Pneumonia

| ICD9 | ICDO | OMIM | MedlinePlus | eMedicineSubj search | eMedicineTopic pneumonia | MeshID D011014 | }} Pneumonia is an Inflammation condition of the lung lt;/ref> It is often characterized as including inflammation of the parenchyma of the lung (that is, the alveolus and abnormal alveolar filling with fluid (consolidation (medicine) and exudation .lt;/ref> The alveoli are microscopic air filled sacs in the lungs responsible for gas exchange. Pneumonia can result from a variety of causes, including infection with bacteria virus s, fungus or parasite , and chemical or physical injury to the lungs. Its cause may also be officially described as unknown when infectious causes have been excluded. Typical symptoms associated with pneumonia include cough chest pain fever and shortness of breath medical diagnosis tools include x-rays and examination of the sputum Treatment depends on the cause of pneumonia; bacterial pneumonia is treated with antibiotic . Pneumonia is common occurring in all age groups, and is a leading cause of death among the young, the old, and the chronic illness lt;/ref> Vaccine to prevent certain types of pneumonia are available. The prognosis depends on the type of pneumonia, the treatment, any complications, and the persons underlying health.

Classification

Pneumonias can be classified in several ways. The primary system of classification is the combined clinical classification, which combines factors such as age, risk factors for certain microorganisms, the presence of underlying lung disease or systemic disease, and whether the person has recently been hospitalized. Other classifications include according to the anatomy changes that can be found in the lungs during autopsy based on the microbial cause, and a radiology classification.

Clinical

Traditionally, clinicians have classified pneumonia by clinical characteristics, dividing them into "acute" (less than three weeks duration) and "chronic" pneumonias. This is useful because chronic pneumonias tend to be either non-infectious, or mycobacterial, fungal, or mixed bacterial infections caused by airway obstruction. Acute pneumonias are further divided into the classic bacterial bronchopneumonias (such as [[Streptococcus pneumoniae]], the atypical pneumonias (such as the interstitial pneumonitis of [[Mycoplasma pneumoniae]]or [[Chlamydia pneumoniae]], and the aspiration pneumonia syndromes. Chronic pneumonias, on the other hand, mainly include those of [[Nocardia]] [[Actinomyces]]and [[Blastomyces dermatitidis]] as well as the granulomatous pneumonias ([[Mycobacterium tuberculosis]]and atypical mycobacteria [[Histoplasma capsulatum]]and [[Coccidioides immitis]].Table 13-7 in: lt;/ref> The combined clinical classification, now the most commonly used classification scheme, attempts to identify a persons risk factors when he or she first comes to medical attention. The advantage of this classification scheme over previous systems is that it can help guide the selection of appropriate initial treatments even before the microbiologic cause of the pneumonia is known. There are two broad categories of pneumonia in this scheme: community-acquired pneumonia and hospital-acquired pneumonia. A recently introduced type of healthcare-associated pneumonia (in patients living outside the hospital who have recently been in close contact with the health care system) lies between these two categories.

Community-acquired

Community-acquired pneumonia (CAP) is infectious pneumonia in a person who has not recently been hospitalized. CAP is the most common type of pneumonia. The most common causes of CAP vary depending on a persons age, but they include [[Streptococcus pneumoniae]] viruses, the atypical bacteria, and [[Haemophilus influenzae]] Overall, Streptococcus pneumoniaeis the most common cause of community-acquired pneumonia worldwide. Gram-negative bacteria cause CAP in certain at-risk populations. CAP is the fourth most common cause of death in the United Kingdom and the sixth in the United States The term "walking pneumonia" has been used to describe a type of community-acquired pneumonia of less severity (because the sufferer can continue to "walk" rather than require hospitalization).lt;/ref> Walking pneumonia is usually caused by the atypical bacterium, [[Mycoplasma pneumoniae]]lt;/ref>

Hospital-acquired

Hospital-acquired pneumonia, also called Nosocomial infection pneumonia, is pneumonia acquired during or after hospitalization for another illness or procedure with onset at least 72 hrs after admission. The causes, microbiology, treatment and prognosis are different from those of community-acquired pneumonia. Up to 5% of patients admitted to a hospital for other causes subsequently develop pneumonia. Hospitalized patients may have many risk factors for pneumonia, including mechanical ventilation prolonged malnutrition underlying heart and lung diseases, decreased amounts of stomach acid, and immune disturbances. Additionally, the microorganisms a person is exposed to in a hospital are often different from those at home . Hospital-acquired microorganisms may include resistant bacteria such as Methicillin-resistant Staphylococcus aureus [[Pseudomonas]] [[Enterobacter]] and [[Serratia]] Because individuals with hospital-acquired pneumonia usually have underlying illnesses and are exposed to more dangerous bacteria, it tends to be more deadly than community-acquired pneumonia. Ventilator-associated pneumonia (VAP) is a subset of hospital-acquired pneumonia. VAP is pneumonia which occurs after at least 48 hours of intubation and mechanical ventilation

Other types

*Severe acute respiratory syndrome (SARS) :SARS is a highly contagious and deadly type of pneumonia which first occurred in 2002 after initial outbreaks in China SARS is caused by the SARS coronavirus a previously unknown pathogen *Bronchiolitis obliterans organizing pneumonia (BOOP) :BOOP is caused by inflammation of the small airways of the lungs. It is also known as cryptogenic organizing pneumonitis (COP). *Eosinophilic pneumonia :Eosinophilic pneumonia is invasion of the lung by eosinophil , a particular kind of white blood cell Eosinophilic pneumonia often occurs in response to infection with a parasite or after exposure to certain types of environmental factors. *Chemical pneumonia :Chemical pneumonia (usually called chemical pneumonitis is caused by chemical toxicant such as pesticide , which may enter the body by inhalation or by skin contact. When the toxic substance is an oil, the pneumonia may be called lipoid pneumonia *Aspiration pneumonia :Aspiration pneumonia (or aspiration pneumonitis) is caused by Pulmonary aspiration foreign objects which are usually oral or gastric contents, either while eating, or after reflux or vomiting which results in bronchopneumonia The resulting lung inflammation is not an infection but can contribute to one, since the material aspirated may contain Anaerobic organism bacteria or other unusual causes of pneumonia. Aspiration is a leading cause of death among hospital and nursing home patients, since they often cannot adequately protect their airways and may have otherwise impaired defenses. *Dust pneumonia :Dust pneumonia describes disorders caused by excessive exposure to dust storms particularly during the Dust Bowl in the United States. With dust pneumonia, dust settles all the way into the alveoli of the lungs, stopping the cilia from moving and preventing the lungs from ever clearing themselves. *Necrotizing pneumonia although overlapping with many other classifications, includes pneumonias that cause substantial necrosis of lung cells, and sometimes even lung abscess Implicated bacteria are extremely commonly anaerobic bacteria, with or without additional facultatively anaerobic ones like Staphylococcus aureus Klebsiella pneumoniae and Streptococcus pyogenes Table 13-7 in: lt;/ref> Type 3 pneumococcus is uncommonly implicated. *Opportunistic pneumonia includes those that frequently strike immunocompromised victims. Main pathogens are cytomegalovirus Pneumocystis jiroveci Mycobacterium avium-intracellulare invasive aspergillosis invasive candidiasis as well as the "usual bacteria" that strike immunocompetent people as well. *Double pneumonia is a historical term for acute lung injury (ALI) or acute respiratory distress syndrome (ARDS).lt;/ref>. However, the term was, and is used still, especially by lay people, to denote pneumonia affecting both lungs. Accordingly, the term double pneumonia is more likely to be used to describe bilateral pneumonia than it is ALI or ARDS.

Other

Initial descriptions of pneumonia focused on the anatomic or pathology appearance of the lung, either by direct inspection at autopsy or by its appearance under a microscope * A Lobar pneumonia is an infection that only involves a single lobe, or section, of a lung Lobar pneumonia is often due to [[Streptococcus pneumoniae]](though [[Klebsiella pneumoniae]]is also possible.)lt;/ref> * Multilobarpneumonia involves more than one lobe, and it often causes a more severe illness. * Bronchial pneumonia affects the lungs in patches around the tubes (bronchi or bronchioles). * Usual interstitial pneumonia involves the areas in between the alveoli, and it may be called "interstitial pneumonitis." It is more likely to be caused by viruses or by atypical bacteria. The discovery of x-rays made it possible to determine the anatomic type of pneumonia without direct examination of the lungs at autopsy and led to the development of a radiology classification. Early investigators distinguished between typical lobar pneumonia and atypical (e.g. Chlamydophila) or viral pneumonia using the location, distribution, and appearance of the opacities they saw on chest x-rays. Certain x-ray findings can be used to help predict the course of illness, although it is not possible to clearly determine the microbiologic cause of a pneumonia with x-rays alone. With the advent of modern microbiology, classification based upon the causative microorganism became possible. Determining which microorganism is causing an individuals pneumonia is an important step in deciding treatment type and length. Sputum cultures, blood cultures, tests on respiratory secretions, and specific blood tests are used to determine the microbiologic classification. Because such laboratory testing typically takes several days, microbiologic classification is usually not possible at the time of initial diagnosis.

Signs and symptoms

File:Symptoms of pneumonia.svg People with infectious pneumonia often have a cough producing greenish or yellow sputum or phlegm and a high fever that may be accompanied by rigors Shortness of breath is also common, as is pleuritic chest pain a sharp or stabbing pain, either experienced during deep breaths or coughs or worsened by them. People with pneumonia may hemoptysis experience headache , or develop diaphoresis and clammy skin. Other possible symptoms are anorexia (symptom) fatigue, cyanosis nausea vomiting mood swings, and arthralgia or myalgia Less common forms of pneumonia can cause other symptoms; for instance, pneumonia caused by [[Legionella]]may cause abdominal pain and diarrhea while pneumonia caused by tuberculosis or [[Pneumocystis jiroveci|Pneumocystis]]may cause only weight loss and Sleep hyperhidrosis In elderly people, manifestations of pneumonia are seldom typical. They may develop a new or worsening confusion (delirium or may experience unsteadiness, leading to falls. Infants with pneumonia may have many of the symptoms above, but in many cases they are simply sleepy or have a decreased appetite.lt;/ref> File:New Pneumonia cartoon.jpg with fluid, keeping oxygen from reaching the bloodstream. The alveolus on the left is normal, while the alveolus on the right is full of fluid from pneumonia.]] Symptoms of pneumonia need immediate medical evaluation. Physical examination by a health care provider may reveal fever or sometimes hypothermia an tachypnea hypotension a tachycardia or a low oxygen saturation which is the amount of oxygen in the blood as indicated by either pulse oximetry or arterial blood gas People who are struggling to breathe, who are confused, or who have cyanosis (blue-tinged skin) require immediate attention. Findings from physical examination of the lungs may be normal, but often show decreased expansion of the chest on the affected side, bronchus breathing on auscultation with a stethoscope (harsher sounds from the larger airways transmitted through the inflamed and consolidated lung), and rales (or crackles) heard over the affected area during inspiration. Percussion (medicine) may be dulled over the affected lung, but increased rather than decreased vocal resonation (which distinguishes it from a pleural effusion . While these signs are relevant, they are insufficient to diagnose or rule out a pneumonia; moreover, in studies it has been shown that two doctors can arrive at different findings on the same patient.lt;/ref>lt;/ref>

Cause

File:Pneumonia alveolus.jpg that contain air. Lower panelshows a lung with pneumonia under a microscope. The alveoli are filled with inflammation and debris.]] Pneumonia can be caused by microorganisms, irritants and unknown causes. When pneumonias are grouped this way, infectious causes are the most common type. The symptoms of infectious pneumonia are caused by the invasion of the lungs by microorganism and by the immune system s response to the infection. Although more than one hundred strains of microorganism can cause pneumonia, only a few are responsible for most cases. The most common causes of pneumonia are virus s and bacteria Less common causes of infectious pneumonia are fungi and parasites

Viruses

Viruses have been found to account for between 18—28% of pneumonia in a few limited studies. 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 cell , mainly lymphocyte , activate certain chemical cytokine 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 organ (anatomy) 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.lt;/ref> Viral pneumonia is commonly caused by viruses such as influenza virus respiratory syncytial virus (RSV), adenovirus and parainfluenza Herpes simplex virus is a rare cause of pneumonia except in newborns. People with weakened immune systems are also at risk of pneumonia caused by cytomegalovirus (CMV).

Bacteria

File:Streptococcus pneumoniae.jpg , a common cause of pneumonia, photographed through an electron microscope ]] Bacteria are the most common cause of community acquired pneumonia with Streptococcus pneumoniaethe most commonly isolated bacteria. Another important Gram-positive cause of pneumonia is [[Staphylococcus aureus]] with [[Streptococcus agalactiae]]being an important cause of pneumonia in newborn babies. Gram-negative 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|Pseudomonas aeruginosa]]and [[Moraxella catarrhalis]] These bacteria often live in the gastrointestinal tract and may enter the lungs if vomit is inhaled. Bacterial_pneumonia#Atypical which cause pneumonia include [[Chlamydophila pneumoniae]] [[Mycoplasma pneumoniae]] and [[Legionella pneumophila]] 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 neutrophil , a type of defensive white blood cell, to the lungs. The neutrophils phagocytosis and kill the offending organisms, and also release cytokine , 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.

Fungi

Fungal pneumonia is uncommon, but it may occur in individuals with Immunodeficiency due to AIDS immunosuppresive drug , 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 [[Histoplasmosis|Histoplasma capsulatum]] blastomyces, [[Cryptococcus neoformans]] [[Pneumocystis jiroveci]] and [[Coccidioides immitis]] Histoplasmosis is most common in the Mississippi embayment and coccidioidomycosis in the southwestern United States

Parasites

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

Idiopathic interstitial pneumonias (IIP) are a class of diffuse lung disease . In some types of IIP, e.g. some types of usual interstitial pneumonia the cause, indeed, is unknown or idiopathic. In some types of IIP the cause of the pneumonia is known, e.g. desquamative interstitial pneumonia is caused by smoking and the name is a misnomer

Diagnosis

File:Pneumonia x-ray.jpg File:CTpnemonia09.JPG If pneumonia is suspected on the basis of a patients medical history and findings from physical examination further investigations are needed to confirm the diagnosis. Information from a chest X-ray and blood test are helpful, and sputum Microbiological culture in some cases. The chest X-ray is typically used for diagnosis in hospitals and some clinics with X-ray facilities. However, in a community setting (general practice , pneumonia is usually diagnosed based on symptoms and physical examination alone.Diagnosing pneumonia can be difficult in some people, especially those who have other illnesses. Occasionally a chest CT scan or other tests may be needed to distinguish pneumonia from other illnesses.

Investigations

An important test for pneumonia in unclear situations is a chest x-ray Chest x-rays can reveal areas of Opacity (optics) (seen as white) which represent consolidation. Pneumonia is not always seen on x-rays, either because the disease is only in its initial stages, or because it involves a part of the lung not easily seen by x-ray. In some cases, chest CT (computed tomography can reveal pneumonia that is not seen on chest x-ray. X-rays can be misleading, because other problems, like lung scarring and congestive heart failure can mimic pneumonia on x-ray.lt;/ref> Chest x-rays are also used to evaluate for complications of pneumonia ([[Pneumonia#Complications|see below]]. If antibiotics fail to improve the patients health, or if the health care provider has concerns about the diagnosis, a microbiological culture of the persons sputum may be requested. Sputum cultures generally take at least two to three days, so they are mainly used to confirm that the infection is sensitive to an antibiotic that has already been started. A blood sample may similarly be blood culture to look for bacteria in the blood. Any bacteria identified are then tested to see which antibiotics will be most effective. A complete blood count may show a leukocytosis indicating the presence of an infection or inflammation. In some people with immunocompromised the white blood cell count may appear deceptively normal. Blood tests may be used to evaluate kidney function (important when prescribing certain antibiotics) or to look for hyponatremia Low blood sodium in pneumonia is thought to be due to extra anti-diuretic hormone produced when the lungs are diseased (Syndrome of inappropriate antidiuretic hormone . Specific blood serology tests for other bacteria (Mycoplasma Legionellaand Chlamydophila and a urine test for Legionellaantigen are available. Respiratory secretions can also be tested for the presence of viruses such as influenza respiratory syncytial virus and adenovirus Liver function test should be carried out to test for damage caused by sepsis.

Combining findings

One study created a prediction rule that found the five following signs best predicted infiltrates on the chest radiograph of 1134 patients presenting to an emergency room:lt;/ref> *Fever > *Pulse > 100 beats/min *Rales *Decreased breath sounds *Absenceof asthma The probability of an infiltrate in two separate validations was based on the number of findings: *5 findings – 84% to 91% probability *4 findings – 58% to 85% *3 findings – 35% to 51% *2 findings – 14% to 24% *1 findings – 5% to 9% *0 findings – 2% to 3% A subsequent studylt;/ref> comparing four prediction rules to physician judgment found that two rules, the one above and alsolt;/ref> were more accurate than physician judgment because of the increased specificity of the prediction rules.

Differential diagnosis

Several diseases and/or conditions can present with similar clinical features to pneumonia. Chronic obstructive pulmonary disease (COPD) or asthma can present with a polyphonic wheeze, similar to that of pneumonia. Pulmonary edema can be mistaken for pneumonia (and vice versa, especially in the elderly, due to its similar symptoms and signs. Other diseases to be taken into consideration include bronchiectasis lung cancer and pulmonary emboli

Appearance on X ray

File:Normal AP.JPG|Normal AP CXR File:Normal_L.JPG|Normal lateral CXR File:LLL_pneumonia_with_effusionM.jpg|AP CXR showing left lower lobe pneumonia associated with a small left sided pleural effusion File:RLL_pneumoniaM.jpg|AP CXR showing right lower lobe pneumonia File:RLL_pneumoniaLM.jpg|A lateral CXR showing right lower lobe pneumonia File:Pneumnia1.jpg|AP CXR showing pneumonia of the lingula of the left lung File:PneumoniaRUL.jpg|Right upper lobe pneumonia as marked by the circle.

Prevention

There are several ways to prevent infectious pneumonia. Appropriately treating underlying illnesses (such as AIDS can decrease a persons risk of pneumonia. Smoking cessation is important not only because it helps to limit lung damage, but also because cigarette smoke interferes with many of the bodys natural defenses against pneumonia. Research shows that there are several ways to prevent pneumonia in newborn infant . 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 Vaccination is important for preventing pneumonia in both children and adults. 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 pneumoniaehas 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. In 2009, Rwanda became the first low-income country to introduce pneumococcal conjugate vaccine into their national immunization program.PneumoADIP. http://preventpneumo.org/vaccine/rwanda.cfm Vaccine Introduction: Rwanda.] A Pneumococcal polysaccharide vaccine is also available for adults. In the U.S., it is currently recommended for all healthy individuals older than 65 and any adults with emphysema congestive heart failure diabetes mellitus cirrhosis of the liver alcoholism cerebrospinal fluid leaks, or those who do not have a asplenia A repeat vaccination may also be required after five or ten years.lt;/ref> Influenza vaccine should be given yearly to the same individuals who receive vaccination against [[Streptococcus pneumoniae]] In addition, health care workers, nursing home residents, and pregnant women should receive the vaccine.|titlePrevention and control of influenza: recommendations of the Advisory Committee on Immunization Practices (ACIP) |journalMMWR Recomm Rep |volume48 |issueRR-4 |pages1–28 |year1999 |monthApril |pmid10366138 |urlhttp://www.cdc.gov/mmwr/preview/mmwrhtml/00057028.htm}} When an influenza outbreak is occurring, medications such as amantadine rimantadine zanamivir and oseltamivir can help prevent influenza.lt;/ref>lt;/ref>

Treatment

In the United States more than 80% of cases of community acquired pneumonia are treated without hospitalization. Typically, oral antibiotics, rest, fluids, and home care 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.lt;/ref>

Bacterial

Antibiotic improve outcomes in those with bacterial pneumonia. 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 therapy is usually with amoxicillin erythromycin or azithromycin for community-acquired pneumonia.lt;/ref> In North America where the "atypical" forms of community-acquired pneumonia are becoming more common, macrolide (such as azithromycin , and doxycycline have displaced amoxicillin as first-line outpatient treatment for community-acquired pneumonia lt;/ref> The use of fluoroquinolones in uncomplicated cases is discouraged due to concerns of side effects and resistance. 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.lt;/ref> Antibiotics recommended for hospital-acquired pneumonia include third- and fourth-generation cephalosporins carbapenem , fluoroquinolone , aminoglycoside , and vancomycin lt;/ref> These antibiotics are often given intravenous therapy and may be used in combination.

Viral

No specific treatments exist for most types of viral pneumonia including SARS adenovirus hantavirus and parainfluenza virus with the exception of influenza A and influenza B Influenza A may be treated with rimantadine or amantadine while influenza A or B may be treated with oseltamivir or zanamivir These are beneficial only if they are started within 48 hours of the onset of symptoms. Many strains of H5N1 influenza A, also known as avian influenza or "bird flu," have shown resistance to rimantadine and amantadine.

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 lt;/ref> Corticosteroid are commonly used in aspiration pneumonia, but there is no evidence to support their use either.

Complications

Sometimes pneumonia can lead to additional Complication (medicine) Complications are more frequently associated with bacterial pneumonia than with viral pneumonia. The most important complications include:

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. Non-invasive 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 Medical 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. File:Pleural effusion.jpg 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 pneumoniaeis the most common cause. Individuals with sepsis or septic shock need hospitalization in an intensive care unit They often require intravenous fluid 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.

Pleural effusion, empyema, and abscess

Occasionally, microorganisms infecting the lung will cause fluid (a pleural effusion to build up in the space that surrounds the lung (the pleural cavity . If the microorganisms themselves are present in the pleural cavity, the fluid collection is called an empyema When pleural fluid is present in a person with pneumonia, the fluid can often be collected with a needle (thoracentesis and examined. Depending on the results of this examination, complete drainage of the fluid may be necessary, often requiring a chest tube In severe cases of empyema, Decortication may be needed. If the fluid is not drained, the infection may persist, because antibiotics do not penetrate well into the pleural cavity. Rarely, bacteria in the lung will form a pocket of infected fluid called an 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 surgery or Interventional radiology

Prognosis

With treatment, most types of bacterial pneumonia can be cleared within two to four weeks. specifically, "The chest radiograph usually clears within 4 weeks in patients younger than 50 years without underlying pulmonary disease" Symptoms are often resolved within 1–2 weeks.] Viral pneumonia may last longer, and mycoplasmal pneumonia may take four to six weeks to resolve completely. The eventual outcome of an episode of pneumonia depends on how ill the person is when he or she is first diagnosed. In the United States, about one of every twenty people with pneumococcal pneumonia die. In cases where the pneumonia progresses to blood poisoning (bacteremia , just over 20% of sufferers die.lt;/ref> The death rate (or Mortality rate 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.lt;/ref> 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 coutries.World Health Organization. Acute Respiratory Infections: http://www.who.int/vaccine_research/diseases/ari/en/index6.html Streptococcus pneumoniae. Adenovirus can cause severe necrotizing pneumonia in which all or part of a lung has Swyer-James Syndrome radiographically, which is called Swyer-James Syndrome lt;ref name"isbn0-8089-2325-0">lt;/ref>. Severe adenovirus pneumonia also may result in bronchiolitis obliterans a subacute inflammatory process in which the bronchioles are replaced by fibrosis resulting in a reduction in lung volume and lung compliance

Clinical prediction rules

Clinical prediction rules have been developed to more objectively prognosticate outcomes in pneumonia. These rules can be helpful in deciding whether or not to hospitalize the person. * Pneumonia severity index (or PORT Scorelt;/ref> – http://pda.ahrq.gov/clinic/psi/psicalc.asp online calculator] * CURB-65 score, which takes into account the severity of symptoms, any underlying diseases, and agelt;/ref> – http://www.mecriticalcare.net/clinical_criteria/pneumonia_severity_score.php online calculator]

Epidemiology

Pneumonia is a common illness in all parts of the world. It is a major cause of death among all age groups and is the leading cause of death in children in low income countries lt;/ref> In children, 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.lt;/ref> Over two million children under five die each year worldwide and it is estimated that up to 1 million of these (vaccine preventable) deaths are caused by the bacteria Streptococcus pneumoniae and over 90% of these deaths take place in developing countries.lt;/ref> Mortality from pneumonia generally decreases with age until late adulthood with increased mortality in the elderly. In the United Kingdom the annual incidence of pneumonia is approximately 6 cases for every 1000 people for the 18–39 age group. For those over 75 years of age, this rises to 75 cases for every 1000 people. Roughly 20–40% of individuals who contract pneumonia require hospital admission of which between 5–10% are admitted to a critical care unit The mortality rate in the UK is around 5–10%. In the United States community acquired pneumonia affects 5.6 million people a year making it the 6th leading cause of death.lt;/ref> More cases of pneumonia occur during the winter months than during other times of the year. Pneumonia occurs more commonly in males than females, and more often in Blacks than Caucasians due to differences in synthesizing Vitamin D from sunlight. Individuals with underlying illnesses such as Alzheimer's disease cystic fibrosis emphysema tobacco smoking alcoholism or immunosuppression are at increased risk for pneumonia.lt;/ref> These individuals are also more likely to have repeated episodes of pneumonia. People who are hospitalized for any reason are also at high risk for pneumonia.

History

File:Hippocrates.jpg the ancient Greek physician known as the "father of medicine"|altHead portrait drawing of an older bald man with a beard]] Image:WPA Pneumonia Poster.jpg 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.Hippocrates On Acute Diseasess:On Regimen in Acute Diseases lt;/ref>

However, Hippocrates referred to pneumonia as a disease "named by the ancients." He also reported the results of surgical drainage of empyemas. Maimonides (1138–1204 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."Maimonides, Fusul Musa("Pirkei Moshe). 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.lt;/ref> Initial work identifying the two common bacterial causes Streptococcus pneumoniaeand Klebsiella pneumoniaewas performed by Carl Friedländer lt;ref namefried>lt;/ref> and Albert Fränkel (1848–1916) lt;ref namefraenkel>lt;/ref> in 1882 and 1884, respectively. Friedländers initial work introduced the Gram staining 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.lt;/ref> 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. (The phrase was originally coined by John Bunyan with regard to consumption, or tuberculosis.lt;/ref>) 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.lt;/ref> Vaccination against Streptococcus pneumoniaein adults began in 1977 and in children began in 2000, resulting in a similar decline.lt;/ref>

Society and culture

Because of the very high burden of disease in developing countries and because of 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.

References

Category:Infectious diseases Category:Pneumonia Category:Pulmonology Category:Respiratory and cardiovascular disorders specific to the perinatal period am:ኒሞንያ ar:ذات الرئة an:Pneumonía az:Ağciyər iltihabı bn:নিউমোনিয়া be:Пнеўманія bs:Upala pluća bg:Пневмония ca:Pneumònia cs:Zápal plic cy:Niwmonia da:Lungebetændelse pdc:Bruschtfiewer de:Lungenentzündung dv:ނިއުމޯނިޔާ el:Πνευμονία es:Neumonía eo:Pneŭmonito eu:Pneumonia fa:سینه‌پهلو fr:Pneumonie gl:Pneumonía ko:폐렴 hi:निमोनिया hr:Pneumonija id:Radang paru-paru is:Lungnabólga it:Polmonite he:דלקת ריאות ku:Sîyê sokan la:Pneumonia lv:Pneimonija lb:Pneumonie lt:Plaučių uždegimas hu:Tüdőgyulladás mk:Пневмонија ms:Paru-paru berair nl:Longontsteking new:निमोनिया ja:肺炎 no:Lungebetennelse nn:Lungebetennelse pl:Zapalenie płuc pt:Pneumonia ro:Pneumonie ru:Пневмония sq:Pneumonia scn:Purmunìa si:නියුමෝනියාව simple:Pneumonia sl:Pljučnica sr:Упала плућа fi:Keuhkokuume sv:Lunginflammation ta:நுரையீரல் அழற்சி te:న్యుమోనియా th:โรคปอดบวม tr:Zatürre uk:Пневмонія vi:Viêm phổi war:Pneumonia wuu:肺炎 yi:לונגען אנטצינדונג bat-smg:Plautiu oždegėms zh:肺炎

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