Pneumonia
Assessment and treatment of lung infection, with care based on the cause and severity
What is pneumonia?
Pneumonia is an infection of the air sacs at the ends of the airways. The sacs fill with fluid and inflammatory cells instead of air, and that part of the lung stops transferring oxygen into the blood. How ill you are depends on how much lung is involved and on how well the rest of you can compensate.
Most cases are caused by bacteria, with viruses accounting for a substantial share, particularly in children and during influenza seasons. Fungi cause pneumonia mainly in people whose immunity is suppressed. Pneumonia can also follow the inhalation of food or stomach contents, which is common after a stroke, with alcohol excess and at the extremes of age.
The risk of becoming seriously ill is concentrated in identifiable groups: infants, people over sixty-five, smokers, people with existing lung disease, diabetes, heart, kidney or liver disease, anyone on medicines that suppress the immune system, and children who are malnourished. Where the illness has been building over weeks with weight loss and night sweats instead of days, tuberculosis is considered alongside pneumonia in India and looked for specifically.
What you might notice
- A cough that brings up phlegm most mornings
- Getting out of breath on stairs
- Fever in the evenings with night sweats
How it is diagnosed
The measurements come first and they determine everything. Your doctor records your temperature, your pulse, your blood pressure, how many breaths you take in a minute and your oxygen saturation from a clip on the finger. A high breathing rate and a low saturation are the two readings that most reliably identify someone who needs to be in hospital.
They then examine the chest, tapping over it and listening. They are looking for an area that sounds dull and where the breath sounds have changed or crackle, which localises the affected part of the lung. They also check whether you are alert and oriented, since new confusion is a marker of severity, particularly in older people.
A chest X-ray confirms the diagnosis and shows how much lung is involved and whether fluid has collected around it. Blood tests show the intensity of the inflammation and how the kidneys are coping. Sputum and blood cultures are sent where you are ill enough to be admitted. The whole assessment is aimed at one decision, which is whether you are treated at home or in hospital.
Recovery
Recovery is much slower than most people expect and the timeline is worth knowing in advance. On appropriate treatment the fever usually settles within two to three days and you start feeling less ill. The cough carries on for three to six weeks. Tiredness is the last thing to go and commonly lasts six weeks, with full energy taking up to three months in older adults.
Finish the whole course of antibiotics even though you feel better partway through, since stopping early is a common route to relapse and to resistant organisms. Rest in the first week, drink well, and build activity back gradually across the following month.
Plan one to two weeks off work for a mild illness treated at home, and four to six weeks after an admission. Your doctor will want to see you at around six weeks, and in smokers and people over fifty will usually repeat the chest X-ray then, because the X-ray clears well after the symptoms do and a shadow that has not cleared needs explaining.
If it is left untreated
Pneumonia that is not treated can progress within days. The infection spreads through more of the lung, oxygen levels fall, and the bacteria can enter the bloodstream and cause sepsis, in which blood pressure drops and other organs begin to fail. This is the commonest way pneumonia kills, and it moves fast in the very young, the very old and anyone whose immunity is reduced.
Infection can also collect as pus in the space between the lung and the chest wall, which no antibiotic clears on its own and which needs draining. An abscess can form in the lung itself. Both of these turn a week of treatment into several weeks.
Go to hospital the same day for breathlessness at rest, a breathing rate that is obviously fast, chest pain on breathing in, new confusion or drowsiness, blue lips, coughing blood, or an inability to keep fluids down. In an infant, watch for fast breathing, the skin sucking in between the ribs, grunting, refusal to feed and unusual sleepiness. Vaccination against influenza and pneumococcus is worth discussing with your doctor if you are in one of the higher-risk groups.
Questions about pneumonia
Do I need to be admitted to hospital?
Most people with pneumonia are treated at home with antibiotics by mouth. Your doctor decides using measurements and not by how unwell you feel: the number of breaths you take per minute, your oxygen saturation, your blood pressure, your age, whether you are confused, and whether you have diabetes, heart, kidney or lung disease. A fast breathing rate and a low saturation are the two readings that most often lead to admission. If you are being treated at home, you should be reviewed at forty-eight hours, and you should go in sooner if you become breathless at rest, confused or drowsy, cannot keep fluids down, or your lips look blue.
It has been a month and I am still exhausted. Is that normal?
Yes, and this catches almost everybody out. The fever settles in two to three days on the right antibiotic, but the lung takes far longer to clear the debris and the inflammation. A cough lasting three to six weeks is expected, and tiredness commonly lasts six weeks, with older adults taking up to three months to get their energy back. Build activity back gradually across the weeks instead of testing yourself early. What is not expected is getting worse again: a returning fever, new breathlessness, chest pain on breathing in or coughing blood should be seen promptly. Your doctor will usually review you at six weeks.
Can my family catch it from me?
The organisms that cause pneumonia spread from person to person through droplets, though most people who pick them up develop nothing worse than a cold. Pneumonia itself is much more about the susceptibility of the person who gets it, and it settles on infants, older adults, smokers and people with diabetes or existing lung, heart or kidney disease. Sensible precautions for the first week: cover coughs, wash hands, use your own towel and utensils, and keep infants and anyone with low immunity at a little distance. If the illness has been building over weeks with weight loss and night sweats, tuberculosis needs excluding, and that has different contact precautions your doctor will explain.
Other pulmonology treatments
Long-term management of airway inflammation and narrowing that causes wheezing, cough and breathing difficulty
Day CareTreatment and monitoring of chronic obstructive lung disease to reduce symptoms and improve daily function
Day CareTalk to a care coordinator about pneumonia
Leave a number and a care coordinator calls you back with what the treatment involves and which hospital it would be at. They book a consult only if you want one