera at the end, which allows the
doctor to view the inside of your trachea, bronchi, and lungs;
collect fluid samples or a biopsy (a small tissue sample); and
determine whether there is an underlying cause of infection, such
as a growth or inhaled foreign body.
PNEUMONIA TREATMENT
The goal of treatment for community-acquired pneumonia (CAP) is
to get rid of the infection and prevent complications. Initial
treatment of CAP with antibiotics is based on which type of
organism is likely to be causing pneumonia (called "empiric"
treatment). Most people improve with empiric treatment.
Hospital versus home care — Most people with CAP are treated at
home with oral antibiotics. People who are seriously ill or are at
increased risk for complications may be hospitalized. Hospital
monitoring usually includes measurement of your heart rate and
breathing rate, temperature, and oxygen levels. People who are
hospitalized usually get intravenous (IV) antibiotics initially. When
they start improving, they can usually be switched to antibiotic
pills. Some people need extra oxygen (given through small nasal
tubes or a face mask) to help them breathe more easily. People
who are still having a hard time breathing may need a breathing
tube connected to a machine called a "ventilator." Some people
who need to stay in the hospital are also given steroid medications
to help reduce inflammation in the lungs. (This medicine is not the
same as the steroids athletes take to build up muscle.)The number
of days a person needs to stay in the hospital varies and depends
on the person'sresponds to treatment and underlying medical
problems. Some people, including people with previous lung
damage or disease, a weakened immune system, or infection in
more than one lobe of the lungs (called multilobar pneumonia),
may take longer to recover and require a longer hospitalization.
Antibiotic choice — A number of antibiotic treatment regimens
exist for treatment of CAP. The choice of which antibiotic to use is
based upon several factors, including your underlying medical
problems and the likelihood of being infected with a type of
bacteria that is resistant to specific drugs. People with certain
medical problems and those who have used antibiotics in the past
three months have a higher risk of infection with drug-resistant
bacteria. For all antibiotic regimens, it is important to finish the
entire course of medication and take it exactly as directed.
EXPECTED RECOVERY FROM PNEUMONIA
Most people begin to improve after three to five days of antibiotic
treatment. Improvement may be defined as feeling better or
having fewer symptoms, such as cough and fever. Fatigue and a
persistent but milder cough can last for a month or longer,
although most people are able to resume their usual activities
within a week. People treated in the hospital may not be able to
resume their normal activities for three weeks or longer.
Regardless of whether you are treated at home or in the hospital,
it's important to take care of yourself as your body recovers. This
includes getting plenty of rest at night and taking naps during the
day if needed. It's also important to drink plenty of fluids to avoid
becoming dehydrated. Be sure to finish all of your antibiotic
medication, even if you start to feel better after a few days. If you
are treated at home, you should have a follow-up visit or
communication with a health care provider within several days
after being diagnosed. This allows the provider to see if you are
improving and to check for any complications of pneumonia.
People who have been discharged from the hospital with a
pneumonia diagnosis should also have a follow-up visit, usually
within one week. In addition, a later visit is often recommended to
confirm that the pneumonia has resolved, both in people who
were treated at home and in those who were treated in the
hospital. If your symptoms do not improve or get worse after yo’ve
started treatment, let your health care provider know.
PNEUMONIA COMPLICATIONS
Pneumonia can usually be treated successfully without leading to
complications. However, complications can develop in some
people, especially those in high-risk groups. Complications can be
related to the pneumonia itself or to the drugs used to treat the
pneumonia. In addition, pneumonia may result in worsening of
chronic conditions such as chronic obstructive pulmonary disease
(eg, emphysema) or congestive heart failure. Possible
complications due to the pneumonia include:
-Fluid accumulation – Fluid can develop between the covering of
the lungs (pleura) and the inner lining of the chest wall; this is
called a pleural effusion. If the fluid becomes infected as a result of
pneumonia (called empyema), a chest tube (or, less commonly,
surgery) may be needed to drain the fluid.
-Abscess – A collection of pus in the part of the lung that was
infected is known as an abscess. They can usually be treated with
antibiotics; rarely, surgical removal is needed.
-Bacteremia – Bacteremia occurs when the pneumonia infection
spreads from the lungs to the bloodstream. This is a serious
complication since infection can spread quickly from the
bloodstream to other organs. Bacteremia can also cause the blood
pressure to be dangerously low.
-Cardiovascular events – Some studies have shown that people
who have had pneumonia are at increased risk of having a
cardiovascular event, such as a heart attack, during recovery and
for several years afterward. Possible complications due to
medications include diarrhea and rash. Each medication comes
with a list of potential side effects, and it's important to be familiar
with these when starting a treatment regimen. Most people
recover completely from pneumonia, especially those who do not
require hospitalization. However, in some cases, it can be fatal.
The risk of death is higher in people who are hospitalized,
particularly those who are admitted to the intensive care unit
(ICU). For these reasons, it's very important to see a health care
provider if you have symptoms of pneumonia, so it can be treated
as soon as possible.
WHEN TO SEEK HELP Anyone who suspects that they have
pneumonia should seek medical care as soon as possible.
Pneumonia is a serious illness that can be life-threatening if not
treated, especially for people who are older than 65 years, abuse
alcohol, have underlying medical problems, or have a weakened
immune system. If you develop any of the following symptoms,
you should see your health care provider promptly:
-Fever and cough with phlegm that does not improve or worsens
-New shortness of breath with normal daily activities
-Chest pain with breathing
-Feeling suddenly worse after a cold or the flu
-Confusion along with respiratory symptoms (as listed above)
PREVENTION
The pneumococcal vaccine is one of the most effective ways to
prevent pneumonia. The influenza (or "flu") vaccine is important
not only for preventing influenza but also for preventing potential
complications, including pneumonia. Avoiding smoking is another
important way to prevent pneumonia as well as other health
problems. If you smoke, there are treatments that can help you
quit. If you have an underlying medical conditions such as asthma,
congestive heart failure, or diabetes, controlling this condition can
also help to prevent pneumonia.
Infection control — "Infection control" refers to measures used to
prevent the spread of any type of infection, including pneumonia.
Infection control is most commonly practiced in healthcare
settings but is useful in the community as well. Simple practices
such as frequent hand washing with soap and water or alcohol-
based hand rubs can be effective. Because pneumonia can be
spread through the air (eg, if you inhale respiratory secretions
from an infected person's cough or sneeze), people with
pneumonia should limit face-to-face contact with family and
friends. To help prevent the infection from spreading, be careful to
cover your mouth and nose while coughing or sneezing, and throw
away tissues immediately after use. Sneezing or coughing into
your sleeve (ie, at the inner elbow) is another way to prevent the
spray of saliva and secretions; this also helps you to keep your
hands clean.
