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more about Pneumonia

Lung infection, lobar pneumonia, or Bronchial Pneumonia

  • The cells in the body need oxygen to survive. When one breathes in oxygen-rich air, it travels through the nose or mouth and into the lungs via a system of pipe like air canals known as bronchi.
  • The left and the right lungs are spongy organs located underneath the rib cage on either side of the chest cavity.
  • In pneumonia, inflammation (irritation, swelling) or infection of the lungs cause fluid and pus to fill a section of a lung(Lobar p.) or form patches in both lungs (Bronchial p.), interfering with the uptake of oxygen.

  • Bacterial p.:
    1. Fever > 38.3 degrees Celsius or 100 degrees Fahrenheit
    2. Chills -- sudden onset
    3. Cough -- dry
    4. Cough -- productive with sputum that has a rusty color.  It may be thick and have a pinkish tone or blood specks (Streptococcus p.).  In Aspiration p., sputum may be foul-smelling and green. Pseudomonas p. may produce greenish sputum.  In Klebsiella p., sputum will look like currant jelly.
    5. Chest pain -- sharp, especially upon inhalation (Pleurisy)
    6. Rapid shallow breathing
    7. Shortness of breath (SOB) -- especially with activity
    8. Headache, nausea, vomiting, Diarrhea, and weakness may occur with all types, but more often is due to Legionella p.
    9. Abdominal pain
    10. Fatigue
  • Viral p.:
    1. Starts with upper respiratory symptoms such as a dry cough, low-grade fever (< 100 degrees Fahrenheit), headache, Nasal Congestion, sore throat, along with muscle and joint aches
    2. Skin rash may appear as in Measles
    3. Cough -- dry, can have sputum
    4. Chest pain -- especially with breathing, and on one side
    5. Chills
    6. Shortness of breath, especially with activity
    7. Nausea, vomiting, Diarrhea
  • Mycoplasma p.:
    1. Slow progression
    2. Headache
    3. Low-grade fever
    4. Cough -- dry, violent runs of coughing
    5. Nasal Congestion
    6. Sore throat
    7. Muscle and joint pain
    8. Wheezing sound when breathing
  • Pneumocystis Carinii p.:
    1. Often first presentation in HIV Infection or AIDS
    2. Symptoms may develop suddenly.
    3. Cough with white-clear sputum
    4. Shortness of breath -- at first only with activity, but then advancing to SOB at rest
    5. Weakness
    6. Fatigue
    7. Chills
    8. Weight loss
    9. Loss of appetite

  • Pneumonia is not a single disease.
  • Infections:

    - Bacteria (bacterial p.) or wet p. -- when the body's resistance is lowered due to certain conditions (i.e., age, disease, alcohol, Malnutrition) the normal bacteria of the mouth and the throat multiply and invade one or all of the 5 sections (lobes) of the lungs.  The infected lobe (or lobes) then fills with fluid and pus (Consolidation), in turn interfering with the lung's normal oxygen exchange.

    1. The infection can spill into the blood stream and invade the whole body.  Bacteria can also enter the lungs from the air or from other sites in the body.  Infections can either be acquired from the community at large or while in the hospital.
    2. Streptococcus pneumonia is the most common cause of bacterial (Lobar) pneumonia.
    3. Other bacteria include H. influenzae (winter and early spring), Staphylococcus aureus (common in intravenous drug abusers -- IVDA, and more common in infants versus children), Chlamydia, Moraxella catarrhalis (smokers), Legionella (summer and fall, in water delivery systems, air conditioning units), and gram-negative bacteria such as Pseudomonas aeruginosa, Klebsiella, and anaerobes.
  • Aspiration p. occurs when stomach contents get into the lungs.  Aspiration takes place when the normal swallowing mechanism is impaired while unconscious (e.g., seizure, stroke, overdose), and from acid Reflux or vomiting (alcoholics and hypotonic, weak, debilitated infants).  Multiple types of bacteria can infect the lungs in these ways.
  • Empyema -- refers to the pus in the space between the 2 layers of pleura covering the lungs.
  • Viruses -- usually acquired by inhaling air borne infected virus droplets from someone's sneezing or coughing.  Viruses are responsible for 50% of all pneumonias, usually causing upper respiratory illness (airways near the throat and mouth), but can work their way down to the lower airways where the lungs are, and produce a patchy type of pneumonia that usually resolves on its own.  Some of the viruses include influenza virus(types A, B, C -- most common in adults), RSV (most common in infants), parainfluenza (1,2,3,4), adenovirus, CMV, Chicken Pox, EBV, Measles.  Viral pneumonia usually occurs in children who are between 2 and 3 years of age.
  • Mycoplasma pneumoniae (i.e., Walking Pneumonia) -- classified as a small organism between a virus and a bacteria, it causes pneumonia with a nagging dry cough that comes in violent attacks.  Accounts for approximately 70% of all pneumonias in children ages 9 -15.
  • Pneumocystis carinii (PCP) -- believed to be a fungus, it often causes pneumonia in patients with AIDS or decreased body defenses.
  • Tuberculosis (TB) -- caused by the organism known as Mycobacterium Tuberculosis (i.e., M. bovis and M. africanum).  It is contagious, and can infect the lungs and other organs (brain, spine, kidney, etc.).
  • Rickettsiae -- small organisms that cause diseases such as Rocky Mountain Spotted Fever. It may also have a mild to severe effect on the lungs.
  • Parasites -- ascariasis (round worm) in children
    -- Others -- substances can get into the lungs and cause a blockage of the air passages, promoting bacterial overgrowth or directly inflaming the lung tissue.
  • Food -- vomiting or swallowing a small object, like a pea
  • Gases -- furniture polish
  • Dust -- usually dust, fungus, or mold inhalation in farmers, mushroom pickers, or miners (nickel dust).
  • Liquids -- gasoline, kerosene
  • Foreign body (e.g., inhaling a coin or tooth that was loose in the mouth)

  • Varies with type of pneumonia

    1. History:

      • Symptoms
      • Illnesses
      • Surgeries
      • Medications
      • Habits
      • Travel
      • Hobbies
      • Allergies
      • Occupation

    2. Physical exam:

      • Skin may show a rash, cyanosis (blue lips)
      • Increased heart and respiratory rate (number of breaths per minute)
      • Blood pressure may be low
      • There may be fever
      • The chest (rib cage) may expand poorly
      • There may be decreased breath sounds or abnormal sounds (friction rub, rales, crackles, wheezing) due to destruction of lung tissue, narrowing of airways, or presence of fluid and pus.

  • Changes in mentation -- confusion, Anxiety

    - Tests:

    1. Sputum samples may be collected and sent for microscopic analysis using special stains to reveal the particular bacterium.
    2. Sputum may be sent for cultures grown in order to identify the organism type, along with sensitivity to antibiotics.
    3. Cultures may take anywhere from 48 hours (bacteria) to several weeks (TB) until final results are known.
    4. Viral cultures can be done as well.
    5. Blood may also be collected and sent for bacterial cultures (positive in 8-20% of bacterial p).
    6. Blood may show high ESR (viral), white blood cell count (may be normal in elderly and low in Viral p.), low oxygen levels (hypoxia), low Sodium levels (empyema or Lung Abscess), high LDH enzyme (PCP), and acidity (acidosis).
    7. Blood can also be screened for presence of specific Proteins called antibodies.
    8. In Mycoplasma p., 1-2 weeks after infection there are high levels of IgM antibodies in almost 80% of patients.
    9. One can look for organisms such as viruses (herpes, influenza, RSV) by doing a throat swab using a sterile Q-tip and swabbing the throat; or by performing tracheal aspiration (suction tube used to suck secretions from the trachea, i.e. the main airway).
    10. In PCP, an HIV test may be needed -- CD4 cell count falls below 200 if HIV is present.
    11. Pictures of the lungs are done using -- Chest X-Ray -- may show infection in one or more lobes of the lungs (bacterial p.), diffuse pattern of infection (PCP, V. p., M. p.), and effusions.
    12. CAT scan or MRI is rarely necessary unless cancer or abscess is suspected; or when preparing for a procedure.
    13. Your doctor may consult with an infectious disease specialist, or a pulmonologist (lung specialist).

  • The pulmonologist may recommend:

    1. Bronchoscopy -- flexible tube with a camera at its tip is passed through the mouth to the lungs, taking a sample of secretions for culture or biopsy (taking a tiny piece).
    2. Thoracentesis is performed by inserting a needle between the ribs and removing fluid for analysis.  This is done in effusions and empyema.

  • Recent viral infections
  • Hospitalizations:
    1. Tube feeding
    2. Mechanical ventilation
    3. Antibiotic use
  • Alcohol
  • Smoking
  • Age -- extremes of age, i.e., infants and elderly (> 65)
  • Weakened immune system, or body's natural defenses are weakened:
    1. AIDS
    2. Cancers
    3. Chemotherapy -- cancer-killing drugs
  • Diseases:
    1. Chronic obstructive lung disease (COPD)
    2. Kidney failure
    3. Heart disease
    4. Diabetes Mellitus
  • Impaired gag reflex:
    1. Seizure
    2. Stroke
    3. Overdose of drugs
    4. IVDA (intravenous drug abuse)
  • Close community living:
    1. Family members
    2. Military
    3. Prison
    4. Mental hospitals
    5. Nursing homes
  • Occupational -- farmers, people exposed to infected birds (e.g., pigeons, parakeets), miners

  • Depends on the type
  • Prevention:
    1. Reduce risk factors
    2. Vaccination -- against Measles, influenza, Pneumococcal p., especially in those over age 65 and those who have other significant diseases
    3. Bed-ridden individuals -- avoid prolonged bed rest, perform exercises in bed, breathing and coughing exercises after an operation.
    4. Avoid alcohol, drugs, nasogastric tube feedings.
    5. Avoid smoking.
    6. Avoid taking antibiotics for viral pneumonias.
    7. Foods high in vitamins, minerals, and other nutrients
  • May need admission to hospital if patient has a high fever, shortness of breath, or in shock.
  • If treated on outpatient basis, one needs to be monitored closely afterward to make sure he is improving.
  • Bed rest, plenty fluids, and Tylenol for pain are usually sufficient for mild uncomplicated cases.
  • Antibiotic pills may be started if the patient does not appear too sick.
  • General antibiotics (e.g., erythromycin) may be given until the cultures come back from the lab, then changed to the appropriate specific antibiotic.
  • Antibiotics are not given for virus infections.
  • Antivirus medications such as Amantadine (influenza A and B) or Ribavirin (RSV, hanta virus) and Gancyclovir (CMV, herpes) are available and only given to those whose infections have been identified and typed.
  • If the patient is very sick, he or she should be admitted to the hospital.
  • Intravenous (IV) fluids started.
  • Oxygen given, if oxygen blood levels are low.
  • IV antibiotics started.
  • If one has TB or other dangerous forms of pneumonia, isolate from other patients.
  • If unable to breathe, respiratory support is provided via mechanical ventilation (machine breathes for you).
  • A respiratory therapist may be needed to work with the patient.
  • Follow up laboratory tests and X-Rays are done to check treatments.
  • Medical follow up after discharge and a repeat X-Ray in 6-9 weeks.

  • Contact your physician immediately. If the patient has difficulty breathing, call 911.  Further Information can be obtained from the American Lung Association in the U.S. by calling 1-212-315-8700.

more about Pneumonia

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