lung infection

Pneumonia: short overview

• Typical symptoms: severe malaise, fever, chills, dry or productive cough
• Causes: Infection with bacteria, viruses, fungi or parasites, inhalation of toxic fumes, smoke, aspiration of stomach contents or blood
• Particularly at risk: Children, the elderly, people with heart or lung disease, immunodeficiency, diabetes, alcohol abuse
• Likelihood of confusion: (chronic) bronchitis, tumors, foreign bodies in the bronchi, lung / pleurisy
• Important investigations: Listening (auscultation) and tapping (percussion) of the lungs, X-ray, CT, ultrasound
• Treatment: Consistent protection, antibiotics (in bacteria) or fungicides, treatment of the symptoms (pain and fever), cough suppressants, secretolytic drugs
• Hazards: Oxygen deficiency (life-threatening), carryover with chronic course, spreading of the exciters into other organs (meningitis, heart inflammation etc.), blood poisoning (sepsis)
• Rare form: Pneumocystis carinii (fungal infection in severely weakened immune system)

Pneumonia: symptoms

A sudden onset of illness is typical of pneumonia. Signs such as general malaise and weakness are among the first symptoms.

Here are other symptoms of pneumonia:

• fever
• Cough with sputum (productive cough) or dry cough
• chills
• Shortness of breath (in severe pneumonia)

In pneumonia, the gas exchange in the lungs is disturbed. This leads to an oxygen deficiency (hypoxemia) and an increase of carbon dioxide (hypercapnia). To compensate for this, people with severe pneumonia often breathe very quickly and flatter (tachypnea).

The breathing effort causes the nostrils to inflate with every breath – a clear indication of shortness of breath and thus of pneumonia. If the lack of oxygen can not be compensated by this, the lips and fingertips turn bluish. Doctors speak of cyanosis.

The cough is initially dry in the early stages of pneumonia. This means that no expectoration (mucus) can be coughed off. As a rule, however, after a short time a productive cough occurs, in which greenish-yellowish mucus is coughed off.

Any coughing can cause the victim chest pain, which often radiates to the lower abdomen. Existence of other lung diseases such as asthma or bronchitis, so they often worsen by the pneumonia in addition.

Atypical pneumonia: symptoms less clear

Atypical pneumonia can be triggered by certain bacteria as well as by fungi, viruses or parasites. The cough stays dry all the time. Significantly mild symptoms, which often last for weeks, are further signs of atypical pneumonia. There is a lack of symptoms typical of typical pneumonia, which is why atypical pneumonia is often overlooked and therefore not properly cured.

Pneumonia: Symptoms of viruses or parasites

If viruses or parasites are responsible for pneumonia, symptoms may be different from bacterial pneumonia. Symptoms often include fever and chills. Only after a few days a dry cough occurs.

Other signs: Pneumonia with viral or parasitic cause is often accompanied by difficult mucus from expectoration and a cough that persists for a long time.

Pneumonia: symptoms in the elderly

In older people, pneumonia is often much more severe than in younger and sometimes life-threatening. Symptoms of pneumonia in the elderly include cough (often with brownish sputum) and dyspnoea.

The brownish color of the sputum is caused by the addition of blood, for example from tears of the smallest blood vessels in the pharynx. However, addition of blood in the sputum are also possible symptoms of a Legionella pneumonia.

The respiratory distress, which often accompanies pneumonia in the elderly, is due to the diminished power reserve of the lungs in old age. Sometimes the sufferers have to be temporarily ventilated even in hospital.

In the case of a serious illness, older people in particular, due to lack of oxygen and increased carbon dioxide levels, can also become in a kind of twilight state, in which they become confused about their environment or appear completely apathetic. Then the treatment in the hospital is necessary.

Pneumonia: symptoms in children

Children and adults often develop different signs of pneumonia. Symptoms that only affect children are bloated abdomen and headache and body aches. With these complaints, parents do not immediately think of pneumonia! Recognize pneumonia in children is often more likely to change behavior, especially if the little ones can not speak yet.

The first signs of pneumonia in children can therefore be:

• high fever
• bloated stomach
• erected nostrils inhaling
• fast breathing (tachypnoea)
• aversion to drinking
• Reduced appetite
• especially high heart rate

Also in children, severe cough, accompanied by mucus depending on the cause of the pneumonia or dry, and a general malaise are among the classic signs of pneumonia. As with adults, coughing is often accompanied by greenish or yellowish expectoration in children. When coughing, chest pain can occur, sometimes radiating into the right lower abdomen.

Pneumonia: symptoms of weakened defense

People with compromised immune systems are particularly susceptible to pneumonia. Symptoms can be more pronounced here and last longer. They additionally weaken the body, so that in patients with weakened immune systems, the treatment of pneumonia in the hospital should be done.

A weakened immune defense occurs, for example, in the context of an immunosuppressive therapy. This is a treatment that restricts or completely suppresses the function of the immune system (for example, after organ transplantation). But even in diseases such as AIDS or diabetes (diabetes mellitus), the immune system can be significantly weakened.

Pneumocystis pneumonia symptoms

In addition, people with a weakened immune system may experience a rare form of pneumonia that is virtually non-existent in people with normal defenses: Pneumocystis pneumonia (Pneumocystis carinii pneumonia). It is caused by the fungus Pneumocystis jirovecii.

Pneumocystis pneumonia usually begins slowly with coughing and mild fever. Over time, this type of pneumonia is accompanied by symptoms such as dry cough and increased dyspnea. Fever can also occur but is rare.

“Cold” pneumonia

The so-called cold pneumonia is characterized by the absence of fever. However, since fever is usually one of the typical symptoms of pneumonia, cold pneumonia is often not recognized as such.

Typical of cold pneumonia are symptoms such as:

• dry, irritating cough, no coughing up of mucus
• no or very low fever
• jerky, heavy breathing
• difficulty in breathing
• Feeling of tightness in the ribcage

In addition, symptoms of cold pneumonia do not occur in other forms of pneumonia: for example, cold pain in the chest can cause back pain and cold hands in children to the already familiar symptoms.

Bronchitis or pneumonia?

An acute bronchitis is an inflammation of the inner wall of the bronchial tree, through which the air enters the lungs. The bronchial walls thicken, the small blood vessels around the bronchi swell and mucus is produced. Bronchitis is therefore associated with symptoms similar to pneumonia.

In the distinction between bronchitis and pneumonia, an X-ray of the chest area helps further: A pneumonia is shown as shading in the chest, bronchitis, however, can not be seen in the radiograph. Nevertheless, the doctor often can not give a clear answer to the question: bronchitis or pneumonia? The symptoms of both diseases are much too similar.

Pneumonia: treatment

How a pneumonia is treated depends on what triggered the inflammation (bacteria, viruses, fungi, parasites, etc.). The age of the patient and possibly existing accompanying or pre-existing diseases also play a role in the therapy.

Tip: Diseased people can support recovery in all types of pneumonia by taking good care of themselves and drinking a lot.

antibiotics

When bacterial pneumonia almost always antibiotics are prescribed to kill the pathogens, or to prevent the bacteria multiply.

The sooner a bacterial pneumonia is detected and treated, the higher the likelihood that it will progress without complications. Therefore, antibiotics are often prescribed with a confirmed diagnosis, if the exact pathogen is not yet established. The broad-spectrum antibiotics used for this purpose are effective against many possible germs.

If the pathogen is known by a bacteriological examination of the blood or the sputum, the patient can also get a more targeted antibiotic.

The duration of treatment in typical pneumonia is on average seven days, but may be prolonged or shortened depending on the individual course of the disease. If there is no improvement after two to three days of taking antibiotics, the antibiotic may need to be changed or the diagnosis must be checked.

Anyone suffering from drug allergy, intolerance and chronic diseases should inform their doctor about this before starting therapy. Also, inform him if you have been abroad for up to three months prior to the onset of the illness. Pathogens from other countries sometimes require different treatment.

Not effective is antibiotic treatment in a virus-induced or any other non-bacterial form of pneumonia. Nevertheless, antibiotics are often prescribed concomitantly. The reason: It prevents an additional infection (superinfection) with bacteria.

An antibiotic therapy is also ineffective if individual pathogen strains have developed so-called resistance, ie are insensitive to the antibiotic. Resistant bacteria are particularly common in hospitals because antibiotics are widely used there.

As a patient, you can help prevent such resistance by taking prescribed antibiotics for as long as prescribed by your doctor.

Other treatment measures

In pneumonia caused by viruses, fungi or parasites, the treatment approach is different. Depending on the pathogens, antifungals or special medicines for parasites may be necessary. In addition, medicines are used that are primarily intended to alleviate the symptoms and prevent secondary diseases:

• Antitussives (e.g., codeine, dextromethorphan) attenuate the coughing sensation in dry irritated cough
• Secretolytic agents (mucolytics, for example, acetylcysteine, bromhexine) facilitate coughing off productive cough
• Painkillers and antipyretics (for example, aspirin, paracetamol) dampen the general symptoms, such as pain in the limbs and fever

Cough blockers and cough suppressants should never be taken at the same time. Otherwise the mucus can not be coughed off and the respiratory distress worsens.

Pneumonia: outpatient treatment or hospital?

Young people without comorbidities can usually be treated at home. Pneumonia is usually over after two or three weeks at the latest. Treatment in the hospital is necessary if

• the inflammation captures large parts of the lungs
• severe symptoms occur
• the patient has a high age
• an immunodeficiency or a poor general condition exists
• Complications (for example, blood poisoning or pleurisy) occur

What is pneumonia?

Pneumonia is one of the most prevalent infectious diseases per year with an estimated 500,000 cases per year. Almost a third of those affected have to be hospitalized. About three to five percent of the patients die. This makes pneumonia the most frequently fatal infectious disease in Western Europe.

In pneumonia, predominantly either the alveoli (alveolar pneumonia) or the lung tissue (interstitial pneumonia) are damaged and can no longer work properly. As a result, the gas exchange is impaired, and the body does not get enough oxygen. At the same time, it can deliver too little carbon dioxide.

In some pneumonia, many smaller sites of inflammation exist in the lobes (lobular pneumonia). In others, an entire lung lobe is affected (lobar pneumonia, lobar pneumonia).

But not only the spread is used to characterize pneumonia. There are many other criteria of distinction:

Primary or secondary pneumonia?

If a healthy person with no significant health risk factors falls ill with pneumonia, doctors speak of one primary pneumonia, If, on the other hand, there is another disease or event that causes pneumonia to develop (such as asthma, COPD, heart failure, smoke poisoning, aspiration, etc.), this is called a secondary pneumonia.

Ambulatory or nosocomial pneumonia?

An outpatient pneumonia (CAP, English for communitis acquired pneumonia) can be obtained outside a hospital. This also includes pneumonia with which someone is infected in retirement or nursing homes. A hospital acquired pneumonia (HAP) refers to the pneumonia that occurs in the hospital (more precisely, more than two days after admission or within 14 days of discharge).

The problem with nosocomial pneumonia: Hospitals are increasingly finding antibiotic-resistant germs, the treatment of which is particularly difficult. Because most antibiotics are no longer effective in these bacteria. The risk is particularly high in patients in the intensive care unit, where the immune system is weakened. In particular, artificial respiration may favor pneumonia.

Typical or atypical pneumonia?

Pneumonia is also classified according to its course and symptoms. Doctors refer to a “typical pneumonia” when the classic symptoms of pneumonia such as productive cough (= with sputum), fever and typical findings in the X-ray and physical examination show. In the process, pus and water retention clog the air sacs, which are important for the exchange of respiratory gases.

An “atypical pneumonia” (also called “interstitial pneumonia”) is present when the alveoli are not inflamed, but the tissue that embeds the alveoli and blood vessels (interstitium) is inflamed. Atypical pneumonia is caused by pathogens other than the typical forms: mycoplasma, chlamydia, rickettsia or legionella (all bacteria), as well as fungi or parasites.

Mycoplasma pneumonia is common in community operations such as schools, homes or barracks. Chlamydia-induced pneumonia is caused by the genus Chlamydia pneumoniae, which is transmitted exclusively from human to human. Legionella are found mainly in stagnant, warm or hot waters. These can be lakes, showers, air conditioning or ventilation systems have a creeping, lengthy course, hot water boiler or heaters. In addition to the known symptoms, legionella pneumonia also causes confusion, lethargy and diarrhea.

Special form of pneumonia: Pneumocystis carinii pneumonia

Pneumocystis pneumonia is a special form of pneumonia. It is triggered by a fungus, Pneumocystis jirovecii. Healthy people are not affected by the infection. Pneumocystis carinii pneumonia mainly affects people with immune system weakness and is in most cases the first sign of infection with HIV.

Pneumonia: causes and risk factors

Infectious agents are usually bacteria in pneumonia. A certain type of bacteria, the pneumococci, are responsible for half of all diseases. Contagion to patients via a droplet infection is a common cause of pneumonia.

Many of the bacteria responsible for pneumonia also occur in healthy people in the mouth. However, if these germs get into the airways in large quantities, it can cause pneumonia. Sometimes the pathogens are also carried to the lungs via the blood of other organs.

Mushroom pneumonia usually affects people with poor general condition and weakened immune systems. Parasitic pneumonia is rare and more likely to occur in immunocompromised individuals or after traveling to tropical countries.

Other pneumonia causes can be:

• Secretion in the bronchi
• lung tumors
• Foreign matter in the airways
• corrosive irritants, gases, smoke or solvents
• radiotherapy
• Inhalation (aspiration) of food, fluid, blood, stomach contents / gastric juice
• Heart failure (heart failure)
• Pulmonary embolism after thrombosis
• Germ contamination via the bloodstream (hematogenous scattering) from other sources of inflammation in the body (for example in the case of bone inflammation)

Risk groups for pneumonia:

The risk of pneumonia increases above all under the following conditions:

• in older and weakened people
• in chronic diseases, especially heart disease, chronic bronchitis, COPD or diabetes (diabetes mellitus)
• in people whose body’s defenses are significantly weakened (for example, in HIV infections)
• in people who take medicines that suppress the body’s defenses (for example, immunosuppressants or cytostatics)
• in alcoholic people
• in toddlers

In these risk groups, it is particularly important to recognize as quickly as possible what type of pneumonia is present in order to be able to treat them accordingly. Because by an infection, they are particularly at risk.

Is pneumonia contagious?

Depending on the form and cause, pneumonia can be contagious. In pneumonia caused by viral or bacterial agents, for example, pathogens are distributed in the air through coughing or sneezing and can infect other people (droplet infection).

Pneumonia in children

Pneumonia is the most common childhood respiratory disease. It is sometimes difficult to recognize because the symptoms of pneumonia in (small) children can be very unspecific. Signs include a fever, coughing and high pulse, a bloated abdomen, nostrils on inhalation, apathetic behavior, and no desire to eat and drink.

Since the immune system in adolescents does not work so effectively, children have little to oppose a budding pneumonia. It is all the more important to be alert as a parent and to pay attention to the disease-specific symptoms. This is particularly important in suspected pneumonia in babies and toddlers, as they can not speak yet.

If the child has no other illnesses, the pneumonia usually heals within seven to ten days.

Find out more about pneumonia in children here.

Pneumonia: examinations and diagnosis

To diagnose pneumonia, the attending physician will first record the medical history (anamnesis), asking for past and existing illnesses and complaints, for example:

• Do you have a cough? If so, is it dry or ejected?
• How is the ejection (quantity, consistency, color)?
• Have you noticed chills or fever in the last few days?
• Do you have shortness of breath or a sense of tightness in the chest area?
• How are you in general, do you feel weak and tired?

Then follows the physical examination. In doing so, the doctor tries to detect ventilation by listening to the lungs with the stethoscope (auscultation) and by tapping the density of the lung tissue. Decreased breath sounds and a compression speak for a pneumonia.

Blood test, urine examination

A blood test also provides evidence of inflammation. In bacterial pneumonia, the number of white blood cells (leukocytes) is greatly increased. Different precursors of the leukocytes can be detected in the blood. This finding is referred to as median left shift. If there is a viral pneumonia, the number of leukocytes is hardly or not increased, but the proportion of lymphocytes (specialized white blood cells).

Legionella can be detected in the urine (urine test).

X-ray

If there is a suspicion of pneumonia, an X-ray of the chest (X-ray thorax) is always required. It serves to confirm the diagnosis and to detect the extent and location of the inflammation. In addition, it can expose other diseases (e.g., tumors, lung abscesses, tuberculosis) that can trigger similar symptoms.

If no X-ray device is initially available, suitably trained physicians can also perform an ultrasound examination to confirm the suspected diagnosis of pneumonia. If there is a suspicion of atypical pneumonia, a computed tomography may be required, with which even small sources of inflammation can be detected.

Bronchoscopy and bacteriological examination

Especially with atypical pneumonia, it may be important to track down the pathogen. Only then can often be an effective pneumonia treatment initiate. For this purpose, a reflection of the bronchi (bronchoscopy) is performed. The doctor inserts a flexible tube into the bronchi, which is connected to a camera and has several working channels.

These can be used to flush the bronchi and to specifically extract mucus for examination for pathogens. Other pathological changes in the bronchi (constrictions, outgrowths or tumors) can often be detected via bronchoscopy.

Pneumonia: disease course and prognosis

Therapy and recovery of pneumonia are better the earlier the disease is noticed and treated. The prognosis is also dependent on the pathogen, the age of the patient and his general (health) condition.

Some factors can negatively affect the course of pneumonia:

• old age
• existing heart or lung diseases
• weakened immune system

In rare cases, there are complications of pneumonia, which can extend the duration of treatment. This includes:

• antibiotic-resistant bacteria as the cause of pneumonia
• Inflammation of the lung or pleura (pleurisy)
• Fluid accumulation between lung and pleura (pleural effusion)
• Bronchiectasis (irreversible, saccular bronchi)
• Formation of pus-filled cavities in lung tissue (lung abscess)
• Inflammation of the pericardium or the inner lining of the heart (pericarditis and endocarditis)
• Pus accumulation in the brain
• Blood clots (thrombosis)
• Bone marrow inflammation (osteomyelitis)
• Joint inflammation (arthritis)

A dangerous complication of pneumonia is the spread of the pathogens via the bloodstream to other organs (hematogenous scattering). For example, the meninges, the heart or the ears may be affected or a general blood poisoning (sepsis) may occur.

Worldwide, three to four million people die of pneumonia every year. Nevertheless, the prognosis is good with early, adequate therapy and without existing comorbidities. Affected individuals usually recover completely in this case.

However, a worse prognosis can be expected if the pneumonia occurred during a hospital stay. As antibiotics are widely used there, there is an increased risk that the bacterial strains are resistant to many antibiotic agents, which makes therapy much more difficult.

Pneumonia: duration

As a rule, a pneumonia therapy with antibiotics should be successful within seven days. For certain pathogens, however, a longer treatment may be required to reduce the relapse rate (recurrence rate). After two to three weeks, the symptoms of pneumonia have usually subsided.

However, affected individuals can sometimes feel choppy and limp weeks after pneumonia, and coughing can persist. In order not to relapse, you should only go back to work when the physical performance is back to normal and there are no symptoms.

Carried out pneumonia

It takes much longer if the disease is “kidnapped”. For example, because the affected person is physically stressed again too soon or because the therapy was delayed.

A six to eight weeks abducted pneumonia call medical professionals as chronic pneumonia. It can cause irreversible bronchial secretions (bronchiectasis), recurrent inflammation in the lungs or even bleeding.

As a result, the lung tissue is scarred and later less elastic. This can severely restrict lung function (restrictive lung dysfunction). Particularly at risk for a delayed pneumonia are people with a weakened immune system or severe pre-existing conditions of the lungs and the heart.

Vaccination against pneumonia

There is no vaccine against all possible agents of pneumonia. Nevertheless, vaccination with pneumonia can often be effective in preventing it. The Robert Koch Institute recommends three different vaccinations, which are important for different groups of people and can prevent pneumonia:

Pneumococcal vaccine

A large part of all pneumonia is due to pneumococci as a pathogen. Therefore, it is recommended that the following groups of people undergo a pneumococcal vaccine:

• all children up to 24 months
• People over the age of 65, who often suffer from upper respiratory infections
• Groups of people with a weakened immune system
• Persons whose spleen was removed
• People with a chronic illness (such as bronchitis, coronary heart disease, heart failure or diabetes mellitus)

Haemophilus influenzae vaccine

In about ten percent of all young patients, the bacterium Haemophilus influenzae is responsible for pneumonia. Also against this pathogen can be vaccinated.

Flu shot

The influenza virus (influenza) can damage the mucous membrane and weaken the immune system. Those affected become more susceptible to pneumonia and can counteract their less endogenous antibodies. In the following cases you should regularly vaccinate against flu:

• from the age of 60 years
• in cardiovascular diseases such as hypertension or angina pectoris
• in metabolic diseases such as diabetes mellitus
• in lung or kidney diseases
• in an HIV infection
• in leukemia
• in a daily contact with many different people

Prevent pneumonia

The best way to prevent pneumonia is to have a healthy, active lifestyle. Balanced and vitamin-rich nutrition and regular exercise improve overall health and help reduce the risk of pneumonia. On the other hand, you should consume tobacco and alcohol as moderately as possible – both weaken your immune system and make you a lighter “victim”. Especially if you have ever had pneumonia.

People suffering from a chronic respiratory disease such as asthma, COPD or chronic bronchitis should never change or pause their basic therapy in an acute respiratory infection without consulting their doctor. The risk of a secondary infection, possibly also with pathogens of pneumonia, is generally increased in them.

Additional information

S3 Guideline “Treatment of Adult Patients with Community Acquired Pneumonia and Prevention – Update 2016” of the German Society for Pulmonology and Respiratory Medicine, the PaulEhrlich-Gesellschaft für Chemotherapie, the German Society of Infectiology, the Competence Network CAPNETZ, the Austrian Society for Pulmonology, the Austrian Society for Infectious Diseases and Tropical Medicine and the Swiss Society of Pulmonology

S3_Leitline “Epidemiologie, Diagnostik und Therapie erwachsener Patienten mit nosokomialer Pneumonie” der Deutschen Gesellschaft für Anästhesiologie und Intensivmedizin e.V. et al. (Update: 2017)