Pneumonia

Definition
Every year, more than 60,000 Americans die of pneumonia — an inflammation of the
lungs that's usually caused by infection with bacteria, viruses, fungi or other
organisms. Pneumonia is a particular concern for older adults and people with chronic
illnesses or impaired immune systems, but it can also strike young, healthy people.
Worldwide, it's a leading cause of death in children.

There are many kinds of pneumonia ranging in seriousness from mild to life-
threatening. Pneumonia acquired while in the hospital can be particularly virulent and
deadly. Although signs and symptoms vary, many cases of pneumonia develop
suddenly, with chest pain, fever, chills, cough and shortness of breath. Infection often
follows a cold or the flu, but it can also be associated with other illnesses or occur on
its own.

Although antibiotics can treat some of the most common forms of bacterial
pneumonias, antibiotic-resistant strains are a growing problem. For that reason, and
because the disease can be very serious, it's best to try to prevent infection in the first
place.

Symptoms
Pneumonia can be difficult to spot. It often mimics a cold or the flu, beginning with a
cough and a fever, so you may not realize you have a more serious condition. Chest
pain is a common symptom of many types of pneumonia. Pneumonia symptoms can
vary greatly, depending on any underlying conditions you may have and the type of
organism causing the infection:

 Bacteria. Many types of bacteria can cause pneumonia. Bacterial pneumonia

can occur on its own, at the same time as viral pneumonia, or you may
develop it after you've had a viral upper respiratory infection such as
influenza. Signs and symptoms, which are likely to come on suddenly, include
shaking chills, a high fever, sweating, shortness of breath, chest pain, and a
cough that produces thick, greenish or yellow phlegm.

Ironically, high-risk groups such as older adults and people with a chronic
illness or compromised immune system may have fewer or milder symptoms
than less vulnerable people do. And instead of the high fever that often
characterizes pneumonia, older adults may even have a lower than normal
temperature.

Bacterial pneumonia is often confined to just one area (lobe) of the lung. This
is called lobar pneumonia.
  Viruses. About half of pneumonias are caused by viruses. Viral pneumonia
tends to begin with flu-like signs and symptoms. It usually starts with a dry
(nonproductive) cough, headache, fever, muscle pain and fatigue. As the
disease progresses, you may become breathless and develop a cough that
produces just small quantities of phlegm that may be clear or white. When you
have viral pneumonia, you run the risk of also developing a secondary
bacterial pneumonia.
 Mycoplasma. This tiny organism causes signs and symptoms similar to those
of other bacterial and viral infections, although symptoms appear more
gradually and are often mild and flu-like. You may not be sick enough to stay
in bed or to seek medical care and may never even know you've had
pneumonia. That's why this type of pneumonia is often called walking
pneumonia.

Mycoplasma pneumonia spreads easily in situations where people congregate

and is common among schoolchildren and young adults. Mycoplasma
pneumonia responds well to treatment with the appropriate antibiotics,
although you may continue to have a dry, nagging cough and continue to feel
weak during your convalescence.

 Fungi. Certain types of fungus also can cause pneumonia, although these
types of pneumonia are much less common. Most people experience few if
any symptoms after inhaling these fungi, but some develop symptoms of acute
pneumonia, and still others may develop a chronic pneumonia that persists for
months.
 Pneumocystis carinii. Pneumonia caused by P. carinii is an opportunistic
infection that affects people living with AIDS. People whose immune systems
are compromised by organ transplants, chemotherapy, or treatment with
corticosteroids or other immune-suppressing drugs such as tumor necrosis
factor (TNF) inhibitors also are at risk. The signs and symptoms of
Pneumocystis carinii pneumonia include a cough that doesn't go away, fever
and shortness of breath.

Causes
Your lungs are two spongy organs surrounded by a moist membrane (the pleura).
Each lung is divided into lobes — three on the right and two on the left. When you
inhale, air is carried through the windpipe (trachea) to your lungs. Inside your lungs,
there are major airways called bronchi. The bronchi repeatedly subdivide into many
smaller airways (bronchioles), which finally end in clusters of tiny air sacs called
alveoli.

Your body has mechanisms to protect your lungs from infection. In fact, you're
frequently exposed to bacteria and viruses that can cause pneumonia, but your body
normally prevents most of these organisms from invading and overwhelming your
airways. For example, the nasal cilia screen out a lot of organisms but can't stop all
from getting into your airways. Sometimes — for reasons that aren't always well
understood — these microorganisms can get past your body's defenses, finally finding
their way into your lungs' air sacs.

There, white blood cells (leukocytes), a key part of your immune system, begin to
attack the invading organisms. The accumulating pathogens, white cells and immune
proteins cause the air sacs to become inflamed and filled with fluid, leading to the
difficult breathing that characterizes many types of pneumonia. If both lungs are
involved, it's called double pneumonia.

Classifications of pneumonia
Pneumonia is sometimes classified according to the cause of pneumonia:

 Community-acquired pneumonia. This refers to pneumonia you acquire in the course of

your daily life — at school, work or the gym, for instance.
 Hospital-acquired (nosocomial) pneumonia. If you're hospitalized, you're at
a higher risk of pneumonia, especially if you are on a mechanical ventilator,
are in the intensive care unit or have a compromised immune system. This
type of pneumonia can be extremely serious, especially for older adults, young
children and people with chronic obstructive pulmonary diseases (COPD) or
HIV/AIDS.

A common predisposing factor for this type of pneumonia is gastroesophageal

reflux. This occurs when some of the contents of your stomach back up into
the upper esophagus. From there, the gastroesophageal contents can be
aspirated into the trachea and then into your airways. Even very small amounts
of gastroesophageal reflux can lead to pneumonia in people who are
hospitalized.

 Aspiration pneumonia. This type of pneumonia occurs when foreign matter

is inhaled (aspirated) into your lungs — most often when the contents of your
stomach enter your lungs after you vomit. This commonly happens when a
brain injury or other condition affects your normal gag reflex.

Another common cause of aspiration pneumonia is consuming too much

alcohol. This happens when the inebriated person passes out, and then vomits
due to the effects of alcohol on the stomach. If someone's unconscious, it's
possible to aspirate the liquid contents and possibly solid food from the
stomach into the lungs, causing aspiration pneumonia.
  Pneumonia caused by opportunistic organisms. This type of pneumonia strikes people with
compromised immune systems. Organisms that aren't harmful for healthy people can be
extremely dangerous for people with AIDS, organ transplantation and other conditions that
impair the immune system. For example, P. carinii pneumonia almost never occurs in
otherwise healthy people. Medications that suppress your immune system, such as
corticosteroids or chemotherapy also can put you at risk of opportunistic pneumonia.
 Emerging pathogens. Outbreaks of the H5N1 influenza (bird flu) virus and severe acute
respiratory syndrome (SARS) have caused serious, sometimes deadly pneumonia infections,
even in otherwise healthy people.

Risk factors
Adults age 65 or older and very young children, whose immune systems aren't fully
developed, are at increased risk of pneumonia. You're also more likely to develop
pneumonia if you:

 Have certain diseases. These include immune deficiency diseases such as

HIV/AIDS and chronic illnesses such as cardiovascular disease, emphysema
and diabetes. You're also at increased risk if you've had your spleen removed,
or your immune system has been impaired by chemotherapy or long-term use
of immunosuppressant drugs.
 Smoke, or abuse alcohol. Millions of microscopic hairs (cilia) cover the
surface of the cells lining your bronchial tubes. The hairs beat in a wave-like
fashion to clear your airways of normal secretions, but irritants such as
tobacco smoke paralyze the cilia, causing secretions to accumulate. If these
secretions contain bacteria, they can develop into pneumonia. Alcohol
interferes with your normal gag reflex as well as with the action of the white
blood cells that fight infection.
 Are hospitalized in an intensive care unit. Pneumonia acquired in the
hospital tends to be more serious than other types of pneumonia. People who
require mechanical ventilation are particularly at risk because the breathing
tube (endotracheal tube) bypasses the normal defenses of the respiratory tract,
prevents coughing, may allow the stomach's contents to back up into the
esophagus where they can be aspirated, and can harbor bacteria and other
harmful organisms.
 Are exposed to certain chemicals or pollutants. Your risk of developing
some uncommon types of pneumonia may be increased if you work in
agriculture, construction or around certain industrial chemicals or animals.
Exposure to air pollution or toxic fumes can also contribute to lung
inflammation, which makes it harder for the lungs to clear themselves.
 Have had surgery or experienced a traumatic injury. People who've had
surgery or who are immobilized from a traumatic injury have a higher risk of
pneumonia because surgery or serious injuries may make coughing — which
helps clear the lungs — more difficult and lying flat can allow mucous to
collect in your lungs, providing a breeding ground for bacteria.

When to seek medical advice

If you think you may have pneumonia, don't hesitate to get medical care. Serious
pneumonia can be life-threatening. See your doctor right away if you have a persistent
cough, shortness of breath, chest pain that fluctuates with your breathing (pleurisy),
an unexplained fever — especially a lasting fever of 102 F or higher along with chills
and sweats — or if you suddenly feel worse after a cold or the flu.

Be especially prompt about seeking medical care if you're an older adult or you're
affected by tobacco use, alcoholism, injury, chemotherapy or the use of drugs such as
prednisone that suppress your immune system. For some older adults and people with
heart failure or lung ailments, pneumonia can quickly prove fatal.

Tests and diagnosis

Your doctor may first suspect pneumonia based on your medical history and a
physical exam. During the exam, your doctor will listen to your lungs with a
stethoscope to check for abnormal bubbling or crackling sounds (rales) and for
rumblings (rhonchi) that signal the presence of thick liquid. Both these sounds may
indicate inflammation caused by infection.

You're also likely to have chest X-rays to confirm the presence of pneumonia and to
determine the extent and location of the infection. Your doctor can suspect
pneumonia, but he or she can't diagnose it without a chest X-ray.

You may also have blood tests to check your white cell count, or to look for the
presence of viruses, bacteria or other organisms. Sometimes your doctor may examine
a sample of your phlegm or your blood to help identify the microorganism that's
causing your illness.

The extent of all this testing depends on how sick you are and your underlying risk
factors, and whether or not you're responding to therapy.

Complications
How serious pneumonia is for you depends on your overall health and the type and
extent of pneumonia you have. If you're young and healthy, your pneumonia can
usually be treated successfully. But if you have heart failure or lung ailments,
especially from smoking, or if you're older, your pneumonia may be harder to cure.
You're also more likely to develop complications, some of which can be life-
threatening.

 Bacteria in the bloodstream. Pneumonia can turn deadly when inflammation

from the disease fills the air sacs in your lungs and interferes with your ability
to breathe. In some cases the infection may invade your bloodstream
(bacteremia). It can then spread quickly to other organs. This is detected by
doing cultures of your blood.
 Fluid accumulation and infection around the lungs. Sometimes fluid
accumulates between the thin, transparent membrane (pleura) covering your
lungs and the membrane that lines the inner surface of your chest wall — a
condition known as pleural effusion. Normally, the pleurae are silky smooth,
allowing your lungs to slide easily along your chest wall when you breathe in
and out. But when the pleurae around your lungs become inflamed (pleurisy)
— often as a result of pneumonia — fluid can accumulate and may become
infected (empyema). In that case, you may have a tube placed between your
ribs to drain the fluid or, occasionally, a surgical procedure to clear out some
of the infected material.
 Lung abscess. A cavity containing pus (abscess) that forms within the area
affected by pneumonia is another potential complication. Abscesses usually
are treated with antibiotics, but in rare cases they may need to be removed
surgically.

If you have emphysema or pneumonia in both lungs (double pneumonia), you may
need a mechanical respirator to help you breathe.

Treatments and drugs

Pneumonia treatments vary, depending on the severity of your symptoms and the type
of pneumonia you have.

 Bacterial. Doctors usually treat bacterial pneumonia with antibiotics.

Although you may start to feel better shortly after beginning your medication,
be sure to complete your entire course of antibiotics. Stopping medication too
soon may cause your pneumonia to return. It also helps create strains of
bacteria that are resistant to antibiotics — an increasingly serious problem in
the United States.
 Viral. Antibiotics aren't effective against most viral forms of pneumonia. And
although a few viral pneumonias may be treated with antiviral medications,
the recommended treatment is generally the same as for the flu — rest and
plenty of fluids.
 Mycoplasma. Mycoplasma pneumonias are treated with antibiotics. Even so,
recovery may not be immediate. In some cases fatigue may continue long after
the infection itself has cleared. Many cases of mycoplasma pneumonia go
undiagnosed and untreated. The signs and symptoms mimic those of a bad
chest cold, so some people never seek medical attention.
  Fungal. If your pneumonia is caused by a fungus, you'll likely be treated with
antifungal medication.

In addition to these treatments, your doctor may recommend over-the-counter

medications to reduce fever, treat your aches and pains, and soothe the cough
associated with pneumonia. You don't want to suppress your cough completely,
though, since coughing helps clear your lungs. If you must use a cough suppressant,
use the lowest dose that helps you get some rest.

If you have severe pneumonia, you'll be hospitalized and treated with intravenous
antibiotics and put on oxygen. If you don't need oxygen, you may recover as quickly
at home with oral antibiotics as in the hospital, especially if you have access to
qualified home health care. Sometimes you may spend three or four days in the
hospital receiving intravenous antibiotics and then continue to recover at home with
oral medication.

Your doctor will most likely schedule a follow-up X-ray and an office visit after your
initial diagnosis and treatment. By that time your infection should have cleared, but
it's important for your doctor to see you, even if you're feeling better. Follow-up
appointments and X-rays are especially important in smokers. If you're not feeling
better, the follow-up visit is an opportunity for your doctor to schedule tests to
determine more specifically what's causing your symptoms.

Prevention
You usually don't "catch" pneumonia from someone else. Instead, you develop the
disease because your immune system is temporarily weakened, often for no known
reason. The following suggestions can help keep you healthy:

 Get vaccinated. Because pneumonia can be a complication of the flu, getting

a yearly flu shot is a good way to prevent viral influenza pneumonia, which
can lead to bacterial pneumonia. In addition, get a vaccination against
pneumococcal pneumonia at least once after age 55, and if you have any risk
factors, every five years thereafter. Your doctor may recommend a pneumonia
vaccine if you're a smoker, if you're younger but have a lung or cardiovascular
disease, certain types of cancer, diabetes or sickle cell anemia, if your immune
system is compromised or if you've had your spleen removed for any reason.

A vaccine known as pneumococcal conjugate vaccine can help protect young

children against pneumonia. It's recommended for all children younger than
age 2 and for children 2 years and older who are at particular risk of
pneumococcal disease, such as those with an immune system deficiency,
cancer, cardiovascular disease or sickle cell anemia. Side effects of the
pneumococcal vaccine are generally minor and include mild soreness or
swelling at the injection site.

 Wash your hands. Your hands are in almost constant contact with germs that
can cause pneumonia. These germs enter your body when you touch your eyes
or rub the inside of your nose. Washing your hands thoroughly and often can
 help reduce your risk. When washing isn't possible, use an alcohol-based hand
sanitizer, which can be more effective than soap and water in destroying the
bacteria and viruses that cause disease. What's more, most hand sanitizers
contain ingredients that keep your skin moist. Carry one in your purse or in
your pocket.
 Don't smoke. Smoking damages your lungs' natural defenses against
respiratory infections.
 Take care of yourself. Proper rest and a diet rich in fruits, vegetables and
whole grains along with moderate exercise can help keep your immune system
strong.
 Protect others from infection. If you have pneumonia, try to stay away from
anyone with a compromised immune system. When that isn't possible, you can
help protect others by wearing a face mask and always coughing into a tissue.

Lifestyle and home remedies

If you have pneumonia, the following measures can help you recover more quickly
and decrease your risk of complications:

 Get plenty of rest. Even when you start to feel better, be careful not to overdo
it.
 Drink lots of fluids, especially water. Liquids keep you from becoming
dehydrated and help loosen mucus in your lungs.
 Take the entire course of any prescribed medications. Stopping medication
too soon can cause your pneumonia to come back and contributes to the
development of antibiotic-resistant bacteria.
 Keep all of your follow-up appointments. Even though you feel better, your
lungs may still be infected. It's important to have your doctor monitor your
progress.