Pneumonia is defined as an acute respiratory illness associated with recently developed radiological pulmonary shadowing which may be segmental, lobar or multilobar. Pneumonia can also be defined as an inflammation of the substance of the lungs.Pneumonia is a major cause of illness in people all over the world. People can harbor the causative organism of pneumonia while performing daily life activities at home or workplace (community-acquired pneumonia). Nocosmial pneumonia includes cases of pneumonia contracted in a health care facility, such as a nursing home or a hospital or age care facilities .Pneumonia is more common during the winter when the temperature goes down.
Millions of the people get infected with the community acquired pneumonia each year and they have to go to the hospital. May people die from this disease each year.
People of age group above 65 years of age make up about one-third of all cases of community-acquired pneumonia. They tend to get hospital admission more than than any age group and have a longer hospital stay than younger people.
I. According to the site involved : –
- Lobar pneumonia : Consolidation of one or more lung lobes, often with associated pleural inflammation.
- Bronchopneumonia: Refers to more patchy alveolar consolidation associated with bronchial and bronchiolar inflammation often affecting both lower lobes.
II. According to etiology:-
1. Infect (bacterial, viral, parasitic, fungal).
2. Chemically induced.
3. Radiotherapy induced.
III. Clinical Types :-
1. Community acquired pneumonia caused by organisms like streptococcus pneumonia, Chlamydia pneumonia, Mycoplasma pneumonia, etc.
Predisposing factors of pneumonia
Some of the predisposing factors of pneumonia are given below:
1. Cigarette smoking
2. Upper respiratory tract infection
4. Corticosteroid therapy
5. Old age
6. Recent influenza infection
7. Preexisting lung disease
9. Indoor air pollution
These predisposing factors are risk factors for pneumonia. It may or may not cause pneumonia. The incidence of pneumonia is higher in groups having predisposing factors.
Symptoms of pneumonia
1. Fever :-
Fever is usually high grade, sudden in onset and is associated with rigor and chills.
2. Chest pain :-
Pleuritic chest pain(chest pain on coughing, sneezing or deep inspiration) Occasionally referred to the shoulder or anterior abdominal wall.
The cough is short in duration and is painful. It starts usually as dry cough and with time becomes productive. The Sputum may rust colored or even blood stain.
5. Loss of appetite and headache
Signs of pneumonia
Signs are results of clinical examination performed by the doctor.
1. Elevated temperature(pyrexia)
2. Increased heart rate(tachycardia)
3. Increased respiratory rate(tachypnoea)
7. Herpes labialis may be present
On chest examination
– Respiratory rate is increased
– Respiratory movement is diminished on the affected side of the chest
– Chest wall movement is diminished on the affected side
– Chest wall expansion is diminished
– Woody dull in case of consolidation
– Breath sound is high pitched bronchial in consolidation
– Vocal resonance is increased in consolidation
– Fine crepitation early and coarse crepitation in resolution phase
– Pleural rub in pleurisy
1. Chest X ray P/A View : Confirmatory findings consolidation : III defined homogeneous opacity in the affected area.
2. Microbiological investigation :
a. All patients :
– Sputum – direct smear by gram and Ziehl-Neelsen stains, culture and antimicrobial sensitivity testing.
– Blood culture – frequently positive in pneumococcal pneumonia.
– Serology – acute and convalescent titers to diagnose Mycoplasma, Chlamydia, Legionella and viral infections. Pneumococcal antigen detection in serum.
b. Severe community-acquired pneumonia
The above tests, plus consider :
– Tracheal aspirate, induced sputum, bronchoalveolar lavage, protected brush specimen or percutaneous needle aspiration. Direct fluorescent antibody stain for legionnella and viruses.
– Serology – Legionella antigen in urine. Pneumococcal antigen in sputum and blood. Immediate IgM for Mycoplasma.
– Cold agglutinins- Positive in 50% of patients with Mycoplasma.
c. Selected patients :
– Throat/nasopharyngeal swabs- helpful in children or during influenza epidemic.
– Pleural fluid- should always be sampled when present in more than trivial amounts, preferably with ultrasound guidance.
– TC, DC, – Neutrophilic leucocytosis
– CRP- positive
– ESR- high (>100 mm in 1st hour)
4. Assessment of Gas exchange
5. Pluse oximetery: to determine the oxygen saturation in the blood.
Scoring system to assess the severity of Pneumonia
Pneumonia is divided into mild, moderate and severe on the basis of the CURB-65 scoring system. It includes the following
– Urea > 7 mmol/l
– Respiratory rate 30/min
– Blood pressure (systolic < 90 mm Hg or diastolic 60 mm Hg)
– Age 65 years
Score 1 point for each feature present.
- CURB – 65 score 0 or 1
– Likely to be suitable for home treatment
- CURB- 65 score 2
– Consider hospital supervised treatment which may include short-stay inpatient, Hospital supervised outpatient.
- CURB- 65 score 3 or more
– Manage in hospital as severe pneumonia
– Access for ICU admission, especially if CURB-65 score= 4 or 5
Treatment of pneumonia
1. Rest in bed.
2. 0xygen inhalation.
3. Adequate hydration by fluid balance – I/V if only severe cases otherwise normal.
4. Antibiotic- depends on severity and type :
a. Community acquired pneumonia
- Uncomplicated Community acquired pneumonia :-
– Amoxicillin 500 mg 8 hourly orally
– If patient is allergic to penicillin
a. Clarithromycin 500 mg 12 – hourly orally or
b. Erythromycin 500 mg 6- hourly orally
– If staphylococcus is cultured or suspected
a. Flucloxacillin 1-2 g 6-hourly i.v plus
b. Clarithromycin 500 mg 12-hourly i.v.
– If mycoplasma or legionalla is suspected
a. Clarithromycin 500 mg 12- hourly orally or i.v or
b. Erythromycin 500 mg 6- hourly orally or i.v plus
c. Rifampicin 600 mg 12 – hourly i.v in severe cases
II. Severe community acquired pneumonia
– Clarithromycin 500 mg 12- hourly i.v. Or
– Erthromycin 500 mg 6- hourly i.v plus
– Co-amoxiclav 1.2 g 8- hourly i.v or
– Ceftraixone 1-2 g daily i.v. Or
– Cefuroxime 1.5 g 8- hourly i.v or
– Amoxicillin 1 g 6- hourly i.v plus flucloxacillin 2 g 6- hourly i.v
- Hospital acquired pneumonia
– Cefotaxime plus gentamycin or
- Aspiration pneumonia
– Co – amxiclav 1.2 mg 8 hourly plus metronidazole 500 mg 8 hourly
Treatment of pleural pain – opiates such
– Pethedine 50- 100 mg or morphine 10 mg IM or IV
Physiotherapy- assisted coughing.
Prevention of pneumonia
The risk of pneumonia can be minimized by several ways. Some of which are mentioned below:
Flu is one of the commonest causes of pneumonia. Preventing the flu by vaccination against it is an effective way to prevent pneumonia.
Children less than 5yrs of age and adults at or above 65 yrs should get vaccinated against pneumococcal pneumonia. Pnuemococcal pneumonia is the commonest form of bacterial pneumonia.vaccination against Pneumococcii is recommended for all age groups who are at risk of pneumococcal disease due to other health conditions.
Several other vaccines are also available in the market which help in the prevention of infections by bacteria and viruses leading pneumonia. The vaccines are protective against pertussis, chicken pox and measles, which are considered as major risk factors for pneumonia.
# Hand hygiene
Washing hands frequently i.e especially after going to the bathroom, clearing your nose, changing diapers, before eating and after using the washroom helps in preventing pneumonia.
# Avoid smoking
Tobacco consumption either by chewing or smoking damages the defense system system of lung and weakens its ability to fight against infection. Smokers are at higher risk of getting pneumonia than non smokers. Since, Smokers are at high risk of being infected with pneumonia, they are advised to get vaccinated with pneumococcal vaccine.
# According to many health surveys respiratory infections often result in pneumonia. So always be aware of any respiratory symptoms that hangs around for more than a few days.
Lifestyle modifications, including a healthy diet, rest, regular exercise, etc not only prevents you from getting ill from viruses and respiratory illnesses but also help in quick recovery in case you get infected with the common cold, the flu or other respiratory illness.
- In case of children vaccinated with the Haemophilus influenza type B vaccine helps in preventing pneumonia from Haemophilus influenza type B. Nowadays drugs like palivizumab are given to children younger than 2yrs to prevent pneumonia. This drug prevents a pneumonia caused by respiratory syncytial virus (RSV).
Complications of Pneumonia
– Para-pneumonic effusion-common
– Retention of sputum causing labor collapse
– Development of thromboembolic disease
– Pneumothorax- particularly with staph. Aureus
– Suppurative pneumonia/lung abscess
– ARDS, renal failure, multi – organ failure
– Ectopic abscess formation (staph.aureus)
– Hepatitis, pericarditis, myocarditis, meningoencephalitis
– Pyrexia due to drug hypersensitivity