Pneumonia

Pneumonia

Pneumonia
Classification and external resources
A black and white X-ray picture showing a triangular white area on the left side. A circle highlights the area.
A chest X-ray showing a very prominent wedge-shape area of airspace consolidation in the right lung characteristic of bacterial pneumonia.
ICD-10 J12, J13, J14, J15, J16, J17, J18, P23
ICD-9 480-486, 770.0
DiseasesDB 10166
MedlinePlus 000145
eMedicine topic list
Patient UK Pneumonia
MeSH D011014

Pneumonia (nu-mo'ne-a) is an drugs and other conditions such as autoimmune diseases.[1][3] Typical symptoms include a cough, chest pain, fever, and difficulty breathing.[4] Diagnostic tools include x-rays and culture of the sputum. Vaccines to prevent certain types of pneumonia are available. Treatment depends on the underlying cause. Pneumonia presumed to be bacterial is treated with antibiotics. If the pneumonia is severe, the affected person is, in general, admitted to hospital. Pneumonia affects approximately 450 million people globally per year, seven percent of population, and results in about 4 million deaths, mostly in developing countries. Although pneumonia was regarded by William Osler in the 19th century as "the captain of the men of death",[5] the advent of antibiotic therapy and vaccines in the 20th century has seen improvements in survival.[6] Nevertheless, in developing countries, and among the very old, the very young, and the chronically ill, pneumonia remains a leading cause of death.[6][7] In the terminally ill and elderly, especially those with other conditions, pneumonia is often the immediate cause of death. In such cases, particularly when it cuts short the suffering associated with lingering illness, pneumonia has often been called "the old man's friend."[8]

Contents

  • Signs and symptoms 1
  • Cause 2
    • Bacteria 2.1
    • Viruses 2.2
    • Fungi 2.3
    • Parasites 2.4
    • Idiopathic 2.5
  • Mechanisms 3
    • Viral 3.1
    • Bacterial 3.2
  • Diagnosis 4
    • Physical exam 4.1
    • Imaging 4.2
    • Microbiology 4.3
    • Classification 4.4
    • Differential diagnosis 4.5
  • Prevention 5
    • Vaccination 5.1
    • Other 5.2
  • Management 6
    • Bacterial 6.1
    • Viral 6.2
    • Aspiration 6.3
  • Prognosis 7
    • Clinical prediction rules 7.1
    • Pleural effusion, empyema, and abscess 7.2
    • Respiratory and circulatory failure 7.3
  • Epidemiology 8
    • Children 8.1
  • History 9
  • Society and culture 10
  • References 11
  • External links 12

Signs and symptoms

Symptoms frequency[9]
Symptom Frequency
Cough
79–91%
Fatigue
90%
Fever
71–75%
Shortness of breath
67–75%
Sputum
60–65%
Chest pain
39–49%
A diagram of the human body outlining the key symptoms of pneumonia
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, and an increased respiratory rate.[10] In the elderly, confusion may be the most prominent sign.[10] The typical signs and symptoms in children under five are fever, cough, and fast or difficult breathing.[11]

Fever is not very specific, as it occurs in many other common illnesses, and may be absent in those with severe disease or malnutrition. In addition, a cough is frequently absent in children less than 2 months old.[11] More severe signs and symptoms may include blue-tinged skin, decreased thirst, convulsions, persistent vomiting, extremes of temperature, or a decreased level of consciousness.[11][12]

Bacterial and viral cases of pneumonia usually present with similar symptoms.[13] Some causes are associated with classic, but non-specific, clinical characteristics. Pneumonia caused by Legionella may occur with abdominal pain, diarrhea, or confusion,[14] while pneumonia caused by Streptococcus pneumoniae is associated with rusty colored sputum,[15] and pneumonia caused by Klebsiella may have bloody sputum often described as "currant jelly".[9] Bloody sputum (known as hemoptysis) may also occur with tuberculosis, Gram-negative pneumonia, and lung abscesses as well as more commonly with acute bronchitis.[12] Mycoplasma pneumonia may occur in association with swelling of the lymph nodes in the neck, joint pain, or a middle ear infection.[12] Viral pneumonia presents more commonly with wheezing than does bacterial pneumonia.[13]

Cause

Three one round objects in a black background
The bacterium Streptococcus pneumoniae, a common cause of pneumonia, imaged by an electron microscope.

Pneumonia is due to infections caused primarily by bacteria or viruses and less commonly by fungi and parasites. Although there are more than 100 strains of infectious agents identified, only a few are responsible for the majority of the cases. Mixed infections with both viruses and bacteria may occur in up to 45% of infections in children and 15% of infections in adults.[6] A causative agent may not be isolated in approximately half of cases despite careful testing.[8]

The term pneumonia is sometimes more broadly applied to any condition resulting in inflammation of the lungs (caused for example by autoimmune diseases, chemical burns or drug reactions); however, this inflammation is more accurately referred to as pneumonitis.[16][17] Infective agents were historically divided into "typical" and "atypical" based on their presumed presentations, but the evidence has not supported this distinction, thus it is no longer emphasized.[18]

Conditions and risk factors that predispose to pneumonia include smoking, immunodeficiency, alcoholism, chronic obstructive pulmonary disease, chronic kidney disease, and liver disease.[12] The use of acid-suppressing medications—such as proton-pump inhibitors or H2 blockers—is associated with an increased risk of pneumonia.[19] The risk is also increased in old age.[12]

Bacteria

Bacteria are the most common cause of community-acquired pneumonia (CAP), with Streptococcus pneumoniae isolated in nearly 50% of cases.[20][21] Other commonly isolated bacteria include Haemophilus influenzae in 20%, Chlamydophila pneumoniae in 13%, and Mycoplasma pneumoniae in 3% of cases;[20] Staphylococcus aureus; Moraxella catarrhalis; Legionella pneumophila and Gram-negative bacilli.[8] A number of drug-resistant versions of the above infections are becoming more common, including drug-resistant Streptococcus pneumoniae (DRSP) and methicillin-resistant Staphylococcus aureus (MRSA).[12]

The spreading of organisms is facilitated when risk factors are present.[8]

External links

  • John F. Murray (2010). Murray and Nadel's textbook of respiratory medicine (5th ed.). Philadelphia, PA: Saunders/Elsevier.  
  • Burke A. Cunha, ed. (2010). Pneumonia essentials (3rd ed.). Sudbury, MA: Physicians' Press.  

Bibliography

  1. ^ a b McLuckie, A., ed. (2009). Respiratory disease and its management. New York: Springer. p. 51.  
  2. ^ Leach, Richard E. (2009). Acute and Critical Care Medicine at a Glance (2nd ed.). Wiley-Blackwell.  
  3. ^ Jeffrey C. Pommerville (2010). Alcamo's Fundamentals of Microbiology (9th ed.). Sudbury MA: Jones & Bartlett. p. 323.  
  4. ^ Ashby, Bonnie; Turkington, Carol (2007). The encyclopedia of infectious diseases (3rd ed.). New York: Facts on File. p. 242.  
  5. ^ Osler, William (1901). Principles and Practice of Medicine, 4th Edition. New York: D. Appleton and Company. p. 108. 
  6. ^ a b c d e f g h i j k l m n o p q r s t u v w x Ruuskanen, O; Lahti, E; Jennings, LC; Murdoch, DR (2011-04-09). "Viral pneumonia". Lancet 377 (9773): 1264–75.  
  7. ^ George, Ronald B. (2005). Chest medicine : essentials of pulmonary and critical care medicine (5th ed.). Philadelphia, PA: Lippincott Williams & Wilkins. p. 353.  
  8. ^ a b c d e f g h i j Eddy, Orin (Dec 2005). "Community-Acquired Pneumonia: From Common Pathogens To Emerging Resistance". Emergency Medicine Practice 7 (12). 
  9. ^ a b Tintinalli, Judith E. (2010). Emergency Medicine: A Comprehensive Study Guide (Emergency Medicine (Tintinalli)). New York: McGraw-Hill Companies. p. 480.  
  10. ^ a b c d e f Hoare Z; Lim WS (2006). "Pneumonia: update on diagnosis and management" (PDF). BMJ 332 (7549): 1077–9.  
  11. ^ a b c d e f g h i j k l Singh, V; Aneja, S (March 2011). "Pneumonia — management in the developing world". Paediatric respiratory reviews 12 (1): 52–9.  
  12. ^ a b c d e f g h i j k l m n o p q r s t Nair, GB; Niederman, MS (November 2011). "Community-acquired pneumonia: an unfinished battle". The Medical clinics of North America 95 (6): 1143–61.  
  13. ^ a b c d e f g "Pneumonia (Fact sheet N°331)". World Health Organization. August 2012. 
  14. ^ Darby, J; Buising, K (October 2008). "Could it be Legionella?". Australian family physician 37 (10): 812–5.  
  15. ^ Ortqvist, A; Hedlund, J; Kalin, M (December 2005). "Streptococcus pneumoniae: epidemiology, risk factors, and clinical features". Seminars in respiratory and critical care medicine 26 (6): 563–74.  
  16. ^ Lowe, J. F.; Stevens, Alan (2000). Pathology (2nd ed.). St. Louis: Mosby. p. 197.  
  17. ^ Snydman, editors, Raleigh A. Bowden, Per Ljungman, David R. (2010). Transplant infections (3rd ed.). Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins. p. 187.  
  18. ^ a b c d e f g h i Murray and Nadel (2010). Chapter 32.
  19. ^ Eom, CS; Jeon, CY; Lim, JW; Cho, EG; Park, SM; Lee, KS (22 February 2011). "Use of acid-suppressive drugs and risk of pneumonia: a systematic review and meta-analysis". CMAJ : Canadian Medical Association journal = journal de l'Association medicale canadienne 183 (3): 310–9.  
  20. ^ a b c d e f g h i Sharma, S; Maycher, B; Eschun, G (May 2007). "Radiological imaging in pneumonia: recent innovations". Current Opinion in Pulmonary Medicine 13 (3): 159–69.  
  21. ^ a b c Anevlavis S; Bouros D (February 2010). "Community acquired bacterial pneumonia". Expert Opin Pharmacother 11 (3): 361–74.  
  22. ^ a b c d e f g h i j Murray and Nadel (2010). Chapter 31.
  23. ^ a b Figueiredo LT (September 2009). "Viral pneumonia: epidemiological, clinical, pathophysiological, and therapeutic aspects". J Bras Pneumol 35 (9): 899–906.  
  24. ^ a b Behera, D. (2010). Textbook of pulmonary medicine (2nd ed.). New Delhi: Jaypee Brothers Medical Pub. pp. 391–394.  
  25. ^ a b Maskell, Nick; Millar, Ann (2009). Oxford desk reference.. Oxford: Oxford University Press. p. 196.  
  26. ^ a b c d e f Murray and Nadel (2010). Chapter 37.
  27. ^ Vijayan, VK (May 2009). "Parasitic lung infections". Current Opinion in Pulmonary Medicine 15 (3): 274–82.  
  28. ^ ed. in chief Richard K. Root. Eds. Francis Waldvogel (1999). Clinical infectious diseases : a practical approach. New York, NY [u.a.]: Oxford Univ. Press. p. 833.  
  29. ^ Volume editors, Ulrich Costabel (2007). Diffuse parenchymal lung disease : ... 47 tables ([Online-Ausg.] ed.). Basel: Karger. p. 4.  
  30. ^ a b Ranganathan, SC; Sonnappa, S (February 2009). "Pneumonia and other respiratory infections". Pediatric clinics of North America 56 (1): 135–56, xi.  
  31. ^ a b editors, Gary R. Fleisher, Stephen Ludwig ; associate editors, Richard G. Bachur [et at.] (2010). Textbook of pediatric emergency medicine (6th ed.). Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins Health. p. 914.  
  32. ^ Hammer, edited by Stephen J. McPhee, Gary D. (2010). Pathophysiology of disease : an introduction to clinical medicine (6th ed.). New York: McGraw-Hill Medical. pp. Chapter 4.  
  33. ^ a b Fein, Alan (2006). Diagnosis and management of pneumonia and other respiratory infections (2nd ed.). Caddo, OK: Professional Communications. pp. 28–29.  
  34. ^ Kumar, Vinay (2010). Robbins and Cotran pathologic basis of disease. (8th ed.). Philadelphia, PA: Saunders/Elsevier. pp. Chapter 15.  
  35. ^ a b Lynch, T; Bialy, L; Kellner, JD; Osmond, MH; Klassen, TP; Durec, T; Leicht, R; Johnson, DW (2010-08-06). Huicho, Luis, ed. "A systematic review on the diagnosis of pediatric bacterial pneumonia: when gold is bronze". PLoS ONE 5 (8): e11989.  
  36. ^ a b Ezzati, edited by Majid; Lopez, Alan D.; Rodgers, Anthony; Murray, Christopher J.L. (2004). Comparative quantification of health risks. Genève: Organisation mondiale de la santé. p. 70.  
  37. ^ a b c d e f g h i j k l m n Lim, WS; Baudouin, SV; George, RC; Hill, AT; Jamieson, C; Le Jeune, I; Macfarlane, JT; Read, RC; Roberts, HJ; Levy, ML; Wani, M; Woodhead, MA; Pneumonia Guidelines Committee of the BTS Standards of Care, Committee (October 2009). "BTS guidelines for the management of community acquired pneumonia in adults: update 2009". Thorax 64 (Suppl 3): iii1–55.  
  38. ^ Saldías, F; Méndez, JI; Ramírez, D; Díaz, O (April 2007). "[Predictive value of history and physical examination for the diagnosis of community-acquired pneumonia in adults: a literature review]". Revista medica de Chile 135 (4): 517–28.  
  39. ^ a b Call, SA; Vollenweider, MA; Hornung, CA; Simel, DL; McKinney, WP (2005-02-23). "Does this patient have influenza?". JAMA: the Journal of the American Medical Association 293 (8): 987–97.  
  40. ^ Helms, editors, William E. Brant, Clyde A. (2012-03-20). Fundamentals of diagnostic radiology (4th ed.). Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins. p. 435.  
  41. ^ a b c d Mandell, LA; Wunderink, RG; Anzueto, A; Bartlett, JG; Campbell, GD; Dean, NC; Dowell, SF; File TM, Jr; Musher, DM; Niederman, MS; Torres, A; Whitney, CG; Infectious Diseases Society of America; American Thoracic Society (1 March 2007). "Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults". Clinical infectious diseases : an official publication of the Infectious Diseases Society of America 44 (Suppl 2): S27–72.  
  42. ^ Stedman's medical dictionary. (28th ed.). Philadelphia: Lippincott Williams & Wilkins. 2006.  
  43. ^ Dunn, L (June 29 – July 5, 2005). "Pneumonia: classification, diagnosis and nursing management". Nursing standard (Royal College of Nursing (Great Britain) : 1987) 19 (42): 50–4.  
  44. ^ organization, World health (2005). Pocket book of hospital care for children : guidelines for the management of common illnesses with limited resources.. Geneva: World Health Organization. p. 72.  
  45. ^ Jefferson, T; Di Pietrantonj, C; Rivetti, A; Bawazeer, GA; Al-Ansary, LA; Ferroni, E (2010-07-07). Jefferson, Tom, ed. "Vaccines for preventing influenza in healthy adults". Cochrane Database of Systematic Reviews (7): CD001269.  
  46. ^ "Seasonal Influenza (Flu)". Center for Disease Control and Prevention. Retrieved 29 June 2011. 
  47. ^ Jefferson T; Deeks, JJ; Demicheli, V; Rivetti, D; Rudin, M (2004). Jefferson, Tom, ed. "Amantadine and rimantadine for preventing and treating influenza A in adults". Cochrane Database Syst Rev (3): CD001169.  
  48. ^ Jefferson, T; Jones, MA; Doshi, P; Del Mar, CB; Heneghan, CJ; Hama, R; Thompson, MJ (18 January 2012). Jefferson, Tom, ed. "Neuraminidase inhibitors for preventing and treating influenza in healthy adults and children". Cochrane Database of Systematic Reviews 1: CD008965.  
  49. ^ Moberley, SA; Holden, J; Tatham, DP; Andrews, RM (2008-01-23). Andrews, Ross M, ed. "Vaccines for preventing pneumococcal infection in adults". Cochrane Database of Systematic Reviews (1): CD000422.  
  50. ^ a b c "Pneumonia Can Be Prevented — Vaccines Can Help". Centers for Disease Control and Prevention. Retrieved 22 October 2012. 
  51. ^ Gray, DM; Zar, HJ (May 2010). "Community-acquired pneumonia in HIV-infected children: a global perspective". Current Opinion in Pulmonary Medicine 16 (3): 208–16.  
  52. ^ Huang, L; Cattamanchi, A; Davis, JL; den Boon, S; Kovacs, J; Meshnick, S; Miller, RF; Walzer, PD; Worodria, W; Masur, H; International HIV-associated Opportunistic Pneumonias (IHOP), Study; Lung HIV, Study (June 2011). "HIV-associated Pneumocystis pneumonia". Proceedings of the American Thoracic Society 8 (3): 294–300.  
  53. ^ Green H, Paul M, Vidal L, Leibovici L (2007). Green, Hefziba, ed. "Prophylaxis for Pneumocystis pneumonia (PCP) in non-HIV immunocompromised patients". Cochrane Database Syst Rev (3): CD005590.  
  54. ^ Taminato, M; Fram, D; Torloni, MR; Belasco, AG; Saconato, H; Barbosa, DA (November–December 2011). "Screening for group B Streptococcus in pregnant women: a systematic review and meta-analysis". Revista latino-americana de enfermagem 19 (6): 1470–8.  
  55. ^ Darville, T (October 2005). "Chlamydia trachomatis infections in neonates and young children". Seminars in pediatric infectious diseases 16 (4): 235–44.  
  56. ^ Global Action Plan for Prevention and Control of Pneumonia (GAPP). World Health Organization. 2009. 
  57. ^ a b Roggensack, A; Jefferies, AL; Farine, D; Basso, M; Delisle, MF; Hudon, L; Mundle, WR; Murphy-Kaulbeck, LC; Ouellet, A; Pressey, T (April 2009). "Management of meconium at birth". Journal of obstetrics and gynaecology Canada : JOGC = Journal d'obstetrique et gynecologie du Canada : JOGC 31 (4): 353–4, 355–7.  
  58. ^ van der Maarel-Wierink, CD; Vanobbergen, JN; Bronkhorst, EM; Schols, JM; de Baat, C (6 March 2012). "Oral health care and aspiration pneumonia in frail older people: a systematic literature review". Gerodontology 30 (1): 3–9.  
  59. ^ a b Bradley, JS; Byington, CL; Shah, SS; Alverson, B; Carter, ER; Harrison, C; Kaplan, SL; Mace, SE; McCracken GH, Jr; Moore, MR; St Peter, SD; Stockwell, JA; Swanson, JT (2011-08-31). "The Management of Community-Acquired Pneumonia in Infants and Children Older Than 3 Months of Age: Clinical Practice Guidelines by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America". Clinical infectious diseases : an official publication of the Infectious Diseases Society of America 53 (7): e25–76.  
  60. ^ Yang, M; Yuping, Y; Yin, X; Wang, BY; Wu, T; Liu, GJ; Dong, BR (2010-02-17). Dong, Bi Rong, ed. "Chest physiotherapy for pneumonia in adults". Cochrane Database of Systematic Reviews (2): CD006338.  
  61. ^ Zhang, Y; Fang, C; Dong, BR; Wu, T; Deng, JL (14 March 2012). Dong, Bi Rong, ed. "Oxygen therapy for pneumonia in adults". Cochrane Database of Systematic Reviews 3: CD006607.  
  62. ^ a b Chang CC, Cheng AC, Chang AB (2012). Chang, Christina C, ed. "Over-the-counter (OTC) medications to reduce cough as an adjunct to antibiotics for acute pneumonia in children and adults". Cochrane Database Syst Rev 2: CD006088.  
  63. ^ Haider, BA; Lassi, ZS; Ahmed, A; Bhutta, ZA (5 October 2011). Bhutta, Zulfiqar A, ed. "Zinc supplementation as an adjunct to antibiotics in the treatment of pneumonia in children 2 to 59 months of age". Cochrane Database of Systematic Reviews (10): CD007368.  
  64. ^ a b c Kabra SK; Lodha, R; Pandey, RM (2010). Kabra, Sushil K, ed. "Antibiotics for community-acquired pneumonia in children". Cochrane Database Syst Rev 3 (3): CD004874.  
  65. ^ Lutfiyya MN; Henley, E; Chang, LF; Reyburn, SW (February 2006). "Diagnosis and treatment of community-acquired pneumonia" (PDF). Am Fam Physician 73 (3): 442–50.  
  66. ^ Eliakim-Raz, N; Robenshtok, E; Shefet, D; Gafter-Gvili, A; Vidal, L; Paul, M; Leibovici, L (12 September 2012). Eliakim-Raz, Noa, ed. "Empiric antibiotic coverage of atypical pathogens for community-acquired pneumonia in hospitalized adults". Cochrane Database of Systematic Reviews 9: CD004418.  
  67. ^ Scalera NM; File, TM (April 2007). "How long should we treat community-acquired pneumonia?". Current Opinion in Infectious Diseases 20 (2): 177–81.  
  68. ^ a b  
  69. ^ a b Marik, PE (May 2011). "Pulmonary aspiration syndromes". Current Opinion in Pulmonary Medicine 17 (3): 148–54.  
  70. ^ O'Connor S (2003). "Aspiration pneumonia and pneumonitis". Australian Prescriber 26 (1): 14–7. 
  71. ^ a b Behera, D. (2010). Textbook of pulmonary medicine (2nd ed.). New Delhi: Jaypee Brothers Medical Pub. pp. 296–297.  
  72. ^ a b c Cunha (2010). Pages6-18.
  73. ^ Rello, J (2008). "Demographics, guidelines, and clinical experience in severe community-acquired pneumonia". Critical care (London, England). 12 Suppl 6 (Suppl 6): S2.  
  74. ^ a b c d e f g h i Yu, H (March 2011). "Management of pleural effusion, empyema, and lung abscess". Seminars in interventional radiology 28 (1): 75–86.  
  75. ^ Cunha (2010). Pages 250–251.
  76. ^ "WHO Disease and injury country estimates".  
  77. ^ Liu, L; Johnson, HL; Cousens, S; Perin, J; Scott, S; Lawn, JE; Rudan, I; Campbell, H; Cibulskis, R; Li, M; Mathers, C; Black, RE; Child Health Epidemiology Reference Group of WHO and, UNICEF (Jun 9, 2012). "Global, regional, and national causes of child mortality: an updated systematic analysis for 2010 with time trends since 2000". Lancet 379 (9832): 2151–61.  
  78. ^ Rudan, I; Boschi-Pinto, C; Biloglav, Z; Mulholland, K; Campbell, H (May 2008). "Epidemiology and etiology of childhood pneumonia". Bulletin of the World Health Organization 86 (5): 408–16.  
  79. ^ Garenne M; Ronsmans, C; Campbell, H (1992). "The magnitude of mortality from acute respiratory infections in children under 5 years in developing countries". World Health Stat Q 45 (2–3): 180–91.  
  80. ^ WHO (1999). "Pneumococcal vaccines. WHO position paper". Wkly. Epidemiol. Rec. 74 (23): 177–83.  
  81. ^ Weiss AJ, Wier LM, Stocks C, Blanchard J (June 2014). "Overview of Emergency Department Visits in the United States, 2011". HCUP Statistical Brief #174. Rockville, MD: Agency for Healthcare Research and Quality. 
  82. ^ a b Feigin, Ralph (2004). Textbook of Pediatric Infectious Diseases (5th ed.). Philadelphia:  
  83. ^ Hippocrates On Acute Diseases wikisource link
  84. ^ Maimonides, Fusul Musa ("Pirkei Moshe").
  85. ^ Klebs E (1875-12-10). "Beiträge zur Kenntniss der pathogenen Schistomyceten. VII Die Monadinen" [Signs for Recognition of the Pathogen Schistomyceten]. Arch. Exptl. Pathol. Parmakol. 4 (5/6): 40–488. 
  86. ^ Friedländer C (1882-02-04). "Über die Schizomyceten bei der acuten fibrösen Pneumonie". Virchow's Arch pathol. Anat. U. Physiol. 87 (2): 319–324.  
  87. ^ Fraenkel A (1884-04-21). "Über die genuine Pneumonie, Verhandlungen des Congress für innere Medicin". Dritter Congress 3: 17–31. 
  88. ^ Gram C (1884-03-15). "Über die isolierte Färbung der Schizomyceten in Schnitt- und Trocken-präparaten". Fortschr. Med 2 (6): 185–9. 
  89. ^ edited by J.F. Tomashefski, Jr. [] et al. (2008). Dail and Hammar's pulmonary pathology (3rd ed.). New York: Springer. p. 228.  
  90. ^ William Osler, Thomas McCrae (1920). The principles and practice of medicine: designed for the use of practitioners and students of medicine (9th ed.). D. Appleton. p. 78. One of the most widespread and fatal of all acute diseases, pneumonia has become the "Captain of the Men of Death," to use the phrase applied by John Bunyan to consumption. 
  91. ^ Adams WG; Deaver, KA; Cochi, SL; et al. et al. (January 1993). "Decline of childhood Haemophilus influenzae type B (Hib) disease in the Hib vaccine era". JAMA 269 (2): 221–6.  
  92. ^ Whitney CG; Farley, MM; Hadler, J; et al. et al. (May 2003). "Decline in invasive pneumococcal disease after the introduction of protein-polysaccharide conjugate vaccine". N. Engl. J. Med. 348 (18): 1737–46.  
  93. ^ "World Pneumonia Day Official Website". World Pneumonia Day Official Website. Fiinex. Retrieved 13 August 2011. 

References

Due to the high burden of disease in developing countries and a relatively low awareness of the disease in developed countries, the global health community has declared 12 November as World Pneumonia Day, a day for concerned citizens and policy makers to take action against the disease.[93] The global economic cost of community-acquired pneumonia has been estimated at $17 billion annually.[12]

Society and culture

Several 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 20th century, mortality from pneumonia, 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.[91] Vaccination against Streptococcus pneumoniae in adults began in 1977, and in children in 2000, resulting in a similar decline.[92]

Sir William Osler, known as "the father of modern medicine," appreciated the death and disability caused by 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 this time. This phrase was originally coined by John Bunyan in reference to "consumption" (tuberculosis).[89][90] Osler also described pneumonia as "the old man's friend" as death was often quick and painless when there were many slower more painful ways to die.[8]

[88]

Pneumonia has been a common disease throughout human history.[82] The symptoms were described by Hippocrates (c. 460 BC – 370 BC):[82] "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."[83] However, Hippocrates referred to pneumonia as a disease "named by the ancients." He also reported the results of surgical drainage of empyemas. Maimonides (1135–1204 AD) observed: "The basic symptoms that occur in pneumonia and that are never lacking are as follows: acute fever, sticking pleuritic pain in the side, short rapid breaths, serrated pulse and cough."[84] 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.

A poster with a shark in the middle of it, which reads
WPA poster, 1936/1937

History

[81] In 2011, pneumonia was the most common reason for admission to the hospital after an emergency department visit in the U.S. for infants and children.[80] Approximately half of these deaths can be prevented, as they are caused by the bacteria for which an effective vaccine is available.[79] It is the leading cause of death among children in [78] Countries with the greatest burden of disease include India (43 million), China (21 million) and Pakistan (10 million).[77][11][6] In 2010, it resulted in 1.3 million deaths, or 18% of all deaths in those under five years, of which 95% occurred in the developing world.[6] In 2008, pneumonia occurred in approximately 156 million children (151 million in the developing world and 5 million in the developed world).

Children

Pneumonia is a common illness affecting approximately 450 million people a year and occurring in all parts of the world.[6] It is a major cause of death among all age groups resulting in 4 million deaths (7% of the world's total death) yearly.[6][64] Rates are greatest in children less than five, and adults older than 75 years.[6] It occurs about five times more frequently in the developing world than in the developed world.[6] Viral pneumonia accounts for about 200 million cases.[6] In the United States, as of 2009, pneumonia is the 8th leading cause of death.[12]

A map of the world with a far bit of dark-red in Africa, orange colors in parts of Asia and South America, and yellow in Europe and North America
Age-standardized death rate: lower respiratory tract infections per 100,000 inhabitants in 2004.[76]
  no data
  <100
  100–700
  700–1400
  1400–2100
  2100–2800
  2800–3500
  3500–4200
  4200–4900
  4900–5600
  5600–6300
  6300–7000
  >7000

Epidemiology

myocardial infarction or a pulmonary embolism.[75]

Pneumonia can 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 stiff. This stiffness, combined with severe difficulties extracting oxygen due to the alveolar fluid, may require long periods of mechanical ventilation for survival.[22]

Respiratory and circulatory failure

In rare circumstances, bacteria in the lung will form a pocket of infected fluid called a lung abscess.[74] Lung abscesses can usually be seen with a chest X-ray but frequently require a chest CT scan to confirm the diagnosis.[74] Abscesses typically occur in aspiration pneumonia, and often contain several types of bacteria. Long-term antibiotics are usually adequate to treat a lung abscess, but sometimes the abscess must be drained by a surgeon or radiologist.[74]

In pneumonia, a empyema.[74] To distinguish an empyema from the more common simple parapneumonic effusion, the fluid may be collected with a needle (thoracentesis), and examined.[74] If this shows evidence of empyema, complete drainage of the fluid is necessary, often requiring a drainage catheter.[74] In severe cases of empyema, surgery may be needed.[74] 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 must be drained only if it is causing symptoms or remains unresolved.[74]

An X-ray showing a chest lying horizontal. The lower black area, which is the right lung, is smaller with a whiter area below it of a pulmonary effusion. There are red arrows marking the size of these.
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 the lung is reduced because of the collection of fluid around the lung.

Pleural effusion, empyema, and abscess

Clinical prediction rules have been developed to more objectively predict outcomes of pneumonia.[18] These rules are often used in deciding whether or not to hospitalize the person.[18]

Clinical prediction rules

Complications may occur in particular in the elderly and those with underlying health problems.[72] This may include, among others: empyema, lung abscess, bronchiolitis obliterans, acute respiratory distress syndrome, sepsis, and worsening of underlying health problems.[72]

With treatment, most types of bacterial pneumonia will stabilize in 3–6 days.[71] It often takes a few weeks before most symptoms resolve.[71] X-ray finding typically clear within four weeks and mortality is low (less than 1%).[12][72] In the elderly or people with other lung problems, recovery may take more than 12 weeks. In persons requiring hospitalization, mortality may be as high as 10%, and in those requiring intensive care it may reach 30–50%.[12] Pneumonia is the most common hospital-acquired infection that causes death.[18] Before the advent of antibiotics, mortality was typically 30% in those that were hospitalized.[8]

Prognosis

In general, clindamycin, a combination of a beta-lactam antibiotic and metronidazole, or an aminoglycoside.[70] Corticosteroids are sometimes used in aspiration pneumonia, but there is limited evidence to support their effectiveness.[69]

Aspiration

Neuraminidase inhibitors may be used to treat viral pneumonia caused by influenza viruses (influenza A and influenza B).[6] No specific antiviral medications are recommended for other types of community acquired viral pneumonias including SARS coronavirus, adenovirus, hantavirus, and parainfluenza virus.[6] Influenza A may be treated with rimantadine or amantadine, while influenza A or B may be treated with oseltamivir, zanamivir or peramivir.[6] These are of most benefit if they are started within 48 hours of the onset of symptoms.[6] Many strains of H5N1 influenza A, also known as avian influenza or "bird flu," have shown resistance to rimantadine and amantadine.[6] The use of antibiotics in viral pneumonia is recommended by some experts, as it is impossible to rule out a complicating bacterial infection.[6] The British Thoracic Society recommends that antibiotics be withheld in those with mild disease.[6] The use of corticosteroids is controversial.[6]

Viral

Antibiotics improve outcomes in those with bacterial pneumonia.[64] Antibiotic choice depends initially on the characteristics of the person affected, such as age, underlying health, and the location the infection was acquired. In the UK, empiric treatment with amoxicillin is recommended as the first line for community-acquired pneumonia, with doxycycline or clarithromycin as alternatives.[37] In North America, where the "atypical" forms of community-acquired pneumonia are more common, macrolides (such as azithromycin or erythromycin), and doxycycline have displaced amoxicillin as first-line outpatient treatment in adults.[21][65] In children with mild or moderate symptoms, amoxicillin remains the first line.[59] The use of fluoroquinolones in uncomplicated cases is discouraged due to concerns about side-effects and generating resistance in light of there being no greater clinical benefit.[21][66] The duration of treatment has traditionally been seven to ten days, but increasing evidence suggests that shorter courses (three to five days) are similarly effective.[67] Recommended for hospital-acquired pneumonia include third- and fourth-generation cephalosporins, carbapenems, fluoroquinolones, aminoglycosides, and vancomycin.[68] These antibiotics are often given intravenously and used in combination.[68] In those treated in hospital, more than 90% improve with the initial antibiotics.[18]

Bacterial

Oral antibiotics, rest, simple analgesics, and fluids usually suffice for complete resolution.[37] However, those with other medical conditions, the elderly, or those with significant trouble breathing may require more advanced care. If the symptoms worsen, the pneumonia does not improve with home treatment, or complications occur, hospitalization may be required.[37] Worldwide, approximately 7–13% of cases in children result in hospitalization,[11] whereas in the developed world between 22 and 42% of adults with community-acquired pneumonia are admitted.[37] The CURB-65 score is useful for determining the need for admission in adults.[37] If the score is 0 or 1, people can typically be managed at home; if it is 2, a short hospital stay or close follow-up is needed; if it is 3–5, hospitalization is recommended.[37] In children those with respiratory distress or oxygen saturations of less than 90% should be hospitalized.[59] The utility of chest physiotherapy in pneumonia has not yet been determined.[60] Non-invasive ventilation may be beneficial in those admitted to the intensive care unit.[61] Over-the-counter cough medicine has not been found to be effective[62] nor has the use of zinc in children.[63] There is insufficient evidence for mucolytics.[62]

CURB-65
Symptom Points
Confusion
1
Urea>7 mmol/l
1
Respiratory rate>30
1
SBP<90mmHg, DBP<60mmHg
1
Age>=65
1

Management

Testing pregnant women for Group B Streptococcus and Chlamydia trachomatis, and administering antibiotic treatment, if needed, reduces rates of pneumonia in infants;[54][55] preventive measures for HIV transmission from mother to child may also be efficient.[56] Suctioning the mouth and throat of infants with meconium-stained amniotic fluid has not been found to reduce the rate of aspiration pneumonia and may cause potential harm,[57] thus this practice is not recommended in the majority of situations.[57] In the frail elderly good oral health care may lower the risk of aspiration pneumonia.[58]

Appropriately treating underlying illnesses (such as HIV/AIDS, diabetes mellitus, and malnutrition) can decrease the risk of pneumonia.[13][50][51] In children less than 6 months of age, exclusive breast feeding reduces both the risk and severity of disease.[13] In those with HIV/AIDS and a CD4 count of less than 200 cells/uL the antibiotic trimethoprim/sulfamethoxazole decreases the risk of Pneumocystis pneumonia[52] and may also be useful for prevention in those that are immunocomprised but do not have HIV.[53]

Smoking cessation[37] and reducing indoor air pollution, such as that from cooking indoors with wood or dung, are both recommended.[11][13] Smoking appears to be the single biggest risk factor for pneumococcal pneumonia in otherwise-healthy adults.[41] Hand hygiene and coughing into one's sleeve may also be effective preventative measures.[50] Wearing surgical masks by the sick may also prevent illness.[41]

Other

Vaccinations against Haemophilus influenzae and Streptococcus pneumoniae have good evidence to support their use.[30] Vaccinating children against Streptococcus pneumoniae has led to a decreased incidence of these infections in adults, because many adults acquire infections from children. A Streptococcus pneumoniae vaccine is available for adults, and has been found to decrease the risk of invasive pneumococcal disease.[49] Other vaccines for which there to support for a protective effect against pneumonia include pertussis, varicella, and measles.[50]

Vaccination prevents against certain bacterial and viral pneumonias both in children and adults. Influenza vaccines are modestly effective against influenza A and B.[6][45] The Center for Disease Control and Prevention (CDC) recommends yearly vaccination for every person 6 months and older.[46] Immunizing health care workers decreases the risk of viral pneumonia among their patients.[41] When influenza outbreaks occur, medications such as amantadine or rimantadine may help prevent the condition.[47] It is unknown whether zanamivir or oseltamivir is effective due to the fact that the company that manufactures oseltamivir has refused to release the trial data for independent analysis.[48]

Vaccination

Prevention includes vaccination, environmental measures and appropriate treatment of other health problems.[11] It is believed that, if appropriate preventive measures were instituted globally, mortality among children could be reduced by 400,000; and, if proper treatment were universally available, childhood deaths could be decreased by another 600,000.[13]

Prevention

Several diseases can present with similar signs and symptoms to pneumonia, such as: chronic obstructive pulmonary disease (COPD), asthma, pulmonary edema, bronchiectasis, lung cancer, and pulmonary emboli.[10] Unlike pneumonia, asthma and COPD typically present with wheezing, pulmonary edema presents with an abnormal electrocardiogram, cancer and bronchiectasis present with a cough of longer duration, and pulmonary emboli presents with acute onset sharp chest pain and shortness of breath.[10]

Differential diagnosis

[44] Pneumonia in children may additionally be classified based on signs and symptoms as non-severe, severe, or very severe.[43]

Classification

[10] The causative agent is determined in only 15% of cases with routine microbiological tests.[6] (PCR), among other techniques.polymerase chain reaction or culture Viral infections can be confirmed via detection of either the virus or its antigens with [41].Streptococcus and Legionella to antigens as well as testing the urine for [37] are recommended,blood cultures In those hospitalized for severe disease, both sputum and [37] For people that do not respond to treatment, [11] In patients managed in the community, determining the causative agent is not cost-effective and typically does not alter management.

Microbiology

X-ray presentations of pneumonia may be classified as lobar pneumonia, bronchopneumonia (also known as lobular pneumonia), and interstitial pneumonia.[40] Bacterial, community-acquired pneumonia classically show lung consolidation of one lung segmental lobe, which is known as lobar pneumonia.[20] However, findings may vary, and other patterns are common in other types of pneumonia.[20] Aspiration pneumonia may present with bilateral opacities primarily in the bases of the lungs and on the right side.[20] Radiographs of viral pneumonia may appear normal, appear hyper-inflated, have bilateral patchy areas, or present similar to bacterial pneumonia with lobar consolidation.[20] Radiologic findings may not be present in the early stages of the disease, especially in the presence of dehydration, or may be difficult to be interpreted in the obese or those with a history of lung disease.[12] A CT scan can give additional information in indeterminate cases.[20]

A chest radiograph is frequently used in diagnosis.[11] In people with mild disease, imaging is needed only in those with potential complications, those not having improved with treatment, or those in which the cause is uncertain.[11][37] If a person is sufficiently sick to require hospitalization, a chest radiograph is recommended.[37] Findings do not always match the severity of disease and do not reliably separate between bacterial infection and viral infection.[11]

CT of the chest demonstrating right-side pneumonia (left side of the image).

Imaging

Physical examination may sometimes reveal low blood pressure, high heart rate, or low oxygen saturation.[12] The respiratory rate may be faster than normal, and this may occur a day or two before other signs.[12][18] Examination of the chest may be normal, but it may show decreased chest expansion on the affected side. Harsh breath sounds from the larger airways that are transmitted through the inflamed lung are termed bronchial breathing and are heard on auscultation with a stethoscope.[12] Crackles (rales) may be heard over the affected area during inspiration.[12] Percussion may be dulled over the affected lung, and increased, rather than decreased, vocal resonance distinguishes pneumonia from a pleural effusion.[10]

Physical exam

In general, in adults, investigations are not needed in mild cases:[37] There is a very low risk of pneumonia if all vital signs and auscultation are normal.[38] In persons requiring hospitalization, pulse oximetry, chest radiography and blood tests—including a complete blood count, serum electrolytes, C-reactive protein level, and possibly liver function tests—are recommended.[37] The diagnosis of influenza-like illness can be made based on the signs and symptoms; however, confirmation of an influenza infection requires testing.[39] Thus, treatment is frequently based on the presence of influenza in the community or a rapid influenza test.[39]

Pneumonia is typically diagnosed based on a combination of physical signs and a cough or difficulty breathing and a rapid respiratory rate, chest indrawing, or a decreased level of consciousness.[36] A rapid respiratory rate is defined as greater than 60 breaths per minute in children under 2 months old, 50 breaths per minute in children 2 months to 1 year old, or greater than 40 breaths per minute in children 1 to 5 years old.[36] In children, increased respiratory rate and lower chest indrawing are more sensitive than hearing chest crackles with a stethoscope.[11]

Crackles heard in the lungs of a person with pneumonia using a stethoscope.

Problems playing this file? See .

Diagnosis

[34] The neutrophils, bacteria, and fluid from surrounding blood vessels fill the alveoli, resulting in the consolidation seen on chest X-ray.[33] This leads to the fever, chills, and fatigue common in bacterial pneumonia.[33], causing a general activation of the immune system.cytokines The neutrophils also release [32]) attempt to inactivate the bacteria.white blood cells (defensive neutrophils and macrophages Once in the lungs, bacteria may invade the spaces between cells and between alveoli, where the [13] Bacteria can spread also via the blood.[12] reach the lungs via contaminated airborne droplets.Legionella pneumophila and Mycobacterium tuberculosis A minority of types of bacteria such as [18] ones reside there only at certain times and under certain conditions.potentially infectious While the throat always contains bacteria, [18] Half of normal people have these small aspirations during sleep.[12] Most bacteria enter the lungs via small

Bacterial

Viruses may reach the lung by a number of different routes. Respiratory syncytial virus is typically contracted when people touch contaminated objects and then they touch their eyes or nose.[22] Other viral infections occur when contaminated airborne droplets are inhaled through the mouth or nose.[12] Once in the upper airway, the viruses may make their way in the lungs, where they invade the cells lining the airways, alveoli, or co-morbid condition.[23]

Viral

Pneumonia frequently starts as an upper respiratory tract infection that moves into the lower respiratory tract.[30]

A schematic diagram of the human lungs with an empty circle on the right representing a normal alveola and one on the right showing an alveola full of fluid as in pneumonia
Pneumonia fills the lung's alveoli with fluid, hindering oxygenation. The alveolus on the left is normal, whereas the one on the right is full of fluid from pneumonia.

Mechanisms

Idiopathic interstitial pneumonia or noninfectious pneumonia[28] are a class of nonspecific interstitial pneumonia, lymphocytic interstitial pneumonia, desquamative interstitial pneumonia, respiratory bronchiolitis interstitial lung disease, and usual interstitial pneumonia.[29]

Idiopathic

[27] Around the world, these infections are most common in the immunodeficient.[26] these infections are most common in people returning from travel or in immigrants.developed world In the [26] In other infections, such as malaria, lung involvement is due primarily to cytokine-induced systemic inflammation.[26].eosinophilic pneumonia reaction, which may result in eosinophilic genera, stimulate a strong Strongyloides and Ascaris Some parasites, in particular those belonging to the [26], most parasites do not affect specifically the lungs but involve the lungs secondarily to other sites.Paragonimus westermani Except for [26] A variety of

Parasites

Fungal pneumonia is uncommon, but occurs more commonly in individuals with weakened immune systems due to AIDS, immunosuppressive drugs, or other medical problems.[8][25] It 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 is most common in the Southwestern United States.[8] The number of cases have been increasing in the later half of the 20th century due to increasing travel and rates of immunosuppression in the population.[25]

Fungi

In adults, immunocompromised present high rates of cytomegalovirus pneumonia.[22][24] Those with viral infections may be secondarily infected with the bacteria Streptococcus pneumoniae, Staphylococcus aureus, or Haemophilus influenzae, particularly when other health problems are present.[12][22] Different viruses predominate at different periods of the year; during influenza season, for example, influenza may account for over half of all viral cases.[22] Outbreaks of other viruses also occasionally occur, including hantaviruses and coronavirus.[22]

Viruses

[12]