Overview of Pneumonia
In the United States, about 2 to 3 million people develop pneumonia each year, and 60,000 of them die. In the United States, pneumonia, along with influenza, is the eighth leading cause of death and is the leading infectious cause of death. Pneumonia is the most common cause of death among infections that develop while people are hospitalized and is the most common overall cause of death in developing countries. Pneumonia is also one of the most common serious infections in children and in infants, with an annual incidence of 34 to 40 cases per 1,000 children in Europe and North America.
(See also Overview of the Respiratory System.)
Pneumonia is caused by different microorganisms—including bacteria, viruses, mycobacteria, fungi, and parasites. Bacterial and viral pneumonias are much more common than mycobacterial, fungal, or parasitic pneumonias. The specific organisms vary depending on the person's age, health, location, and other factors. More than one microorganism may be involved. For example, influenza (a viral infection) is often complicated by bacterial pneumonia.
The airways and small air sacs of the lungs are constantly exposed to microorganisms. The nose and throat are full of bacteria and sometimes viruses, and people regularly inhale from the air or aspirate from the digestive tract, mouth, or throat small amounts of these organisms. Normally these organisms are readily dealt with by the lungs' defense mechanisms, which include
The cough reflex, which helps expel mucus and foreign substances
The cells lining the lung passageways, which prevent microorganisms from invading the lungs and which push mucus and foreign substances upward so that they can be coughed out
Proteins made by lung cells, which attack microorganisms
White blood cells within the lungs, which are part of the normal immune system and which also attack microorganisms
Pneumonia develops when
Usually pneumonia starts after microorganisms are aspirated from the upper airways into the lungs, but sometimes the infection is caused by microorganisms that are inhaled from the air, carried to the lungs by the bloodstream, or invade the lungs directly from a nearby site of infection.
Where people are when pneumonia develops is important because different organisms tend to be present in different settings. Organisms in some settings, such as hospitals, are typically more dangerous and more commonly resistant to antibiotics than organisms present in other settings. Also, people in some settings are more likely to have disorders that make them more likely to develop pneumonia. Some categories of pneumonia include
Health care–associated pneumonia, which is an infection acquired in a health care setting other than the hospital, such as a nursing home or dialysis center, is no longer considered a separate category of pneumonia.
Other categories of pneumonia include
Aspiration pneumonia, which occurs when larger volumes or particles (for example, saliva, food, or vomit) are aspirated and are not cleared from the lungs. Aspiration pneumonia can occur in people with swallowing difficulties, such as people who have had strokes, and in people with decreased level of consciousness due to sedating drugs, alcohol, or other reasons.
"Walking" pneumonia is a nonmedical term used to describe a mild case of community-acquired pneumonia that does not require bedrest or hospitalization. Some people might even feel well enough to go to work and participate in other daily activities.
Pneumonia may occur after surgery, particularly abdominal surgery, or after an injury (trauma), particularly a chest injury, because the pain of those conditions keeps people from breathing deeply and from coughing. If people do not breathe deeply and cough, microorganisms are more likely to remain in the lungs and cause infection. Other people who do not breathe deeply and cough include those who are debilitated, bedridden, paralyzed, or unconscious. Such people are also at risk of pneumonia.
Another critical feature is whether the pneumonia occurs in a healthy person or in someone who has an impaired immune system. A person who has an impaired immune system is far more likely to contract pneumonia, including pneumonia caused by unusual bacteria and viruses and even fungi or parasites. Also, a person whose immune system is impaired may not respond as well to treatment as someone whose immune system is healthy. People who may have an impaired immune system include those who
The most common symptom of pneumonia is
Other common pneumonia symptoms include
These symptoms may vary, however, depending on how extensive the disease is and which organism is causing it.
Sometimes people who have pneumonia have digestive symptoms such as nausea, diarrhea, and loss of appetite (anorexia).
Symptoms vary even more in infants and older people. Fever may not occur. Chest pain may not occur, or people may not be able to communicate that they have chest pain. Sometimes the only symptom is rapid breathing or a sudden refusal to eat. Sometimes sudden confusion may be the only sign of pneumonia in an older person.
Common complications include
Severe pneumonia can prevent oxygen from getting to the bloodstream, causing people to feel short of breath. Low levels of oxygen can be life threatening.
The microorganism causing the pneumonia can enter the bloodstream, or the body's response to the infection can be excessive, resulting in decreased blood pressure that can be life threatening, a condition called sepsis.
Some pneumonias can lead to lung abscess or empyema. An abscess is a pocket of pus within tissue. A lung abscess forms when a small area of the lung dies and a collection of pus forms in its place. An empyema is a collection of pus in the space between the lung and the chest wall.
An overwhelming infection or excessive inflammation in response to the infection can cause severe injury to the lungs, which can manifest as ARDS. ARDS causes shortness of breath, usually with rapid, shallow breathing. People who have ARDS usually require breathing support with a mechanical ventilator for an extended amount of time.
A doctor checks for pneumonia by listening to the chest with a stethoscope. Pneumonia usually produces distinctive sounds. These abnormal sounds are caused by narrowing or closing of the airways or filling of the normally air-filled parts of the lungs with inflammatory cells and fluid, a process called consolidation. In most cases, the diagnosis of pneumonia is confirmed with a chest x-ray but sometimes a CT scan of the chest is done. In mild cases doctors may decide to treat based on the symptoms and the results of the examination.
In people who are sick enough to require hospitalization, doctors often test specimens of sputum, blood, and urine in an attempt to identify the organism causing pneumonia. In very sick people, in people with a known problem of the immune system, or when looking for certain unusual organisms, doctors sometimes will obtain sputum samples by giving a vapor treatment that causes the person to cough deeply (inducing sputum production) or insert a bronchoscope (a small flexible tube equipped with a camera) into the airways. Sputum samples obtained by inducing a cough and particularly those obtained with a bronchoscope are less likely to contain saliva and are more likely than expectorated sputum samples to allow doctors to identify the organism causing pneumonia.
It is particularly important for doctors to identify the organism that is causing pneumonia when people are severely ill, do not have a normal immune system, or are not responding well to treatment. However, despite these tests, the precise organism cannot be identified conclusively in most people who have pneumonia.
The most effective way to prevent pneumonia is to stop smoking.
Deep-breathing exercises and therapy to remove mucus and secretions from the lungs help prevent pneumonia in people at high risk, such as those who have had chest or abdominal surgery and those who are debilitated.
Vaccines can help prevent pneumonia. Sometimes when an unvaccinated person has contact with a person known to have a virus that can cause pneumonia (such as influenza), doctors will prescribe certain antiviral drugs to try to prevent infection and pneumonia.
Vaccines are available that offer partial protection against pneumonia caused by
Pneumococcal vaccine can sometimes prevent pneumococcal pneumonia, which is caused by the bacterium Streptococcus pneumoniae (pneumococcus). The organism that causes pneumococcal pneumonia can also cause many other pneumococcal infections (such as infections of the blood and meningitis). The pneumococcal pneumonia vaccine also protects people from many of these serious pneumococcal infections.
There are two formulations of pneumococcal vaccine:
These formulations are given to different groups of people. The conjugate vaccine is routinely given to all children beginning at age 2 months, and it is increasingly being given to people in other age groups. The polysaccharide vaccine is routinely recommended for all people aged 65 years and over.
Haemophilus influenzae type b vaccine can prevent pneumonia caused by Haemophilus influenzae type b strain. This vaccine is recommended for all children to prevent pneumonia as well as other infections caused by this organism. The vaccine is given in three or four doses—at ages 2 months, 4 months, and sometimes 6 and/or 12 months.
Influenza vaccine can usually prevent pneumonia caused by the influenza virus. More importantly, because influenza weakens the immune system and makes the lungs vulnerable to bacterial pneumonia, prevention of influenza with vaccination can also help prevent bacterial pneumonias. Routine annual influenza vaccination is recommended for all people 6 months old or older, unless they are allergic to the vaccine. Vaccination is especially important for health care workers, older people, and people with chronic conditions such as chronic obstructive pulmonary disease (COPD), diabetes, heart disease, and kidney disease.
Vaccination in the US should take place every year during the fall (September through November) so that levels of antibodies will be highest during the peak influenza months—November through March. A different vaccine is introduced every year based on predictions of which strains are most likely to cause influenza.
The ability of vaccines to prevent pneumonia caused by the influenza virus depends on how well the strains used in the vaccine match the epidemic strain that occurs in a particular year. Even though the level of protection varies year to year, people still benefit from receiving an annual influenza vaccine.
Varicella vaccine may prevent pneumonia caused by the chickenpox virus (varicella virus). Pneumonia caused by this virus is very rare. The varicella vaccine is part of the routine vaccination schedule for all children. One dose is given between ages 12 months and 15 months and another between ages 4 years and 6 years.
People with pneumonia also need to clear secretions and may benefit from deep-breathing exercises. People with pneumonia who are short of breath or have low levels of oxygen in their blood are given oxygen, usually by a small plastic tube in the nostrils (nasal cannula). Although rest is an important part of treatment, complete bed rest can be harmful, and people are encouraged to move often and get out of bed and into a chair.
Usually antibiotics are started whenever bacterial pneumonia is suspected, even before the organism is identified. The prompt use of antibiotics reduces the severity of pneumonia and the chance of developing complications, some of which can lead to death.
When choosing an antibiotic, doctors consider which organism is likely to be the cause. Several factors may give clues to the organism causing pneumonia:
Type of pneumonia (community-acquired pneumonia, hospital-acquired pneumonia, obstructive pneumonia, aspiration pneumonia)
The person's age
Whether or not the person's immune system is functioning correctly or if the person has other lung diseases
Severity of the pneumonia
Use of antibiotics given by vein within the last 90 days
Information about what organisms are common in the local area and which antibiotics are able to kill them
Any available information from diagnostic testing, such as the identification of specific bacteria in sputum cultures
In general, a doctor chooses an antibiotic that has "broader" activity, meaning that the antibiotic is effective against a wide range of microorganisms, even microorganisms that are resistant to some antibiotics, in the following circumstances:
When pneumonia is severe
If the person's immune system is not working correctly
If the person has hospital-acquired pneumonia, or other risk factors for developing pneumonia caused by a microorganism that is resistant to some antibiotics (for example, living in a nursing home and unable to do daily living activities and recent treatment with antibiotics)
Doctors may give a different antibiotic later, after the organism has been identified and its susceptibility to various antibiotics is known.
Of note, a "broad" antibiotic also kills the normal bacteria that live in the intestine and can result in a severe diarrhea that can be life-threatening, a condition called Clostridium difficile-induced colitis or antibiotic-associated colitis. Therefore, a broad antibiotic is used only in the circumstances described above. In comparison, for people with less severe pneumonia and for those in general good health, a "narrower" antibiotic is chosen that is usually appropriate for the most common microorganisms that cause pneumonia. Though these antibiotics can also cause diarrhea, it happens less frequently. These antibiotics are usually successful, and this approach decreases the risk of Clostridium difficile-induced colitis, which is much more common with a broader antibiotic.
Antibiotics are not helpful for viral pneumonias. However, specific antiviral drugs are sometimes given if certain viral infections are suspected, such as influenza or chickenpox. For influenza, specific antiviral drugs (such as oseltamivir or zanamivir) can reduce the duration and severity of illness if people begin taking the drugs within 48 hours of when symptoms start. However, once a person has developed influenza pneumonia, doctors are not sure whether the antiviral drugs will help, but they still usually give them. Often a bacterial pneumonia can develop after the viral infection. In this case, doctors give affected people antibiotics.
In rare cases, a fungus or parasite is the cause of the pneumonia, and an antifungal or antiparasitic drug is given.
Often, people who have pneumonia but are not very sick can stay at home and take antibiotics by mouth. Older people, infants, and those who are short of breath, are very sick, or have preexisting heart or lung disease are usually hospitalized and given intravenous antibiotics, antivirals, or antifungals to start. Those antibiotics are usually switched to oral ones after a few days. People who need to be hospitalized may also need supplemental oxygen and intravenous fluids. People who are very sick may need to be sedated and temporarily put on a breathing machine (mechanical ventilator) that pushes air in and out of the lungs via a tube inserted in the throat.
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