Pneumonia in Adults Diagnosis

  • Diagnosis

    The term “pneumonia” most commonly refers to an infection of the lungs that causes inflammation in the lung tissue, and fluid in or around the air sacs of the lungs Figure 01.

    Pneumonia is the sixth most common cause of death in the United States. It can occur any time of the year, but is more common during the winter.

    In most cases of pneumonia, a germ invades the lung tissue and causes it to become inflamed (swell). This may cause fluid to collect inside or around the air sacs of the lungs (alveoli). The fluid interferes with the ability of the lung to take in oxygen and move it to the cells of the body, where it is needed. The body is also stressed because it has to work to fight the infection that caused the pneumonia.

    Doctors usually divide pnemonia into three types: community-acquired, nursing home-acquired, and hospital-acquired. Community-acquired pneumonia (CAP) is transmitted between people in the course of their normal activities. Nursing home-acquried pneumonia is spread between residents of a nursing home. Hospital-acquired pneumonia (also called nosocomial pneumonia) is spread between patients in the hospital. It is important for clinicians to find out where a person may have caught pneumonia, since different germs are more likely in each environment. This may help the clinician better treat the pneumonia.

    People with pneumonia may have symptoms ranging from mild to severe, depending on their age, their general health, and the cause of their pneumonia.

    Click to enlarge: How Pneumonia Happens

    Figure 01. How Pneumonia Happens

    Infectious pneumonia occurs when microorganisms (germs) invade the lungs. Bacteria and viruses are the most common causes of pneumonia. These tiny organisms can reach the airways by being inhaled, or by moving there from other areas of the body Table 01.

    There are more than 50 known organisms that can cause pneumonia. That is why the exact organism causing some cases of pneumonia can be difficult for clinicians to identify.

    Organisms that cause pneumonia may be directly inhaled from the environment. They can also move into the lungs from the areas around the mouth and in the throat, where they normally thrive without causing any harm. Infections from other areas of the body can also move into the lungs and cause pneumonia.

    Table 1.  Some Common Pneumonias and Why They Happen

    Type of pneumonia Why it happens
    Bacterial Pneumonia This type of pneumonia usually starts after the flu, a cold, or an upper respiratory infection (URI) has weakened the immune system. Weakened defenses allow bacteria to multiply in the lungs, causing illness. There are many different bacteria that can cause pneumonia. The most common is Streptococcus pneumoniae (pneumococcus). Germs may be spread when an infected person coughs or sneezes or touches objects with unwashed hands. Bacterial pneumonia can be more serious than viral pneumonia.
    Viral Pneumonia Many different viruses can cause viral pneumonia. Examples include influenza, chickenpox, herpes simplex, and respiratory syncytial virus (RSV). Viruses can be passed between humans through coughing or sneezing, or by touching something that has come in contact with fluid from an infected person.
    Fungal Pneumonia Different kinds of fungi can cause pneumonia. It is most often caused by fungi inhaled from the environment.
    Mycoplasmal Pneumonia Mycoplasmas are tiny organisms that are easily spread where many people congregate (such as schools or office buildings). This type of pneumonia is usually very mild, and may be referred to as ?walking pneumonia.?
    Pneumocystis Pneumonia The parasite pneumocystis carinii, which normally resides in the lungs without causing problems, may grow too much and cause pneumonia in people whose immune systems are weak as a result of AIDS, organ transplant, cancer, or chemotherapy.
    Aspiration Pneumonia Aspiration pneumonia occurs when stomach contents or a foreign object is inhaled into the air passages, causing injury, infection, or blockage.
    Legionnaires' Disease Caused by a bacterium that lives in water, Legionnaires' disease can be spread through contaminated plumbing, showerheads, or air conditioning.

    Pneumonia can produce a wide range of symptoms, from mild to severe. These symptoms may include a cough that can be dry or productive (mucus-producing), shortness of breath, chills, fever, and chest pain. How sick people get with pneumonia depends on their age, their general health, and what caused their illness Table 02.

    Specific symptoms can depend on the cause of the infection. For example, the organism Streptococcus pneumoniae, which is responsible for about two-thirds of all cases of pneumonia, may cause an infection that comes on very abruptly. Symptoms of this type of pneumonia may include fever, chills, chest pain, and a cough that may either be dry or bring up mucus. The mucus that is brought up with a productive cough may smell bad, or be bloodstained or a “rusty” color.

    A less typical pneumonia (caused by the organism Mycoplasma pneumoniae) generally causes very mild symptoms. This type of pneumonia might come on slowly, with headache, a general feeling of illness, a low-grade fever, and a dry cough. Mild cases of pneumonia, such as Mycoplasmal pneumonia, are sometimes referred to as “walking pneumonia”.

    Symptoms in the elderly can be less specific, and may include rapid breathing, a low-grade fever (99° to 100°F [37° to 38°C]), and confusion Table 02.

    Symptoms in the elderly can be unlike those normally seen with pneumonia, and may be difficult to recognize. Rapid breathing is an important sign that may occur with a lung infection in an elderly person. Confusion and pain in the upper part of the abdomen are also common with pneumonia in an elderly person.

    Symptoms similar to those produced by pneumonia may occur with bronchitis, people who abuse alcohol or drugs, a drug allergy or reaction, blood clots in the lungs (pulmonary emboli), heart failure, and certain forms of lung cancer. To determine what is causing your pneumonia-like symptoms, clinicians may need to ask you questions, complete a physical exam, and perform tests.

    Table 2.  Common Symptoms of Pneumonia

    Signs of Common Pneumonia
    In Adults In the Elderly
    Cough: can be dry or productive (mucus-producing) Changes in chronic (long-term) coughs and the sputum (mucus) they produce
    Sudden onset of fever Chills Low-grade fever (99? to 100?F [37? to 38?C])
    Shortness of breath Shortness of breath Rapid breathing (more than 20 breaths a minute while at rest)
    Fatigue (feeling tired) Fatigue New onset of confusion
    Chest pain when taking a breath Chest pain or pain in the upper abdomen
    Signs of Severe Pneumonia (requires immediate medical attention)
    Temperature that rises above 104?F (40?C) or falls below 95?F (35?C)
    Pulse equal to or greater than 125 beats per minute while at rest
    Breathing rate greater than 30 breaths per minute while at rest
    Falling blood pressure (systolic blood pressure less than 90 mmHg), causing dizziness, confusion, or fainting

    Pneumonia tends to be more severe among the elderly, the very young, and people with other health problems Table 03.

    People with diseases that affect the immune system, and chronic (long-term) health problems are at higher risk for pneumonia. This is because a body with a weak immune system has trouble protecting itself against germs that enter the lungs. People with weak immune systems include the elderly and the very young, those with human immunodeficiency virus (HIV), those who have cancer or are receiving chemotherapy, and organ transplant patients. Other illnesses such as liver or kidney disease, stroke, diabetes, and heart disease also increase the risk for pneumonia.

    Pneumonia can occur after a chest injury, surgery, or any condition that requires a person to stay in bed for an extended period of time. Smoking and alcohol or drug abuse also increase a person's risk for pneumonia.

    Table 3.  Things That Put You at Greater Risk of Getting Pneumonia

    Medical Conditions
    Cancer, or receiving chemotherapy or other cancer treatments
    Recent organ transplant
    Heart disease/coronary artery disease
    Diabetes
    Liver or kidney disease
    HIV
    Chronic bronchitis or emphysema
    Recent upper respiratory tract infection, cold, or flu-like symptoms
    Recent viral infection
    Recent nausea and vomiting
    Problems with gag reflex (frequent choking or difficulty swallowing)
    Recent chest injury, surgery, or condition that required prolonged bedrest
    Age 65 or older
    Smoking
    Alcohol or drug abuse
    Exposure to birds, farm animals, chemicals, or pollutants
    Recent travel to the Southwest or Ohio-Mississippi Valley (places where the risk of inhaling certain fungi may increase)
    Recent hospital stay
    Living in a nursing home

    The clinician may ask questions about past illnesses, life/work environments, and other risk factors Table 03 that may provide clues to the cause of the symptoms.

    You should tell your clinician about any illnesses you have, if you've recently been exposed to a person with HIV, or if you've experienced any sort of change in consciousness, impaired gag reflex, or vomiting. Alcohol or intravenous drug abuse, smoking history, a recent hospital stay, and exposure to birds and farm animals can also provide important information about the potential source of your infection. You should tell your clinician if you have had a recent viral infection or flu-like symptoms. Tell your clinician if you have recently traveled to the Southwest or Ohio-Mississippi Valley, since that may increase your chance of having been exposed to pneumonia-causing fungi.

    A physical examination is necessary to diagnose pneumonia. It can also help determine how bad the pneumonia is, and what may be causing it.

    If you think you may have pneumonia, your clinician will need to see you. The clinician will listen to your heart, lungs, and chest through a stethoscope. The clinician will also review your vital signs, which include temperature, pulse rate, blood pressure, and breathing rate. The information gathered during your physical examination may help your clinician determine if your pneumonia is mild or serious.

    Chest x-rays may be necessary, but are not always required to confirm a diagnosis of pneumonia.

    Many people with mild pneumonia can be effectively treated without having a chest x-ray taken. However, in people with moderate to severe pneumonia, a chest x-ray is often taken to determine the extent of the illness and any need for additional testing. X-rays are especially useful in people with weak immune systems since they can help assess whether it is pneumonia or some other illness that is responsible for symptoms. Chest x-rays can also be used to show complications of disease, such as a build-up of pus in the lungs (empyemas) or other complications.

    Laboratory tests are sometimes required to diagnose pneumonia. Lab tests may help your clinician find out what caused the pneumonia so it can be treated properly. Tests may also help determine how your body is tolerating your illness.

    The most common laboratory tests include a complete blood cell count (CBC), which measures the number and type of white blood cells in the blood, and the use of a sputum sample (a sample of mucus coughed from the lungs) to help identify possible causes of the infection. People with breathing difficulties may be given tests that assess the lungs' ability to move oxygen into the blood. These tests may include pulse oximetry and an arterial blood gas test.

    If you are at risk for pneumonia, get a yearly flu shot (vaccination). Adults with chronic illnesses such as heart disease, and all adults 65 and over should receive a pneumonia vaccination.

    Becoming ill with the flu (influenza) increases the risk of pneumonia because it significantly weakens the natural defenses of the respiratory system against invasion by bacteria and other organisms. Influenza itself can also cause pneumonia. It is important to have a yearly influenza vaccination, especially if you are age 65 or over, have a chronic illness, have a compromised immune system, or are a healthcare worker.

    Pneumococcal (nu-moh-KOK-uhl) vaccinations (also called PPV) have also proven effective in preventing pneumonia, and vaccinations are recommended for people at high risk Table 03. Unlike the influenza vaccine, which must be received annually, the pneumococcal vaccine lasts for six years or more. The vaccine is around 60% effective in preventing pneumococcal pneumonias in adults with normal immune systems.

    Your clinician may want you to get the pneumococcal vaccine if you are over the age of 50. Since there are many kinds of germs that cause pneumonia, your clinician may want you to have the pneumococcal vaccine even if you've had pneumonia before.

    Some strains of pneumococcal bacteria have become resistant to antibiotics. If you become ill with an antibiotic-resistant infection, there may be limited antibiotics that fight your illness. This is another good reason to prevent infection from this type of bacteria.

    Most people need the pneumococcal vaccine only once; however, your clinician may want you to receive a booster after a number of years. Keep track of when you received your pneumococcal vaccination.

    Develop a habit of washing your hands frequently, especially during the winter months.

    Frequent hand washing is a good way to decrease your risk of falling ill with many different illnesses. Hand washing is especially important when someone in your home is ill. There is no guarantee that a family member or a caregiver won't catch pneumonia while caring for an ill person. However, the risk can be lowered with frequent hand washing before eating, before touching the eyes or nose, and after going outside. Also wash your hands after caring for the sick person, or handling their laundry, discarded tissues or handkerchiefs, or eating utensils.

    Take care of yourself to keep your immune system healthy. Eat a balanced diet, drink enough fluids, and get plenty of rest.

    Your body will be better able to defend itself if you lead a healthy lifestyle. Be sure to get enough rest every day. Regular exercise has many benefits, including making your heart and lungs healthier.

    Eat foods that are rich in the antioxidant vitamins C and E. Ensure that your diet also has foods rich in beta-carotene, such as dark green leafy vegetables (broccoli, spinach) and orange or yellow fruits and vegetables (carrots, oranges, mangos, apricots).

    Drink plenty of fluids throughout the day (preferably water). This helps to keep your mucus membranes hydrated (moist), which can help your body stop bacteria and viruses from entering.

    Quitting smoking can decrease your risk of becoming ill with pneumonia. Your clinician has many ways to help you quit smoking.

    Smoking can damage the airways of the lungs. It can also reduce the ability of the cilia to function effectively. Cilia are small, hair-like cells that move germs and foreign particles out of the lungs. If the cilia are not working right, these particles may stay in your lungs and increase the likelihood of infection. Ask your clinician for information about medications and programs to help you quit smoking.

  • Prevention and Screening

    If you are at risk for pneumonia, get a yearly flu shot (vaccination). Adults with chronic illnesses such as heart disease, and all adults 65 and over should receive a pneumonia vaccination.

    Becoming ill with the flu (influenza) increases the risk of pneumonia because it significantly weakens the natural defenses of the respiratory system against invasion by bacteria and other organisms. Influenza itself can also cause pneumonia. It is important to have a yearly influenza vaccination, especially if you are age 65 or over, have a chronic illness, have a compromised immune system, or are a healthcare worker.

    Pneumococcal (nu-moh-KOK-uhl) vaccinations (also called PPV) have also proven effective in preventing pneumonia, and vaccinations are recommended for people at high risk [Table 3]. Unlike the influenza vaccine, which must be received annually, the pneumococcal vaccine lasts for six years or more. The vaccine is around 60% effective in preventing pneumococcal pneumonias in adults with normal immune systems.

    Your clinician may want you to get the pneumococcal vaccine if you are over the age of 50. Since there are many kinds of germs that cause pneumonia, your clinician may want you to have the pneumococcal vaccine even if you've had pneumonia before.

    Some strains of pneumococcal bacteria have become resistant to antibiotics. If you become ill with an antibiotic-resistant infection, there may be limited antibiotics that fight your illness. This is another good reason to prevent infection from this type of bacteria.

    Most people need the pneumococcal vaccine only once; however, your clinician may want you to receive a booster after a number of years. Keep track of when you received your pneumococcal vaccination.

    Develop a habit of washing your hands frequently, especially during the winter months.

    Frequent hand washing is a good way to decrease your risk of falling ill with many different illnesses. Hand washing is especially important when someone in your home is ill. There is no guarantee that a family member or a caregiver won't catch pneumonia while caring for an ill person. However, the risk can be lowered with frequent hand washing before eating, before touching the eyes or nose, and after going outside. Also wash your hands after caring for the sick person, or handling their laundry, discarded tissues or handkerchiefs, or eating utensils.

    Take care of yourself to keep your immune system healthy. Eat a balanced diet, drink enough fluids, and get plenty of rest.

    Your body will be better able to defend itself if you lead a healthy lifestyle. Be sure to get enough rest every day. Regular exercise has many benefits, including making your heart and lungs healthier.

    Eat foods that are rich in the antioxidant vitamins C and E. Ensure that your diet also has foods rich in beta-carotene, such as dark green leafy vegetables (broccoli, spinach) and orange or yellow fruits and vegetables (carrots, oranges, mangos, apricots).

    Drink plenty of fluids throughout the day (preferably water). This helps to keep your mucus membranes hydrated (moist), which can help your body stop bacteria and viruses from entering.

    Quitting smoking can decrease your risk of becoming ill with pneumonia. Your clinician has many ways to help you quit smoking.

    Smoking can damage the airways of the lungs. It can also reduce the ability of the cilia to function effectively. Cilia are small, hair-like cells that move germs and foreign particles out of the lungs. If the cilia are not working right, these particles may stay in your lungs and increase the likelihood of infection. Ask your clinician for information about medications and programs to help you quit smoking.

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