Pneumonia is an inflammatory condition of the lung, especially of the alveoli (microscopic air sacs in the lungs) associated with

fever, chest symptoms, and consolidation on a chest radiograph.[1][2] While typically caused by an infection there are a number of non infectious causes.[1] Infectious agents include: bacteria, viruses, fungi, and parasites.[3] Typical symptoms include cough, chest pain, fever, and difficulty breathing.[4] Diagnostic tools include x-rays and examination of the sputum.[5] Vaccines to prevent certain types of pneumonia are available. Treatment depends on the underlying cause with presumed bacterial pneumonia being treated with antibiotics. Although pneumonia was regarded by William Osler in the 19th century as "the captain of the men of death", the advent of antibiotic therapy and vaccines in the 20th century have seen radical improvements in survival outcomes for patients. Nevertheless, in the third world, and among the very old, the very young and the chronically ill, pneumonia remains a leading cause of death.[6] Pneumonia can be classified in several ways. It is most commonly classified by where or how it was acquired (community-acquired, aspiration, healthcare-associated,hospital-acquired, and ventilator-associated pneumonia),[7] but may also be classified by the area of lung affected (lobar pneumonia, bronchial pneumonia and acute interstitial pneumonia)[7] or by the causative organism.[8] Pneumonia in children may additionally be classified based on signs and symptoms into non severe, severe, and very severe.[9]

Signs and symptoms

Main symptoms of infectious pneumonia 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, confusion, and an increased respiratory rate.[10] In the elderly confusion may be the most prominent symptom.[10] The typical symptoms in children under five are fever, cough, and fast or difficult breathing.[11] Fever however is not very specific as it occurs in many other common illnesses and may be absent in those with severe disease or malnutrition while a cough is frequently absent in those

less than 2 months of age.[11] More severe symptoms may include: central cyanosis, decreased drinking, convulsions, persistent vomiting, or a decreased level of consciousness.[11] Some causes of pneumonia are associated with specific symptoms. Pneumonia caused by Legionella may occur with abdominal pain and diarrhea, while pneumonia caused by tuberculosis or Pneumocystis may cause only weight loss and night sweats. Physical examination may sometimes reveal low blood pressure, a high heart rate, or a low oxygen saturation. Struggling to breathe, confusion, and blue-tinged skin are signs of a medical emergency. Findings from physical examination of the lungs may be normal, but often show decreased expansion of the chest on the affected side. Harsher sounds from the larger airways transmitted through the inflamed lung are heard as bronchial breathing on auscultation with a stethoscope. Rales (or crackles) may be heard over the affected area during inspiration. Percussion may be dulled over the affected lung, and increased rather than decreased vocal resonance distinguishes pneumonia from a pleural effusion.[10] Because some of these signs are subjective, physical examination alone is insufficient to diagnose or rule out pneumonia.[12][13]

Cause
Pneumonia can be due to micro organisms, irritants or unknown causes with infectious causes being the most common. Although more than one hundred strains of micro organism can cause pneumonia, only a few are responsible for most cases. The most common infectious causes are viruses and bacteria with less common being fungi and parasites. Mixed infections with both viruses and bacterial may occur in up to 45% of infections in children and 15% of infections in adults.[14] The term pneumonia is sometimes more broadly applied to inflammation of the lung (for example caused by autoimmune disease, chemical burns or drug reactions), but this is more correctly referred to as pneumonitis.[15][16]

Viruses
Main article: Viral pneumonia In adults viruses account for approximately a third of pneumonia cases.[14] Commonly implicated agents include: rhinoviruses,[14] coronaviruses,[14] influenza virus,[17] respiratory syncytial virus (RSV),[17] adenovirus,[17] and parainfluenza.[17] Herpes simplex virus is a rare cause of pneumonia except in newborns. People with weakened immune systems are at increased risk of pneumonia caused by cytomegalovirus (CMV).

Bacteria
Main article: Bacterial pneumonia

The bacterium Streptococcus pneumoniae, a common cause of pneumonia, imaged by an electron microscope Bacteria are the most common cause of community acquired pneumonia with Streptococcus pneumoniae isolated in nearly 50%.[18][7] Other commonly isolated bacteria include: Haemophilus influenzae in 20%, Chlamydophila pneumoniae in 13%, , and Mycoplasma pneumoniae in 3%.[7] Other important Gram-positive cause of pneumonia is Staphylococcus aureus, with Streptococcus agalactiae being an important cause of pneumonia in newborn babies. Gramnegative bacteria cause pneumonia less frequently than gram-positive bacteria. Some of the gram-negative bacteria that cause pneumonia include Haemophilus influenzae, Klebsiella pneumoniae, Escherichia coli, Pseudomonas aeruginosa and Moraxella catarrhalis. These bacteria often live in the stomach or intestines and may enter the lungs if vomit is inhaled. "Atypical" bacteria which cause pneumonia include Chlamydophila pneumoniae, Mycoplasma pneumoniae, and Legionella pneumophila.

Fungi
Main article: Fungal pneumonia Fungal pneumonia is uncommon, but it may occur in individuals with immune system problems due to AIDS, immunosuppressive drugs, or other medical problems. The pathophysiology of pneumonia caused by fungi is similar to that of bacterial pneumonia. Fungal pneumonia is most often caused by Histoplasma capsulatum, blastomyces, Cryptococcus neoformans, Pneumocystis jiroveci, and Coccidioides immitis. Histoplasmosis is most common in the Mississippi River basin, and coccidioidomycosis in the southwestern United States.

Parasites
Main article: Parasitic pneumonia A variety of parasites can affect the lungs. These parasites typically enter the body through the skin or by being swallowed. Once inside, they travel to the lungs, usually through the blood. There, as in other cases of pneumonia, a combination of cellular destruction and immune response causes disruption of oxygen transportation. One type of white blood cell, the eosinophil, responds vigorously to parasite infection. Eosinophils in the lungs can lead to

eosinophilic pneumonia, thus complicating the underlying parasitic pneumonia. The most common parasites causing pneumonia are Toxoplasma gondii, Strongyloides stercoralis, and Ascariasis.

Idiopathic
Main article: Idiopathic interstitial pneumonia Idiopathic interstitial pneumonia or noninfectious pneumonia[19] are a class of diffuse lung diseases. They include: diffuse alveolar damage, organizing pneumonia, nonspecific interstitial pneumonia, lymphocytic interstitial pneumonia, desquamative interstitial pneumonia, respiratory bronchiolitis interstitial lung disease, and usual interstitial pneumonia.[20]

Pathophysiology

Pneumonia fills the lung's alveoli with fluid, hindering oxygenation. The alveolus on the left is normal, while on the right it is full of fluid from pneumonia.

Viral
Viruses invade cells in order to reproduce. Typically, a virus reaches the lungs when airborne droplets are inhaled through the mouth and nose. Once in the lungs, the virus invades the cells lining the airways and alveoli. This invasion often leads to cell death, either when the virus directly kills the cells, or through a type of cell controlled self-destruction called apoptosis. When the immune system responds to the viral infection, even more lung damage occurs. White blood cells, mainly lymphocytes, activate certain chemical cytokines which allow fluid to leak into the alveoli. This combination of cell destruction and fluid-filled alveoli interrupts the normal transportation of oxygen into the bloodstream.

As well as damaging the lungs, many viruses affect other organs and thus disrupt many body functions. Viruses can also make the body more susceptible to bacterial infections; for which reason bacterial pneumonia may complicate viral pneumonia.[17]

Bacterial
Bacteria typically enter the lung when airborne droplets are inhaled, but can also reach the lung through the bloodstream when there is an infection in another part of the body. Many bacteria live in parts of the upper respiratory tract, such as the nose, mouth and sinuses, and can easily be inhaled into the alveoli. Once inside, bacteria may invade the spaces between cells and between alveoli through connecting pores. This invasion triggers the immune system to send neutrophils, a type of defensive white blood cell, to the lungs. The neutrophils engulf and kill the offending organisms, and also release cytokines, causing a general activation of the immune system. This leads to the fever, chills, and fatigue common in bacterial and fungal pneumonia. The neutrophils, bacteria, and fluid from surrounding blood vessels fill the alveoli and interrupt normal oxygen transportation.

Diagnosis
Crackles Crackles heard in the lungs of a person with pneumonia using a stethoscope.
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Pneumonia is typically diagnosed based on a combination of physical signs and a chest X-ray. [21] Confirming the underlying cause can be difficult however with no definitive test able to distinguish between bacterial and not bacterial aetiology.[14][21] The World Health Organization has defined pneumonia in children clinical based on a either a cough or difficulty breathing and a rapid respiratory rate, chest indrawing, or a decreased level of consciousness.[22] A rapid respiratory rate is defined as greater than 50 breaths per minute in children two month to one year of age or greater than 40 breaths per minute in children one to five years of age.[22] In those under two months of age a respiratory rate of greater than 60 per minute can be used.[11] In children an increased respiratory rate and lower chest indrawing are more sensitive than auscultation of chest crackles.[11] Investigations are generally not needed in those with mild disease.[23] In those requiring admission to hospital pulse oximetry, chest radiography, and blood tests including a complete blood count, serum electrolytes, C-reactive protein, and possibly liver function tests are recommended.[23]

Imaging

CT of the chest demonstrating right sided pneumonia (left side of the image). A chest radiograph is frequently used in diagnosis.[11] In people with mild disease it is recommended that imaging be restricted to those with potential complications, those who have not improved with treatment, or those in which the cause in uncertain.[11][23] If a person however is sufficiently sick to require hospitalization a chest radiograph is recommended.[23] Finding however do not always correlate with severity of disease and do not reliably distinguish between bacterial versus viral infection.[11] X-ray signs of bacterial community acquired pneumonia are classically lung consolidation of one lung segmental lobe.[7] Radiographic finding however may be variable especially in other types of pneumonia.[7] Aspiration pneumonia may present with bilateral opacities primarily in the basis of the lungs and on the right side.[7] While viral pneumonia may appear normal, be hyperinflated, have patchy areas on both sides, or present similar to bacterial pneumonia with lobar consolidation.[7] A CT scan can give additional information in indeterminate cases.[7]

Microbiology
For people managed in the community figuring out the causative agent is not cost effective and typically does not alter management.[11] For those who do not respond to treatment sputum culture should be considered and culture for Mycobacterium tuberculosis should be carried out in those with a chronic productive cough.[23] Testing for other specific organisms may be recommended during outbreaks for public health reasons.[23] In those who are hospitalized for severe disease both sputum and blood cultures are recommended.[23] Viral infections can be confirmed via detection of either the virus or its antigens with culture or polymerase chain reaction (PCR) among other techniques.[14] With routine microbiological testing a causative agent is determined in only 15% of cases.[10]

Differential diagnosis
Several diseases can present similar to pneumonia including: chronic obstructive pulmonary disease (COPD), asthma, pulmonary edema, bronchiectasis, lung cancer and pulmonary emboli.[10] Aspects that can help distinguish these from pneumonia include the fact that COPD and asthma typically present with wheezing, pulmonary edema an abnormal electrocardiogram, bronchiectasis and lung cancer a cough of greater duration, and pulmonary emboli with acute onset sharp chest pain and shortness of breath.[10]

Prevention
Prevention includes vaccination, environmental measures, and appropriately treating other diseases.[11]

Vaccination
Vaccination is effective for preventing certain bacterial and viral pneumonias in both children and adults. Influenza vaccines are modestly effective against influenza A and B.[14][24] The Center for Disease Control and Prevention (CDC) recommends that everyone 6 months and older get yearly vaccination.[25] When an influenza outbreak is occurring, medications such as amantadine, rimantadine, zanamivir, and oseltamivir can help prevent influenza.[26][27] Vaccinations against Haemophilus influenzae and Streptococcus pneumoniae in the first year of life have greatly reduced the role these bacteria play in causing pneumonia in children. Vaccinating children against Streptococcus pneumoniae has also led to a decreased incidence of these infections in adults because many adults acquire infections from children. Hib vaccine is now widely used around the globe. The childhood pneumococcal vaccine is still as of 2009 predominantly used in high-income countries, though this is changing. A vaccine against Streptococcus pneumoniae is also available for adults. It has been found to decrease the risk of invasive pneumococcal disease.[28]

Environmental
Reducing indoor air pollution is recommended.[11] Smoking cessation is important not only because it helps to limit lung damage, but also because cigarette smoke interferes with many of the body's natural defenses against pneumonia.

Other
Appropriately treating underlying illnesses (such as AIDS) can decrease a person's risk of pneumonia. There are several ways to prevent pneumonia in newborn infants. Testing pregnant women for Group B Streptococcus and Chlamydia trachomatis, and then giving antibiotic treatment if needed, reduces pneumonia in infants. Suctioning the mouth and throat of infants with meconium-stained amniotic fluid decreases the rate of aspiration pneumonia.

Management
Typically, oral antibiotics, rest, and fluids are sufficient for complete resolution. However, people who are having trouble breathing, with other medical problems, and the elderly may need greater care. If the symptoms get worse, the pneumonia does not improve with home treatment,

or complications occur, then hospitalization may be recommended. Over the counter cough medicine has not been found to be helpful in pneumonia.[29] Worldwide approximately 7-13% of cases in children result in hospitalization.[11]

Bacterial
Antibiotics improve outcomes in those with bacterial pneumonia.[30] Initially antibiotic choice depends on the characteristics of the person affected such as age, underlying health, and location the infection was acquired. In the UK empiric treatment is usually with amoxicillin, erythromycin, or azithromycin for community-acquired pneumonia.[31] In North America, where the "atypical" forms of community-acquired pneumonia are becoming more common, macrolides (such as azithromycin), and doxycycline have displaced amoxicillin as first-line outpatient treatment.[18][32] The use of fluoroquinolones in uncomplicated cases is discouraged due to concerns of side effects and resistance.[18] The duration of treatment has traditionally been seven to ten days, but there is increasing evidence that short courses (three to five days) are equivalent.[33] Antibiotics recommended for hospital-acquired pneumonia include third- and fourth-generation cephalosporins, carbapenems, fluoroquinolones, aminoglycosides, and vancomycin.[34] These antibiotics are often given intravenously and may be used in combination.

Viral
Neuraminidase inhibitors may be used to treat viral pneumonia caused by influenza viruses (influenza A and influenza B).[14] Otherwise no specific antiviral medication are recommended for other types of community acquired pneumonias including SARS coronavirus, adenovirus, hantavirus, and parainfluenza virus.[14] Influenza A may be treated with rimantadine or amantadine while influenza A or B may be treated with oseltamivir, zanamivir or peramivir.[14] These are of most benefit if they are started within 48 hours of the onset of symptoms.[14] Many strains of H5N1 influenza A, also known as avian influenza or "bird flu," have shown resistance to rimantadine and amantadine.[14] The use of antibiotics in viral pneumonia is recommended by some experts as it is impossible to rule out a complicating bacterial infection.[14] The British Thoracic Society recommends that they be withheld in those with mild disease.[14] The use of corticosteroids is controversial.[14]

Aspiration
There is no evidence to support the use of antibiotics in chemical pneumonitis without bacterial superinfection. If infection is present in aspiration pneumonia, the choice of antibiotic will depend on several factors, including the suspected causative organism and whether pneumonia was acquired in the community or developed in a hospital setting. Common options include clindamycin, a combination of a beta-lactam antibiotic and metronidazole, or an aminoglycoside.[35] Corticosteroids are commonly used in aspiration pneumonia, but there is no evidence to support their use either.[35]

Prognosis

With treatment, most types of bacterial pneumonia can be cleared within two to four weeks[36] and mortality is very low.[14] Viral pneumonia may last longer, and mycoplasmal pneumonia may take four to six weeks to resolve completely.[36] The eventual outcome of an episode of pneumonia depends on how ill the person is when he or she is first diagnosed.[36] In the United States, about one of every twenty people with pneumococcal pneumonia die. In cases where the pneumonia progresses to blood infection, just over 20% die.[37] The death rate (or mortality) also depends on the underlying cause of the pneumonia. Pneumonia caused by Mycoplasma, for instance, is associated with little mortality. However, about half of the people who develop methicillin-resistant Staphylococcus aureus (MRSA) pneumonia while on a ventilator will die.[38] In regions of the world without advanced health care systems, pneumonia is even deadlier. Limited access to clinics and hospitals, limited access to x-rays, limited antibiotic choices, and inability to treat underlying conditions inevitably leads to higher rates of death from pneumonia. For these reasons, the majority of deaths in children under five due to pneumococcal disease occur in developing countries.[39] Adenovirus can cause severe necrotizing pneumonia in which all or part of a lung has increased translucency radiographically, which is called Swyer-James Syndrome.[40] Severe adenovirus pneumonia also may result in bronchiolitis obliterans, a subacute inflammatory process in which the small airways are replaced by scar tissue, resulting in a reduction in lung volume and lung compliance.[40] Sometimes pneumonia can lead to additional complications. Complications are more frequently associated with bacterial pneumonia than with viral pneumonia. The most important complications include respiratory and circulatory failure and pleural effusions, empyema or abscesses.

Clinical prediction rules

Clinical prediction rules have been developed to more objectively prognosticate outcomes in pneumonia. Although these rules are often used in deciding whether or not to hospitalize the person, they were derived simply to inform on prognosis; neither index was designed or tested as guide to determine whether the person would benefit by hospital admission.
y y

Pneumonia severity index (or PORT Score)[41] online calculator CURB-65 score, which takes into account the severity of symptoms, any underlying diseases, and age[42] online calculator

Pleural effusion, empyema, and abscess

A pleural effusion as seen on chest x-ray. The A arrow indicates fluid layering in the right chest. The B arrow indicates the width of the right lung. The volume of useful lung is reduced because of the collection of fluid around the lung. In pneumonia, a collection of fluid (pleural effusion) often forms in the space that surrounds the lung (the pleural cavity). Occasionally, microorganisms will infect this fluid thereby causing what is called an empyema. To distinguish an empyema from the more common simple parapneumonic effusion, the fluid is collected with a needle (thoracentesis) and examined. If this shows evidence of empyema, complete drainage of the fluid may be necessary, often requiring a chest tube. In severe cases of empyema, surgery may be needed. If the infected fluid is not drained, the infection may persist, because antibiotics do not penetrate well into the pleural cavity. If the fluid is sterile, it would only need drainage if very large, causing symptoms, or not resolving. Rarely, bacteria in the lung will form a pocket of infected fluid called a lung abscess. Lung abscesses can usually be seen with a chest x-ray or chest CT scan. Abscesses typically occur in aspiration pneumonia and often contain several types of bacteria. Antibiotics are usually adequate to treat a lung abscess, but sometimes the abscess must be drained by a surgeon or radiologist.

Respiratory and circulatory failure

Because pneumonia affects the lungs, often people with pneumonia have difficulty breathing, and it may not be possible for them to breathe well enough to stay alive without support. Noninvasive breathing assistance may be helpful, such as with a bi-level positive airway pressure machine. In other cases, placement of an endotracheal tube (breathing tube) may be necessary, and a ventilator may be used to help the person breathe. Pneumonia can also cause respiratory failure by triggering acute respiratory distress syndrome (ARDS), which results from a combination of infection and inflammatory response. The lungs quickly fill with fluid and become very stiff. This stiffness, combined with severe difficulties extracting oxygen due to the alveolar fluid, create a need for mechanical ventilation. Sepsis and septic shock are potential complications of pneumonia. Sepsis occurs when microorganisms enter the bloodstream and the immune system responds by secreting cytokines. Sepsis most often occurs with bacterial pneumonia; Streptococcus pneumoniae is the most

common cause. Individuals with sepsis or septic shock need hospitalization in an intensive care unit. They often require intravenous fluids and medications to help keep their blood pressure from dropping too low. Sepsis can cause liver, kidney, and heart damage, among other problems, and it often causes death.

Epidemiology
Main article: Epidemiology of pneumonia

Age-standardized death from lower respiratory tract infections per 100,000 inhabitants in 2004.[43] no data 3500-4200 <100 4200-4900 100-700 4900-5600 700-1400 5600-6300 1400-2100 6300-7000 2100-2800 >7000 2800-3500 Pneumonia is a common illness affecting approximately 450 million people a year and occurring in all parts of the world.[14] It is a major cause of death among all age groups resulting in 4 million deaths (7% of the worlds yearly total).[30][14] Rates are greatest in children less than five and adults older than 75 years of age.[14] It occurs about five times more frequently in the developing world versus the developed world.[14] Viral pneumonia accounts for about 200 million cases.[14]

Children
In 2008 pneumonia occurred in approximately 156 million children (151 million in the developing world and 5 million in the developed world).[14] It resulting in 1.6 million deaths or 2834% of all deaths in those under five years of age of which 95% occurr in the developing world.[14][11] Countries with the greatest burden of disease include: India (43 million), China (21 million) and Pakistan (10 million).[44] It is the leading cause of death among children in low income countries.[30][14] Many of these deaths occur in the newborn period. The World Health Organization estimates that one in three newborn infant deaths are due to pneumonia.[45] Approximately half of these cases and deaths are theoretically preventable, being caused by the bacteria for which an effective vaccine is available.[46]

History

Hippocrates, the ancient Greek physician known as the "father of medicine"

WPA poster, 1936/1937 The symptoms of pneumonia were described by Hippocrates (c. 460 BC 370 BC): Peripneumonia, and pleuritic affections, are to be thus observed: If the fever be acute, and if there be pains on either side, or in both, and if expiration be if cough be present, and the sputa expectorated be of a blond or livid color, or likewise thin, frothy, and florid, or having any other character different from the common... When pneumonia is at its height, the case is beyond remedy if he is not purged, and it is bad if he has dyspnoea, and urine that is thin and acrid, and if sweats come out about the neck and head, for such sweats are bad, as proceeding from the suffocation, rales, and the violence of the disease which is obtaining the upper hand.[47] However, Hippocrates referred to pneumonia as a disease "named by the ancients." He also reported the results of surgical drainage of empyemas. Maimonides (11381204 AD) observed "The basic symptoms which occur in pneumonia and which are never lacking are as follows: acute fever, sticking [pleuritic] pain in the side, short rapid breaths, serrated pulse and cough."[48] This clinical description is quite similar to those found in modern textbooks, and it reflected the extent of medical knowledge through the Middle Ages into the 19th century.

Bacteria were first seen in the airways of individuals who died from pneumonia by Edwin Klebs in 1875.[49] Initial work identifying the two common bacterial causes Streptococcus pneumoniae and Klebsiella pneumoniae was performed by Carl Friedlnder[50] and Albert Frnkel[51] in 1882 and 1884, respectively. Friedlnder's initial work introduced the Gram stain, a fundamental laboratory test still used to identify and categorize bacteria. Christian Gram's paper describing the procedure in 1884 helped differentiate the two different bacteria and showed that pneumonia could be caused by more than one microorganism.[52] Sir William Osler, known as "the father of modern medicine," appreciated the morbidity and mortality of pneumonia, describing it as the "captain of the men of death" in 1918, as it had overtaken tuberculosis as one of the leading causes of death in his time. This phrase was originally coined by John Bunyan with regard to "consumption" (tuberculosis).[53] However, several key developments in the 1900s improved the outcome for those with pneumonia. With the advent of penicillin and other antibiotics, modern surgical techniques, and intensive care in the twentieth century, mortality from pneumonia, which had approached 30%, dropped precipitously in the developed world. Vaccination of infants against Haemophilus influenzae type B began in 1988 and led to a dramatic decline in cases shortly thereafter.[54] Vaccination against Streptococcus pneumoniae in adults began in 1977 and in children began in 2000, resulting in a similar decline.[55]

Society and culture

See also: List of notable pneumonia deaths Because of the combination of a very high burden of disease in developing countries and a relatively low awareness of the disease in industrialized countries, the global health community has declared November 2 to be World Pneumonia Day, a day for concerned citizens and policy makers to take action against the disease.
Definition of Pneumonia Pneumonia is a serious infection or inflammation of one or both lungs. Description of Pneumonia Pneumonia is caused by the inhalation of infected microorganisms (tiny, single-celled living organisms, such as bacteria, viruses, fungi or protozoa) spread through contact with an infected person. The microorganisms enter the body through the mouth, nose and eyes. If the body's resistance is down, the natural process of fighting off diseases is weakened and the microorganisms are free to spread into the lungs and the lungs' air sacs. The air sacs become filled with fluid and pus from the infectious agent, making it more difficult for the body to get the oxygen it needs, and the person may become sick. Potential complications of pneumonia include pleural effusion (fluid around the lung), empyema (pus in the pleural cavity), hyponatremia (low blood sodium) and rarely, an abscess in the lung.

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Causes and Risk Factors of Pneumonia There are over 30 different causes of pneumonia, but the most common causes are bacteria (including mycoplasma) and viruses. Corresponding to these causes are the most common types of pneumonia - bacterial pneumonia, viral pneumonia and mycoplasma pneumonia. Bacterial pneumonia Pneumonia-causing bacteria is present in many throats, but when the body's defenses are weakened (for example, by illness, old age, malnutrition or impaired immunity) the bacteria can multiply, working its way into the lungs, inflaming the air sacs and filling the lungs with liquid and pus. The bacteria that cause bacterial pneumonia are streptococcus pneumonia (resulting in lobar pneumonia), hemophilus influenza (resulting in bronchopneumonia), legionella pneumophilia (resulting in Legionnaires' disease) and staphylococcus aureus. Viral pneumonia Half of all pneumonias are believed to be caused by viruses, such as influenza (flu), adenovirus, coxsackievirus, chickenpox, measles, cytomegalovirus and respiratory syncytial virus. These viruses invade the lungs and multiply. Mycoplasmal pneumonia (also called "walking pneumonia") Similar to bacterial pneumonia, the mycoplasmas multiply and spread, causing infection. Some of the other pneumonia-related disorders are aspiration pneumonia, chlamydial pneumonia, Loffler's syndrome, pneumocystis carinii pneumonia, pediatric pneumonia and necrotizing pneumonia. Risk factors include: y y y y y y y y y y y y 65 years of age or older People in nursing homes or other chronic care facilities Male Children under the age of two People with colds or other respiratory infections People with reduced immunity People with other lung diseases, such as asthma, cystic fibrosis and lung cancer People with AIDS or HIV Organ transplant recipients People who have had their spleen removed People receiving chemotherapy People who smoke

y y

Alcoholics People with chronic health problems, such as lung disease, heart disease, kidney disorders, sickle cell anemia or diabetes

Symptoms of Pneumonia Symptoms vary, depending on the type of pneumonia and the individual. With bacterial pneumonia, the person may experience: y y y y y y y y y shaking chills chattering teeth severe chest pain cough that produces rust-colored or greenish mucus very high fever sweating rapid breathing rapid pulse rate

With viral pneumonia, the person may experience: y y y y fever dry cough headache muscle pain and weakness

These flu-like symptoms may be followed within one or two days by: y y y y increasing breathlessness dry cough becomes worse and produces a small amount of mucus higher fever bluish color to the lips

With mycoplasma pneumonia, the person may experience: y y y y y y y y y y y violent coughing attacks chills fever nausea vomiting slow heartbeat breathlessness bluish color to lips and nailbeds diarrhea rash muscle aches

Regardless of the type of pneumonia, the person may also experience the following symptoms:

y y y y y y y y y

a loss in appetite feeling ill clammy skin nasal flaring fatigue mental confusion joint and muscle stiffness anxiety, stress and tension abdominal pain

Diagnosis of Pneumonia To diagnose pneumonia, the doctor begins with a medical history and physical examination. By placing a stethoscope on the chest, the doctor may be able to hear crackling sounds, coarse breathing, wheezing and/or the breathing may be faint in a particular area of the chest. Additionally, the doctor may order a chest x-ray, a sputum gram stain and a blood test. The chest x-ray may show a blotchy-white area, where fluid and pus has accumulated in the lung's air sacs. The sputum grain stain and the blood test may determine the cause and severity of the condition. If these tests are inconclusive, the doctor may perform a procedure called a bronchoscopy. In this procedure, a flexible, thin and lit viewing tube is inserted into the nose or mouth after a local anesthetic is administered. The breathing passages can then be directly examined by the doctor and specimens from the infected part of the lung can be obtained. Treatment of Pneumonia Treatment depends on the severity of symptoms and the type of organism causing the infection. Bacterial pneumonia (caused by the streptococcus pneumonia bacteria) is often treated with penicillin, ampicillin-clavulanate (Augmentin) and erythromycin. Bacterial pneumonia (caused by the hemophilus influenza bacteria) is treated with antibiotics, such as cefuroxime (Ceftin), ampicillin-clavulanate (Augmentin), ofloxacin (Floxin), and trimethoprim-sulfanethoxazole (Bactrim and Septra). Bacterial pneumonia (caused by legionella pneumophilia and staphylococcus aureus bacteria) are treated with antibiotics, such as erythromycin. Viral pneumonia does not respond to antibiotic treatment. This type of pneumonia usually resolves over time. If the lungs become infected with a secondary bacterial infection, the doctor will prescribe an appropriate antibiotic to eliminate the bacterial infection. Mycoplasma pneumonia is often treated with antibiotics, such as erythromycin, clarithromycin (Biaxin), tetracycline or azithromycin (Zithromax). In addition to the pharmaceutical intervention, the doctor will also recommend bedrest, plenty of fluids, therapeutic coughing, breathing exercises, proper diet, cough suppressants, pain relievers and fever reducers, such as aspirin (not for children) or acetaminophen. In severe cases, oxygen therapy and artificial ventilation may be required.

The course of pneumonia varies. Recovery time depends upon the organism involved, the general health of the person and how promptly medical attention was obtained. A majority of sufferers recover completely within a few weeks, with residual coughing persisting between six and eight weeks after the infection has gone. Prevention of Pneumonia y y y Practice good hygiene. Get an influenza shot each fall. Get a pneumonococcal vaccine. People who stand to benefit most from vaccination are those over the age 65; anyone with chronic health problems (such as diabetes, kidney disease, heart disease, etc.); anyone who has had their spleen removed; anyone living in a nursing home or chronic care facility; caregivers of the chronically ill (healthcare workers or family caregivers); children with chronic respiratory diseases (such as asthma), and anyone who has had pneumonia in the past (due to increased risk of reinfection). The pneumonococcal vaccine is 90 percent effective against the bacteria and protects against infection for five to 10 years. Practice good preventive measures by eating a proper diet, getting regular exercise and plenty of sleep. Do not smoke.

y y

Questions To Ask Your Doctor About Pneumonia Are tests needed to diagnose or determine the cause of this pneumonia? What is the cause? How serious is the condition? What treatment do you recommend? How long until full recovery? Can pneumonia recur more frequently? Do you recommend a vaccination?

Diagnosis
Diagnostic Difficulties in Community-Acquired Pneumonia (CAP). It is important to determine whether the cause of CAP is a bacterium, atypical bacterium, or virus, because they require different treatments. In children, for example, S. pneumonia is the most common cause of pneumonia, but respiratory syncytial virus may also cause the disease. Although symptoms may differ, they often overlap, which can make it difficult to identify the organism by symptoms alone. The cause of CAP is found in only about half of cases. Nevertheless, in many cases of mild-to-moderate CAP, the physician is able to diagnose and treat pneumonia based solely on a history and physical examination.

Diagnostic Difficulties with Hospital-Acquired (Nosocomial) Pneumonia. Diagnosing pneumonia is particularly difficult in hospitalized patients for a number of reasons:
y y

Many hospitalized patients have similar symptoms, including fever or signs of lung infiltration on x-rays. In hospitalized patients, sputum or blood tests often indicate the presence of bacteria or other organisms, but such agents do not necessarily indicate pneumonia.

Doctors making a diagnosis of pneumonia should rule out other conditions using:
y y y y

Chest x-ray Lung fluid sample Two sets of blood cultures Urine analysis for legionella

Medical and Personal History

The patient's history is an important part of making a pneumonia diagnosis. Patients should be sure to report any of the following:
y y y y y y

Alcohol or drug abuse Exposure to people with pneumonia or other respiratory illnesses (such as tuberculosis) History of smoking Occupational risks Recent or chronic respiratory infection Recent travel

Physical Examination
Use of the Stethoscope. The most important diagnostic tool for pneumonia is the stethoscope. Sounds in the chest that may indicate pneumonia include:
y y y

Rales, a bubbling or crackling sound. Rales on one side of the chest or that are heard while the patient is lying down strongly suggest pneumonia. Rhonchi, abnormal rumblings indicating that there is sputum in the large airways. A dull thud. The physician will use a test called percussion, in which the chest is tapped lightly. A dull thud, instead of a hollow drum-like sound, indicates certain conditions that suggest pneumonia. These conditions include consolidation (in which the lung becomes firm and inelastic) and pleural effusion (fluid build-up in the space between the lungs and the lining around it).

Laboratory Tests for Diagnosing Infection and Identifying Bacteria

Although current antibiotics can destroy a wide spectrum of organisms, it is best to use an antibiotic that targets the specific one making a person sick. Unfortunately, people carry many

bacteria, and sputum and blood tests are not always effective in distinguishing between harmless and harmful kinds. In severe cases, a doctor needs to use invasive diagnostic measures to identify the cause of the infection. Standard lab tests used to help diagnose pneumonia include: Sputum Tests. The color of the mucus (sputum) sample coughed up from the lungs can reveal the severity of the disease. Only a sputum sample will reveal the organism causing the infection. The patient coughs as deeply as possible to bring up mucus from the lungs, since a shallow cough produces a sample that usually only contains normal mouth bacteria. Some people may need to inhale a saline spray to produce an adequate sample. In some cases, a tube will be inserted through the nose into the lower respiratory tract to trigger a deeper cough. The physician will check the sputum for:
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Blood, which means an infection is present. Color and consistency: If it is yellow, green, or brown, an infection is likely.

The sputum sample is sent to the laboratory, where it is analyzed for the presence of bacteria and to determine whether the bacteria are Gram-negative or Gram-positive. Blood Tests. The following blood tests may be performed:
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White blood cell count (WBC). High levels indicate infection. Blood cultures. Cultures are done to determine the specific organism causing the pneumonia, but they usually cannot distinguish between harmless and dangerous organisms. They are accurate in only 10 - 30% of cases. Their use is generally limited to severe cases. Detection of antibodies to S. pneumoniae. Antibodies are immune factors that target specific foreign invaders. One type of immunohistochemical test for S. pneumoniae is showing tremendous promise. The presence of antibodies that are responding to mycoplasma or chlamydia infection are not present early enough in the course of pneumonia to allow for prompt diagnosis and treatment. Polymerase Chain Reaction (PCR). In some difficult cases, PCR may be performed. The test makes multiple copies of the genetic material (RNA) of a virus or bacteria to make it detectable. PCR is useful for identifying certain atypical bacteria strains, including mycoplasma and Chlamydia pneumoniae, and possibly, Haemophilus influenzae type b, but it is expensive. One study found that using a real-time PCR test may help quickly diagnose Pneumocystitis pneumonia in HIV-positive patients.

Urine Tests. Urine antigen tests for Legionella pneumophila (Legionnaires' disease) and Streptococcus pneumoniae may be performed in patients with severe CAP. The S. pneumoniae test takes only 15 minutes and may identify up to 77% of pneumonia cases and rule out S. pneumoniae infection in 98% of patients. It may not be useful in children.

Invasive Tests. In critically-ill patients with ventilator-associated pneumonia, physicians have tried sampling fluid taken from the lungs or trachea. These techniques enabled the physicians to identify the pneumonia-causing bacteria and start the appropriate antibiotics. However, this made no difference in the length of stay in the ICU or hospital, and there was no significant difference in outcome.

Chest X-Rays and Other Imaging Techniques

X-Rays. A chest x-ray is nearly always taken to confirm a diagnosis of pneumonia.

X-rays are a form of electromagnetic radiation (like light). They are of higher energy, however, and can penetrate the body to form an image on film. Structures that are dense (such as bone) will appear white, air will be black, and other structures will be shades of gray depending on density. X-rays can provide information about obstructions, tumors, and other diseases, especially when coupled with the use of barium and air contrast within the bowel. A chest x-ray may reveal the following:
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Complications of pneumonia, including pleural effusions and abscesses White areas in the lung called infiltrates, which indicate infection

Other Imaging Tests. Computed tomography (CT) scans or magnetic resonance imaging (MRI) scans may be useful in some circumstances, especially when:
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A lung tumor is suspected Complications occur Patients do not respond to antibiotics Patients have other serious health problems Pulmonary embolism is suspected

X-ray results are unclear

Click the icon to see an image of a CT scan. CT and MRI can help detect the presence of tissue damage, abscesses, and enlarged lymph nodes. They can also detect some tumors that block bronchial tubes. No imaging technique can determine the actual organism causing the infection. However, features on the CT scan of patients with certain forms of pneumonia -- for example, that caused by Legionella pneumophila -- are usually different from features produced by other bacteria in the lungs.

Invasive Diagnostic Procedures

Invasive diagnostic procedures may be required when:
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AIDS or other immune problems are present Patients have life-threatening complications Standard treatments have failed for no known reason

Invasive procedures include: Thoracentesis. If a doctor detects pleural effusion during the physical exam or on an imaging study, and suspects that pus (empyema) is present, a thoracentesis is performed.
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Fluid in the pleura is withdrawn using a long thin needle inserted between the ribs. The fluid is then sent to the lab for multiple tests.

Complications of this procedure are rare, but can include collapsed lung, bleeding, and introduction of infection. Bronchoscopy. Bronchoscopy is an invasive test to examine respiratory secretions. It is not usually needed in patients with community-acquired pneumonia, but it may be appropriate for patients with severely compromised immune systems who need immediate diagnosis, or in patients whose condition has worsened during treatment. A bronchoscopy is done in the following way:
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The patient is given a local anesthetic, supplementary oxygen, and sedatives. The physician inserts a fiber optic tube into the lower respiratory tract through the nose or mouth. The tube acts like a telescope into the body, allowing the physician to view the windpipe and major airways and look for pus, abnormal mucus, or other problems. The doctor removes specimens for analysis and can also treat the patient by removing any foreign bodies or infected tissue encountered during the process.

Click the icon to see an image of bronchoscopy. Bronchoalveolar lavage (BAL) may be done at the same time as bronchoscopy. This involves injecting high amounts of saline through the bronchoscope into the lung and then immediately sucking the fluid out. The fluid is then analyzed in the laboratory. Studies find BAL to be an effective method for detecting specific infection-causing organisms. The procedure is usually very safe, but complications can occur. They include:
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Allergic reactions to the sedatives or anesthetics Asthma attacks in susceptible patients Bleeding Fever

Lung Biopsy. In very severe cases of pneumonia or when the diagnosis is unclear, particularly in patients with damaged immune systems, a lung biopsy may be required. A lung biopsy involves taking some tissue from the lungs and examining it under a microscope. Lung Tap. This procedure typically uses a needle inserted between the ribs to draw fluid out of the lung for analysis. It is known by a number of names, including:
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Lung aspiration Lung puncture Thoracic puncture Transthoracic needle aspiration Percutaneous needle aspiration Needle aspiration

It is a very old procedure that is not done often any more, since it is invasive and poses a slight risk for collapsed lung. Some experts argue, however, that a lung tap is more accurate than other methods for identifying bacteria, and the risk it poses is slight. Given the increase in resistant bacteria, they believe its use should be reconsidered in young people.

Ruling Out Other Disorders that Cause Coughing or Affect the Lung
Common Causes of Persistent Coughing. Over 30 million people seek medical help each year for persistent coughing, which is nearly always temporary and harmless when other symptoms, such as fever, are not present. The four most common causes of persistent coughing are:
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Asthma Chronic bronchitis Gastroesophageal reflux disease (GERD) Postnasal drip

Other obvious common causes of chronic cough include heavy smoking or the use of heart drugs known as ACE inhibitors. Acute Bronchitis. Acute bronchitis is an infection in the passages that carry air from the throat to the lung. The infection causes a cough that produces phlegm. Acute bronchitis is almost always caused by a virus and usually clears up on its own within a few days. In some cases, acute bronchitis caused by a cold can last for several weeks. Chronic Bronchitis. Chronic bronchitis causes shortness of breath and is often accompanied by infection, mucus production, and coughing, but it is a long-term and irreversible condition. The same microbes that cause pneumonia can cause chronic bronchitis, and symptoms of the two disorders are often similar. They include:
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Coughing Fatigue Fever Sputum production

There are significant differences between chronic bronchitis and pneumonia:

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Patients with bronchitis are less likely to have wheezing, shortness of breath, chills, very high fevers, and other signs of severe illness. Those with pneumonia usually cough up heavy sputum, which is also more likely to contain blood. X-rays of patients with bronchitis do not show fluid or consolidation in the lung.

Asthma. In asthma, the cough is accompanied by wheezing and occurs mostly at night or during activity. Fever is rarely present (unless the patient also has an infection). Asthma symptoms from occupational causes can lead to persistent coughing, which is usually worse during the work week. Tests -- the methacholine inhalation challenge and pulmonary function studies -- may be effective in diagnosing asthma. Anthrax. Because of current terrorist concerns, it is important to differentiate between anthrax and community-acquired pneumonia. According to one study, people with inhalation anthrax are more likely to have rapid heart rate and less likely to have headache, nasal symptoms, and muscle aches than those with pneumonia. Blood tests with anthrax also show high hematocrit and low albumin and sodium levels. Certain chest x-ray findings also raise the likelihood of anthrax. Other Disorders that Affect the Lung. Many conditions mimic pneumonia, particularly in hospitalized patients. They include:
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Acute respiratory distress syndrome (ARDS) Atelectasis, a collapse of lung tissue Bronchial asthma

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Bronchiectasis, an irreversible widening of the airways usually associated with birth defects, chronic sinus or bronchial infection, or blockage Heart failure (if it affects the left side of the heart, fluid build-up can occur in the lungs and cause persistent cough, shortness of breath, and wheezing) Interstitial pulmonary fibrosis, a non-infectious inflammation of the lung marked by progressive damage and scarring Lung cancer Severe allergic reactions, such as reactions to drugs Tuberculosis

Ruling Out Causes in Children. Important causes of coughing in children at different ages include:
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Asthma Physical abnormalities in infants under 18 months Psychological causes in older children and adolescents Sinusitis in children 18 months - 6 years