Target Health Blog

Pneumonia

January 28, 2019

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Quiz
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Main symptoms of infectious pneumonia
Graphic credit: Mikael Haggstrom. When using this image in external works, it may be cited as: 23kmHaggstrom, Mikael (2014). “Medical gallery of Mikael Haggstrom 2014“. WikiJournal of Medicine, DOI:10.15347/wjm/2014.008. ISSN 2002-4436. Public Domain. Or By Mikael Haggstrom, used with permission. - All used images are in public domain., Public Domain,
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Pneumonia is a bacterial, viral, or fungal infection of one or both sides of the 1) ___ that causes the air sacs of the lungs to fill up with fluid or pus. Symptoms can be mild or severe and may include a cough with phlegm (a slimy substance), fever, chills, and trouble breathing. Many factors affect how serious pneumonia is, such as the type of germ causing the lung infection, your age, and your overall health. Pneumonia tends to be more serious for children under the age of five, adults over the age of 65, people with certain conditions such as heart failure, diabetes, or COPD (chronic obstructive pulmonary disease), or people who have weak immune systems due to HIV/AIDS, chemotherapy (a treatment for cancer), or organ or blood and marrow stem cell transplant procedures. Pneumonia is an inflammatory condition of the lung affecting primarily the small air sacs known as 2) ___.

Pneumonia is usually caused by infection with viruses or bacteria and less commonly by other microorganisms, certain medications and conditions such as autoimmune diseases. Risk factors include other lung diseases such as cystic fibrosis, COPD, and asthma, diabetes, heart failure, a history of smoking, a poor ability to cough such as following a stroke, or a weak immune system. Diagnosis is often based on the symptoms and physical examination. Chest X-ray, blood tests, and culture of the sputum may help confirm the diagnosis. The disease may be classified by where it was acquired with community, hospital, or health care associated pneumonia. Vaccines to prevent certain types of pneumonia are available. Other methods of prevention include handwashing and not smoking. Treatment depends on the underlying cause. Pneumonia believed to be due to bacteria is treated with 3) ___. If the pneumonia is severe, the affected person is generally hospitalized. Oxygen therapy may be used if oxygen levels are low.

People with infectious pneumonia often have a productive cough, fever accompanied by shaking chills, shortness of breath, sharp or stabbing chest pain during deep breaths, and an increased rate of breathing. In elderly people, confusion may be the most prominent sign. The typical signs and symptoms in children under five are fever, cough, and fast or difficult breathing. Fever is not very specific, as it occurs in many other common illnesses and may be absent in those with severe disease, malnutrition or in the elderly. In addition, a cough is frequently absent in children less than 2 months old. More severe signs and symptoms in children may include blue-tinged 4) ___, unwillingness to drink, convulsions, ongoing vomiting, extremes of temperature, or a decreased level of consciousness. Bacterial and viral cases of pneumonia usually present with similar 5) ___ symptoms. Some causes are associated with classic, but non-specific, clinical characteristics. Pneumonia caused by Legionella may occur with abdominal pain, diarrhea, or confusion. Pneumonia caused by Streptococcus pneumoniae is associated with rusty colored sputum. Pneumonia caused by Klebsiella may have bloody sputum often described as “currant jelly.“ Bloody 6) ___, known as hemoptysis, may also occur with tuberculosis, Gram-negative pneumonia, lung abscesses and more commonly acute bronchitis. Pneumonia caused by Mycoplasma pneumoniae may occur in association with swelling of the lymph nodes in the neck, joint pain, or a middle ear infection. Viral pneumonia presents more commonly with wheezing than bacterial pneumonia. Pneumonia was historically divided into “typical“ and “atypical“ based on the belief that the presentation predicted the underlying cause. However, evidence has not supported this distinction, therefore it is no longer emphasized.

Pneumonia affects approximately 450 million people globally (7% of the population) and results in about 4 million deaths per year. Pneumonia was regarded by William Osler in the 19th century as “the captain of the men of death“. With the introduction of antibiotics and vaccines in the 20th century, survival improved. Nevertheless, in developing countries, and among the very old, the very young, and the chronically ill, pneumonia remains a leading cause of death. Pneumonia often shortens suffering among those already close to 7) ___ and has thus been called “the old man's friend.“

Pneumonia is due to infections caused primarily by bacteria or viruses and less commonly by fungi and parasites. Although there are over 100 strains of infectious agents identified, only a few are responsible for the majority of the cases. Mixed infections with both viruses and bacteria may occur in roughly 45% of infections in children and 15% of infections in adults. A causative agent may not be isolated in approximately half of cases despite careful testing. The term pneumonia is sometimes more broadly applied to any condition resulting in inflammation of the lungs, caused for example by autoimmune diseases, chemical burns or drug reactions; however, this inflammation is more accurately referred to as pneumonitis. Factors that predispose to pneumonia include smoking, immunodeficiency, alcoholism, chronic obstructive pulmonary disease, asthma, chronic kidney disease, liver disease, and old age. Additional risk in children include not being breastfeed, exposure to cigarettes or air pollution, malnutrition, and poverty. The use of acid-suppressing medications - such as proton-pump inhibitors or H2 blockers - is associated with an increased risk of pneumonia. Approximately 10% of people who require mechanical ventilation develop ventilator associated pneumonia, and people with gastric feeding 8) ___ have an increased risk of developing of aspiration pneumonia. For people with specific variants of FER gene, the risk of death is reduced in sepsis caused by pneumonia. However, for those with TLR6 variants, the risk of getting Legionnaires' disease is increased.

Pneumonia is typically diagnosed based on a combination of physical signs and a chest 9) ___. However, the underlying cause can be difficult to confirm, as there is no definitive test able to distinguish between bacterial and non-bacterial origin. The World Health Organization has defined pneumonia in children clinically based on either a cough or difficulty breathing and a rapid respiratory rate, chest indrawing, or a decreased level of consciousness. A rapid respiratory rate is defined as greater than 60 breaths per minute in children under 2 months old, greater than 50 breaths per minute in children 2 months to 1 year old, or greater than 40 breaths per minute in children 1 to 5 years old. In children, low oxygen levels and lower chest indrawing are more sensitive than hearing chest crackles with a stethoscope or increased respiratory rate. Grunting and nasal flaring may be other useful signs in children less than five years old. Lack of wheezing is an indicator of Mycoplasma pneumoniae in children with pneumonia, but as an indicator it is not accurate enough to decide whether or not macrolide treatment should be used. The presence of chest pain in children with pneumonia doubles the probability of Mycoplasma pneumoniae.

In general, in adults, investigations are not needed in mild cases. There is a very low risk of pneumonia if all vital signs and auscultation are normal. In persons requiring hospitalization, pulse oximetry, chest radiography and blood tests - including a complete blood count, serum electrolytes, C-reactive protein level, and possibly liver function tests - are recommended. Procalcitonin may help determine the cause and support who should receive antibiotics. Antibiotics are encouraged if procalcitonin level reaches 0.25 ?g/L, strongly encouraged if it reaches 0.5 ?g/L, and strongly discouraged if the level is below 0.10 ?g/L. For those with CRP less than 20 mg/L without convincing evidence of pneumonia, antibiotics are not recommended. The diagnosis of influenza-like illness can be made based on the signs and symptoms; however, confirmation of an influenza infection requires testing. Thus, treatment is frequently based on the presence of influenza in the community or a rapid influenza test. Prevention includes vaccination, environmental measures and appropriate treatment of other health problems. It is believed that, if appropriate preventive measures were instituted globally, mortality among children could be reduced by 400,000; and, if proper treatment were universally available, childhood deaths could be decreased by another 600,000. One of the most important preventative measures is not to smoke, or make a major effort to stop 10) ___.

With treatment, most types of bacterial pneumonia will stabilize in 3-6 days. It often takes a few weeks before most symptoms resolve. X-ray finding typically clear within four weeks and mortality is low (less than 1%). In the elderly or people with other lung problems, recovery may take more than 12 weeks. In persons requiring hospitalization, mortality may be as high as 10%, and in those requiring intensive care it may reach 30-50%. Pneumonia is the most common hospital-acquired infection that causes death. Before the advent of antibiotics, mortality was typically 30% in those that were hospitalized. However, for those whose lung condition deteriorates within 72 hours, the problem is usually due to sepsis. If pneumonia deteriorates after 72 hours, it could be due to nosocomial infection or exacerbation of other underlying co-morbidities. About 10% of those discharged from hospital are readmitted due to underlying co-morbidities such as heart, lung, or neurology disorders, or due to new onset of pneumonia.

ANSWERS: 1) lungs; 2) alveoli; 3) antibiotics; 4) skin; 5) symptoms; 6) sputum; 7) death; 8) tube; 9) x-ray; 10) smoking

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