Pneumonia is a lung infection that can be caused by different types of microorganisms, including bacteria, viruses, and fungi.

Symptoms of pneumonia include cough with sputum production, fever, and sharp chest pain on inspiration (breathing in). Pneumonia is suspected when a doctor hears abnormal sounds in the chest, and the diagnosis is confirmed by a chest X-ray. Bacteria causing pneumonia can be identified by sputum culture. A pleural effusion is a fluid collection around the inflamed lung. Bacterial and fungal (but not viral) pneumonia can be treated with antibiotics.

How do people "catch pneumonia"?

Some cases of pneumonia are contracted by breathing in small droplets that contain the organisms that can cause pneumonia. These droplets get into the air when a person infected with these germs coughs or sneezes. In other cases, pneumonia is caused when bacteria or viruses that are normally present in the mouth, throat, or nose inadvertently enter the lung. During sleep, it is quite common for people to aspirate secretions from the mouth, throat, or nose. Normally, the body's reflex response (coughing back up the secretions) and their immune system will prevent the aspirated organisms from causing pneumonia. However, if a person is in a weakened condition from another illness, a severe pneumonia can develop. People with recent viral infections, lung disease, heart disease, and swallowing problems, as well as alcoholics, drug users, and those who have suffered a stroke or seizure are at higher risk for developing pneumonia than the general population. As we age, our swallowing mechanism can become impaired as does our immune system. These factors, along with some of the negative side effects of medications, increase the risk for pneumonia in the elderly.

Once organisms enter the lungs, they usually settle in the air sacs and passages of the lung where they rapidly grow in number. This area of the lung then becomes filled with fluid and pus (the body's inflammatory cells) as the body attempts to fight off the infection.

What are pneumonia symptoms and signs?

Most people who develop pneumonia initially have symptoms of a cold (upper respiratory infection, for example, sneezing, sore throat, cough), which are then followed by a high fever (sometimes as high as 104 F), shaking chills, and a cough with sputum production. The sputum is usually discolored and sometimes bloody. Depending on the location of the infection, certain symptoms are more likely to develop. When the infection settles in the air passages, cough and sputum tend to predominate the symptoms. In some, the spongy tissue of the lungs that contain the air sacs is more involved. In this case, oxygenation of the blood can be impaired, along with stiffening of the lung, which results in shortness of breath. At times, the individual's skin color may change and become dusky or purplish (a condition known as "cyanosis") due to their blood being poorly oxygenated. The only pain fibers in the lung are on the surface of the lung, in the area known as the pleura. Chest pain may develop if the outer aspects of the lung close to the pleura are involved in the infection. This pain is usually sharp and worsens when taking a deep breath and is known as

pleuritic pain or pleurisy. In other cases of pneumonia, depending on the causative organism, there can be a slow onset of symptoms. A worsening cough, headaches, and muscle aches may be the only symptoms. Children and babies who develop pneumonia often do not have any specific signs of a chest infection but develop a fever, appear quite ill, and can become lethargic. Elderly people may also have few symptoms with pneumonia.

How is pneumonia diagnosed?

Pneumonia may be suspected when the doctor examines the patient and hears coarse breathing or crackling sounds when listening to a portion of the chest with a stethoscope. There may be wheezing or the sounds of breathing may be faint in a particular area of the chest. A chest X-ray is usually ordered to confirm the diagnosis of pneumonia. The lungs have several segments referred to as lobes, usually two on the left and three on the right. When the pneumonia affects one of these lobes, it is often referred to as lobar pneumonia. Some pneumonias have a more patchy distribution that does not involve specific lobes. In the past, when both lungs were involved in the infection, the term "double pneumonia" was used. This term is rarely used today.
Two vaccines are available to prevent pneumococcal disease: the pneumococcal conjugate vaccine (PCV13) and the pneumococcal polysaccharide vaccine (PPV23; Pneumovax). The pneumococcal conjugate vaccine is part of the routine infant immunization schedule in the U.S. and is recommended for all children < 2 years of age and children 2-4 years of age who have certain medical conditions. The pneumococcal polysaccharide vaccine is recommended for adults at increased risk for developing pneumococcal pneumonia including the elderly, people who have diabetes, chronic heart, lung, or kidney disease, those with alcoholism, cigarette smokers, and in those people who have had their spleen

removed. This vaccination should be repeated every five to seven years, whereas the flu vaccine is given annually Antibiotics often used in the treatment of this type of pneumonia include penicillin, amoxicillin and clavulanic acid (Augmentin, Augmentin XR), and macrolide antibiotics including erythromycin (E-Mycin, Eryc, Ery-Tab, PCE, Pediazole, Ilosone), azithromycin (Zithromax, Z-Max), and clarithromycin (Biaxin). Penicillin was formerly the antibiotic of choice in treating this infection. With the advent and widespread use of broader-spectrum antibiotics, significant drug resistance has developed. Penicillin may still be effective in treatment of pneumococcal pneumonia, but it should only be used after cultures of the bacteria confirm their sensitivity to this antibiotic

What is the prognosis of pneumonia?

Pneumonia can be a serious and life-threatening infection. This is true especially in the elderly, children, and those who have other serious medical problems, such as COPD, heart disease, diabetes, and certain cancers. Fortunately, with the discovery of many potent antibiotics, most cases of pneumonia can be successfully treated. In fact, pneumonia can usually be treated with oral antibiotics without the need for hospitalization. Pneumonia is an inflammatory condition of the lungespecially affecting the microscopic air sacs (alveoli)associated with fever, chest symptoms, and a lack of air space (consolidation) on a chest X-ray.[1][2] Pneumonia is typically caused by an infection but there are a number of other causes.[1] Infectious agents include: bacteria, viruses, fungi, and parasites.[3] Typical symptoms include cough, chest pain, fever, and difficulty breathing.[4] Diagnostic tools include x-rays and examination of the sputum. Vaccines to prevent certain types of pneumonia are available. Treatment depends on the underlying cause. Presumed bacterial pneumonia is treated with antibiotics. Although pneumonia was regarded by William Osler in the 19th century as "the captain of the men of death", the advent of antibiotic therapy and vaccines in the 20th century have seen radical improvements in survival outcomes. Nevertheless, in the third world, and among the very old, the very young and the chronically ill, pneumonia remains a leading cause of death.[5]

Contents

1 Classification 2 Signs and symptoms 3 Cause o 3.1 Bacteria o 3.2 Viruses o 3.3 Fungi o 3.4 Parasites o 3.5 Idiopathic 4 Pathophysiology o 4.1 Viral o 4.2 Bacterial 5 Diagnosis o 5.1 Imaging o 5.2 Microbiology o 5.3 Differential diagnosis 6 Prevention o 6.1 Vaccination o 6.2 Environmental o 6.3 Other 7 Management o 7.1 Bacterial o 7.2 Viral o 7.3 Aspiration 8 Prognosis o 8.1 Clinical prediction rules o 8.2 Pleural effusion, empyema, and abscess o 8.3 Respiratory and circulatory failure 9 Epidemiology o 9.1 Children 10 History 11 Society and culture 12 References 13 External links

Classification
Main article: Classification of pneumonia

Pneumonitis refers to lung inflammation; pneumonia refers to pneumonitis, usually due to infection but sometimes non infectious, that has the additional feature of pulmonary consolidation.[6] Pneumonia can be classified in several ways. It is most commonly classified by where or how it was acquired (community-acquired, aspiration, healthcare-associated, hospitalacquired, and ventilator-associated pneumonia),[7] but may also be classified by the area of lung affected (lobar pneumonia, bronchial pneumonia and acute interstitial pneumonia),[7] or by the

causative organism.[8] Pneumonia in children may additionally be classified based on signs and symptoms as non-severe, severe, or very severe.[9]

Signs and symptoms

Symptoms frequency in pneumonia[10] Symptom Cough Fatigue Fever Shortness of breath Sputum Chest pain Frequency 7991% 90% 7175% 6775% 6065% 3949%

Main symptoms of infectious pneumonia

People with infectious pneumonia often have a productive cough, fever accompanied by shaking chills, shortness of breath, sharp or stabbing chest pain during deep breaths, confusion, and an increased respiratory rate.[11] In the elderly, confusion may be the most prominent symptom.[11] The typical symptoms in children under five are fever, cough, and fast or difficult breathing.[12] Fever, however, is not very specific, as it occurs in many other common illnesses, and may be absent in those with severe disease or malnutrition. In addition, a cough is frequently absent in children less than 2 months old.[12] More severe symptoms may include: central cyanosis, decreased thirst, convulsions, persistent vomiting, or a decreased level of consciousness.[12] Some causes of pneumonia are associated with classic, but non-specific, clinical characteristics. Pneumonia caused by Legionella may occur with abdominal pain, diarrhea, or confusion,[13] while pneumonia caused by Streptococcus pneumoniae is associated with rusty colored sputum,[14] and pneumonia caused by Klebsiella may have bloody sputum often described as "currant jelly".[10]

o Kulang sa tulog o Naay ubo ug sip-on o gadaot o Gikan sa opera

Physical examination may sometimes reveal low blood pressure, a high heart rate, or a low oxygen saturation. Examination of the chest may be normal, but 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. Rales (or crackles) may be heard over the affected area during inspiration. Percussion may be dulled over the affected lung, and increased, rather than decreased, vocal resonance distinguishes pneumonia from a pleural effusion.[11] Struggling to breathe, confusion, and blue-tinged skin are signs of a medical emergency.

Cause
Pneumonia is due primarily to infections, with less common causes including irritants and the unknown. Although more than one hundred strains of microorganisms can cause pneumonia, only a few are responsible for most cases. The most common types of infectious agents are viruses and bacteria, with its being less commonly due to fungi or parasites. Mixed infections with both viruses and bacteria may occur in up to 45% of infections in children and 15% of infections in adults.[15] A causative agent is not isolated in approximately half of cases despite careful testing.[16] The term pneumonia is sometimes more broadly applied to inflammation of the lung (for example caused by autoimmune disease, chemical burns or drug reactions), however this is more accurately referred to as pneumonitis.[17][18]

Bacteria
Main article: Bacterial pneumonia

The bacterium Streptococcus pneumoniae, a common cause of pneumonia, imaged by an electron microscope

Bacteria are the most common cause of community acquired pneumonia, with Streptococcus pneumoniae isolated in nearly 50% of cases.[7][19] Other commonly isolated bacteria include: Haemophilus influenzae in 20%, Chlamydophila pneumoniae in 13%, Mycoplasma pneumoniae in 3%,[7] Staphylococcus aureus, Moraxella catarrhalis, Legionella pneumophila and gramnegative bacilli.[16]

Risk factors for infection depend on the organism involved.[16] Alcoholism is associated with Streptococcus pneumoniae, anaerobic organisms, and Mycobacterium tuberculosis, smoking is associated with Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, and Legionella pneumophila, exposure to bird with Chlamydia psittaci, farm animals with Coxiella burnetti, aspiration of stomach contents with anaerobes, and cystic fibrosis with Pseudomonas aeruginosa and Staphylococcus aureus.[16] Streptococcus pneumoniae is more common in the winter.[16]

Viruses
Main article: Viral pneumonia

In adults, viruses account for approximately a third of pneumonia cases.[15] Commonly implicated agents include: rhinoviruses,[15]coronaviruses,[15] influenza virus,[20] respiratory syncytial virus (RSV),[20] adenovirus,[20] and parainfluenza.[20] Herpes simplex virus is a rare cause of pneumonia, except in newborns. People with weakened immune systems are at increased risk of pneumonia caused by cytomegalovirus (CMV).

Fungi
Main article: Fungal pneumonia

Fungal pneumonia is uncommon,[16] but it may occur in individuals with weakened immune systems due to AIDS, immunosuppressive drugs, or other medical problems. The pathophysiology of pneumonia caused by fungi is similar to that of bacterial pneumonia. Fungal pneumonia is most often caused by Histoplasma capsulatum, blastomyces, Cryptococcus neoformans, Pneumocystis jiroveci, and Coccidioides immitis. Histoplasmosis is most common in the Mississippi River basin, and coccidioidomycosis is most common in the southwestern United States.[16]

Parasites
Main article: Parasitic pneumonia

A variety of parasites can affect the lungs. These parasites typically enter the body through the skin or the mouth. Once inside the body, they travel to the lungs, usually through the blood. In parasitic pneumonia, as with other kinds of pneumonia, a combination of cellular destruction and immune response causes disruption of oxygen transportation. One type of white blood cell, the eosinophil, responds vigorously to parasite infection. Eosinophils in the lungs can lead to eosinophilic pneumonia, thus complicating the underlying parasitic pneumonia. The most common parasites causing pneumonia are Toxoplasma gondii, Strongyloides stercoralis, and Ascariasis.

Idiopathic

Main article: Idiopathic interstitial pneumonia

Idiopathic interstitial pneumonia or noninfectious pneumonia[21] are a class of diffuse lung diseases. They include: diffuse alveolar damage, organizing pneumonia, nonspecific interstitial pneumonia, lymphocytic interstitial pneumonia, desquamative interstitial pneumonia, respiratory bronchiolitis interstitial lung disease, and usual interstitial pneumonia.[22]

Pathophysiology

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.

Pneumonia frequently starts as an upper respiratory tract infection that moves into the lower respiratory tract.[23]

Viral
Viruses invade cells in order to reproduce. Typically, a virus reaches the lungs when airborne droplets are inhaled through the mouth or nose. Once in the lungs, the virus invades the cells lining the airways and alveoli. This invasion often leads to cell death, either from damage to the cell by the virus or from a protective process called apoptosis in which the infected cell destroys itself before it can be used as a conduit for virus reproduction. When the immune system responds to the viral infection, even more lung damage occurs. White blood cells, mainly lymphocytes, activate certain chemical cytokines that allow fluid to leak into the alveoli. This combination of cell destruction and fluid-filled alveoli interrupts the normal transportation of oxygen into the bloodstream.

As well as damaging the lungs, many viruses affect other organs and thus disrupt many body functions. Viruses can also make the body more susceptible to other bacterial infections; in this way bacterial pneumonia can arise as a co-morbid condition.[20]

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

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

Problems listening to this file? See media help.

Pneumonia is typically diagnosed based on a combination of physical signs and a chest X-ray.[24] Confirming the underlying cause can be difficult, however, with no definitive test able to distinguish between bacterial and not-bacterial origin.[15][24] The World Health Organization has defined pneumonia in children clinically based on either a cough or difficulty breathing and a rapid respiratory rate, chest indrawing, or a decreased level of consciousness.[25] 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 two months to one year old, or greater than 40 breaths per minute in children one to five years old.[25] In children, an increased respiratory rate and lower chest indrawing are more sensitive than hearing chest crackles with a stethoscope.[12] In adults, investigations are in general not needed in mild cases[26] as if all vital signs and auscultation are normal the risk of pneumonia is very low.[27] In those requiring admission to a hospital, pulse oximetry, chest radiography, and blood tests including a complete blood count, serum electrolytes, C-reactive protein, and possibly liver function tests are recommended.[26] The diagnosis of influenza-like illness can be made based on the presenting signs and symptoms however verification of an influenza infection requires testing.[28] Thus treatment is frequently based on the presence of influenza in the community or a rapid influenza test.[28]

Imaging

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

A chest radiograph is frequently used in diagnosis.[12] In people with mild disease, imaging is needed only in those with potential complications, those who have not improved with treatment, or those in which the cause in uncertain.[12][26] If a person is sufficiently sick to require hospitalization, a chest radiograph is recommended.[26] Findings do not always correlate with severity of disease and do not reliably distinguish between bacterial infection and viral infection.[12] X-ray signs of bacterial community acquired pneumonia classically show lung consolidation of one lung segmental lobe.[7] However, radiographic findings may be variable, especially in other types of pneumonia.[7] Aspiration pneumonia may present with bilateral opacities primarily in the bases of the lungs and on the right side.[7] Radiographs of viral pneumonia cases may appear normal, hyper-inflated, have bilateral patchy areas, or present similar to bacterial pneumonia with lobar consolidation.[7] A CT scan can give additional information in indeterminate cases.[7] Radiologic findings often lag behind clinical findings, especially in the presence of dehydration, thus many clinicians make a diagnosis of "clinical pneumonia" on the basis of history and crackles on examination.[29] This lag is more often remarked in Pneumocystis carinii pneumonia, where chest radiograph findings may be normal in 10-39% of patients.[30]

Microbiology
For people managed in the community figuring out the causative agent is not cost effective, and typically does not alter management.[12] For those not responsive to treatment, sputum culture should be considered, and culture for Mycobacterium tuberculosis should be carried out in those with a chronic productive cough.[26] Testing for other specific organisms may be recommended during outbreaks, for public health reasons.[26] In those who are hospitalized for severe disease both sputum and blood cultures are recommended.[26] Viral infections can be confirmed via detection of either the virus or its antigens with culture or polymerase chain reaction (PCR) among other techniques.[15] With routine microbiological testing a causative agent is determined in only 15% of cases.[11]

Differential diagnosis

Several diseases can present similar to pneumonia, including: chronic obstructive pulmonary disease (COPD), asthma, pulmonary edema, bronchiectasis, lung cancer, and pulmonary emboli.[11] 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.[11]

Prevention
Prevention includes vaccination, environmental measures, and appropriately treating other diseases.[12]

Vaccination
Vaccination is effective for preventing certain bacterial and viral pneumonias in both children and adults. Influenza vaccines are modestly effective against influenza A and B.[15][31] The Center for Disease Control and Prevention (CDC) recommends that everyone 6 months and older get yearly vaccination.[32] When an influenza outbreak is occurring, medications such as amantadine, rimantadine, zanamivir, and oseltamivir can help prevent influenza.[33][34] Vaccinations against Haemophilus influenzae and Streptococcus pneumoniae have good evidence to support their use.[23] Vaccinating children against Streptococcus pneumoniae has also led to a decreased incidence of these infections in adults, because many adults acquire infections from children. A vaccine against Streptococcus pneumoniae is also available for adults, and has been found to decrease the risk of invasive pneumococcal disease.[35]

Environmental
Reducing indoor air pollution is recommended[12] as is smoking cessation.[26]

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

Management

Typically, oral antibiotics, rest, simple analgesics, and fluids CURB-65 suffice for complete resolution.[26] However, those with other medical conditions, the elderly, or those with significant Symptom Points trouble breathing may require more advanced care. If the symptoms worsen, the pneumonia does not improve with Confusion 1 home treatment, or complications occur, hospitalization may be required.[26] Worldwide, approximately 713% of cases in Urea>7 mmol/l 1 children result in hospitalization[12] while in the developed world between 22 and 42% of adults with communityRespiratory rate>30 1 acquired pneumonia are admitted.[26] The CURB-65 score is useful for determining the need for admission in adults.[26] If SBP<90mmHg, DBP<60mmHg 1 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 Age>=65 1 is 35 hospitalization is recommended.[26] In children those with respiratory distress or oxygen saturations of less than 90% should be hospitalized.[36] The utility of chest physiotherapy in pneumonia has not yet been determined.[37] Over-the-counter cough medicine has not been found to be effective.[38]

Bacterial
Antibiotics improve outcomes in those with bacterial pneumonia.[39] 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.[26] In North America, where the "atypical" forms of communityacquired pneumonia are more common, macrolides (such as azithromycin), and doxycycline have displaced amoxicillin as first-line outpatient treatment in adults.[19][40] In children with mild or moderate symptoms amoxicillin remains the first line.[36] The use of fluoroquinolones in uncomplicated cases is discouraged due to concerns about side effects and resistance.[19] The duration of treatment has traditionally been seven to ten days, but increasing evidence suggests that short courses (three to five days) are similarly effective.[41] Antibiotics recommended for hospital-acquired pneumonia include third- and fourth-generation cephalosporins, carbapenems, fluoroquinolones, aminoglycosides, and vancomycin.[42] These antibiotics, often given intravenously, may be used in combination.

Viral
Neuraminidase inhibitors may be used to treat viral pneumonia caused by influenza viruses (influenza A and influenza B).[15] No specific antiviral medications are recommended for other types of community acquired viral pneumonias including SARS coronavirus, adenovirus, hantavirus, and parainfluenza virus.[15] Influenza A may be treated with rimantadine or amantadine, while influenza A or B may be treated with oseltamivir, zanamivir or peramivir.[15] These are of most benefit if they are started within 48 hours of the onset of symptoms.[15] Many strains of H5N1 influenza A, also known as avian influenza or "bird flu," have shown resistance to rimantadine and amantadine.[15] The use of antibiotics in viral pneumonia is recommended by some experts as it is impossible to rule out a complicating bacterial infection.[15] The British

Thoracic Society recommends that antibiotics be withheld in those with mild disease.[15] The use of corticosteroids is controversial.[15]

Aspiration
In general, aspiration pneumonitis is treated conservatively with antibiotics indicated only for aspiration pneumonia.[43] 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 betalactam antibiotic and metronidazole, or an aminoglycoside.[44] Corticosteroids are commonly used in aspiration pneumonia, but there is no evidence to support their effectiveness.[44]

Prognosis
With treatment, most types of bacterial pneumonia can be cleared within two to four weeks[45] and mortality is very low.[15] Viral pneumonia may last longer, and mycoplasmal pneumonia may take four to six weeks to resolve completely.[45] The eventual outcome of an episode of pneumonia depends on how ill the person is when he or she was first diagnosed.[45] Before the advent of antibiotics mortality was typically 30% for hospitalized patients.[16] In the United States, about 5% of those diagnosed with pneumococcal pneumonia will die. In cases where the pneumonia progresses to blood infection, just over 20% will die.[46] The death rate (or mortality) also depends on the underlying cause of the pneumonia. Pneumonia caused by Mycoplasma, for instance, is associated with lower mortality. However, about half of the people who develop methicillin-resistant Staphylococcus aureus (MRSA) pneumonia while on a ventilator will die.[47] In regions of the world without advanced health care systems, pneumonia is even more deadly. Limited access to clinics and hospitals, limited access to x-rays, limited antibiotic choices, and inability to diagnose and treat underlying conditions inevitably lead to higher rates of death from pneumonia. For these reasons, the majority of deaths in children under five due to pneumococcal disease occur in developing countries.[48] Adenovirus can cause severe necrotizing pneumonia in which all or part of a lung has increased translucency radiographically, which is called Swyer-James Syndrome.[49] Severe adenovirus pneumonia also may result in bronchiolitis obliterans, a subacute inflammatory process in which the small airways are replaced by scar tissue, resulting in a reduction in lung volume and lung compliance.[49] Sometimes pneumonia can lead to additional complications. Complications are more frequently associated with bacterial pneumonia than with viral pneumonia. The most important complications include respiratory and circulatory failure and pleural effusions, empyema or abscesses.

Clinical prediction rules

Clinical prediction rules have been developed to more objectively prognosticate outcomes in pneumonia. Although these rules are often used in deciding whether or not to hospitalize the

person, they were derived simply to inform on prognosis; neither index was designed or tested as guide to determine whether the person would benefit by hospital admission.

Pneumonia severity index (or PORT Score)[50] online calculator CURB-65 score, which takes into account the severity of symptoms, any underlying diseases, and age[51] online calculator

Pleural effusion, empyema, and abscess

A pleural effusion as seen on chest x-ray. The A arrow indicates fluid layering in the right chest. The B arrow indicates the width of the right lung. The volume of the lung is reduced because of the collection of fluid around the lung.

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

Respiratory and circulatory failure

Because pneumonia affects the lungs, people with pneumonia often have difficulty breathing, sometimes to the point where mechanical assistance is required. 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 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, creates a need for mechanical ventilation. Sepsis and septic shock are potential complications of pneumonia. Sepsis occurs when microorganisms enter the bloodstream and the immune system responds by secreting cytokines. Sepsis most often occurs with bacterial pneumonia; Streptococcus pneumoniae is the most common cause. Individuals with sepsis or septic shock need hospitalization in an intensive care unit. They often require intravenous fluids and medications to help keep their blood pressure up. Sepsis can cause liver, kidney, and heart damage, among other problems, and it is often fatal.

Epidemiology
Main article: Epidemiology of pneumonia

Age-standardized death from lower respiratory tract infections per 100,000 inhabitants in 2004.[52] no data <100 100-700 700-1400 1400-2100 2100-2800 2800-3500 3500-4200 4200-4900 4900-5600 5600-6300 6300-7000 >7000

Pneumonia is a common illness affecting approximately 450 million people a year and occurring in all parts of the world.[15] It is a major cause of death among all age groups resulting in 4 million deaths (7% of the world's yearly total).[15][39] Rates are greatest in children less than five, and adults older than 75 years of age.[15] It occurs about five times more frequently in the

developing world versus the developed world.[15] Viral pneumonia accounts for about 200 million cases.[15]

Children
In 2008 pneumonia occurred in approximately 156 million children (151 million in the developing world and 5 million in the developed world).[15] It resulted in 1.6 million deaths, or 2834% of all deaths in those under five years of age, of which 95% occurred in the developing world.[12][15] Countries with the greatest burden of disease include: India (43 million), China (21 million) and Pakistan (10 million).[53] It is the leading cause of death among children in low income countries.[15][39] 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.[54] Approximately half of these deaths are theoretically preventable, as they are caused by the bacteria for which an effective vaccine is available.[55]

History

WPA poster, 1936/1937

Pneumonia has been a common disease throughout human history.[56] The symptoms were described by Hippocrates (c. 460 BC 370 BC):[56] "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."[57] However, Hippocrates referred to pneumonia as a disease "named by the ancients." He also reported the results of surgical drainage of empyemas. Maimonides (11351204 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."[58] 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.[59] Initial work identifying the two common bacterial causes Streptococcus pneumoniae and Klebsiella pneumoniae was performed by Carl Friedlnder[60] and Albert Frnkel[61] in 1882 and 1884, respectively. Friedlnder's initial work introduced the Gram stain, a fundamental laboratory test still used today 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.[62] Sir William Osler, known as "the father of modern medicine," appreciated the death and disability cause 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).[63][64] 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.[16] 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 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.[65] Vaccination against Streptococcus pneumoniae in adults began in 1977, and in children in 2000, resulting in a similar decline.[66]

Signs and Symptoms

Symptoms vary depending on the age of the child and the cause of the pneumonia, but common ones include:

fever chills cough nasal congestion unusually rapid breathing (in some cases, this is the only symptom) breathing with grunting or wheezing sounds labored breathing that makes the rib muscles retract (when muscles under the ribcage or between ribs draw inward with each breath) and causes nasal flaring vomiting

chest pain abdominal pain decreased activity loss of appetite (in older kids) or poor feeding (in infants), which may lead to dehydration in extreme cases, bluish or gray color of the lips and fingernails

Duration
With treatment, most types of bacterial pneumonia can be cured within 1 to 2 weeks. Viral pneumonia may last longer. Mycoplasmal pneumonia may take 4 to 6 weeks to resolve completely.

Contagiousness
The viruses and bacteria that cause pneumonia are contagious and usually found in fluid from the mouth or nose of someone who's infected. Illness can spread when an infected person coughs or sneezes on others, by sharing drinking glasses and eating utensils, and when someone touches the used tissues or handkerchiefs of an infected person.

When to Call the Doctor

Call your doctor immediately if your child has any of the signs and symptoms of pneumonia, but especially if he or she:

is having trouble breathing or is breathing abnormally fast has a bluish or gray color to the fingernails or lips has a fever of 102F (38.9C), or above 100.4F (38C) in infants under 6 months of age

Home Treatment
If your doctor has prescribed antibiotics for bacterial pneumonia, give the medicine on schedule for as long as directed. This will help your child recover faster and will decrease the chance that infection will spread to other household members. For wheezing, a doctor might recommend using a nebulizer. Ask the doctor before you use a medicine to treat your child's cough because cough suppressants stop the lungs from clearing mucus, which may not be helpful in some types of pneumonia. Over-the-counter cough and cold medications are not recommended for kids under 6 years old. Take your child's temperature at least once each morning and each evening, and call the doctor if it goes above 102F (38.9C) in an older infant or child, or above 100.4F (38C) in an infant under 6 months of age. Check your child's lips and fingernails to make sure that they are rosy and pink, not bluish or gray, which is a sign that the lungs are not getting enough oxygen.

Take care of yourself Ordinary respiratory infections sometimes lead to pneumonia, so do what you can to protect yourself from all kinds of germs. Here are the basics:

Wash your hands. Your hands are in almost constant contact with germs that can cause pneumonia. These germs enter your body when you touch your eyes or rub the inside of your nose. Washing your hands often and thoroughly can help reduce your risk. When washing isn't possible, use an alcohol-based hand sanitizer. Don't smoke. Smoking damages your lungs' natural defenses against respiratory infections. Stay rested and fit. Proper rest and moderate exercise can help keep your immune system strong. Eat a healthy diet. Include plenty of fat-free dairy products, fruits, vegetables and whole grains. Set an example. Stay home when you're sick. When you're in public with a cold, catch your coughs and sneezes in the inner crook of your elbow.

Provide a high calorie, high protein diet of soft foods. Dispose properly